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## Complete Summary

#### GUIDELINE TITLE

K/DOQI clinical practice guidelines for cardiovascular disease in
dialysis patients.

#### BIBLIOGRAPHIC SOURCE(S)

National Kidney Foundation. K/DOQI clinical practice guidelines for
cardiovascular disease in dialysis patients. Am J Kidney Dis 2005
Apr;45(3 Pt 2):16-153. \[736 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15806502)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s)/intervention(s) for which important revised
regulatory and/or warning information has been released.

-   [August 16, 2007, Coumadin
    (Warfarin)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Warfarin):
    Updates to the labeling for Coumadin to include pharmacogenomics
    information to explain that people\'s genetic makeup may influence
    how they respond to the drug.

-   [June 8, 2007, Troponin-I
    Immunoassay](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Architect):
    Class I Recall of all lots of the Architect Stat Troponin-I
    Immunoassay. The assay may report falsely elevated or falsely
    decreased results at and near a low level, which may impact patient
    treatment.

-   [October 6, 2006, Coumadin (warfarin
    sodium)](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Coumadin):
    Revisions to the labeling for Coumadin to include a new patient
    Medication Guide as well as a reorganization and highlighting of the
    current safety information to better inform providers and patients.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Cardiovascular disease (CVD) including:

    -   Coronary artery disease (CAD)

    -   Cardiomyopathy

    -   Valvular heart disease (VHD)

    -   Arrhythmia

    -   Cerebrovascular disease (CBVD)

    -   Peripheral vascular disease (PVD)

-   Chronic kidney disease (CKD) requiring dialysis

#### GUIDELINE CATEGORY

Evaluation\
Management\
Risk Assessment\
Screening\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Nephrology\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To facilitate the evaluation, identification, and treatment of
    patients on dialysis with cardiovascular disease (CVD), recognizing
    that all patients on dialysis are at increased risk for
    cardiovascular disease

-   To highlight those aspects of cardiovascular 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

#### TARGET POPULATION

Adult and pediatric patients with chronic kidney disease Stage 5
requiring renal replacement therapy/dialysis with or at risk for
cardiovascular disease

#### INTERVENTIONS AND PRACTICES CONSIDERED

**[Diagnosis/Evaluation]{.underline}**

Initial and on-going assessment for cardiovascular diseases and
screening for traditional and nontraditional risk factors

1.  Assessment of signs and symptoms, including assessment of arterial
    pulse and skin integrity in peripheral vascular disease (PVD)

2.  Echocardiography, including exercise or pharmacological stress
    echocardiogram

3.  Electrocardiography

4.  Nuclear imaging tests

5.  Assessment for hemorrhagic risk and presence of anemia

6.  Duplex testing for PVD

7.  Blood pressure evaluation

8.  Measurement of physical functioning

    -   Performance testing or questionnaire

    -   Assessment of potential barriers to performance in physical
        activity

9.  Assessment of psychological state with focus on depression, anxiety,
    or hostility

10. Determination of pulse pressure

11. Radiography

12. Intact parathyroid hormone assay

13. Special considerations in dialysis patients

    -   Coronary artery disease (CAD): Use of iso-osmolar radiocontrast
        media (iodixanol) with or without *N*-acetylcysteine in
        angiographic studies

    -   Valvular heart disease (VHD): optimization of dry weight prior
        to testing and consideration of relationship between echo exam
        and hemodialysis treatment or presence/absence of peritoneal
        dialysis fluid when interpreting evaluations.

**[Management/Treatment]{.underline}**

**Cardiovascular Diseases**

*Acute Coronary Syndromes (ACS)*

1.  Standard therapy (percutaneous coronary intervention \[PCI\],
    coronary artery bypass graft \[CABG\], antiplatelet agents,
    beta-blockers, thrombolytic therapy, lipid-lowering agents) with
    attention to drugs that have altered clearance in kidney failure
    (e.g., low molecular weight heparin)

2.  Acute reperfusion therapy for dialysis patient with ST-segment
    elevation myocardial infarction (MI)

*Chronic CAD*

1.  Standard pharmacotherapy (acetylsalicylic acid \[ASA\],
    beta-blockers, nitroglycerin, angiotensin-converting enzyme \[ACE\]
    inhibitors, angiotensin receptor blockers \[ARBs\], statins, calcium
    channel blockers \[CCB\])

2.  Unique aspects include maintenance of hemodynamic dry weight and
    hemoglobin levels, modification of dosing regimens, and use of loop
    diuretics

3.  Surgical interventions, including CABG and PCI with conventional or
    drug-eluting stent

*VHD*

1.  Standard management, including mechanical or tissue valve
    replacement

*Cardiomyopathy*

1.  Standard therapy with attention to potential effects of therapeutic
    agents (e.g., ACE inhibitors, beta-blockers) on intrahemodialytic
    hemodynamics

