This is the current release of the guideline.

The grade of recommendation (A, B, or C) and level of evidence (strong, moderately strong, or weak) are defined at the end of the "Major Recommendations" field.

Section 1: Guidelines on Evaluation and Management of Cardiovascular Diseases

Guideline 1: Evaluation of Cardiovascular Disease in Adult and Pediatric Patients

Cardiovascular disease (CVD) is prevalent in patients receiving dialysis therapies, and it affects long-term outcomes as well as the ability to deliver dialysis in some situations. Thus, it is important to evaluate the extent of all aspects of CVD in dialysis patients. In those patients with limited life expectancy due to severe non-cardiac comorbidity, evaluation and therapy should be individualized.

1.1. At the initiation of dialysis, all patients--regardless of symptoms--require assessment for CVD (coronary artery disease [CAD], cardiomyopathy, valvular heart disease, cerebrovascular disease [CBVD], and peripheral vascular disease [PVD]), as well as screening for both traditional and nontraditional cardiovascular risk factors. (C)

1.1.a. Echocardiograms should be performed in all patients at the initiation of dialysis, once patients have achieved dry weight (ideally within 1 to 3 months of dialysis initiation) (A), and at 3-yearly intervals thereafter. (B) (see Guideline 6)

1.2. Children commencing dialysis should be evaluated for the presence of cardiac disease (cardiomyopathy and valvular disease) using echocardiography once the patient has achieved dry weight (ideally within 3 months of the initiation of dialysis therapy). (C) Children commencing dialysis should be screened for traditional cardiovascular risk factors such as dyslipidemia and hypertension. (C)

Guideline 2: CAD

Ischemic heart disease (IHD) due to atherosclerotic CAD is common in dialysis patients. While its evaluation and treatment are important components of the ongoing care of dialysis patients, there are special considerations for both the evaluation and treatment in dialysis patients due to the issues of preservation of kidney function, vascular access, and bleeding tendencies.

2.1. The evaluation of CAD in dialysis patients depends on individual patient status. (C)

2.1.a. If the patient is on the kidney transplant waitlist and is diabetic (and initial evaluation is negative for CAD), then evaluation for CAD every 12 months is recommended.

2.1.b. If the patient is on the transplant waitlist but is not diabetic and is classified as "high risk,"* then evaluation for CAD every 24 months is recommended.

2.1.c. If the patient is on the transplant waitlist and is classified as not high risk,* then evaluation for CAD every 36 months is recommended.

*Note: High-risk (more than 20% per 10 years cardiovascular event rate risk) according to Framingham data includes those with two or more "traditional" risk factors, a known history of coronary disease, left ventricle (LV) ejection fraction (EF) <40%, or PVD.

2.1.d. If the patient is on the transplant waitlist with known CAD (and not revascularized), evaluation for CAD should be performed every 12 months.

2.1.e. If the patient is on the transplant waitlist and has a history of percutaneous transluminal coronary angioplasty (PTCA) or coronary stent, evaluation for CAD should be performed every 12 months.

2.1.f. If the patient has "complete" coronary revascularization (i.e., all ischemic coronary vascular beds are bypassed), the first re-evaluation for CAD should be performed 3 years after coronary artery bypass (CAB) surgery, then every 12 months thereafter.

2.1.g. If the patient has "incomplete" coronary revascularization after CAB surgery (i.e., not all ischemic coronary beds are revascularized), then evaluation for CAD should be performed annually.

2.1.h. If there is a change in symptoms related to IHD or clinical status (e.g., recurrent hypotension, CHF unresponsive to dry weight changes, or inability to achieve dry weight because of hypotension), evaluation for CAD is recommended.

2.1.i. Dialysis patients with significant reduction in LV systolic function (EF<40%) should be evaluated for CAD.

2.1.j. Evaluation for heart disease should occur at initiation of dialysis and include a baseline electrocardiogram (ECG) and echocardiogram (see Cardiomyopathy guideline for echocardiography after dialysis initiation). Both of these tests provide information pertinent to, but not restricted to, CAD evaluation. Annual ECGs are recommended after dialysis initiation.

