How to manage a patient with Chronic Kidney Disease (CKD) and Congestive Heart Failure (CHF)?

Management of Patients with CKD and CHF

Initiate quadruple therapy with SGLT2 inhibitor, ACE inhibitor or ARB, beta-blocker, and mineralocorticoid receptor antagonist, uptitrated to maximally tolerated doses, as this combination addresses both cardiac and renal protection while reducing mortality and hospitalization. 1

Core Pharmacologic Strategy

SGLT2 Inhibitors (First Priority)

• Start an SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) immediately in all patients with CKD stages G1-G4 and heart failure, regardless of diabetes status. 2, 1
• SGLT2 inhibitors reduce heart failure hospitalizations, slow CKD progression, decrease cardiovascular mortality, and improve diuretic efficacy through multiple mechanisms including reduced glomerular hyperfiltration. 2, 1, 3
• These agents have demonstrated benefit even in patients with eGFR as low as 20 mL/min/1.73 m². 3
• Continue SGLT2 inhibitors throughout CKD stages G1-G4; efficacy persists across this spectrum. 1

Renin-Angiotensin System Inhibition

• Initiate ACE inhibitor or ARB therapy in all patients with CKD and heart failure, targeting maximal tolerated doses rather than stopping at initial doses. 2, 1
• ARBs are preferred if ACE inhibitor intolerance develops (typically due to cough). 1
• Accept transient increases in serum creatinine up to 30% and mild hyperkalemia (potassium <5.5 mEq/L) when initiating or uptitrating these agents—do not discontinue prematurely. 1, 4
• Monitor renal function and potassium within 1-2 weeks after initiation or dose changes, then periodically. 4
• Only withhold or reduce dose if creatinine increases >30% or potassium exceeds 5.5 mEq/L persistently. 1, 4

Beta-Blocker Therapy

• Prescribe beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) to all patients with heart failure and CKD, including those on dialysis, as they improve outcomes across all CKD stages. 3
• Beta-blockers reduce mortality in heart failure with reduced ejection fraction (HFrEF) regardless of kidney function. 3
• Carvedilol and metoprolol do not require dose adjustment for renal impairment. 5, 6
• Uptitrate to target doses used in clinical trials (carvedilol 25 mg twice daily, metoprolol succinate 200 mg daily). 2

Mineralocorticoid Receptor Antagonists

• Add spironolactone or eplerenone for patients with HFrEF and CKD, particularly those with treatment-resistant hypertension or diuretic-resistant volume overload. 1, 7
• Monitor potassium closely; combination with ACE inhibitor/ARB increases hyperkalemia risk. 2, 4
• Consider newer non-steroidal MRAs (finerenone) which reduce cardiovascular and kidney outcomes in CKD with type 2 diabetes. 1

Volume Management

Diuretic Strategy

• Use loop diuretics (furosemide, torsemide, bumetanide) as primary agents for volume overload in CKD-CHF, often requiring higher doses than in patients without CKD. 7
• Thiazide-type diuretics lose efficacy when eGFR falls below 30 mL/min/1.73 m²; switch to loop diuretics at this threshold. 7
• For diuretic resistance, combine loop diuretics with thiazide-type diuretics (sequential nephron blockade) or add mineralocorticoid receptor antagonists. 7
• Consider subcutaneous furosemide (80 mg over 5 hours for 5 days) for stable patients with fluid overload to avoid hospitalization. 8
• Monitor daily weights, renal function, and electrolytes during aggressive diuresis. 8, 7

Target Fluid Status

• Aim for euvolemia without excessive diuresis that precipitates acute kidney injury. 7
• Adjust diuretic doses based on daily weights, clinical examination for edema, and symptoms. 8

Cardiovascular Risk Reduction

Lipid Management

• Prescribe high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) or statin/ezetimibe combination for all patients ≥50 years with eGFR <60 mL/min/1.73 m². 2
• For patients 18-49 years, initiate statins if they have coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10%. 2
• Maximize absolute LDL cholesterol reduction to achieve largest treatment benefits. 2
• Consider PCSK-9 inhibitors for patients with indications (e.g., familial hypercholesterolemia, statin intolerance, inadequate LDL reduction). 2

Antiplatelet Therapy

• Use low-dose aspirin (75-100 mg daily) for secondary prevention in patients with established ischemic cardiovascular disease. 2
• Consider P2Y12 inhibitors (clopidogrel, ticagrelor) if aspirin intolerance exists. 2
• Weigh bleeding risk against cardiovascular benefit, particularly in advanced CKD. 2

