Cardiovascular Disease

GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASE IN DIALYSIS PATIENTS
GUIDELINES FOR THE MANAGEMENT OF

CARDIOVASCULAR DISEASE
IN DIALYSIS PATIENTS
© 2017
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FOREWORD
T he Kenya Renal Association (KRA) is pleased to present this first edition

of the Management of Cardiovascular Disease in dialysis guidelines. It
provides the user with a road map to appropriate interventions that may be
needed when managing dialysis dependent patients presenting with various
cardiovascular conditions.
In coming up with these guidelines, various international guidelines, articles

in peer reviewed journals, nephrology texts as well as expert opinions were
reviewed. The guideline development process involved extensive research
and discussion by a guideline development working group of all aspects of
the subject matter before arriving at consensus recommendations. These
recommendations were then shared electronically with nephrologists
countrywide; their input was then considered and adapted if found appropriate.
The final document was then prepared.
These guidelines are deliberately simplified to make them easy to use. They
are by no means exhaustive and the user must not hesitate to ask for help
or consult more detailed cardiology or nephrology texts if they encounter
situations not envisioned or well captured in these guidelines. These guidelines
will be reviewed periodically as and when significant changes to best practice
recommendations occur.
I believe that these guidelines will prove educative and practical to the user and
help improve the quality of care offered to the dialysis patient.
Prof. S. O. McLigeyo
Chairman
Kenya Renal Association
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ACKNOWLEDGEMENT
M any individuals and institutions contributed their time, effort and resources
to make the publication of these guidelines possible. These include the
following.
1. From the Kenya Renal Association: Prof. Seth O. McLigeyo, Dr. Ahmed
Twahir, Prof. Joshua Kayima, Dr. Doris Kinuthia, Dr. John Ngigi, Dr. Benjamin
Wambugu, Dr. Ahmed Sokwala, Dr. Jonathan Wala, Dr. George Moturi, Dr.
Patrick Mbugua, Dr. Hussein Bagha.
2. From the East Africa Kidney Institute: Dr. Anthony J. O. Were, Dr. Peter
Koech, Dr. John Mutiso, Dr. Beatrice W. Ndege, Dr. Samuel Kabinga, Dr.
James Kahura, Dr. Caroline Mwololo, Dr. David Ndonye, Dr. Edward Njogu.
3. From Kenyatta National Hospital: Ms. Beatrice Mugo, Ms. Diviner Nyarera,
Ms. Matroba Obunaka, Ms. Ms. Nancy Wagombe, Mr. Charles Mwangi.
4. Special appreciation to Dr. Ahmed Twahir (nephrologist) and Dr. Samuel

Kabinga (nephrology fellow) who contributed substantially to the
actualization of these guidelines.
5. The printing of these guidelines is done with the generous support of

Angelica medical supplies limited.
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TABLE OF CONTENTS
FOREWORD: KENYA RENAL ASSOCIATION ......................................... 3
Acknowledgement .................................................................................. 4
Abbreviations and acronyms ................................................................... 6
Definition of terms ................................................................................... 6
Introduction ............................................................................................. 7
Cardiovascular disease risk reduction .................................................... 7
Acute coronary events ............................................................................ 8
Left ventricular hypertrophy (LVH) and congestive heart failure (CHF) .... 8
CKD and peripheral artery disease ......................................................... 9
REFERENCES ......................................................................................... 11
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ABBREVIATIONS AND ACRONYMS
ABI : Ankle-brachial index

ACE : Angiotensin converting enzyme
ACLS : Advanced cardiac life support
ARB : Angiotensin receptor blockers
CCB : Calcium channel blockers
CHF : Congestive heart failure
CKD : Chronic kidney disease
CK-MB : Creatine kinase isoenyme MB
CVD : Cardiovascular Disease
DM : Diabetes mellitus
ECG : Electrocardiogram
HbA1C : Haemoglobin A1c
HD : Haemodialysis
LDH : Lactate dehydrogenase
LVH : Left ventricular hypertrophy
MI : Myocardial infarction
PAOD : Peripheral arterial occlusive disease
Definition of terms
Intermittent Claudication Pain during physical activity, which is reproducible
within the same muscle groups and ceases with
resting.
Ankle brachial index (ABI) The ratio of systolic blood pressure at the ankle
to that in the arm (normal range is 0.9-1.1; <0.9
suggests PAOD).
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INTRODUCTION
T he burden of cardiovascular disease (CVD) in chronic kidney disease (CKD)

is very high in the haemodialysis (HD) population. The commonest CVDs
seen in HD patients include: -
− Ischaemic heart disease
− Ischaemic stroke
− Left ventricular hypertrophy (LVH)
− Congestive heart failure (CHF)
− Peripheral arterial disease (PAD)
Non-traditional CVD risk factors in HD patients include: - volume overload,
anaemia, mineral bone disorder, inflammation, oxidative stress.
People with CKD have a higher risk of recurrent myocardial infarction (MI),
congestive heart failure (CHF) and sudden cardiac death. Optimal management
of modifiable cardiovascular risk factors, such as hypertension and diabetes
mellitus (DM) reduces morbidity and mortality.
Cardiovascular disease risk reduction