2.2. In patients fulfilling 2.1.a--2.1.i above, CAD evaluation should also include exercise or pharmacological stress echocardiographic or nuclear imaging tests. "Automatic" CAD evaluation with stress imaging is currently not recommended for all dialysis patients (i.e., patients not fulfilling 2.1.a--2.1.i). Stress imaging is appropriate (at the discretion of the patient's physician) in selected high-risk dialysis patients for risk stratification even in patients who are not renal transplant candidates. (C)

2.3. Patients who are candidates for coronary interventions and have stress tests that are positive for ischemia should be referred for consideration of angiographic assessment. (C)

2.4. Special considerations in dialysis patients regarding CAD evaluation include the following: (C)

2.4.a. To minimize the risk of potential volume overload from the performance of angiographic studies, iso-osmolar radiocontrast media (e.g., iodixanol) should be used.

2.4.b. Some dialysis patients have residual renal function; there are no data on the value of "nephroprotective" strategies to reduce the potential risk of contrast nephropathy in these patients. The use of N-acetylcysteine (and iodixanol) is appropriate in dialysis patients with residual renal function, as both may offer benefit without known harm. Sodium bicarbonate and hydration are not routinely recommended, as intravascular volume expansion may pose risk to dialysis patients with increased cardiac filling pressures.

2.5. In patients undergoing invasive coronary procedures, it is important to avoid internal jugular sites and to preserve brachial and radial arteries for future dialysis catheter and arteriovenous fistula creation, respectively. (C)

2.6. Patients undergoing planned invasive procedures for evaluation or treatment of CAD should be assessed for hemorrhagic risk and presence of anemia, as anticoagulants and/or antiplatelet agents may be administered adjunctively for percutaneous coronary intervention. (C)

Guideline 3: Acute Coronary Syndromes

The diagnosis of acute coronary syndromes (ACS) in dialysis patients and in the general population is usually based on the triad of symptoms, ECG findings, and cardiac biomarkers. The outcomes of patients on dialysis with ACS are often poor, which may be related to the lack of a consistent and standard approach to the treatment of ACS.

3.1. All dialysis patients presenting with ACS should be treated as in the non-dialysis population, with the exception of specific attention to drugs that have altered clearances in kidney failure (e.g., low molecular weight heparin). These therapies include percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), antiplatelet agents, beta-blockers, thrombolytic therapy, and lipid-lowering agents. (C)

3.1.a. Dialysis patients with ST-segment elevation myocardial infarction (MI) should receive acute reperfusion therapy (as do patients in the non-dialysis population). With the potential for increased hemorrhagic risk associated with thrombolytic therapy, emergent PCI is the preferred treatment if it is available. (C)

3.2. The timing of dialysis in the first 48 hours after ACS should take into account individual risk factors. (C)

Guideline 4: Chronic Coronary Artery Disease

The processes by which atherosclerotic disease may be exacerbated by the uremic milieu, and the outcomes of patients on dialysis with established CAD, are worse than outcomes in the general population.

4.1. The medical management of chronic CAD in dialysis patients should follow that of the general population. In particular, patients should receive acetylsalicylic acid (ASA), beta-blockers, nitroglycerin, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), statins, and/or calcium-channel blockers (CCB) as indicated. Dose adjustments are required for medications that are renally excreted or dialyzed. (C)

4.2. Unique aspects of management in the dialysis population include:

4.2.a. Maintenance of hemodynamic dry weight. (C)

4.2.b. Maintenance of hemoglobin levels in accordance with Kidney Disease Outcomes Quality Initiative Kidney/Disease Outcomes Quality Initiative (K/DOQI) Guidelines (National Kidney Foundation (NKF)-DOQI, 1997). (B)

4.2.c. Modification of dosing regimens so that cardiovascular medications do not adversely impact the delivery of dialysis and ultrafiltration. Nocturnal dosing of medications should be considered (C).

