The assessment and treatment of both risk factors and end organs are essential in the management of cardiovascular diseases. The first section will deal with the end organs and will focus on cardiac, cerebrovascular and peripheral vascular diseases. Cardiac diseases have justifiably received the most attention because they are by far the most common cause of cardiovascular deaths in dialysis patients. Cerebrovascular diseases and peripheral vascular diseases, however, also lead to substantial morbidity and mortality and have often been overlooked by practitioners and clinical researchers.
The workgroup has faced dilemma in the scope and depth of the coverage of end organ diseases. There has been only one small randomized trial that demonstrated beneficial effects of specific cardioprotective drugs (namely, carvedilol) published in dialysis patients. Therefore, most guidelines described in this section are referred from published guidelines in the general population. Nonetheless, there are unusual features in the dialysis patients that the practitioners need to be aware of. For example, the pathophysiology and rate of progression of cardiac valvular calcification appear to be different from those in the general population. Surveillance and treatment strategies should take these caveats into consideration. On the other hand, the implant of tissue valves is proscribed in the existing ACC/AHA guidelines. More recent and stronger evidence, however, suggest that tissue valves are associated with equivalent outcomes in dialysis patients. These similarities, not only differences, between dialysis patients and the general population also need to be emphasized.
The section on end organ diseases is written for not only the nephrologists, but also the general practitioners, cardiologists, vascular surgeons and other practitioners.
Guideline 1: Evaluation of Cardiovascular Disease in Adult and Pediatric Patients
Cardiovascular disease 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 noncardiac comorbidity, evaluation and therapy should be individualized.
1.1 At the initiation of dialysis, all patients—regardless of symptoms—require assessment for cardiovascular disease (CAD, cardiomyopathy, valvular heart disease, CBVD, and 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 1–3 months of dialysis initiation) (A), and at 3-yearly intervals thereafter (see Guideline 6). (B)
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)
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