What is the management approach for a patient with dilated cardiomyopathy (DCM) and chronic kidney disease (CKD)?

Management of Dilated Cardiomyopathy in Patients with Chronic Kidney Disease

For patients with dilated cardiomyopathy and chronic kidney disease, a comprehensive treatment approach should include RAAS inhibitors (ACE inhibitors or ARBs), beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, with careful dose adjustment based on renal function. 1

Pharmacological Management

First-Line Medications

• RAAS inhibitors (ACE inhibitors or ARBs) are recommended as cornerstone therapy for all patients with DCM and reduced ejection fraction, including those with CKD, as they significantly reduce mortality and morbidity 1
• Careful monitoring of renal function and potassium levels is essential when initiating RAAS inhibitors in CKD patients, with dose adjustments based on estimated glomerular filtration rate 2, 3
• Beta-blockers should be used in conjunction with RAAS inhibitors for optimal neurohormonal antagonism in DCM patients with CKD 1
• Mineralocorticoid receptor antagonists (MRAs) are beneficial in patients with symptomatic heart failure and reduced ejection fraction, but require close monitoring of potassium levels in CKD patients 1

Newer Therapies

• SGLT2 inhibitors are strongly recommended for DCM patients with CKD if eGFR is 30 to <90 mL/min/1.73 m², as they are associated with lower risk of renal endpoints 4
• Treatment with GLP1-RAs (liraglutide and semaglutide) should be considered for patients with DCM and CKD if eGFR is >30 mL/min/1.73m², as they are associated with lower risk of renal endpoints 4

Blood Pressure Management

• Blood pressure targets should be individualized in patients with DCM and CKD 4
• For patients with hypertension and CKD, SBP should be targeted to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 4
• In older patients (≥65 years) with DCM and CKD, the SBP goal should be in the range of 130-139 mmHg 4
• For patients with diabetes, CKD, and DCM, an SBP target <130 mmHg is reasonable, though there is less certainty than in non-diabetic populations 4

Device Therapy Considerations

• ICD therapy is recommended for DCM patients with CKD who have documented ventricular fibrillation or hemodynamically unstable ventricular tachycardia in the absence of reversible causes 4, 1
• Cardiac resynchronization therapy (CRT) should be considered in DCM patients with CKD who have left bundle branch block, especially when it may be contributing to cardiomyopathy 1
• The risk-benefit ratio of device therapy should be carefully evaluated in patients with advanced CKD, as they may have higher procedural complications and less certain benefits 4

Management of Arrhythmias

• Beta-blockers are recommended for patients with DCM, CKD, and reduced ejection fraction (<40%) to prevent sudden cardiac death 4
• Amiodarone should be considered in patients with an ICD who experience recurrent appropriate shocks despite optimal device programming 1
• Catheter ablation is recommended for bundle branch re-entry ventricular tachycardia refractory to medical therapy 1

Special Considerations for CKD Patients

• Regular screening for kidney disease is recommended in all DCM patients, with annual assessment of eGFR and urinary albumin:creatinine ratio 4
• Risk of contrast-induced nephropathy should be considered when performing coronary angiography in DCM patients with CKD 4
• Medication doses should be adjusted based on creatinine clearance, preferably using the Cockroft-Gault formula to avoid dosing errors that could lead to increased bleeding risk 4
• Intensive glucose control (HbA1c <7.0%) is recommended in patients with diabetes and CKD to decrease microvascular complications 4

Monitoring and Follow-up

• Regular assessment of cardiac function is essential to evaluate response to therapy and disease progression in DCM patients with CKD 1
• Monitoring of renal function and electrolytes (particularly potassium) is crucial when using RAAS inhibitors, MRAs, and diuretics in patients with DCM and CKD 2, 3
• Echocardiography is the most commonly used method for monitoring cardiac function, providing information on ventricular function, hemodynamics, and valvular status 1

Pitfalls and Caveats

• Despite strong clinical trial evidence and guideline recommendations, there are significant gaps in the use of guideline-directed medical therapy for patients with DCM and CKD 1
• Underuse and underdosing of recommended medications is common, with less than one-quarter of eligible patients receiving all three traditional medications (ACE inhibitor/ARB, beta-blocker, MRA) concurrently 1
• Careful monitoring is necessary when using aliskiren in patients with CKD and DCM, as it can cause normotensive ischemic acute kidney injury, especially with concomitant use of other RAAS inhibitors 5
• Renal dysfunction is an independent predictor of cardiovascular mortality in patients with both ischemic and non-ischemic DCM, highlighting the importance of optimizing renal function 6