4.2.d. Loop diuretics to increase urine output may be helpful for those patients with substantial residual renal function (C).

4.3. In patients with obstructive CAD lesions, PCI and CABG are appropriate revascularization techniques. (C)

4.3.a. Drug-eluting or conventional stents should be implemented according to local practice. The incidence of restenosis after PCI with drug-eluting stents is reduced in the non-dialysis population. As the risk of restenosis is higher in dialysis patients, the use of drug-eluting stents is favored.

4.3.b. Patients with three-vessel and/or left main disease should undergo CABG as preferred therapy. (C)

Guideline 5: Valvular Heart Disease

The presence of valvular heart disease (VHD) impacts long-term outcomes, as in the general population. In addition, VHD in dialysis patients may impair the ability to adequately deliver dialysis, which, in turn, may limit ultrafiltration and toxin removal, resulting in exacerbation of CVD.

5.1. Evaluation of VHD in dialysis patients:

• 5.1.a. Patients should be evaluated for the presence of VHD and for follow-up of VHD in the same manner as the general population except for frequency of follow-up for aortic stenosis. (C)
• 5.1.b. Special considerations for echocardiographic evaluation in dialysis patients:
  • 5.1.b.i. Dry weight optimization should be achieved prior to testing, to enhance the interpretation of results. (B)
  • 5.1.b.ii. The interpretation of repeat echocardiographic evaluations should be done with consideration of the relationship between the echo exam and either the hemodialysis (HD) treatment or the presence or absence of peritoneal dialysis (PD) fluid in the peritoneal cavity. (B)

5.2. Management of VHD in dialysis patients:

5.2.a. Published recommendations for the management of VHD in the general population should be followed. (C)

5.2.b. Both mechanical and tissue valves can be used for replacement, with similar outcomes, in dialysis patients. (B)

5.2.c. Asymptomatic dialysis patients on the transplant waitlist with moderate or more severe aortic stenosis (aortic valve area <1.0 cm²) should have annual Doppler echocardiograms (as aortic stenosis progresses faster in dialysis patients than general population). The same frequency of follow-up is appropriate in other dialysis patients who would be suitable candidates for aortic valve replacement based on overall clinical status. (C)

5.2.d. Newly or increasingly symptomatic (e.g., displaying dyspnea, angina, fatigue, and unstable intradialytic hemodynamics) patients with VHD should be (re)-evaluated for VHD severity by echocardiography (and referred to a cardiologist for further evaluation if the patient is deemed suitable for intervention on clinical grounds). (C)

5.3. Children with VHD should be evaluated by echocardiography. Management of valvular disease should follow recommendation provided by the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Management of Patients With Valvular Heart Disease VI (Bonow et al., 1998). (C)

Guideline 6: Cardiomyopathy (Systolic or Diastolic Dysfunction)

The prevalence of systolic or diastolic dysfunction, or overt left ventricular hypertrophy (LVH), is estimated to be at least 75% at dialysis initiation (see also Guideline 1). De novo and recurrent heart failure occurs in a substantial proportion of patients on dialysis, and impacts on morbidity and mortality, as well as the ability to deliver adequate dialysis.

6.1. Evaluation of cardiomyopathy (systolic or diastolic dysfunction) in dialysis patients:

6.1.a. Dialysis patients should be evaluated for the presence of cardiomyopathy (systolic or diastolic dysfunction) in the same manner as the general population, using echocardiographic testing. (C)

6.1.b. Patients should be re-evaluated if there is change in clinical status (e.g., symptoms of congestive heart failure (CHF), recurrent hypotension on dialysis, postcardiac events) or considered for kidney transplant. (C)

6.1.c. Echocardiograms should be performed in all patients at the initiation of dialysis, once patients have achieved dry weight (ideally within 1-3 months of dialysis initiation) (A), and at 3-yearly intervals thereafter. (B)

