KDOQI (Kidney Disease Outcomes Quality Initiative)


NKF KDOQI GUIDELINES

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KDOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients


Section I. Guidelines on evaluation and management of cardiovascular diseases

The assessment and treatment of both risk factors and end organs are essential in the management of cardiovascular diseases. The first section will deal with the end organs and will focus on cardiac, cerebrovascular and peripheral vascular diseases. Cardiac diseases have justifiably received the most attention because they are by far the most common cause of cardiovascular deaths in dialysis patients. Cerebrovascular diseases and peripheral vascular diseases, however, also lead to substantial morbidity and mortality and have often been overlooked by practitioners and clinical researchers.

The workgroup has faced dilemma in the scope and depth of the coverage of end organ diseases. There has been only one small randomized trial that demonstrated beneficial effects of specific cardioprotective drugs (namely, carvedilol) published in dialysis patients. Therefore, most guidelines described in this section are referred from published guidelines in the general population. Nonetheless, there are unusual features in the dialysis patients that the practitioners need to be aware of. For example, the pathophysiology and rate of progression of cardiac valvular calcification appear to be different from those in the general population. Surveillance and treatment strategies should take these caveats into consideration. On the other hand, the implant of tissue valves is proscribed in the existing ACC/AHA guidelines. More recent and stronger evidence, however, suggest that tissue valves are associated with equivalent outcomes in dialysis patients. These similarities, not only differences, between dialysis patients and the general population also need to be emphasized.

The section on end organ diseases is written for not only the nephrologists, but also the general practitioners, cardiologists, vascular surgeons and other practitioners.

Guideline 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)

8.1a 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)

8.1b 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)

8.1c 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 1–8 years of age, and should ideally deliver pediatric doses and have an arrhythmia detection algorithm.4648(C)

8.1d The goal should be the availability of AEDs in all dialysis units within 12 months of the publication of these Guidelines. (C)

Rationale

Sixty-one percent of all cardiac deaths in dialysis patients have been attributed to arrhythmic mechanisms.17 The rate of cardiac arrest during HD has been reported to be 7 events per 100,000 dialysis sessions.95 The mortality rate immediately following cardiac arrest in the general population is 7%-10% per minute, and survival is unlikely if defibrillation does not occur within 10 minutes. Therefore, rapid defibrillation is essential for improving survival in dialysis patients experiencing cardiac arrest. The safety and efficacy of AEDs have been validated in diverse settings, such as airports, casinos, and commercial aircraft. They are designed to be used even by nonmedical personnel, and do not require advanced training or advanced cardiac life support (ACLS) certification. (Moderately Strong)

In a study based on Emergency Medical Services (EMS) data in Seattle and King County from 1990–1996, there were 47 cardiac arrests in dialysis centers, with an annual incidence per center of 0.746.137 There were 41 witnessed events, and bystander CPR was administered in 41 patients. In 29 patients (62%) the cardiac rhythm was ventricular fibrillation (VF) or ventricular tachycardia (VT). While the overall survival to hospital discharge was 30%; it was 38% for the VT/VF patients. These data reflect the expertise of EMS crews in Seattle/King County and make a compelling case for on-site defibrillator capability in all dialysis units.

Pediatric-modified, FDA-approved AEDs are now commercially available; thus the official AHA Guidelines 2000 on Resuscitation, which do not support the use of AEDs in smaller children are no longer current.138 Evidence for this recommendation is provided by studies in children46,48 It is anticipated that all AEDs approved for sale in the U.S. will be equipped with optional modules or other electrode modifications suitable for pediatric use (children <25 kg and <8 years old) by the time these Guidelines are published, but it is recommended that individual dialysis units verify the AED capabilities of on-site units. The Commissioner of Health, New York State, has issued an official advisory (effective 7/01/02) promoting the safe and effective use of pediatric-modified AEDs in children under age 8.

Dialysis centers providing care for smaller children will need to establish their own protocols consistent with accepted pediatric practice guidelines for pediatric resuscitation. It is recommended that a pediatric nephrologist helps formulate center practice guidelines for this special group of patients. “Standard” AEDs (designed for use in patients 8 years or older) could thus be used with these removable pediatric modifications. These pediatric-modified devices deliver 50 Joules of electricity (compared to 200 Joules for standard AEDs). (Moderately Strong)

Limitations

Implementation issues

Research recommendations