From the Guidelines
Renal function is a crucial factor in decision-making for advanced heart failure therapies, including mechanical support and transplant, according to European guidelines. The European Society of Cardiology (ESC) guidelines emphasize the importance of renal function, measured by estimated glomerular filtration rate (eGFR) and the presence of kidney disease, in selecting appropriate advanced therapies 1.
Key Considerations
- Severe irreversible renal dysfunction (eGFR <30 mL/min/1.73m²) is considered a contraindication for heart transplantation, potentially requiring combined heart-kidney transplantation instead.
- Renal dysfunction significantly impacts patient selection and outcomes for mechanical circulatory support devices like left ventricular assist devices (LVADs), with severe renal impairment associated with higher post-implantation mortality.
- The distinction between reversible (cardiorenal syndrome) and permanent renal dysfunction affects therapy selection, with temporary mechanical circulatory support considered as a bridge to decision in patients with acute kidney injury to determine if renal function recovers 1.
- Regular monitoring of renal function is essential during the management of advanced heart failure, with dose adjustments of medications like ACE inhibitors, ARBs, SGLT2 inhibitors, and diuretics based on renal parameters.
Evaluation and Management
The evaluation and management of kidney dysfunction in advanced heart failure involve careful consideration of clinical trajectories, preoperative, perioperative, and postoperative approaches to kidney disease for advanced surgical therapies, and key concepts in palliative care and decision-making processes unique to advanced heart/kidney medical interventions 1.
Importance of Renal Function
The emphasis on renal function reflects the complex interplay between heart and kidney function, where cardiac output affects renal perfusion, and kidney function impacts volume status, electrolyte balance, and drug metabolism in heart failure patients. Therefore, renal function should be carefully evaluated and monitored in patients with advanced heart failure to optimize outcomes and guide decision-making for advanced therapies.
From the Research
Importance of Renal Function in Advanced Heart Failure Therapies
- Renal function is a crucial factor in the management of heart failure, as it affects the patient's prognosis and treatment outcomes 2.
- The European guidelines emphasize the importance of assessing renal function in patients with heart failure, as it helps to determine the risk of adverse outcomes and guide treatment decisions 2, 3.
- Renal dysfunction is a common feature of congestive heart failure and is a stronger predictor of mortality than left ventricular ejection fraction or New York Heart Association classification 4.
Assessment of Renal Function
- The assessment of renal function is not limited to the estimation of glomerular filtration rate (eGFR) alone, but also includes the evaluation of sodium and water handling by the renal tubules 2.
- Different equations, such as the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Modification of Diet in Renal Disease (MDRD) formulas, can be used to estimate eGFR, but they may yield different results 5, 3.
- The choice of equation used to estimate eGFR can affect the classification of patients into different renal function categories and may impact treatment decisions 5, 3.
Implications for Advanced Heart Failure Therapies
- Patients with advanced heart failure may be candidates for life-prolonging therapies, such as heart transplantation or long-term mechanical circulatory support, and renal function is an important consideration in the selection of these patients 6.
- The evaluation of renal function is essential in determining the optimal treatment strategy for patients with advanced heart failure, including the use of guideline-directed medical therapy and the consideration of palliative care 2, 6.