[14, 15] Heart failure may develop ‘de novo’ after receiving a kidney transplant. Using United States Medicare Claims data, the cumulative incidence of de novo CHF was 10.2% after 12 months and 18.3% after 36 months compared with 12.0% and 32.3%, respectively for patients remaining on dialysis on the transplant waiting list.[16] The cumulative incidence of de novo CHF in patients who survived the first post-transplant year without CHF

has been reported to be 3.6% at 5 years and 12.1% at 10 years.[17] The objectives of this guideline are to summarize the available evidence for the treatment of CHF in patients with CKD defined by a GFR < 60 mL/min not requiring dialysis, patients receiving dialysis and kidney transplant recipients. The following treatments have been FK506 considered: Blockade of the renin-angiotensin system Blockade of beta-adrenergic receptors Aldosterone antagonists BYL719 research buy Digoxin Vasodilators

(hydralazine and nitrates) Treatment of anaemia Strategies to control volume state Use of Implantable Devices Other therapies The recommendations for patients with CKD and kidney transplant are grouped together because these patients are similar in terms of current actual kidney function, and there are no trials that specifically enrolled kidney transplant recipients with CHF to study a heart failure intervention. It is acknowledged that kidney transplant recipients will differ in many ways from CKD, including time receiving dialysis, presence of arteriovenous fistula and immunosuppression. A number of RCTs have been performed in patients with CHF that provide a strong evidence base underpinning many guideline recommendations for the general population.[6, 18, 19] The recommendations for patients with CKD are based

on post-hoc analyses of RCTs of therapies in patients with heart failure. Although these are post-hoc analyses, a large proportion of patients in these studies had an eGFR < 60 mL/min per 1.73 m2 so the results of these trials can be applied to CKD Stage 3. However, PDK4 fewer patients in the trials had an eGFR < 30 mL/min per 1.73 m2 so this should be borne in mind when applying these guidelines to such patients. There are no data specifically for kidney transplant recipients but it is considered reasonable to apply the CKD recommendations to this group, acknowledging this lack of specific data. For dialysis patients, there are smaller trials of lower quality but these data are generally consistent with the CKD and general population data. *Explanation of grades The evidence and recommendations in this KHA-CARI guideline have been evaluated and graded following the approach detailed by the GRADE working group (http://www.gradeworkinggroup.org). A description of the grades and levels assigned to recommendations is provided in Tables 1 and 2. High quality of evidence. We are confident that the true effect lies close to that of the estimate of the effect. Moderate quality of evidence.