How to manage medications in a patient with impaired renal function and heart failure with reduced ejection fraction?

From the Guidelines

Managing medications in a patient with impaired renal function (serum creatinine 2.2, basal 1.6, GFR 35) and heart failure with reduced ejection fraction requires careful dose adjustments and monitoring to prevent further renal deterioration and optimize cardiac function. When managing such patients, it is crucial to check for hypovolaemia/dehydration and exclude the use of other nephrotoxic agents, such as NSAIDs and trimethoprim, as recommended by the European Society of Cardiology guidelines 1. Key considerations include:

• Withholding mineralocorticoid receptor antagonists (MRA) if necessary
• Stopping thiazide diuretics if using concomitant loop and thiazide diuretics
• Considering reducing the dose of ACE inhibitors or ARB, given the patient's impaired renal function
• Avoiding NSAIDs unless essential, as they can further impair renal function
• Considering haemofiltration/dialysis if renal function continues to deteriorate Regular monitoring of blood chemistry is essential, usually only needed for a short period. Renin inhibitors are not recommended in heart failure, and calcium-channel blockers (CCBs) should be discontinued in patients with systolic heart failure unless absolutely necessary, due to their potential negative inotropic action 1. By carefully managing medications and monitoring renal function, it is possible to improve outcomes and prevent further cardiac and renal deterioration in patients with impaired renal function and heart failure with reduced ejection fraction.

From the FDA Drug Label

In patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, reduce the initial dose of lisinopril tablets to half of the usual recommended dose i.e., hypertension, 5 mg; systolic heart failure, 2.5 mg and acute MI, 2. 5 mg. For patients on hemodialysis or creatinine clearance < 10 mL/min, the recommended initial dose is 2.5 mg once daily

The patient has a serum creatinine of 2.2 and a GFR of 35, which indicates impaired renal function.

• The initial dose of lisinopril should be reduced to half of the usual recommended dose, which is 2.5 mg for heart failure.
• The dose can be up-titrated as tolerated to a maximum of 40 mg daily.
• Sacubitril and valsartan dose adjustment is not directly addressed in the provided labels for a patient with a GFR of 35.
• Lisinopril dose adjustment is based on the patient's renal function, as described above 2.

From the Research

Managing Medications in Patients with Impaired Renal Function and Heart Failure

Overview of Renal Function and Heart Failure

• Serum creatinine levels and estimated glomerular filtration rate (eGFR) are crucial in assessing renal function 3, 4, 5, 6, 7.
• A patient with a serum creatinine level of 2.2 and a basal eGFR of 35 indicates impaired renal function.
• Heart failure with reduced ejection fraction (HFrEF) requires careful management of medications to prevent further decline in renal function.

Medication Management

• Sacubitril/valsartan has been shown to reduce the risk of cardiovascular mortality in patients with HFrEF, with similar effects on kidney function as irbesartan 3.
• A meta-analysis found that sacubitril/valsartan increased eGFR and decreased blood pressure and NT-proBNP levels in patients with heart failure and chronic kidney disease (CKD) 4.
• Low-dose sacubitril/valsartan may slow down renal function decline and reverse myocardial remodeling in patients with CKD and heart failure with preserved ejection fraction (HFpEF) 5.
• Individualizing treatment for patients with HFrEF involves adapting therapy to the clinical profile, including congestion, blood pressure, heart rate, renal function, and electrolytes 6.
• Real-life data confirms the favorable renal outcome in patients with HFrEF treated with sacubitril/valsartan, with improved eGFR and decreased blood pressure 7.

Considerations for Patients with Impaired Renal Function

• Patients with CKD may require lower doses of sacubitril/valsartan, and careful monitoring of renal function and electrolytes is necessary 3, 5, 6, 7.
• The incidence of adverse reactions, including hyperkalemia, should be closely monitored in patients with impaired renal function 3, 4, 6.
• Regular assessment of serum creatinine, eGFR, and urinary albumin:creatinine ratio can help guide medication management and prevent further decline in renal function 3, 4, 5, 7.