Risk reduction strategies in patients on dialysis is the same as in the general
population. These strategies include: -
− Cessation of cigarette smoking
− Engaging in regular physical exercises
− Weight reduction to optimal targets
− Reduction of fat intake
− Ensuring optimal diabetes control to HbA1C <7%
− Ensuring optimal blood pressure control to <140/90 mmHg
− Using antiplatelet agents for secondary prevention of ischemic events
− Correction of anemia to individualized targets
− Using statin therapy where recommended (for patients already on statin
therapy at the time of starting dialysis, it is suggested that these agents be
continued. However, starting statins is not recommended in statin - naïve
dialysis patients).
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Acute coronary events

− It is recommended that any suspected acute coronary event be evaluated
with a 12 - lead electrocardiogram (ECG) and cardiac enzymes (CK-MB,
troponin T/I or lactate dehydrogenase (LDH)).
− It is recommended that dialysis unit staff be conversant with advanced
cardiac life support (ACLS).
− It is recommended that acute coronary events be managed as per ACLS
guidelines.
Left ventricular hypertrophy (LVH) and congestive heart

failure (CHF)
Left ventricular hypertrophy (LVH) is associated with increases in the incidence
of heart failure, ventricular arrhythmias, death following myocardial infarction,
decreased left ventricular ejection fraction, sudden cardiac death, aortic
root dilation and cerebrovascular events. Left ventricular hypertrophy has a
prevalence of approximately 40% in patients with chronic renal insufficiency and
rises to about 75% by the time one progresses to ESRD. It may be diagnosed
using electrocardiography (ECG) and echocardiography.
Risk factors include: -
− Old age
− Arteriovenous connections
− Diabetes mellitus
− Anaemia
− Abnormally stiff arteries
− Hypertension
− Extracellular fluid volume expansion
− Uremic internal milieu
− Abnormalities of calcium phosphate homeostasis
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Management of the modifiable risk factors may retard the development and
progression of LVH. Drug classes that have been shown to be associated with
LVH regression (and concomitant risk reduction) include: -
− Angiotensin receptor blockers (ARB)
− Angiotensin converting enzyme (ACE) inhibitors
− Some calcium channel blockers (CCB) (including diltiazem, verapamil,
amlodipine)
These agents should thus be borne in mind when making drug choices for BP
control. Special caution needs to be taken to avoid hyperkalemia when using
ARBs and ACEIs.
It is advised that Specialist consultation be sought when managing these
patients.
CKD and peripheral artery disease

It is recommended that adults with CKD be regularly examined for signs of
peripheral arterial occlusive disease (PAOD). Intermittent claudication is
the typical presentation of PAOD. It is suggested that adults with CKD and
diabetes undergo regular foot assessment. A useful tool in assessing a patient
with claudication is the ankle-brachial index (ABI). It is a non - invasive way of
establishing the presence of PAOD and is calculated as the ratio of systolic
blood pressure at the ankle to that in the arm (normal range, 0.9-1.1; PAOD,
<0.9). Example: If systolic blood pressure at the right ankle is 140 mmHg, and
that at the right arm is 130, ABI is 140mmHg/130mmHg = 1.077.
The risk factors for PAOD include: -
− Diabetes mellitus
− Hypertension
− Hyperlipidemia
− Family history of PAOD
− Sedentary lifestyle
− Tobacco use
− Chronic kidney disease
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Management of these conditions is important in preventing progression

of PAOD. The medical management for PAOD should include Antiplatelet
agents (e.g., aspirin, clopidogrel). Management of dyslipidemia using statins
is important in selected individuals. Revascularization procedures may also
be needed. It is recommended that Specialist consultation be sought when
managing these patients.
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REFERENCES
1. KDIGO 2012 Clinical Practice Guideline for the Evaluation and

