What is the incidence of heart failure in patients undergoing dialysis (renal replacement therapy)?

Heart Failure Prevalence in Dialysis Patients

Heart failure is extremely common in dialysis patients, with approximately 31% having heart failure at dialysis initiation and an additional 25% developing it during their course on dialysis, making it one of the most prevalent cardiovascular complications in this population. 1, 2

Prevalence at Dialysis Initiation

• 31-37% of patients have already experienced heart failure by the time they start dialysis therapy, representing a substantial baseline burden of cardiac disease 3, 2
• Among the cardiovascular diseases present in dialysis patients, heart failure ranks as the second most common condition with a prevalence of 14.51% in the overall dialysis population based on recent 2017 data from China 1
• Coronary heart disease is more prevalent at 37.26%, but heart failure follows closely as a major cardiovascular complication 1

Incidence During Dialysis

• 25% of patients who do not have heart failure at baseline will develop it during their course on dialysis, demonstrating the progressive nature of cardiac dysfunction in this population 2
• The annual incidence rate is substantial, with 76 out of 299 patients (25%) developing new-onset heart failure over a mean follow-up of 41 months 2
• 56% of patients who present with heart failure at dialysis initiation will experience recurrent episodes during follow-up, indicating the chronic and relapsing nature of this condition 2

Systolic vs. Diastolic Dysfunction

• 15% of patients starting dialysis have systolic dysfunction (reduced ejection fraction), though this likely underestimates the total burden since diastolic dysfunction prevalence is unknown but suspected to be high 3
• Approximately 20% of dialysis patients have heart failure with reduced ejection fraction (HFrEF), which carries particularly high mortality rates 4
• Both systolic and diastolic dysfunction can lead to clinically evident congestive heart failure, though the prevalence of diastolic dysfunction at dialysis inception remains poorly characterized 3

Risk Factors for Development

The following factors independently predict heart failure development in dialysis patients:

• Older age is consistently associated with both baseline and incident heart failure 2
• Anemia during dialysis therapy significantly increases risk of developing heart failure 2
• Hypoalbuminemia serves as an independent predictor 2
• Hypertension during dialysis contributes to progressive cardiac dysfunction 2
• Systolic dysfunction at baseline predicts future heart failure episodes 2
• Diabetes mellitus and ischemic heart disease are strongly associated with heart failure at dialysis initiation 2

Prognostic Implications

• Median survival for dialysis patients with heart failure is only 36 months, compared to 62 months for those without heart failure, representing a dramatic reduction in life expectancy 2
• Patients with reduced LVEF (≤45%) have significantly worse survival at 12 and 24 months (68.9% and 55.5%) compared to those with preserved LVEF (87.3% and 73.0%) 5
• Hazard ratio for all-cause mortality is 2.70 in patients with reduced LVEF, increasing to 3.45 in those with LVEF <30% 5
• Cardiovascular disease accounts for at least 40% of deaths in end-stage renal failure patients, with heart failure being a major contributor 6

Clinical Context and Monitoring

• The overall prevalence of cardiovascular disease in dialysis patients is 43.01%, creating a high-risk population for heart failure development 1
• Left ventricular hypertrophy is present in almost 80% of dialysis patients, serving as a substrate for both systolic and diastolic dysfunction 6
• Cardiovascular disease is the most frequent cause for hospitalizations among hemodialysis patients (33.68%), with heart failure representing a substantial portion of these admissions 1

Common Pitfalls

• Underdiagnosis is common due to the coexistence of volume overload, which can mimic or mask heart failure symptoms in dialysis patients 7
• Despite the high prevalence and poor prognosis, only 27% of dialysis patients with reduced LVEF receive the combination of beta-blocker and RAAS inhibitor therapy, and 18% receive no heart failure therapy at all 5
• Most patients receive inadequate doses of neurohormonal blockers (≤25% of recommended daily dose), representing a significant treatment gap 5
• The diagnosis of heart failure in dialysis patients is challenging and requires careful clinical assessment beyond standard volume status evaluation 7