2.  Empirically individualized dosing

3.  Maintenance of euvolemia and adjustment of targeted dry weight

*Dysrhythmia*

1.  Standard therapy, including antiarrhythmic agents (including
    beta-blockers) with dosing adjustments and pacing devices, including
    internal defibrillators

*Cerebrovascular Disease*

1.  American Heart Association guidelines with careful monitoring of
    anticoagulation and imaging to localize thrombotic or bleeding
    events

2.  Standard medical and surgical management of transient ischemic
    attack (TIA) and stroke with assessment of risk of bleeding with use
    of thrombolytics in hemodialysis patients

*PVD*

1.  Standard therapy (smoking cessation, lipid-lowering therapy,
    glycemic control, blood pressure control, ACE inhibitors,
    antiplatelet agents)

2.  Supervised exercise regimens

3.  Medication to increase vasodilation

**Cardiovascular Risk Factors**

*Diabetes*

1.  Treatment according to American Diabetes Association guidelines

*Blood Pressure*

1.  Management of fluid status through education and counseling, low
    sodium intake, increased ultrafiltration, longer and/or more
    frequent dialysis, and drugs that reduce salt appetite

2.  Adjustment of antihypertensive drugs, including use of ACE
    inhibitors or angiotensin II-receptor blockers and timing of
    treatment

*Dyslipidemia*

1.  Previous Kidney Disease Outcomes Quality Initiative (K/DOQI)
    Guidelines

*Smoking, Physical Activity, and Psychological Factors*

1.  Counseling to stop smoking and increase activity level

2.  Appropriate referral to specialists (e.g., smoking cessation,
    physical therapist)

3.  Treatment for depression, anxiety, or hostility, as appropriate

*Anemia*

1.  Previous K/DOQI Guidelines

*Arterial Stiffness, Vascular and Valvular Calcification, Phosphorus and
Parathyroid Hormone*

1.  Non-calcium-containing phosphate binder

2.  Adherence to current guidelines for treatment of calcium, phosphate,
    and parathyroid hormone

*General*

1.  Ensuring availability of external cardiac defibrillators in dialysis
    units

#### MAJOR OUTCOMES CONSIDERED

-   Cardiovascular outcomes

-   Morbidity

-   Mortality

-   Survival

-   Myocardial infarction

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Literature Search**

The Work Group and Evidence Review Team decided in advance that a
systematic process would be followed to obtain information on topics
that relied on primary articles. Only full journal articles of original
data were included. Editorials, letters, and abstracts were not
included. Selected review articles were included for background
material. Though reports of formal studies were preferred, case series
were also included. No systematic process was followed to obtain
textbooks and review articles.

Studies for the literature review were identified through MEDLINE
searches of English language literature conducted between March and
October 2002. These searches were supplemented by relevant articles
known to the domain experts and reviewers through December 2003.

The MEDLINE literature searches were conducted to identify clinical
studies published from 1966 through the search dates. The primary search
was designed to capture studies pertaining to all topics. Supplemental
searches were made to maximize retrieval of studies pertaining to
specific topics, including: anxiety and hostility, carnitine, diet,
hormone replacement therapy, pediatrics, and peripheral vascular
disease. Development of the search strategies was an iterative process
that included input from all members of the Work Group. The text words
or MeSH headings for all topics included \"renal replacement therapy,\"
end-stage renal disease and related terms. The searches were limited to
studies on humans and published in English, and focused on either adults
or children, as relevant.

MEDLINE search results were screened by members of the Evidence Review
Team. Potential papers for retrieval were identified from printed
abstracts and titles, based on study population, relevance to topics,
and study size. For studies of risk factors and treatments, those with
fewer than 10 subjects were excluded; for epidemiology studies, those
with fewer than 30 subjects were excluded. Studies of risk factors had
to evaluate a cardiovascular outcome to be included. Studies of risk
factor or cardiovascular treatments, including surgery, had to be
comparative; thus single-cohort case series were excluded. After
retrieval, each paper was read to verify relevance and appropriateness
for review, based primarily on study design and ascertainment of
necessary variables. Some articles were relevant for two or more topics.
Domain experts made the final decision for inclusion or exclusion of
articles. All articles included were extracted and are contained in the
summary tables. Numerous additional articles that did not meet the
specific criteria necessary to qualify for inclusion were reviewed, with
or without extraction, for use as background material.