6.1.d. As in the general population, dialysis patients identified with significant reduction in LV systolic function (EF <40%) should be evaluated for CAD (if not done previously). This evaluation may include both noninvasive testing (stress imaging) and invasive testing (coronary angiography). In patients at high risk for CAD (e.g., those with diabetic chronic kidney disease [CKD]), coronary angiography may be appropriate, even in patients with negative stress imaging tests, due to lower diagnostic accuracy of noninvasive stress imaging tests in CKD patients. (C)

6.2. The treatment of cardiomyopathy in the dialysis population is similar to that in the nondialysis population, with the important exception of potential effects of therapeutic agents (e.g., ACE inhibitors or beta-blockers) on intrahemodialytic hemodynamics. (C; B for carvedilol)

6.2.a. Congestive heart failure unresponsive to changes in target dry weight may also be a complication of unsuspected VHD or IHD; clinical re-evaluation should be considered in these patients. (C)

6.2.b. Dosing of therapeutic agents may need to be empirically individualized to hemodialysis schedules (in hypotensive patients). (C)

6.2.c. The consistent maintenance of euvolemia is a cornerstone of treatment of CHF in dialysis patients. (C)

6.3. Target "hemodynamic dry weight" may need to be adjusted to compensate for hemodynamic effects of therapeutic agents. (C)

6.4. Children should be evaluated for the presence of cardiomyopathy (systolic and diastolic dysfunction) using echocardiographic testing. (C)

Guideline 7: Dysrhythmia

Patients on maintenance dialysis are at increased risk for dysrhythmias, cardiac arrest, and sudden cardiac death (SCD). The risk of sudden cardiac death or cardiac arrest increases with age and dialysis duration.

7.1. Evaluation of dialysis patients:

7.1.a. All dialysis patients, regardless of age, should undergo a routine 12-lead ECG at the initiation of dialysis. (C)

7.1.b. Patients with dysrhythmias should be treated in the same manner as the general population with regard to antiarrhythmic agents (including beta-blockers) and pacing devices (including internal defibrillators). Refer to Table 5 in the original guideline document for dosage adjustments and drugs to be avoided. (C)

Guideline 8: External Defibrillation

The capability for effective, rapid defibrillation (with negligible risk of inappropriate treatment) is widely available with the development of automatic external defibrillators (AEDs). Given the high prevalence of dysrhythmias (see Guideline 7), the availability of AEDs in dialysis facilities may impact the outcomes of patients who experience cardiac events during dialysis therapy.

8.1. All dialysis units should have on-site capability for external cardiac defibrillation. Automatic external defibrillators are the simplest, most cost-effective means to achieving this guideline, as they do not require advanced life support training by staff for operation, require minimal maintenance, and are designed for use by nonmedical personnel. (A)

8.1.a. Basic life support (CPR) training for dialysis unit staff is recommended as an enhancement to the effectiveness of AEDs, as it includes instruction in use of AEDs, airway and circulatory support during cardiorespiratory arrest, and management of noncardiac emergencies (such as choking). (B)

8.1.b. Non-automatic defibrillators are also appropriate devices for providing on-site defibrillator capability, but they require more maintenance and operators certified in advanced cardiac life support (ACLS). (B)

8.1.c. All dialysis units caring for pediatric patients need to have on-site external automatic defibrillators and/or appropriate pediatric equipment available. Automated external defibrillators may be used for children 1 to 8 years of age, and should ideally deliver pediatric doses and have an arrhythmia detection algorithm (Cecchin et al., 2001; Atkins, Hartley, & York, 1998; Samson, Berg, & Bingham, 2003). (C)

8.1.d. The goal should be the availability of AEDs in all dialysis units within 12 months of the publication of these Guidelines. (C)

Guideline 9: Cerebrovascular Disease

Stroke is the third leading cause of death in the general population in the U.S. and many other countries, with large economic and human burdens as a consequence. Patients with CKD are at increased risk for stroke relative to the general population.

