Proposal for a functional classification system of heart failure in patients with end-stage renal disease: Proceedings of the Acute Dialysis Quality Initiative (ADQI) XI workgroup

Lakhmir S. Chawla, Charles A. Herzog, Maria Rosa Costanzo, James Tumlin, John A. Kellum, Peter A. McCullough, Claudio Ronco

Research output: Contribution to journalReview articlepeer-review

58 Scopus citations


Structural heart disease is highly prevalent in patients with chronic kidney disease requiring dialysis. More than 80% of patients with end-stage renal disease (ESRD) are reported to have cardiovascular disease. This observation has enormous clinical relevance because the leading causes of death for patients with ESRD are of cardiovascular disease etiology, including heart failure, myocardial infarction, and sudden cardiac death. The 2 systems most commonly used to classify the severity of heart failure are the New York Heart Association (NYHA) functional classification and the American Heart Association (AHA)/American College of Cardiology (ACC) staging system. With rare exceptions, patients with ESRD who do not receive renal replacement therapy (RRT) develop signs and symptoms of heart failure, including dyspnea and edema due to inability of the severely diseased kidneys to excrete sodium and water. Thus, by definition, nearly all patients with ESRD develop a symptomatology consistent with heart failure if fluid removal by RRT is delayed. Neither the AHA/ACC heart failure staging nor the NYHA functional classification system identifies the variable symptomatology that patients with ESRD experience depending upon whether evaluation occurs before or after fluid removal by RRT. Consequently, the incidence, severity, and outcomes of heart failure in patients with ESRD are poorly characterized. The 11th Acute Dialysis Quality Initiative has identified this issue as a critical unmet need for the proper evaluation and treatment of heart failure in patients with ESRD. We propose a classification schema based on patient-reported dyspnea assessed both pre- and post-ultrafiltration, in conjunction with echocardiography.

Original languageEnglish (US)
Pages (from-to)1246-1252
Number of pages7
JournalJournal of the American College of Cardiology
Issue number13
StatePublished - Apr 8 2014
Externally publishedYes

Bibliographical note

Funding Information:
A complete list of the ADQI Workgroup members is in the Online Appendix . The 11th international ADQI Consensus Conference was funded in part by generous support in the form of unrestricted educational grants from Alere Medical, Astute Medical, Fresenius Medical Care, and Gambro Medical . The sponsors had no input on the content of this manuscript. Dr. Costanzo has served as a consultant and speaker for Gambro Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.


  • ESRD
  • chronic kidney disease
  • classification
  • dyspnea
  • fluid overload
  • heart failure


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