Cardiovascular Trials in Hemodialysis: Closing the Evidence Gap

Cardiovascular disease (CVD) is highly prevalent in patients receiving hemodialysis and is the leading cause of mortality in this population. Cardiovascular randomized clinical trials frequently exclude patients with kidney failure or on hemodialysis for a variety of reasons, and the current practice is generally to apply guidelines for the management of CVD in patients without kidney failure to patients on hemodialysis. However, the benefits seen in patients without kidney failure have not always translated to those receiving hemodialysis, because the etiology of vascular disease differs, drug metabolism varies, the risk for individual outcomes is different, and the patients are subject to higher all-cause mortality risk. There are several barriers to conduct cardiovascular outcome trials in patients receiving hemodialysis and more efforts are needed to bridge the evidence gap for this population. In this narrative review, we discuss the current state of cardiovascular outcome trials in patients receiving hemodialysis, the barriers that have hindered clinical trial conduct, the potential opportunities in studying this population, and the solutions as well as future directions to improve the evidence derived from clinical trials in patients on hemodialysis.