Management of Chronic Kidney Disease. Kidney International,
January 2013. 3(1).
2. Go, A.S., et al., Chronic kidney disease and the risks of death,
cardiovascular events, and hospitalization. N Engl J Med, 2004. 351:
p. 1296-1305.
3. Anavekar, N.S., et al., Relation between renal dysfunction and
cardiovascular outcomes after myocardial infarction. N Engl J Med,
2004. 351: p. 1285-1295.
4. Ibsen, H., et al., Albuminuria and cardiovascular risk in hypertensive
patients with left ventricular hypertrophy: the LIFE Study. Kidney Int
Suppl, 2004. 92: p. s56-58.
5. Shlipak, M.G., et al., Cardiovascular mortality risk in chronic kidney
disease: comparison of traditional and novel risk factors. JAMA,
2005. 293: p. 1737-1745.
6. Eckardt, K.U., et al., Left ventricular geometry predicts cardiovascular
outcomes associated with anemia correction in CKD. J Am Soc
Nephrol, 2009. 20: p. 2651-2660.
7. Halimi, J.M., et al., Effects of current smoking and smoking
discontinuation on renal function and proteinuria in the general
population. Kidney International, 2000. 58: p. 1285-1292.
8. Boyce, M.L., et al., Exercise training by individuals with predialysis
renal failure:
cardiorespiratory endurance, hypertension, and renal function. Am
J Kidney Dis, 1997. 30: p. 180-192.
9. Navaneethan, S.D., et al., Weight loss interventions in chronic
kidney disease: a systematic review and meta-analysis. Clin J Am
Soc Nephrol, 2009. 4: p. 1565-1574.
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10. Baigent, C., et al., The effects of lowering LDL cholesterol with
simvastatin plus ezetimibe in patients with chronic kidney disease
(Study of Heart and Renal Protection): a randomised placebo-
controlled trial. Lancet 2011. 377: p. 2181-2192.
11. Jardine, M.J., et al., Aspirin is beneficial in hypertensive patients
with chronic kidney disease: a post-hoc subgroup analysis of a
randomized controlled trial. J Am Coll Cardiol, 2010. 56: p. 956-965.
12. KDIGO Anemia Work Group, KDIGO clinical practice guideline
for anemia in chronic kidney disease. Kidney International, 2012.
2(suppl): p. 279-335.
13. McAlister, F.A., et al., Renal insufficiency and heart failure: prognostic
and therapeutic implications from a prospective cohort study.
Circulation, 2004. 109: p. 1004-1009.
14. Smith, G.L., et al., Renal impairment and outcomes in heart failure:
systematic review and meta-analysis. J Am Coll Cardiol, 2006. 47:
p. 1987-1996.
15. Indian Society of Nephrology.(2012) ‘Guidelines for haemodialysis
units’, Indian journal of nephrology, 22(Supplement)
16. Beciani, M., et al., Cardiac troponin I (2nd generation assay) in
chronic haemodialysis patients: prevalence and prognostic value.
Nephrol Dial Transplant, 2003. 18: p. 942946.
17. Ix, J.H. and M.H. Criqui, Epidemiology and diagnosis of peripheral
arterial disease in patients with chronic kidney disease. Adv Chronic
Kidney Dis, 2008. 15: p. 378-383.
18. Lau, J.F., M.D. Weinberg, and J.W. Olin, Peripheral artery disease.
Part 1: clinical evaluation and noninvasive diagnosis. Nat Rev
Cardiol, 2011. 8: p. 405-418.
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GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASE IN DIALYSIS PATIENTS

GUIDELINES FOR THE MANAGEMENT OF

T he Kenya Renal Association (KRA) is pleased to present this first edition

In coming up with these guidelines, various international guidelines, articles

4. Special appreciation to Dr. Ahmed Twahir (nephrologist) and Dr. Samuel

5. The printing of these guidelines is done with the generous support of

FOREWORD: KENYA RENAL ASSOCIATION ......................................... 3

Abbreviations and acronyms ................................................................... 6

Definition of terms ................................................................................... 6

Cardiovascular disease risk reduction .................................................... 7

Acute coronary events ............................................................................ 8

CKD and peripheral artery disease ......................................................... 9

ABBREVIATIONS AND ACRONYMS

ABI : Ankle-brachial index

T he burden of cardiovascular disease (CVD) in chronic kidney disease (CKD)

Cardiovascular disease risk reduction

Acute coronary events

Left ventricular hypertrophy (LVH) and congestive heart

Risk factors include: -

CKD and peripheral artery disease

Management of these conditions is important in preventing progression

1. KDIGO 2012 Clinical Practice Guideline for the Evaluation and

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