In an iterative process, the topics for which articles would be analyzed
in depth and summarized were restricted to those topics that had not
been sufficiently summarized previously by other Kidney Disease Outcomes
Quality Initiative (K/DOQI) Work Groups or others and provided evidence
for the specific guidelines. For most topics, given the small number of
available studies, all comparative studies with at least 10 dialysis
patients per arm were included. For certain topics with relatively large
numbers of studies, stricter criteria were used. For studies of serum
calcium, phosphorus, and parathyroid hormone (PTH) as predictors of
cardiovascular disease (CVD), only studies that reported that they were
sufficiently powered for these predictors were included. Studies that
evaluated tobacco use as a risk factor for CVD had to both define
smoking use categories *a priori* and have a minimum of 100 subjects.
Studies of both lipoprotein(a) \[Lp(a)\] and genetic markers were
required to have at least 10 subjects with CVD outcomes. For predictors
with sufficient numbers of studies, only associations with CVD event
outcomes were included. These included C-reactive protein, random serum
troponin levels, smoking, echocardiogram measurements, and surgical
interventions for coronary artery disease. Intermediate outcomes,
including vascular calcification, intima-media thickness, and
ventricular arrhythmia were included for other predictors analyzed. For
certain predictors, studies were also included that reported prevalent
(as opposed to future) CVD. These included genetic markers and ankle-arm
brachial index.

#### NUMBER OF SOURCE DOCUMENTS

Overall, 16,691 citations were screened (9,078 from the primary search;
7,613 from supplemental searches), from which 396 articles were
retrieved and reviewed. An additional 151 articles, added by Work Group
members and domain experts, were reviewed. Of these, a total of 86
articles met sufficient criteria to be included in summary tables.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE 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).

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Data extraction forms were designed to capture information on various
aspects of the primary articles. Forms for all topics included study
setting and demographics, eligibility criteria, causes of kidney
disease, numbers of subjects, study design, study funding source,
dialysis characteristics, comorbid conditions, descriptions of relevant
risk factors and cardiovascular outcomes, statistical methods, results,
study quality (based on criteria appropriate for each study design, see
below), study applicability (see below), and sections for comments and
assessment of biases.

Training of the Work Group members to extract data from primary articles
occurred at meetings, and subsequently by e-mail and during
teleconferences.

**Format for Evidence Tables**

Two types of evidence tables were prepared. Detailed tables contain data
from each field of the components of the data extraction forms. These
tables were used to efficiently track and transmit data about all
extracted studies. They were completed by the Evidence Review Team from
extraction forms filled out by Work Group members. They were then given
to the Work Group members, but are not included in the report.

Summary tables describe the strength of evidence according to four
dimensions: study size (of both hemodialysis \[HD\] and peritoneal
dialysis \[PD\] patients) and duration, study applicability, results and
methodological quality. Within each table, the studies are first grouped
by outcome type. Outcomes are ordered by all-cause death, cardiovascular
death, and cardiovascular events. Studies with intermediate and
prevalent outcomes are shaded at the bottom of the tables. Within each
outcome, studies are ordered first by methodological quality (best to
worst), then by applicability (most to least) and then by study size
(largest to smallest). When relevant, outcome thresholds (e.g., of
troponin I levels) or definitions of predictors (for genetic predictors)
are included. Results are presented using summary symbols, as defined in
the original guideline document. An example of an evidence table is
shown in table 39 of the original guideline document.

*Study Size and Duration*

The study (sample) size is used as a measure of the weight of the
evidence. In general, large studies provide more precise estimates of
prevalence and associations. In addition, large studies are more likely
to be generalizable; however, large size alone does not guarantee
applicability. A study that enrolled a large number of selected patients
may be less generalizable than several smaller studies that included a
broad spectrum of patient populations. Similarly, longer duration
studies may be of better quality and more applicable, depending on other
factors.

*Applicability*

Applicability (also known as generalizability or external validity)
addresses the issue of whether the study population is sufficiently
broad so that the results can be generalized to the population of
interest at large. The study population is typically defined primarily
by the inclusion and exclusion criteria. The target population was
defined to include patients with end stage renal disease (primarily
those on dialysis). A designation for applicability was assigned to each
article, according to a three-level scale. In making this assessment,
sociodemographic characteristics were considered, as were the stated
causes of chronic kidney disease, and prior treatments. Applicability
referred to either the hemodialysis population or the peritoneal
dialysis population, as appropriate.

*Results*

In general, the result is summarized by both the direction and strength
of the association. Depending on the study type, the results may refer
either to dichotomous outcomes, such as the presence of a specific
genotype or a laboratory test above or below a threshold value, or to
the association of continuous variables with outcomes, such as serum
laboratory tests. The magnitude of the association and both the clinical
and statistical significance of the associations were considered.
Criteria for indicating the presence of an association varied among
predictors depending on their clinical significance. Both univariate and
multivariate associations are presented.

For studies of troponin I and T, sensitivity and specificity data are
included when reported. For clarity, the results for studies of surgical
interventions for coronary artery disease are presented as **coronary
artery bypass graft (CABG), Stent,** or **Tissue** to indicate studies
for which the intervention had significantly better outcomes, or
coronary artery bypass graft for studies where there was a trend toward
better outcomes with coronary artery bypass graft.

