From the Guidelines
The optimal management for a patient with impaired renal function and heart failure with reduced ejection fraction (HFrEF) involves careful medication selection and monitoring, prioritizing renoprotection and cardioprotection to minimize morbidity, mortality, and improve quality of life. When managing such patients, it is crucial to consider the potential impact of medications on renal function, as highlighted in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1.
Key considerations include:
- Avoiding or using with caution medications that may worsen renal function or increase the risk of hyperkalemia, such as the combination of an ACE inhibitor, an ARB, and an MRA, as this combination is not recommended due to the increased risk of renal dysfunction and hyperkalaemia 1.
- Selecting medications that offer renoprotective effects, such as SGLT2 inhibitors, which have been shown to reduce mortality and heart failure hospitalizations while providing renoprotection.
- Careful titration of ACE inhibitors or ARBs, starting at low doses and adjusting based on renal function and potassium levels, as recommended for patients with impaired renal function and heart failure 1.
- The use of loop diuretics for volume management, with doses adjusted based on symptoms and renal function.
- Considering the addition of a mineralocorticoid receptor antagonist if the patient's eGFR is >30 mL/min/1.73m² and potassium is <5.0 mEq/L, with careful monitoring of renal function and electrolytes.
Regular monitoring of renal function, electrolytes, and volume status is essential, with adjustments made to maintain clinical stability while preserving kidney function, as emphasized in the management of heart failure with reduced ejection fraction, especially in patients with impaired renal function 1. This approach aims to balance the need for effective heart failure management with the need to protect renal function and minimize the risk of adverse effects.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Optimal Management for Patients with Impaired Renal Function and Heart Failure
The optimal management for patients with impaired renal function and heart failure with reduced ejection fraction (HFrEF) involves a comprehensive approach that considers the patient's renal function, serum potassium levels, and clinical profile.
- Renin-Angiotensin System Inhibitors: The use of renin-angiotensin system inhibitors, such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), is recommended in patients with HFrEF, including those with impaired renal function 2, 3. However, patients should be monitored frequently for worsening renal function and hyperkalemia.
- Sacubitril/Valsartan: Sacubitril/valsartan is not recommended in patients with an estimated glomerular filtration rate (eGFR) < 30 mL/min per 1.73 m2 2. However, studies have shown that sacubitril/valsartan can lead to a slower rate of decrease in eGFR and improved cardiovascular outcomes, even in patients with chronic kidney disease, despite causing a modest increase in urinary albumin/creatinine ratio (UACR) 4.
- Beta-Blockers: Beta-blockers, such as bisoprolol, carvedilol, and metoprolol succinate, are recommended in patients with HFrEF, including those with impaired renal function 2, 3. However, patients with renal impairment should be titrated to the target dose or the maximally tolerated dose, depending on their clinical response.
- Mineralocorticoid Receptor Antagonists: Mineralocorticoid receptor antagonist therapy should be considered in all patients with HFrEF and an eGFR ≥ 30 mL/min per 1.73 m2 2, 3. The starting dose should be low, and can be uptitrated based on the patient's renal function and serum potassium.
- Sodium-Glucose Cotransporter 2 Inhibitors: Sodium-glucose cotransporter 2 (SGLT2) inhibitors, such as dapagliflozin and empagliflozin, are effective at reducing adverse cardiovascular and renal outcomes in patients with HFrEF and chronic kidney disease (CKD) with an eGFR ≥ 25 mL/min per 1.73 m2 or ≥ 20 mL/min per 1.73 m2, respectively 2. However, declining kidney function is a risk due to the osmotic diuretic effect.
- Individualized Treatment: The treatment of patients with HFrEF should be individualized based on their clinical profile, including congestion, blood pressure, heart rate, renal function, and electrolytes 5. Practical recommendations on how to individualize heart failure therapy according to patient profile are provided.
Key Considerations
When managing patients with impaired renal function and HFrEF, it is essential to consider the following:
- Renal Function: Renal function should be monitored regularly, and drug dosing should be adjusted accordingly.
- Serum Potassium: Serum potassium levels should be monitored regularly, especially in patients taking renin-angiotensin system inhibitors, sacubitril/valsartan, or mineralocorticoid receptor antagonists.
- Clinical Profile: The clinical profile of the patient, including congestion, blood pressure, heart rate, renal function, and electrolytes, should be considered when individualizing treatment.
- Maximal Tolerated Dose: Patients should be titrated to the maximal tolerated dose of each medication, depending on their clinical response.