9.1. All dialysis patients should follow the AHA Guidelines for the prevention, screening and evaluation, and treatment of stroke. A summary of the AHA guidelines with any caveats related to dialysis patients is shown in the table below. (C)

9.2. Special considerations in dialysis patients include:

9.2.a. Anticoagulation in nonvalvular atrial fibrillation: Dialysis patients are at increased risk for bleeding and careful monitoring should accompany intervention. (C)

9.2.b. Acute stroke in dialysis patients: Given that acute stroke syndromes can be due to either thrombotic or bleeding events in dialysis patients, the immediate goal of localization and cause is particularly important in dialysis patients because of increased risk of bleeding associated with anticoagulants in this population. Therefore, imaging with established methods should be undertaken. (C)

9.3. Treatment of stroke and transient ischemic attack (TIA):

• 9.3.a. Treatment of TIAs and strokes should follow the same principles used in the general population for both medical management and surgical management, with the exception of thrombolytics in HD patients. (C)
  • 9.3.a.i. Assessment of the risk of bleeding in patients recently receiving heparin on dialysis should be conducted when considering the use of thrombolytics. (B)

Table: AHA Guidelines for the Prevention, Screening and Evaluation, and Treatment of Stroke, with K/DOQI Modifications

Guideline 10: Peripheral Vascular Disease

Both diabetic and nondiabetic dialysis patients are at risk for PVD, with approximately 15% of incident patients having a clinical diagnosis of PVD.

10.1. Diagnosis of PVD:

10.1.a. At the time of dialysis initiation, all patients should be evaluated for the presence of PVD. (C)

10.1.b. Evaluation should include physical examination including assessment of arterial pulse and skin integrity. (C)

10.1.c. Further specialized studies, such as duplex studies or invasive testing, should be undertaken if abnormalities are detected upon physical examination and interventions are considered. (C)

10.2. Approach to therapy of PVD: (C)

10.2.a. Patients with PVD should be treated in the same manner as the general population in regard to smoking cessation, lipid-lowering therapy, glycemic control, blood pressure control, and the use of ACE inhibitors and antiplatelet agents. In addition, supervised exercise regimens and medications to increase vasodilation should be considered in patients with claudication and without critical leg ischemia. Established national guidelines, similar to those for stroke, are not available for PVD in the general population.

Section II: Guidelines on Management of Cardiovascular Risk Factors

Guideline 11: Diabetes

11.1. All dialysis patients who have diabetes should follow the American Diabetes Association guidelines ("Standards of Medical Care in Diabetes," 2004; Franz et al., 2003). (C).

Guideline 12: Blood Pressure

The management of blood pressure is an important component of CVD risk management for all aspects of CVD: CAD, cardiomyopathy, VHD, CBVD, and PVD. There are unique challenges in both the measurement and management of blood pressure in dialysis patients.

12.1. Measurement of blood pressure:

12.1.a. In patients who have undergone multiple surgical procedures for vascular accesses in both arms, blood pressure should be measured in the thighs or legs. However, health-care professionals should use appropriate cuff size and measure blood pressure only in the supine position. (B)

12.2. Predialysis and postdialysis blood pressure goals should be <140/90 mm Hg and<130/80mmHg, respectively. (C)

12.3. Management of blood pressure by adjustment of dry weight:

• 12.3.a. Management of hypertension in dialysis patients requires attention to both management of fluid status and adjustment of antihypertensive medications. This requires close collaboration among health-care providers. (B) Excessive fluid accumulation between dialysis sessions should be managed with: (B)
  • Education and regular counseling by dietitians
  • Low sodium intake (2-3 g/day sodium intake)
  • Increased ultrafiltration
  • Longer dialysis
  • More than 3 dialysis treatments per week
  • Drugs that reduce salt appetite

12.4. Management of hypertension with drugs in dialysis patients:

12.4.a. Drugs that inhibit the renin-angiotensin system, such as ACE inhibitors or angiotensin II-receptor blockers should be preferred because they cause greater regression of left ventricular hypertrophy (LVH), reduce sympathetic nerve activity, reduce pulse wave velocity, may improve endothelial function, and may reduce oxidative stress. (C)