*Quality*

Methodological quality (or internal validity) refers to the design,
conduct, and reporting of the clinical study. Because studies with a
variety of types of design were evaluated, a three-level classification
of study quality was devised (see original guideline document).

**Summarizing Reviews and Selected Original Articles**

Work Group members had wide latitude in summarizing reviews and selected
original articles for topics that were determined not to require a
systemic review of the literature.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The overall aim of the project was to develop clinical practice
guidelines for the evaluation and management of cardiovascular disease
(CVD) in chronic kidney disease (CKD) patients who require either
hemodialysis (HD) or peritoneal dialysis (PD).

The Work Group sought to develop the guidelines using an evidence-based
approach. Evidence regarding the guideline topics was derived from a
systematic summary of the available scientific literature on the
epidemiology of cardiovascular disease among dialysis patients, the
evaluation and management of cardiac, cerebrovascular, and peripheral
vascular disease among dialysis patients, the evaluation and management
of specific risk factors for cardiovascular disease among dialysis
patients, and cardiovascular risk stratification among dialysis
patients.

**Refinement of Topics and Development of Materials**

The Work Group and Evidence Review Team developed a) draft guideline
statements; b) draft rationale statements that summarized the expected
pertinent evidence; and c) data extraction forms requesting the data
elements to be retrieved from the primary articles. The topic refinement
process began prior to literature retrieval and continued through the
process of reviewing individual articles.

**Translation of Evidence to Guidelines**

*Format*. The guideline document contains 14 guidelines. The format for
each guideline is outlined in Table 40 of the original guideline
document. Each guideline contains one or more specific \"guideline
statements,\" which are presented as \"bullets\" that represent
recommendations to the target audience. Each guideline contains
background information, which is generally sufficient to interpret the
guideline. A discussion of the broad concepts that frame the guidelines
is provided in the preceding section of this report. The rationale for
each guideline contains a discussion of specific topics that support the
guideline statements, together with a classification of the strength of
evidence. The guideline concludes with a discussion of limitations of
the evidence review and a brief discussion of implementation issues and
research recommendations regarding the topic.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**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.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

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]{.underline}**

**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) [\<]{.underline}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
> [\<]{.underline}1.0 cm^2^) 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**

  ------------------------------------------------------------------------------------
  ** **                      **AHA Guideline**             **K/DOQI Modification**
  -------------------------- ----------------------------- ---------------------------
  **Prevention**                                           

  General                    Regular screening for         Target blood pressure (BP)
                             hypertension (HTN) and        in dialysis patients is
                             appropriate management as     less certain than in the
                             summarized in the Seventh     general population. See
                             Report of the Joint National  guideline 10 in this
                             Committee on the Prevention,  document. In addition, see
                             Detection, Evaluation and     caveats in Guideline 10 on
                             Treatment of High Blood       tobacco use, diet, and
                             Pressure (JNC VII). Encourage diabetes.
                             patients to stop smoking.     
                             Provide counseling, nicotine  
                             replacement, and formal       
                             programs when available. In   
                             diabetics, careful control of 
                             hypertension is important.    
                             Glycemic control is           
                             recommended to reduce         
                             microvascular complications.\ 
                             \                             
                             ***Diet/Nutrition***: A       
                             healthy diet containing at    
                             least five servings of fruits 
                             and vegetables may decrease   
                             the risk of stroke and is     
                             therefore encouraged.         

  Asymptomatic Carotid       Endarterectomy may be          
  Stenosis                   considered in patients with   
                             high-grade asymptomatic       
                             carotid stenosis. Careful     
                             patient selection guided by   
                             comorbid conditions, life     
                             expectancy, patient           
                             preference, as well as other  
                             factors, including gender     
                             followed by a thorough        
                             discussion of the risks and   
                             benefits of the procedure is  
                             necessary. Patients should    
                             also be thoroughly evaluated  
                             for other treatable causes of 
                             stroke.                       

  Atrial Fibrillation        Antithrombotic therapy        Dialysis patients are at
                             (warfarin and aspirin) should increased risk for bleeding
                             be considered for patients    and careful monitoring
                             with nonvalvular atrial       should accompany
                             fibrillation, based on an     intervention.
                             assessment of their risk of   
                             embolism and risk of bleeding 
                             complications.                

  **Screening/Evaluation**                                 

  Transient Ischemic Attack  ***Imaging of the brain***:    
  (TIA)                      Patients with symptoms        
                             suggesting a TIA should       
                             receive a computed tomography 
                             (CT) scan of the head in the  
                             initial diagnostic evaluation 
                             to exclude a rare lesion such 
                             as a subdural hematoma or     
                             brain tumor. A CT scan may    
                             also demonstrate an area of   
                             brain infarction appropriate  
                             to TIA symptoms that may      
                             influence subsequent          
                             management. Substitution of   
                             magnetic resonance imaging    
                             (MRI) for CT, for the         
                             evaluation of TIA, is not     
                             warranted.                    

