The treatment of patients with cardiovascular disease (CVD) on dialysis remains suboptimal due to the lack of evidence of treatment efficacy, exclusion of this population from most major cardiovascular trials, and an attitude of therapeutic nihilism on the part of clinicians towards this population.
These guidelines are organized to facilitate the evaluation, identification, and treatment of patients on dialysis with CVD, recognizing that all patients on dialysis are at increased risk for CVD. They are designed for use by cardiologists, nephrologists, primary-care physicians, and nurse practitioners. CVD in these guidelines is defined as coronary artery disease (CAD), cardiomyopathy, valvular heart disease, arrhythmia, cerebrovascular disease (CBVD), or peripheral vascular disease (PVD). Some or all of these entities may co-exist in the same individual, or develop sequentially over time.
The intention of this Work Group was not to rewrite existing guidelines or textbooks of cardiovascular medicine. Instead, we have attempted to highlight those aspects of CVD care that are different or have been construed to be different in dialysis patients compared to the general population, either as a consequence of the kidney disease or the dialysis procedure.
For each guideline, the recommended action (guideline statement) for the management of 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. The final section on research recommendations in each guideline attempts to define those questions that the Work Group believes need to be answered in order to improve the care of patients on dialysis, and in order to update these guidelines in the next 3-5 years based on new data.
In addition to the guidelines, there are a number of topics that the Work Group felt were important, but the available data do not support the establishment of specific guidelines. For these topics, comprehensive literature reviews were performed and individual summaries are presented as state-of-the-science chapters in the second part of this document.