12.4.b. Antihypertensive drugs should be given preferentially at night, because it may reduce the nocturnal surge of blood pressure and minimize intradialytic hypotension, which may occur when drugs are taken the morning before a dialysis session. (C)

12.4.c. In patients with difficult-to-control hypertension, the dialyzability of antihypertensive medications should be considered (see Table 10 in the original guideline document). (C)

12.5. Determination and management of blood pressure in children should follow recommendations by The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents ("The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents," 2004). (C)

• 12.5.a. Optimal systolic and diastolic blood pressure should be <95% for age, gender and height. (B)
• 12.5.b. Management of hypertension on dialysis requires attention to fluid status and antihypertensive medications, minimizing intradialytic fluid accumulation by (C):
  • Education by dietitians every 3 months
  • Low salt intake (2 g/day sodium intake)
  • Increased ultrafiltration
  • Longer dialysis duration
  • Intradialytic sodium modeling to minimize intradialytic hypotension
  • More than 3 dialysis treatments per week
  • Antihypertensives: consider if medications are cleared on dialysis.

Guideline 13: Dyslipidemia

Since the NKF K/DOQI Clinical Practice Guidelines for Managing Dyslipidemia in Chronic Kidney Disease Patients were established only recently (K/DOQI, 2003), the Work Group refers the reader to those guidelines. However, the Work Group adds the information on four recent studies that provide some new insights on the inverse association between cholesterol level and mortality, as well as further indirect evidence of the beneficial effects of lipid-lowering therapy. Furthermore, unpublished results of the recently completed "4D Trial" on the effect of statins in chronic HD patients recently became available and will be discussed.

Management of dyslipidemias for prepubertal children with CKD and CKD Stage 5 should follow recommendations by National Cholesterol Expert Panel in Children and Adolescents. Postpubertal children or adolescents with CKD Stages 4 and 5 should follow the recommendations provided in the K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease (K/DOQI, 2003).

Guideline 14: Smoking, Physical Activity, and Psychological Factors

While there are few data specific to CVD in dialysis patients regarding smoking, physical activity, and psychological factors (depression, anxiety, and hostility), the evidence in the general population is clearly in favor of addressing each of these issues. In order to ensure that clinicians caring for dialysis patients do not overlook the importance of each of these factors, the Work Group has dedicated an entire guideline to them.

14.1. All dialysis patients should be counseled and regularly encouraged to stop smoking. (A) Referral to smoking cessation specialists is recommended. (C)

14.1.a. Special consideration should be given to cessation of smoking in depressed individuals with little ability to engage in physical activity. (C)

14.2. All dialysis patients should be counseled and regularly encouraged by nephrology and dialysis staff to increase their level of physical activity. (B)

14.2.a. Unique challenges to exercise in dialysis patients need to be identified in order to refer patients appropriately (e.g., to physical therapy or cardiac rehabilitation) and to enable the patients to follow regimens successfully. Such challenges include orthopedic/musculoskeletal limitations, cardiovascular concerns, and motivational issues. (C)

14.3. Measurement of physical functioning:

14.3.a. Evaluation of physical functioning and re-evaluation of the physical activity program should be done at least every 6 months. (C)

14.3.b. Physical functioning can be measured using physical performance testing or questionnaires (e.g., SF-36). (C)

14.3.c. Potential barriers to participation in physical activity should be assessed in every patient. (C)

14.4. Physical activity recommendations:

• 14.4.a. Many dialysis patients are severely deconditioned and therefore may need a referral for physical therapy to increase strength and endurance to the point where they are able to adopt the recommended levels of physical activity.
  • 14.4.a.i. Patients who qualify for cardiac rehabilitation should be referred to a specialist. (C)
  • 14.4.a.ii. The goal for activity should be for cardiovascular exercise at a moderate intensity for 30 minutes most, if not all, days per week. Patients who are not currently physically active should start at very low levels and durations, and gradually progress to this recommended level. (C)
• 14.4.b. Follow-up:
  • 14.4.b.i. Physical functioning assessment and encouragement for participation in physical activity should be part of the routine patient care plan. Regular review should include assessment of changes in activity and physical functioning. (C)