                             ***Imaging of the vessels***:  
                             Magnetic resonance            
                             angiography (MRA) provides    
                             sufficient images for         
                             evaluation of vertebrobasilar 
                             ischemia. Duplex              
                             ultrasonography is a          
                             screening tool that can be    
                             used to determine those with  
                             significant stenosis of the   
                             carotid arteries. This should 
                             be followed by arteriography  
                             to determine vessels best     
                             suited for intervention.      

  Acute Stroke               ***Imaging***: The immediate   
                             goal in an acute stroke is    
                             localizing and exclusion of   
                             other causes for symptoms. A  
                             CT scan with contrast is      
                             recommended as the primary    
                             tool for evaluation for an    
                             acute stroke. A follow-up CT  
                             in 2 to 10 days is            
                             recommended for negative CT   
                             scans when further            
                             documentation is necessary or 
                             when the provider suspects    
                             that transformation to        
                             hemorrhage has occurred.      
                             Magnetic resonance imaging is 
                             useful for posterior          
                             circulation strokes, small    
                             hemorrhages, or when dating   
                             the hemorrhage is needed, but 
                             is not recommended for        
                             routine use. Imaging vessels  
                             is not necessary in acute     
                             stroke. Techniques such as    
                             ultrasound or magnetic        
                             resonance angiography may     
                             serve as a screening          
                             procedure for considering     
                             carotid angiography and       
                             monitoring of vascular        
                             abnormalities.                

  **Treatment**                                            

  TIA                        ***Antiplatelet agents***:    Dialysis patients are at
                             Daily aspirin should be used  high risk for bleeding, and
                             for patients who have an      adequate precautions should
                             atherothrombotic TIA to       be taken to prevent
                             reduce the risk of recurrent  bleeding associated with
                             stroke.\                      antiplatelet agents and
                             \                             anticoagulants.
                             ***Ticlopidine***:            
                             Ticlopidine is limited by its 
                             side effects and should be    
                             used in patients intolerant   
                             to aspirin or who have had a  
                             major ischemic event despite  
                             aspirin.\                     
                             \                             
                             ***Clopidogrel***:            
                             Clopidogrel is limited by its 
                             side effects and should be    
                             used in patients intolerant   
                             to aspirin or who have had a  
                             major ischemic event despite  
                             aspirin.\                     
                             \                             
                             ***Anticoagulants:***         
                             Warfarin is recommended for   
                             subjects with atrial          
                             fibrillation who have a TIA.  
                             A target international        
                             normalized ratio (INR) of 2.5 
                             is recommended. Warfarin is   
                             also recommended for patients 
                             who are at high risk for      
                             other sources of              
                             cardioembolism. Aspirin may   
                             be used for those that have   
                             contraindications to oral     
                             anticoagulation.              

                             ***Surgical management of      
                             carotid disease***: Patients  
                             with a recent TIA or          
                             nondisabling stroke with an   
                             ipsilateral carotid stenosis  
                             \>50% may benefit from        
                             surgery. Benefits vary by     
                             risk factors and are greatest 
                             among men, nondiabetics, and  
                             those with hemispheric        
                             symptoms and angiographically 
                             demonstrated ulcers.          

                             ***Angioplasty and stent       
                             placement***: Not currently   
                             recommended.                  

  Stroke                     Intra-arterial thrombolysis   The stipulation of
                             should be considered          excluding patients who have
                             investigational. Intravenous  had heparin during the 48
                             tissue plasminogen activator  hours prior to thrombolysis
                             is recommended within 3 hours was not designed to address
                             after the onset of ischemic   dialysis patients on
                             stroke. This should be done   intermittent dialysis, and
                             in the setting of a stroke    would eliminate the
                             confirmed by CT. It should    majority of dialysis
                             not be used if the patient    patients on thrombolytics.
                             has had heparin during the    Therefore, the use of
                             prior 48 hours.               thrombolytics in dialysis
                                                           patients should be
                                                           considered on an individual
                                                           basis.

                             Heparin therapy is not        
                             recommended as thrombolytic   
                             therapy                       

                             Surgery: Emergent carotid     
                             endarterectomy is not         
                             recommended.                  
  ------------------------------------------------------------------------------------

> **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]{.underline}**
>
> **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]{.underline}**
>
> 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]{.underline}**:
>
> **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).

