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J Am Coll Cardiol. 2014 Apr 8;63(13):1246-52. doi: 10.1016/j.jacc.2014.01.020. Epub 2014 Feb 12.

Proposal for a functional classification system of heart failure in patients with end-stage renal disease: proceedings of the acute dialysis quality initiative (ADQI) XI workgroup.

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  • 1Department of Medicine, Division of Nephrology, Washington DC Veterans Affairs Medical Center, and Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, DC. Electronic address:
  • 2Department of Medicine, Division of Cardiology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota.
  • 3Midwest Heart Specialists-Advocate Medical Group, Naperville, Illinois.
  • 4Southeast Renal Research Institute, Chattanooga, Tennessee.
  • 5Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
  • 6Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas; Heart Hospital, Plano, Texas.
  • 7Department of Nephrology, Dialysis, and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy.


Structural heart disease is highly prevalent in patients with chronic kidney disease requiring dialysis. More than 80% of patients with end-stage renal disease (ESRD) are reported to have cardiovascular disease. This observation has enormous clinical relevance because the leading causes of death for patients with ESRD are of cardiovascular disease etiology, including heart failure, myocardial infarction, and sudden cardiac death. The 2 systems most commonly used to classify the severity of heart failure are the New York Heart Association (NYHA) functional classification and the American Heart Association (AHA)/American College of Cardiology (ACC) staging system. With rare exceptions, patients with ESRD who do not receive renal replacement therapy (RRT) develop signs and symptoms of heart failure, including dyspnea and edema due to inability of the severely diseased kidneys to excrete sodium and water. Thus, by definition, nearly all patients with ESRD develop a symptomatology consistent with heart failure if fluid removal by RRT is delayed. Neither the AHA/ACC heart failure staging nor the NYHA functional classification system identifies the variable symptomatology that patients with ESRD experience depending upon whether evaluation occurs before or after fluid removal by RRT. Consequently, the incidence, severity, and outcomes of heart failure in patients with ESRD are poorly characterized. The 11th Acute Dialysis Quality Initiative has identified this issue as a critical unmet need for the proper evaluation and treatment of heart failure in patients with ESRD. We propose a classification schema based on patient-reported dyspnea assessed both pre- and post-ultrafiltration, in conjunction with echocardiography.

Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.


ESRD; chronic kidney disease; classification; dyspnea; fluid overload; heart failure

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