Risk stratification and determinants of cardiac recovery in hemodialysis patients with reduced ejection fraction

Heart failure and atherosclerotic comorbidities are common among patients receiving maintenance hemodialysis, yet therapeutic options remain limited. We aimed to clarify the long-term prognostic impact of reduced left ventricular ejection fraction (LVEF) and coronary heart disease (CHD) and explore potential determinants of cardiac recovery in this population. We retrospectively analyzed 310 hemodialysis patients who underwent coronary angiography for suspected CHD. Patients were stratified by baseline LVEF (< 40% vs. ≥ 40%) and the presence of CHD. Five-year mortality was compared between the groups, and associations with coronary intervention were examined. In a subset with follow-up echocardiography, changes in LVEF were analyzed in relation to medication use, coronary intervention, and relative post-dialysis body weight reduction. Patients with reduced LVEF had worse survival than those with normal LVEF (log-rank p = 0.001). Moreover, patients with reduced LVEF and concomitant CHD exhibited the poorest prognosis (log‑rank p = 0.001). Neither PCI nor medical therapy was associated with improvement in LVEF. In contrast, greater post-dialysis body weight reduction independently predicted attenuated recovery of cardiac function (HR 0.89; 95% CI 0.81-0.98; p = 0.018), with continuous analyses confirming an inverse relationship between ultrafiltration intensity and ΔLVEF. In hemodialysis patients with reduced LVEF, the coexistence of CHD requiring intervention identifies a high-risk phenotype, while cardiac recovery appears more strongly influenced by dialysis-related physiology than by conventional therapies. These findings highlight the need for personalized care strategies that integrate ischemic risk assessment with individualized dialysis management.