What guideline-directed medical therapy (GDMT) for heart failure can be started in a patient with acute kidney injury (AKI)?

GDMT for Heart Failure That Can Be Started During AKI

Beta-blockers can be safely initiated in patients with heart failure who develop acute kidney injury (AKI), provided they are hemodynamically stable without hypotension or shock. 1

Evidence-Based Approach to GDMT During AKI

Beta-Blockers

• The 2022 AHA/ACC/HFSA guidelines specifically state that "HFrEF patients requiring HF hospitalization on GDMT should continue GDMT except in cases of hemodynamic instability or where contraindicated" (Class I, Level B recommendation) 1
• Beta-blockers should be initiated at low doses after optimization of volume status and discontinuation of intravenous agents 1
• For patients who develop AKI during heart failure hospitalization:
  • If hemodynamically stable: Continue beta-blockers or initiate at low dose 1
  • If hypotensive or showing signs of shock: Temporarily withhold beta-blockers 1

Other GDMT Considerations During AKI

1. ACEi/ARB/ARNi (Renin-Angiotensin System Inhibitors)

   • Should be used cautiously in AKI
   • May need dose reduction or temporary discontinuation in severe AKI or hypotension 1, 2
   • Can be restarted at lower doses once renal function stabilizes 1

2. MRAs (Mineralocorticoid Receptor Antagonists)

   • Use with caution in AKI, especially with hyperkalemia risk
   • May need to be temporarily held during acute kidney injury 1, 3

3. SGLT2 Inhibitors

   • Recent evidence supports their use in heart failure regardless of kidney function 4
   • Can be initiated before discharge in stabilized patients 1
   • Should be avoided in severe AKI (eGFR <30 ml/min/1.73m²)

Practical Algorithm for GDMT Initiation in HF with AKI

1. Assess hemodynamic stability:

   • If unstable (SBP <90 mmHg, signs of shock): Hold all GDMT until stabilized
   • If stable: Proceed with cautious initiation/continuation of GDMT

2. For stable patients with AKI:

   • First priority: Start/continue beta-blockers at low dose (e.g., metoprolol 12.5mg daily or carvedilol 3.125mg twice daily) 1, 5
   • Monitor vital signs and renal function closely
   • Titrate slowly based on hemodynamic tolerance

3. Once stabilized with beta-blocker:

   • Consider adding SGLT2i if eGFR permits
   • Add ACEi/ARB at low dose when renal function begins to improve
   • Add MRA last, once potassium and renal function are stable

Important Monitoring Parameters

• Daily assessment of renal function and electrolytes
• Blood pressure and heart rate monitoring
• Signs of volume status and congestion
• Adjust diuretic therapy based on volume status

Common Pitfalls to Avoid

1. Completely discontinuing all GDMT during AKI - Evidence shows this leads to worse outcomes 1, 6
2. Failing to restart GDMT after AKI resolves - Many patients never get restarted on life-saving therapies 3
3. Excessive concern about mild renal function changes - Small increases in creatinine (up to 30%) may be acceptable with GDMT 1
4. Simultaneous initiation of multiple agents - Start with beta-blockers first, then add others sequentially

Special Considerations

• For severe AKI requiring dialysis, beta-blockers may still be used but require careful dose adjustment 6
• Patients with cardiorenal syndrome may particularly benefit from SGLT2i once stabilized 4
• Elderly patients and those with baseline CKD require more cautious dosing and closer monitoring 3

Remember that temporary adjustments to GDMT during AKI should be followed by careful reintroduction of these medications once the patient stabilizes, as they provide significant mortality benefit in heart failure patients, even those with kidney disease 4.