In a patient with heart failure (HF) and impaired renal function, currently on beta-blocker, Angiotensin-Converting Enzyme Inhibitor (ACEI), spironolactone (aldactone), and dapagliflozin, do we need to change treatment due to a creatinine clearance of less than 30%?

Management of Heart Failure with Creatinine Clearance <30 mL/min

Continue all current medications (beta-blocker, ACEI, spironolactone, and dapagliflozin) with close monitoring, as the evidence strongly supports continuation of guideline-directed medical therapy even with severe renal impairment, given the mortality benefit outweighs the risks. 1, 2

Dapagliflozin Management

• Continue dapagliflozin even with CrCl <30 mL/min - the FDA label explicitly states that once enrolled in trials, patients were not required to discontinue therapy if eGFR fell below 25 mL/min/1.73 m² or if dialysis was initiated 3
• Pooled analysis of DAPA-HF and DELIVER trials demonstrated that patients with eGFR deterioration to <25 mL/min/1.73 m² who continued dapagliflozin had lower risk of primary outcomes (HR: 0.53; 95% CI: 0.33-0.83) compared to placebo, with no excess safety events 2
• The benefit-to-risk ratio favors continuation of dapagliflozin in patients experiencing deterioration of kidney function 2

ACEI Management

• Continue ACEI with dose adjustment rather than discontinuation - guidelines emphasize it is very rarely necessary to stop an ACE inhibitor and clinical deterioration is likely if treatment is withdrawn 1
• An increase in creatinine of up to 50% above baseline, or to 3 mg/dL (266 μmol/L), whichever is greater, is acceptable 1
• If creatinine rises by 100% or to above 4 mg/dL (354 μmol/L), halve the ACEI dose and recheck blood chemistry rather than stopping 1
• ACE inhibitors improve survival in patients with moderate renal insufficiency (GFR 30-60 mL/min/1.73 m²), though evidence is limited for more advanced dysfunction 4

Spironolactone Management

• Continue spironolactone if creatinine ≤2.5 mg/dL in men or ≤2.0 mg/dL in women and potassium <5.0 mEq/L 1
• The 2009 ACC/AHA guidelines recommend aldosterone antagonists in selected patients with moderately severe to severe HF symptoms who can be carefully monitored for preserved renal function and normal potassium 1
• Monitor potassium at 1 week, then at 1,2,3,6 months, and then 6-monthly if stable 1
• Halve the dose if potassium reaches 5.5-5.9 mmol/L; stop if it reaches 6.0 mmol/L 1

Beta-Blocker Management

• Continue beta-blocker at current dose - beta-blockers improve survival in patients with heart failure regardless of renal function 4, 5, 6
• Beta-blocker users with renal insufficiency had lower 12-month mortality (OR 0.75,95% CI 0.62-0.90) irrespective of renal function 5
• The beneficial effect of beta-blockers is unlikely to differ according to renal function 4

Monitoring Algorithm

Immediate actions:

• Check for concomitant disorders that could alter renal function (infection, diarrhea, hyperthermia, nephrotoxic drugs) 7
• Assess volume status: look for signs of congestion (elevated JVP, peripheral edema, pulmonary rales) versus dehydration (orthostatic hypotension, decreased skin turgor) 7
• Measure blood pressure and potassium level 1

Monitoring frequency:

• Recheck blood chemistry (urea, creatinine, K+) in 1-2 weeks after any medication adjustment 1
• If stable, monitor renal function every 3 months for patients on ACEI/ARB 1
• For spironolactone, monitor at 1 week, then 1,2,3,6 months, then 6-monthly 1

Medication Adjustments Based on Clinical Scenarios

If congestion present:

• Increase diuretic dose rather than stopping RAAS blockers 7
• Reassess volume status after diuretic adjustment 7

If dehydration present:

• Reduce diuretic dose if no signs of congestion 1
• Continue RAAS blockers at current dose 7

If hyperkalemia (K+ 5.5-5.9 mmol/L):

• Halve spironolactone dose 1
• Stop potassium supplements and potassium-retaining agents (triamterene, amiloride) 1
• Continue ACEI unless K+ ≥6.0 mmol/L 1

If severe hyperkalemia (K+ ≥6.0 mmol/L):

• Stop spironolactone 1
• Seek specialist advice before stopping ACEI 1

Common Pitfalls to Avoid

• Do not stop RAAS blockers based solely on creatinine elevation - RAAS blockers are not nephrotoxic drugs; they only have a functional effect on renal function 7
• Do not confuse hemodynamic changes with acute tubular necrosis - an initial dip in eGFR after SGLT2 inhibitor initiation is expected and reverses after discontinuation, suggesting acute hemodynamic changes rather than true kidney injury 1
• Do not withhold life-saving medications due to therapeutic nihilism - patients with renal insufficiency are less likely to be prescribed efficacious therapies but have better outcomes if they receive these medications 5
• Do not stop medications without specialist consultation - ideally, specialist advice should be sought before treatment discontinuation of ACEI 1