#### CLINICAL ALGORITHM(S)

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

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

> [References open in a new
> window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=7149)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

> 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.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

> Appropriate evaluation and management of cardiovascular disease (CVD)
> in dialysis patients

#### POTENTIAL HARMS

> Risks associated with many of the recommended diagnostic and
> therapeutic procedures are addressed in the \"Major Recommendations\"
> field of this summary and in the original guideline document.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Dofetilide is contraindicated in patients with creatinine clearance
    of \<20 mL/min. Its use should be avoided in dialysis-dependent
    patients.

-   Metformin is contraindicated in dialysis patients because of
    decreased clearance and the possibility of lactic acidosis.

-   Sotalol is contraindicated in dialysis patients because of decreased
    clearance.

-   Table 12 in the original guideline document titled
    \"Antihypertensive drug therapy in dialysis: guidelines for
    selection\" identifies the following relative or absolute
    contraindications:

    -   Direct vasodilators in patients with angina pectoris,
        post-myocardial infarction (MI), or hypertrophic cardiomyopathy
        with diastolic dysfunction

    -   Alpha-1-blockers in patients with hypertrophic cardiomyopathy
        with diastolic dysfunction

    -   Beta-blockers in patients with bradycardia, heart block, or sick
        sinus syndrome; peripheral vascular disease; or asthma/chronic
        obstructive pulmonary disease (COPD)

    -   Labetalol in patients with bradycardia, heart block, or sick
        sinus syndrome; or liver disease

    -   Verapamil or diltiazem in patients with bradycardia, heart
        block, or sick sinus syndrome; or with cyclosporine-induced
        hypertension

    -   Calcium channel blockers (CCBs) in patients with heart failure
        (decreased left ventricular \[LV\] ejection fraction)

    -   Nicardipine in patients with cyclosporine-induced hypertension

    -   Methyldopa in patients with liver disease

    -   Angiotensin-converting enzyme (ACE) inhibitors in patients with
        erythropoietin-induced hypertension

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

> **Use of the Guidelines**
>
> These Guidelines are based upon the best information available at the
> time of publication. They are designed to provide information and
> assist decision-making. They are not intended to define a standard of
> care, and should not be construed as one. Neither should they be
> interpreted as prescribing an exclusive course of management.
>
> Variations in practice will inevitably and appropriately occur when
> clinicians take into account the needs of individual patients,
> available resources, and limitations unique to an institution or type
> of practice. Every health-care professional making use of these
> Guidelines is responsible for evaluating the appropriateness of
> applying them in the setting of any particular clinical situation.
>
> The recommendations for research contained within this document are
> general and do not imply a specific protocol.
>
> **Limitations of Approach**
>
> While the literature searches were intended to be comprehensive, they
> were not exhaustive. MEDLINE was the only database searched, and
> searches were limited to English language publications. Hand searches
> of journals were not performed, and review articles and textbook
> chapters were not systematically searched. However, important studies
> known to the domain experts that were missed by the literature search
> were included in the review.
>
> Exhaustive literature searches were hampered by limitations in
> available time and resources that were judged appropriate for the
> task. The sensitive search strategies required to capture every
> article that may have had data on each of the questions frequently
> yielded upwards of 10,000 articles. Given the large number of topics,
> this approach was not feasible. The difficulty of finding all
> potentially relevant studies was compounded by the fact that in many
> studies, the information of interest for this report was a secondary
> finding for the original studies. We used our best judgment in
> developing search strategies to balance the yield of potentially
> useful articles and feasibility.
>
> **Guideline 2: Coronary Artery Disease**

-   Most studies deal with patients who are eligible for kidney
    transplantation. There are only sparse data on general dialysis
    patients.

-   The specific noninvasive screening method for coronary artery
    disease (CAD) is dependent on the institution.

-   No decision analysis has been done on the trade-off of performing
    angiography versus further diminution of residual kidney function.

> **Guideline 3: Acute Coronary Syndromes**

-   There have been very few dialysis-specific clinical trials.

-   It is difficult to assess bleeding diathesis, and therefore risk
    associated with glycoprotein (GP) IIb/IIIa inhibitors, in individual
    dialysis patients.

> **Guideline 4: Chronic Coronary Artery Disease**

-   All published studies are retrospective analyses. There are no
    randomized controlled trials comparing percutaneous coronary
    intervention (PCI) and surgical bypass of coronary arteries in
    dialysis patients.

-   There have also been no studies in the dialysis population on the
    newest generation of drug-eluting stents (e.g., stents eluting
    sirolimus or paclitaxel).

> **Guideline 5: Valvular Heart Disease**

-   The mortality risk of nonintervention or delayed intervention is not
    known.

> **Guideline 6: Cardiomyopathy (Systolic or Diastolic Dysfunction)**

-   There is only a single, small trial for carvedilol in dialysis
    patients.

-   There are no data on the use of angiotensin-converting enzyme (ACE)
    inhibitors in dialysis patients with potential hypotension.