Blood Pressure Control

• Target blood pressure <140/90 mmHg in all CKD patients to prevent progression and reduce cardiovascular events. 1
• Use ambulatory blood pressure monitoring when available for accurate assessment. 2

Management of Anemia and Iron Deficiency

Iron Replacement

• Administer intravenous iron (iron sucrose or ferric carboxymaltose) to patients with heart failure and iron deficiency (ferritin <100 ng/mL or ferritin 100-300 ng/mL with transferrin saturation <20%), regardless of anemia status, to improve functional status and quality of life. 2
• IV iron is superior to oral iron in this population and reduces heart failure hospitalizations. 2, 3
• Assess iron status with serum ferritin and transferrin saturation at baseline. 2

Erythropoiesis-Stimulating Agents

• Do not use erythropoietin-stimulating agents (ESAs) in patients with heart failure and anemia, as they do not improve morbidity or mortality and may cause harm. 2
• This recommendation applies even when anemia is present; focus on iron repletion instead. 2

Coronary Artery Disease Management

Initial Approach

• For stable ischemic heart disease with CKD, prioritize intensive medical therapy over immediate invasive procedures. 2
• Intensive medical therapy includes optimal GDMT, statins, antiplatelet agents, and blood pressure control. 2

Indications for Invasive Strategy

• Pursue coronary angiography and revascularization for acute coronary syndromes, unstable angina despite optimal medical therapy, left ventricular systolic dysfunction attributable to ischemia, or left main coronary disease. 2
• Use iso-osmolar contrast agents and minimize contrast volume to prevent contrast-induced nephropathy. 9
• Ensure adequate hydration protocols before and after procedures. 9

Atrial Fibrillation Management

Anticoagulation

• Prescribe non-vitamin K antagonist oral anticoagulants (NOACs) preferentially over warfarin for thromboprophylaxis in atrial fibrillation with CKD stages G1-G4. 2
• Adjust NOAC doses based on eGFR; exercise caution in CKD stage G4 (eGFR 15-29 mL/min/1.73 m²). 2, 1
• Consider warfarin in CKD stage G5 (eGFR <15 mL/min/1.73 m²) as NOAC data are limited. 1
• Use opportunistic pulse-based screening followed by ECG or Holter monitoring to detect atrial fibrillation. 2

Rate Control

• Use beta-blockers as first-line agents for ventricular rate control, targeting resting heart rate <90 bpm. 2

Lifestyle and Dietary Modifications

Dietary Approach

• Recommend a plant-based Mediterranean-style diet to reduce both cardiovascular and kidney disease risk. 2, 1
• Limit dietary sodium intake to <2 grams per day. 2, 9
• Restrict protein intake to 0.8 g/kg body weight/day to slow CKD progression. 9
• Limit alcohol, red meat, and high-fructose corn syrup intake. 2, 9

Physical Activity

• Prescribe 150-300 minutes per week of moderate-intensity aerobic exercise (or 75-150 minutes of vigorous exercise). 9
• Reduce sedentary time and encourage regular physical activity. 1, 9

Monitoring and Follow-Up

Laboratory Surveillance

• Monitor eGFR, serum creatinine, potassium, and hemoglobin at baseline, 1-2 weeks after medication changes, then every 3-6 months. 1, 4
• Assess iron status (ferritin, transferrin saturation) at baseline and periodically. 2
• Check lipid panel to guide statin therapy intensity. 2

Clinical Assessment

• Evaluate volume status at each visit through weight, edema assessment, and symptom review. 8, 7
• Screen for atrial fibrillation with pulse checks and ECG when indicated. 2
• Assess functional status and quality of life using validated tools (NYHA class, 6-minute walk test). 2

Critical Pitfalls to Avoid

• Do not discontinue ACE inhibitors/ARBs prematurely for mild creatinine elevations (<30% increase) or potassium 5.0-5.5 mEq/L, as these medications provide critical cardio-renal protection. 1, 4
• Do not withhold SGLT2 inhibitors due to concerns about kidney function; they are beneficial across CKD stages G1-G4. 1, 3
• Do not use NSAIDs for pain management, as they worsen renal function and increase cardiovascular risk. 2
• Do not prescribe ESAs for anemia in heart failure; focus on IV iron replacement instead. 2
• Do not undertitrate GDMT medications; push to maximally tolerated target doses for optimal outcomes. 2, 1

Multidisciplinary Care

• Consider combined cardiology-nephrology clinics for complex patients with CKD-CHF, as this approach improves implementation of evidence-based therapy. 3
• Involve pharmacists for medication reconciliation and monitoring. 8
• Engage dietitians for sodium restriction and dietary counseling. 2
• Coordinate with primary care for longitudinal management and medication adjustments. 8