Management of Heart Failure in CKD Patients on Intermittent Dialysis
For patients with heart failure and CKD on intermittent dialysis, management should focus on volume control through dialysis ultrafiltration, careful use of cardiovascular medications, and consideration of peritoneal dialysis for improved hemodynamic stability. 1
Volume Management Strategies
- Dialysis ultrafiltration is the primary method for controlling fluid overload in heart failure patients on intermittent dialysis, with the ability to precisely titrate fluid removal 1
- Peritoneal dialysis should be considered as an alternative to hemodialysis due to fewer hemodynamic fluctuations, no need for heparin (reducing bleeding risk), and better maintenance of residual kidney function 1
- Daily weight monitoring and careful assessment of dry weight targets are essential to guide ultrafiltration goals during dialysis sessions 2
- Dietary sodium restriction to <2.0 g/day enhances volume control and reduces interdialytic weight gain 1, 2
Pharmacological Management
Recommended Medications
- Beta-blockers are strongly recommended for heart failure with reduced ejection fraction (HFrEF) in all stages of CKD, including patients on dialysis 2, 3
- Consider angiotensin receptor neprilysin inhibitors (ARNIs) for patients with HFrEF, which have been studied in patients with eGFR as low as 20 ml/min/1.73m² 3
- Intravenous iron supplementation should be used to treat iron deficiency, which has been shown to improve symptoms in heart failure patients with CKD and reduce hospitalizations in dialysis patients 2, 3
- Statins or statin/ezetimibe combinations are recommended for cardiovascular risk reduction in adults aged ≥50 years with CKD not on dialysis 1
Medications Requiring Caution
- Diuretics may have limited efficacy in dialysis patients but can be considered in patients with residual kidney function 1, 2
- ACE inhibitors and ARBs require careful monitoring of potassium levels and residual kidney function 2, 3
- Aldosterone antagonists may be considered but carry significant risks of hyperkalemia in dialysis patients 4
- Routine intermittent infusions of vasoactive and positive inotropic agents are not recommended for patients with refractory end-stage heart failure 1
Dialysis Considerations
- Hemodialysis advantages include precise control of ultrafiltration and less requirement for patient autonomy 1
- Hemodialysis disadvantages include hemodynamic fluctuations, need for heparin (increasing bleeding risk), and vascular access complications 1
- Peritoneal dialysis offers advantages of fewer large hemodynamic swings, no need for vascular access, and can be performed at home 1
- For patients with severe fluid overload resistant to conventional therapy, ultrafiltration or hemofiltration may be needed to achieve adequate control 1
Monitoring and Follow-up
- Regular monitoring of electrolytes, especially potassium, is essential after each dialysis session and with medication adjustments 2
- Cardiac biomarkers (BNP/NT-proBNP) should be interpreted with caution in dialysis patients due to altered clearance 2
- Echocardiography should be performed periodically to assess cardiac structure and function 5
- Monitor for signs of worsening heart failure, including increasing dyspnea, orthopnea, and peripheral edema 2
Additional Considerations
- Cardiac resynchronization therapy has been shown to reduce death and hospitalizations in heart failure patients with CKD stage 3 and should be considered when appropriate 3
- Anemia management with ESAs should be considered after iron repletion, particularly with persistent anemia 2
- A multidisciplinary approach involving both cardiology and nephrology is recommended for optimal management 3
- Early identification of patients with advanced heart failure and kidney disease is critical for timely interventions 1
Common Pitfalls to Avoid
- Overaggressive ultrafiltration can lead to intradialytic hypotension and myocardial stunning 2, 6
- Underutilization of evidence-based heart failure therapies due to concerns about side effects 3
- Failure to adjust dry weight targets in response to changes in cardiac status 2
- Inadequate attention to residual kidney function, which should be preserved when possible 1