The Burden of Heart Failure in End-Stage Renal Disease: Insights from a Retrospective Cohort of Hemodialysis Patients

Background: Heart failure (HF) is highly prevalent among patients on maintenance hemodialysis (HD) and contributes substantially to morbidity and mortality. This study aimed to evaluate the prevalence, clinical characteristics, and prognostic impact of HF in a chronic HD population. Methods: A single-center observational study was conducted on 271 HD patients (January 2022–September 2024). HF was defined and classified according to 2021 ESC criteria using echocardiography and NT-proBNP. Clinical, laboratory, and dialysis parameters were compared between HF and non-HF patients. Predictors of HF were assessed using multivariable logistic regression, and survival analyses were performed using Cox regression and Kaplan–Meier curves. Results: HF was identified in 75% of patients: 45% had a preserved EF, 31% had a mildly reduced EF, and 24% had a reduced EF. HF patients were older, had higher NT-proBNP, lower EF, more atrial fibrillation, CAD, and increased interdialytic weight gain. In the multivariable analysis, a reduced EF (OR = 0.77, p = 0.001), older age (OR = 1.12, p = 0.001), and UF rate (OR = 1.31, p = 0.02) were found to independently predict HF. During the 34-month follow-up, HF was found to be associated with significantly higher all-cause and cardiac mortality and more frequent HF-related hospitalizations (log-rank p < 0.001). In the multivariable Cox regression, two variables were found to independently predict all-cause death, NT-proBNP (per 1000 pg/mL) (HR 1.030, p = 0.029) and a lower EF: (HR 0.97, p = 0.019). For cardiac death, a higher NT-proBNP (HR 1.038, p = 0.033) and a lower EF (HR 0.933, p = 0.001) together with a lower BMI (HR = 0.929, p = 0.028) persisted as independent predictors. Conclusions: HF is extremely common in HD patients and identifies a subgroup with distinct clinical characteristics and poor prognosis. NT-proBNP and left ventricular ejection fraction are key independent predictors of mortality, underscoring the importance of early cardiac evaluation and integrated volume and dialysis management to improve outcomes.