Recent advances in the management of hemodialysis patients: a focus on cardiovascular disease

The number of patients requiring chronic hemodialysis is rapidly growing worldwide. Hemodialysis both greatly reduces quality of life and is associated with extremely high mortality rates. Management of care of patients requiring chronic hemodialysis is complex, and randomized controlled trials aimed at reducing primary outcomes of cardiovascular disease events, mortality, or both in this population have largely been unsuccessful. Topics of major concern in the management of maintenance hemodialysis patients as related to these outcomes include the overall cardiovascular disease burden, blood pressure control, anemia, abnormalities in mineral metabolism, and inflammation. The focus of this review is a discussion of these topics on the basis of current recommendations from major organizations, expert opinion, and the available randomized controlled trials to date. These issues are further complicated by sometimes conflicting observational and randomized controlled trial data. Overall, treatment options for reducing these endpoints in maintenance hemodialysis patients are limited, and future randomized controlled trials are essential to continuing to advance care in this population, with the goal of ultimately improving hard outcomes. Such trials should consider new therapies to better target these factors, additional risk factors that have not been well tested to date, and therapies with new targets, including inflammation.