Managing Heart Failure in Patients on Dialysis: State-of-the-Art Review

Heart failure (HF) and end-stage kidney disease (ESKD) frequently co-exist with one comorbidity worsening the prognosis of the other. HF is responsible for almost half the deaths in patients on dialysis. Despite patients with ESKD comprising an extremely high-risk population, they have mainly been excluded from landmark clinical trials of HF and there is thus a paucity of data regarding the management of HF in patients on dialysis and most of the available evidence is observational. Likewise, in clinical practice, guideline-directed medical therapy (GDMT) for HF is often down-titrated and discontinued in patients ESKD undergoing dialysis due to safety and tolerability concerns. In this state-of-the-art review, we discuss the available evidence for each of the foundational HF therapies in ESKD, review current challenges and barriers to managing patients with HF on dialysis, and outline future directions to optimize the management of HF in these high-risk patients.