14.5. Depression, anxiety, and hostility should be identified and treated in dialysis patients. (B)

14.5.a. Every dialysis patient should be seen by the dialysis social worker at initiation of dialysis, and at least biannually thereafter, to assess the patient's psychological state, with specific focus on the presence of depression, anxiety, and hostility. (C)

14.5.b. Dialysis patients should be treated for depression, anxiety, and hostility if they are experiencing these psychological states. (C)

Guideline 15: Anemia

The impact of anemia on CVD (specifically, LVH) and exacerbation of CAD is well described in the dialysis population. Given the prevalence of anemia in the dialysis population, and its association with poor outcomes, anemia is considered a "uremic-specific" CVD risk factor.

15.1. All dialysis patients with anemia should follow the K/DOQI Guidelines for Treatment of Anemia (NKF-DOQI, 1997).

Guideline 16: Arterial Stiffness, Vascular and Valvular Calcification, Calcium, Phosphorus and Parathyroid Hormone

The role of abnormalities of calcium, phosphorus, and parathyroid hormone (PTH) in contributing to arteriosclerosis, subsequent arterial stiffness, calcification, and cardiac valve calcification is an area of intense research. The importance of these parameters to CVD outcomes and the biological plausibility of these variables in CVD processes require attention to them as "uremia-related" risk factors.

16.1. All dialysis patients should have pulse pressure (PP) determined monthly before dialysis.

16.1.a. For PP >60 mm Hg and systolic blood pressure >135 mm Hg, it is recommended that PP be reduced by achieving ideal body weight and the use of antihypertensive medication with the target PP being 40 mm Hg. (B)

16.2. Identification and treatment of calcification:

16.2.a. If arterial calcification is identified by plain radiography in any of the following sites (abdominal aorta, carotid arteries, ileo-femoral axis or femoropopliteal axis), identification of calcification at another site should be sought. (C)

16.2.b. If vascular calcification is present in two or more sites, consideration should be given to prescription of a non-calcium-containing phosphate binder. (B)

16.3. All dialysis patients should follow current K/DOQI Guidelines for treatment of calcium, phosphate, and PTH ("K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease," 2003).

• 16.3.a. Serum phosphorus should be maintained between 3.5 and 5.5 mg/dL (1.13 to 1.78 mmol/L). (B)
• 16.3.b. PTH should be measured every 3 months using an intact PTH assay (first-generation immunoradiometric assay). (C)
  • 16.3.b.i. For prevention of CVD, the target PTH value should be between 150 and 300 pg/mL (16.5 to 33.0 pmol/L). (B)
  • 16.3.b.ii. Treatment strategies for PTH values <150 pg/mL (16.5 pmol/L) and >300 pg/mL (33.0 pmol/L) should be developed according to the K/DOQI Bone Disease Guidelines ("K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease," 2003). (B)

Section III: State of the Science: Novel and Controversial Topics in Cardiovascular Diseases

Please refer to the original guideline document for discussions on intradialytic hypotension, biomarkers, nutritional and metabolic factors, risk stratification, menopause, preventive foot care in diabetes, and aspirin use.

Definitions:

Recommendation Grades

Grade A: It is strongly recommended that clinicians routinely follow the guideline for eligible patients. There is strong evidence that the practice improves health outcomes.

Grade B: It is recommended that clinicians routinely follow the guideline for eligible patients. There is moderately strong evidence that the practice improves health outcomes.

Grade C: It is recommended that clinicians consider following the guideline for eligible patients. This recommendation is based on either weak evidence or on the opinions of the Work Group and reviewers, that the practice might improve health outcomes.

Note: Health outcomes are health-related events, conditions, or symptoms that can be perceived by individuals to have an important effect on their lives. Improving health outcomes implies that benefits outweigh any adverse effects.

