Diagnosis and treatment of heart failure with preserved ejection fraction in patients on hemodialysis

Heart failure (HF) is a frequent complication and the main cause of death in patients on dialysis. HF with preserved ejection fraction (HFpEF) is a complicated syndrome that manifests as diastolic dysfunction and increased left ventricular filling pressure. Few studies have investigated HFpEF in dialysis patients, so the diagnosis and treatment of HFpEF remains challenging. The recently published the Japanese Circulation Society (JCS)/the Japanese Heart Failure Society (JHFS) 2021 guidelines have reported a new diagnostic procedure for HF. In dialysis patients, HF is typically observed as left ventricular diastolic dysfunction in association with HFpEF. Recent reports have shown that risk factors for HF in dialysis patients include not only traditional risk factors, such as age, smoking, obesity, hypertension, dyslipidemia, and diabetes, but also nontraditional risk factors such as fluid overload, renal anemia, disorders of calcium and phosphate metabolism, uremic toxins, and malnutrition. In the management of dialysis patients, volume control is important for controlling intradialytic hypotension, which is associated with higher mortality. Also, adequate pharmacological treatment of HFpEF is difficult in these patients, so a robust protocol developed for non-dialysis patients with HFpEF may be useful for treating patients on dialysis. This review explores the characteristics of hemodialysis patients with HFpEF and diagnostic and treatment procedures for these patients.