-   The longitudinal cohort study on echocardiographic changes in
    chronic hemodialysis (HD) patients by Foley and Parfrey was
    conducted in patients recruited from 1982 to 1991, mostly before the
    use of erythropoietin. Despite the newer therapies that became
    available since then, cardiac events are still the major cause of
    death and cardiac mortality increases with years on dialysis,
    according to United States Renal Data System (USRDS) data. Long-term
    echocardiographic surveillance of dialysis patients in the modern
    treatment era is lacking. The appropriate time interval for
    re-evaluation in chronic dialysis patients is therefore uncertain.

> **Guideline 7: Dysrhythmia**

-   Although there is an existing and evolving body of evidence about
    the primary and secondary prevention of cardiac events in the form
    of arrhythmias in the general population, such evidence is
    apparently lacking from the growing population of chronic kidney
    disease (CKD) and dialysis-dependent patients.

-   Without definitive evidence from prospective trials in the dialysis
    population, there may remain an increased concern over the safety
    and efficacy of interventions.

> **Guideline 8: External Defibrillation**

-   Automatic external defibrillators (AEDs) are easy to operate and the
    operator does not require medical training, but automatic external
    defibrillators need to be widely available.

> **Guideline 9: Cerebrovascular Disease**

-   There are extensive data from the general population regarding risk
    factors, screening, and treatment of stroke. However, the
    epidemiology of stroke is different in the dialysis population. In
    addition, exposures related to dialysis may alter the effectiveness
    and complications associated with treatment. All recommendations
    regarding screening and treatment are opinion-based and should be
    taken with caution.

-   There are limited data regarding stroke that are specific to the
    dialysis population. Data addressing the association between risk
    factors and stroke are scant. Data supporting screening for stroke
    are based on limited and weak data, while data addressing treatment
    do not exist.

-   There are no data in the dialysis population regarding medical or
    surgical management of stroke. However, due to the high risk of
    bleeding in the chronic kidney disease population, caution should be
    used when treating with antiplatelet agents.

> **Guideline 10: Peripheral Vascular Disease**

-   There are no randomized, controlled trials of any of the
    interventions for therapy of peripheral vascular disease (PVD) in
    dialysis patients.

-   The above recommendations are based on retrospective, observational
    studies in dialysis patients. Further large, prospective
    observational studies and randomized, controlled trials are
    warranted.

> **Guideline 11: Diabetes**

-   Many of the recommendations supported by the American Diabetes
    Association (ADA) on the care of diabetes are based on large
    clinical studies that provide strong evidence for the particular
    recommendation, but those studies do not target dialysis patients.

> **Guideline 12: Blood Pressure**

-   One major limitation of these guidelines is the lack of large-scale
    clinical trials correlating levels of blood pressure with
    cardiovascular disease (CVD) events. Particularly puzzling is the
    U-shaped relationship between systolic blood pressure and
    cardiovascular morbidity and mortality, and the apparent lack of
    high blood pressure effects on cardiovascular disease events until
    systolic blood pressure reaches approximately 180 mm Hg. The
    increased mortality in patients with lower blood pressure could be
    related to poor ventricular function. The lack of effects of blood
    pressure on cardiovascular events over a wide range of blood
    pressure between 100 and 180 mm Hg could be related to variable
    ventricular function, and to \"survival bias,\" whereby high-risk
    patients with higher blood pressure may not have survived to be
    entered into the study.

-   Another limitation of these guidelines is related to the great
    variability of blood pressure with dialysis and the lack of firm
    criteria on definition of hypertension in this patient population.

-   Another major limitation of these guidelines is the lack of
    controlled studies on the effect of different blood pressure goals
    and different therapeutic interventions on CVD events. Most of the
    recommendations are based on inference from studies performed in the
    general population with normal renal function. Other studies were
    performed in patients with various degrees of kidney disease, but
    not on dialysis therapy, and the outcomes were deterioration of
    renal function but not CVD.

> **Guideline 14: Smoking, Physical Activity, and Psychological
> Factors**
>
> *Smoking*

-   Cessation of smoking in dialysis patients may be difficult to
    achieve, as in the general population.

-   There are no comprehensive studies of the use of the
    pharmacotherapies recommended for smoking cessation in dialysis
    patients.

> *Physical Activity*

-   There are no randomized trials in dialysis patients of the effects
    of exercise on cardiovascular risk profile; however, there are
    randomized trials in dialysis patients that demonstrate the effects
    of exercise training on physical functioning. Many patients are
    severely debilitated and will require lower levels of rehabilitation
    efforts. These levels may not be sufficient to modify cardiovascular
    risks; however, they will prove adequate to improve physical
    functioning.

