What is the treatment for a patient with chronic heart failure with preserved ejection fraction (HFpEF) and chronic kidney disease stage 4 (CKD 4)?

Treatment of Heart Failure with Preserved Ejection Fraction and CKD Stage 4

SGLT2 inhibitors are the cornerstone of treatment for patients with HFpEF and CKD stage 4, with careful diuretic management for symptom control. 1, 2

Pharmacological Management

First-Line Therapies

• SGLT2 inhibitors (dapagliflozin or empagliflozin)

  • Effective in reducing heart failure hospitalizations in HFpEF patients 1
  • Safe and effective in CKD stage 4 (eGFR ≥25 mL/min/1.73m² for dapagliflozin or ≥20 mL/min/1.73m² for empagliflozin) 2
  • Monitor for initial decline in eGFR, which typically stabilizes over time 2

• Diuretics

  • Use loop diuretics judiciously for congestion and symptom relief 1
  • Start with low doses (e.g., furosemide 20-40mg) and adjust based on symptoms 1
  • Monitor closely for dehydration, hypotension, and worsening renal function 1
  • Avoid thiazide diuretics as they are not recommended when eGFR <30 mL/min 1

Second-Line Therapies

• Mineralocorticoid Receptor Antagonists (MRAs)

  • Consider in selected patients with careful monitoring
  • Use very low starting doses (6.25-12.5mg daily or 12.5mg every other day) 3
  • Monitor potassium and renal function closely
  • Discontinue if persistent hyperkalemia or significant worsening of renal function occurs

• Beta-blockers

  • Indicated for specific comorbidities: prior myocardial infarction, angina, or atrial fibrillation 1
  • Monitor for chronotropic incompetence affecting exercise tolerance 1
  • Of the recommended beta-blockers, bisoprolol may accumulate in renal impairment but can still be titrated to target dose with careful monitoring 3

Therapies to Use with Caution

• ACE inhibitors/ARBs

  • May provide modest benefit in reducing HF hospitalizations 4
  • Start at very low doses with close monitoring of renal function and potassium 2
  • Accept small initial decline in eGFR if clinically stable 2

• Sacubitril/valsartan (ARNI)

  • Not recommended in patients with eGFR <30 mL/min/1.73m² 3

Management of Comorbidities

Hypertension Control

• Target blood pressure control while balancing risk of hypotension
• Calcium channel blockers may be considered for hypertension management in HFpEF (unlike in HFrEF) 1

Atrial Fibrillation Management

• Rate control is essential in patients with AF
• Beta-blockers or rate-limiting calcium channel blockers (verapamil) may improve exercise capacity and symptoms 1

Volume Status Monitoring

• Teach patients to monitor daily weight and adjust diuretics if weight increases by 1.5-2.0 kg over 2 days 5
• Regular assessment of symptoms, vital signs, and volume status 5

Lifestyle Modifications

• Moderate sodium restriction, especially in severe heart failure 5
• Regular aerobic exercise to improve functional capacity 5
• Limit alcohol consumption 5
• Smoking cessation 5

Monitoring Recommendations

• Check electrolytes, BUN, and creatinine:
  • 1-2 weeks after initiation or dose changes of diuretics, ACEi/ARBs, or MRAs
  • More frequently in unstable patients
• Monitor daily weight, urine output, and clinical status 5

Pitfalls and Caveats

• Don't discontinue HF medications solely based on mild, stable decline in eGFR if the patient is clinically improving 2
• Avoid rapid correction of hyponatremia and excessive diuresis 5
• Absolutely avoid NSAIDs due to risk of worsening renal function and fluid retention 5
• Be aware that most HFpEF trials excluded patients with advanced CKD (stage 4-5), limiting the evidence base 2, 6
• Hyperkalemia is a significant concern with RAASi and MRAs in advanced CKD; close monitoring is essential 7

This treatment approach balances the benefits of disease-modifying therapies with the risks of worsening renal function in this challenging patient population.