Management of Cardiomegaly in Dialysis Patients

Diagnosis and Evaluation

Evaluate for underlying ischemic heart disease if cardiomegaly is unresponsive to volume management, as recommended by the American Society of Nephrology 1
Consider unsuspected valvular heart disease or ischemic heart disease in refractory cases, as suggested by the American Heart Association 1

Establish and maintain strict dry weight through aggressive ultrafiltration during dialysis sessions, with consideration of more frequent or longer dialysis sessions for patients with difficulty achieving dry weight, as suggested by the National Kidney Foundation 1
Implement strict sodium restriction (≤2g daily) and limiting fluid intake to 2 liters daily to optimize dry weight in dialysis patients with CHF, as recommended by the American College of Cardiology 2
Consider ultrafiltration with pulmonary artery catheter monitoring for refractory cases, and evaluate for continuous veno-venous hemofiltration (CVVH), as recommended by the American Society of Nephrology 1
Consider mechanical methods of fluid removal like CVVH for truly refractory cases of CHF in dialysis patients, as recommended by the European Heart Journal 3

Carvedilol is the preferred beta-blocker for dialysis patients with cardiomegaly, starting with a low dose (12.5 mg/day) and titrating up to 25 mg/day as tolerated, as recommended by the American College of Cardiology 1
ACE inhibitors or ARBs may be added when blood pressure permits, to help reduce left ventricular hypertrophy, as suggested by the European Society of Cardiology 1
Consider adding ACE inhibitors or ARBs when blood pressure permits, to help reduce LVH, sympathetic nerve activity, and improve endothelial function, administering preferentially at night to reduce nocturnal blood pressure surge and minimize intradialytic hypotension 1
Hydralazine in combination with nitrates may be beneficial for patients who cannot tolerate ACE inhibitors or beta-blockers, as suggested by the American College of Cardiology 2

Regular echocardiographic assessment of LV function and dimensions, and monitor cardiothoracic index via chest X-ray, as recommended by the American Society of Echocardiography 1
Use echocardiography to evaluate cardiac filling pressures and volume status, including assessment of pulmonary artery pressure, pulmonary vein patterns, and inferior vena cava for estimation of right atrial pressure 1
Monitor electrolytes, particularly potassium levels, and assess for improvement in symptoms and signs of CHF 4
Target predialysis blood pressure <140/90 mmHg and postdialysis <130/80 mmHg, monitoring blood pressure in supine position with appropriate cuff size 1
Avoid excessive intradialytic hypotension which can worsen cardiac function, and exercise caution when initiating beta-blockers in patients with significant fluid retention or recent need for IV inotropic therapy, as recommended by the American College of Cardiology 2, 1, 5