> *Psychological Factors*

-   Research studies have produced conflicting data that may be due to
    using different definitions of the constructs, examining components
    within a construct rather than using the entire construct, or using
    varying methods of measuring psychological constructs. Additional
    problems in some studies included small sample sizes, large
    percentages of a study population lost to follow-up, and not
    controlling for variables that could affect the outcome.

-   This guideline is largely based upon observational studies,
    meta-analyses, and review articles. No research could be found that
    evaluated the association between psychological factors and CVD in
    dialysis patients.

> **Guideline 15: Anemia**

-   There is a clear association between poor outcomes and low
    hemoglobin, but there are little data to suggest that hemoglobin
    levels \>13 g/dL are associated with improved outcomes. The data
    supporting an association between anemia treatment and improvements
    in CVD are limited.

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

-   The data addressing the relationship between increased pulse
    pressure (PP) and increased mortality rates are robust, while data
    relating high pulse pressure with medial calcification are less
    robust. The data supporting the efficacy of interventions to
    decrease the pulse pressure and to improve clinical outcomes are
    relatively weak. Earlier interventions that prevent the development
    of noncompliant blood vessels might be more effective than the
    treatment of established vascular stiffness in dialysis patients.

> *Serum Phosphorus*

-   The evidence linking hyperphosphatemia to an increased risk of
    all-cause and cardiovascular mortality is based on observational
    data. The evidence linking hyperphosphatemia with vascular
    calcification is based on empirical data that are consistent with
    clinical observations. The randomized clinical trial comparing
    sevelamer to calcium-containing phosphate binders showed a
    convincing decrease in the rate of vascular calcification. However,
    the demonstration of improved clinical outcomes awaits longer-term
    studies.

-   The mechanisms by which vascular calcification leads to specific
    cardiovascular events are not clear and further studies are
    required.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

> Implementation issues related to each of the guidelines are discussed
> in the original guideline document.

#### IMPLEMENTATION TOOLS

> Clinical Algorithm
>
> For information about
> [availability](#identifying-information-and-availability), see the
> \"Availability of Companion Documents\" and \"Patient Resources\"
> fields below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

> Living with Illness

#### IOM DOMAIN

> Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

> National Kidney Foundation. K/DOQI clinical practice guidelines for
> cardiovascular disease in dialysis patients. Am J Kidney Dis 2005
> Apr;45(3 Pt 2):16-153. \[736 references\]
> [PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15806502)

#### ADAPTATION

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

#### DATE RELEASED

> 2005 Apr

#### GUIDELINE DEVELOPER(S)

> National Kidney Foundation - Disease Specific Society

#### SOURCE(S) OF FUNDING

> National Kidney Foundation (NKF)

#### GUIDELINE COMMITTEE

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

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

> *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

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

> 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.

#### GUIDELINE STATUS

> This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

> Electronic copies: Available from the [National Kidney Foundation
> (NKF) Web
> site](http://www.kidney.org/professionals/kdoqi/guidelines_cvd/index.htm).
>
> Print copies: Available from the National Kidney Foundation (NKF), 30
> East 33rd St., New York, NY 10016. These guidelines are also available
> on CD-ROM from NKF.

#### AVAILABILITY OF COMPANION DOCUMENTS

> None available

#### PATIENT RESOURCES

> None available

#### NGC STATUS

> 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).

#### COPYRIGHT STATEMENT

> K/DOQI is a trademark of the National Kidney Foundation, Inc. All
> rights reserved. No part of this publication may be reproduced or
> transmitted in any form or by any means, electronic or mechanical,
> including photocopy, recording, or any information storage retrieval
> system, without permission in writing from the National Kidney
> Foundation.

### DISCLAIMER

#### NGC DISCLAIMER

> The National Guideline Clearinghouse™ (NGC) does not develop, produce,
> approve, or endorse the guidelines represented on this site.
>
> All guidelines summarized by NGC and hosted on our site are produced
> under the auspices of medical specialty societies, relevant
> professional associations, public or private organizations, other
> government agencies, health care organizations or plans, and similar
> entities.
>
> Guidelines represented on the NGC Web site are submitted by guideline
> developers, and are screened solely to determine that they meet the
> NGC Inclusion Criteria which may be found at
> <http://www.guideline.gov/about/inclusion.aspx> .
>
> NGC, AHRQ, and its contractor ECRI Institute make no warranties
> concerning the content or clinical efficacy or effectiveness of the
> clinical practice guidelines and related materials represented on this
> site. Moreover, the views and opinions of developers or authors of
> guidelines represented on this site do not necessarily state or
> reflect those of NGC, AHRQ, or its contractor ECRI Institute, and
> inclusion or hosting of guidelines in NGC may not be used for
> advertising or commercial endorsement purposes.
>
> Readers with questions regarding guideline content are directed to
> contact the guideline developer.

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> © 1998-2008 National Guideline Clearinghouse
>
> Date Modified: 11/3/2008
>
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