Strength of Evidence

Strong: Evidence includes results from well-designed, well-conducted study/studies in the target population that directly assess effects on health outcomes.

Moderately strong: Evidence is sufficient to determine effects on health outcomes in the target population, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; OR evidence is from a population other than the target population, but from well-designed, well-conducted studies; OR evidence is from studies with some problems in design and/or analysis; OR evidence is from well-designed, well-conducted studies on surrogate endpoints for efficacy and/or safety in the target population.

Weak: Evidence is insufficient to assess the effects on net health outcomes because it is from studies with some problems in design and/or analysis on surrogate endpoints for efficacy and/or safety in the target population; OR the evidence is only for surrogate measures in a population other than the target population; OR the evidence is from studies that are poorly designed and/or analyzed.

The strength of evidence for a group of studies was graded using a rating system that takes into account:

1. Methodological quality of the studies
2. Target population (patients on dialysis or other populations)
3. Study outcomes (health outcomes or surrogate measures for those outcomes)

(See table 42 in the original guideline document).

A clinical algorithm is provided in the original guideline document for the treatment of hypertension in dialysis patients.

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

For each guideline, the recommended action (guideline statement) for the management of cardiovascular disease (CVD) is first described, with the strength of recommendation (A, B, or C, with A being the strongest) provided for each statement. This is followed by the synopsis of a comprehensive review of literature on that particular topic, with the primary focus on the literature that is specific to the dialysis patients. This review provides the rationale for the guideline statement and the strength of recommendation. The strength of evidence (strong, moderately strong, or weak) of the rationale is provided within this section.

Not applicable: The guideline was not adapted from another source.

2005 Apr

National Kidney Foundation - Disease Specific Society

National Kidney Foundation (NKF)

NKF-K/DOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) Cardiovascular Disease in Dialysis Patients Work Group

Members: Alfred K. Cheung, MD (Co-Chair) University of Utah, Salt Lake City, UT; William L. Henrich, MD (Co-Chair) University of Maryland School of Medicine, Baltimore, MD; Srinivasan Beddhu, MD, University of Utah, Salt Lake City, UT; Vito Campese, MD, USC/Keck School of Medicine, Los Angeles, CA; Blanche M. Chavers, MD, University of Minnesota, Minneapolis, MN; David Churchill, MD, St. Joseph's Hospital/McMaster University, Ontario, Canada; D. Jordi Goldstein, D.Sc, RD, University of Nevada Reno, Reno, NV; Charles Herzog, MD, Hennepin County Medical Center, Minneapolis, MN; Karren King, MSW,ACSW, LCSW, Kansas City, MO; Florian Kronenberg, MD, Innsbruck Medical University, Innsbruck, Austria; B. Sandra Miholics, RN, CNN, Gambro Health Care, Inc., Neshanic Station, NJ; Patricia Painter, PhD, University of California San Francisco, San Francisco, CA; Rulan Parekh, MD, Johns Hopkins Hospital, Baltimore, MD; Mark Roberts, MD, MPP, University of Pittsburgh School of Medicine, Pittsburgh, PA; Catherine Stehman-Breen, MD, Amgen, Thousand Oaks, CA; Peter Stenvinkel, MD, Karolinska University Hospital at Huddinge, Stockholm, Sweden; RavinderWali, MD, University of Maryland School of Medicine, Baltimore, MD; MiriamWeiss, MD, University Hospitals of Cleveland, Cleveland, OH

Liaison Member: Kline Bolton, MD (RPA), University of Virginia Hospital, Charlottesville, VA

The National Kidney Foundation makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the working group.

Specifically, all members of the working group are required to complete, submit, and sign a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. All affiliations are published in their entirety at the end of the original guideline document in the Work Group Biographies section.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on June 2, 2005. This summary was updated by ECRI on March 6, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin sodium). This summary was updated by ECRI Institute on July 12, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Troponin-1 Immunoassay. This summary was updated by ECRI Institute on September 7, 2007 following the revised U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin).

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