From the Guidelines
Patients with heart failure with reduced ejection fraction (HFrEF) who also have end-stage renal disease (ESRD) on hemodialysis (HD) should receive guideline-directed medical therapy (GDMT) with careful monitoring and dose adjustments, as outlined in the 2022 AHA/ACC/HFSA guideline 1. The goal of GDMT in these patients is to improve morbidity, mortality, and quality of life by reducing symptoms, slowing disease progression, and minimizing the risk of hospitalization and death.
Key Components of GDMT for HFrEF in ESRD Patients
- ACE inhibitors or ARBs: Start with low doses, such as lisinopril 2.5-5mg daily or losartan 25mg daily, and titrate slowly while monitoring potassium and blood pressure, particularly post-dialysis 1.
- Beta-blockers: Prefer agents with less renal clearance, such as carvedilol (starting at 3.125mg twice daily) or metoprolol succinate (starting at 12.5-25mg daily) 1.
- Mineralocorticoid receptor antagonists (MRAs): Use cautiously at low doses, such as spironolactone 12.5mg daily or every other day, with close potassium monitoring 1.
- SGLT2 inhibitors: Consider dapagliflozin 10mg daily, despite limited data in ESRD, as it has shown benefits in reducing CV death and HF hospitalization 1.
Important Considerations
- Volume status assessment: Collaborate between cardiology and nephrology to determine ultrafiltration goals.
- Medication administration timing: Give most heart failure medications after dialysis sessions to prevent excessive removal.
- Regular monitoring: Electrolytes, blood pressure, and symptoms should be closely monitored, with interdisciplinary management between cardiology and nephrology teams. While ESRD patients were often excluded from major heart failure trials, observational data suggests GDMT benefits outweigh risks when carefully implemented with appropriate dose adjustments and monitoring 1.
From the Research
Guideline-Directed Medical Therapy (GDMT) for Heart Failure with Reduced Ejection Fraction (HFrEF)
The GDMT for HFrEF consists of several medication classes, including:
- Renin-angiotensin system inhibitors, such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers 2, 3, 4
- Evidence-based β-blockers 2, 3, 4
- Mineralocorticoid inhibitors 3, 4
- Sodium glucose cotransporter 2 inhibitors 5, 3, 4
Considerations for Patients with End-Stage Renal Disease (ESRD) on Hemodialysis (HD)
For patients with ESRD on HD, the use of GDMT is often limited due to concerns about potential complications, such as hyperkalemia and hypotension 2, 4. However, studies have shown that GDMT can be safe and effective in patients with HFrEF and ESRD, even those on HD 4. The key is to carefully initiate and titrate these medications, monitoring for potential adverse effects 5, 3.
Strategies for Initiating or Modifying GDMT in Patients with HFrEF and ESRD
Strategies for initiating or modifying GDMT in patients with HFrEF and ESRD include:
- Starting with low doses and gradually increasing as tolerated 5, 3
- Monitoring renal function and electrolyte levels closely 2, 4
- Adjusting medications as needed to minimize the risk of adverse effects 5, 3
- Considering the use of sodium glucose cotransporter 2 inhibitors, which have been shown to be safe and effective in patients with HFrEF and ESRD 4
Barriers to GDMT Use in Patients with HFrEF and ESRD
Despite the benefits of GDMT, there are several barriers to its use in patients with HFrEF and ESRD, including: