What is the next recommended step in management for a 72-year-old male patient with Chronic Kidney Disease (CKD), a past medical history (PMH) of Heart Failure with preserved Ejection Fraction (HFpEF) of 51%, atrial fibrillation (afib) on rivaroxaban (Xarelto), Type 2 Diabetes Mellitus (TIIDM), Hypertension (HTN), and Obstructive Sleep Apnea (OSA)?

From the Guidelines

The next recommended step in management for this patient's CKD is to optimize RAAS inhibition with an ACE inhibitor or ARB, and consider adding an SGLT2 inhibitor, while also managing his multiple comorbidities, including heart failure, atrial fibrillation, type 2 diabetes, hypertension, and obstructive sleep apnea. The patient's complex medical history, including HFpEF, atrial fibrillation, type 2 diabetes, hypertension, and OSA, necessitates a comprehensive approach to managing his CKD, with a focus on reducing morbidity, mortality, and improving quality of life 1.

Key Management Strategies

• Optimizing RAAS inhibition with an ACE inhibitor or ARB, such as lisinopril 10mg daily or losartan 50mg daily, with careful monitoring of kidney function and potassium levels 1-2 weeks after initiation 1
• Considering the addition of an SGLT2 inhibitor, such as empagliflozin 10mg daily or dapagliflozin 10mg daily, to provide cardiorenal protection and benefit both CKD and heart failure 1
• Controlling blood pressure to a target of <130/80 mmHg, while also optimizing diabetes management with a target HbA1c of 7-8% considering the patient's age and comorbidities 1
• Continuing rivaroxaban for stroke prevention with atrial fibrillation, with potential dose adjustment based on kidney function, and assessing and optimizing CPAP therapy compliance for OSA

Rationale

The use of RAAS inhibitors and SGLT2 inhibitors has been shown to slow CKD progression and improve heart failure outcomes, while also providing glycemic control 1. The patient's multiple comorbidities require a multidisciplinary approach to management, involving primary care physicians, nephrologists, endocrinologists, cardiologists, and dietitians, to address underlying comorbidities and prevent further complications 1. By prioritizing the patient's CKD management and addressing his multiple comorbidities, we can reduce his risk of morbidity, mortality, and improve his quality of life.

From the FDA Drug Label

In patients with CrCl <30 mL/min a dose of XARELTO 10 mg once daily is expected to result in serum concentrations of rivaroxaban similar to those in patients with moderate renal impairment (CrCl 30 to <50 mL/min) Patients with Chronic Kidney Disease not on Dialysis Patients with a CrCl <15 mL/min at screening were excluded from COMPASS and VOYAGER, and limited data are available for patients with a CrCl of 15 to 30 mL/min.

The next recommended step in management for a patient's CKD is not directly stated in the provided drug label, as it does not provide specific guidance on the management of CKD. However, it does provide information on the use of rivaroxaban in patients with chronic kidney disease.

• Dose adjustment may be necessary for patients with CrCl <30 mL/min.
• The patient's renal function should be closely monitored.
• Signs and symptoms of blood loss should be promptly evaluated in patients with CrCl 15 to <30 mL/min. However, the FDA drug label does not provide a clear answer to the question of the next recommended step in management for a patient's CKD. 2

From the Research

Management of CKD

The patient's CKD management should focus on controlling blood pressure and reducing cardiovascular risk.

• The American College of Cardiology/American Heart Association 2017 hypertension guidelines recommend a blood pressure goal of <130/80 mm Hg for patients with CKD and others at elevated cardiovascular risk 3.
• A BP goal of <130/80 is a reasonable, evidence-based BP goal in patients with CKD, as it may reduce mortality in patients with CKD 3.
• The European Society of Cardiology (ESC) recommends office BP targets for people with CKD of <140-130 mmHg SBP and <80 mmHg DBP 4.
• The Kidney Disease: Improving Global Outcomes (KDIGO) suggests an SBP target of <120 mmHg, when tolerated 4.

Use of ACEi/ARB

The use of Angiotensin-Converting Enzyme Inhibitors (ACEi) and Angiotensin Receptor Blockers (ARB) in patients with CKD is a topic of debate.

• There is insufficient evidence to determine the effectiveness of ACEi or ARB in patients with stage 1 to 3 CKD who do not have DM 5.
• The available evidence is overall of very low certainty and high risk of bias 5.
• ACEi and ARB may be beneficial in reducing cardiovascular events and slowing CKD progression, but their use should be individualized and monitored closely 6.

Monitoring and Follow-up

Regular monitoring of blood pressure, kidney function, and cardiovascular risk factors is essential in managing CKD.

• Increased adverse events, including electrolyte abnormalities and decreased eGFR, necessitate careful laboratory monitoring 3.
• The patient's blood pressure should be monitored regularly, and the treatment plan should be adjusted as needed to achieve the target blood pressure goal 3, 4.