Is it recommended to start a 76-year-old patient with End-Stage Renal Disease (ESRD) on dialysis and heart failure, with elevated B-type Natriuretic Peptide (BNP), on spironolactone, furosemide, and Entresto (sacubitril/valsartan)?

Management of Heart Failure in ESRD Patient on Dialysis

For a 76-year-old patient with ESRD on dialysis and heart failure with elevated BNP (4,378), it is not recommended to start spironolactone, furosemide, and Entresto (sacubitril/valsartan) together as a combination therapy.

Recommended Approach

Diuretic Management

• Loop diuretics like furosemide have limited efficacy in ESRD patients on dialysis since these patients have minimal residual kidney function 1
• High doses of furosemide (250-500mg) are associated with increased risk of hyponatremia in heart failure patients 2
• Diuretic dosing should be carefully considered in dialysis patients, as the risk of electrolyte abnormalities is significantly higher 1

Mineralocorticoid Receptor Antagonists (MRAs)

• Spironolactone use in ESRD carries a high risk of hyperkalemia, with rates reaching up to 36% in certain populations 1
• Elevated potassium is a main predictor of mortality in heart failure inpatients 1
• The patient's current potassium of 5.3 mEq/L is already elevated, making spironolactone a high-risk medication 1

ARNI (Sacubitril/Valsartan)

• Recent evidence suggests Entresto may be beneficial in ESRD patients on dialysis with heart failure 3, 4, 5
• Studies show improvement in left ventricular ejection fraction and reduction in BNP/NT-proBNP levels in dialysis patients treated with sacubitril/valsartan 3
• A 2023 study demonstrated reduced heart failure rehospitalization rates without significant effects on serum creatinine or potassium levels in dialysis patients 5

Recommended Treatment Algorithm

1. First-line approach: Consider sacubitril/valsartan (Entresto) monotherapy

   • Start at a low dose (49/51mg twice daily) and titrate as tolerated 3
   • Monitor for hypotension, especially with the patient's current blood pressure 1
   • Recent evidence supports its use in ESRD patients on dialysis 4, 5

2. Volume management:

   • Rather than furosemide, optimize ultrafiltration during dialysis sessions 4
   • Adjust dry weight targets based on clinical assessment 4

3. Avoid spironolactone due to:

   • Already elevated potassium level (5.3 mEq/L) 1
   • High risk of life-threatening hyperkalemia in ESRD 1
   • Limited evidence for benefit in dialysis patients 1

Important Monitoring Considerations

• Closely monitor serum potassium levels, especially if initiating Entresto 4
• Monitor blood pressure carefully, as hypotension is a common adverse effect of Entresto 1
• Regular assessment of volume status through clinical examination 4
• Consider regular BNP monitoring to assess treatment response 4

Common Pitfalls to Avoid

• Combining multiple drugs that affect potassium (spironolactone + Entresto) in an ESRD patient can lead to dangerous hyperkalemia 1
• Overdiuresis with furosemide in a dialysis patient can lead to hypotension and electrolyte abnormalities without significant benefit 1
• Starting multiple medications simultaneously makes it difficult to determine which agent is causing adverse effects 1

Special Considerations for ESRD Patients

• ESRD patients were excluded from most major heart failure clinical trials 1
• Dialysis effectively removes fluid, making loop diuretics less necessary 4
• Medication clearance is altered in ESRD, potentially leading to drug accumulation 1
• The risk-benefit profile of standard heart failure medications differs significantly in the ESRD population 1