What is the best management plan for an elderly female patient with acute on chronic diastolic heart failure, chronic kidney disease (CKD) stage 3B, debility, bilateral lower extremity edema, and shortness of breath, with a history of paroxysmal atrial fibrillation, essential hypertension, hypothyroidism, chronic anemia, vitamin D deficiency, protein-calorie malnutrition, and morbid obesity?

Management of Acute on Chronic Diastolic Heart Failure with CKD Stage 3B

Immediate Priorities

Continue aggressive diuresis with bumetanide while maintaining current RAAS inhibition, add SGLT2 inhibitor therapy, and optimize heart rate control with beta-blockers to maximize diastolic filling time. 1, 2

The patient demonstrates clinical compensation with improving volume status (weight reduction from 214.6 to 206-208 lb), stable renal function (Cr 1.06, GFR 52), and only trace bilateral lower extremity edema. This represents successful initial management that should be continued and optimized. 2, 3

Heart Failure Management

Diuretic Therapy

• Continue bumetanide at current dose given the favorable response with weight reduction and improved edema 2, 3
• Monitor daily weights with target maintenance at current 206-208 lb range 1
• If diuretic resistance develops, consider sequential nephron blockade with addition of thiazide-type diuretic (hydrochlorothiazide) or acetazolamide, though this increases risk of worsening renal function 1
• Tolerate acute eGFR decreases ≤30% after diuretic intensification—do not discontinue therapy prematurely 1

RAAS Inhibition

• Continue current ACE inhibitor or ARB therapy as cornerstone medication for diastolic dysfunction 2, 3
• These agents provide blood pressure control while directly improving ventricular relaxation and promoting regression of left ventricular hypertrophy 2
• With GFR 52 ml/min (CKD stage 3B) and stable creatinine, RAAS inhibition is safe and beneficial 1
• Target blood pressure <130/80 mmHg 2

Beta-Blocker Optimization

• Continue metoprolol and titrate to achieve resting heart rate 55-60 bpm to maximize diastolic filling period 2, 3
• Current heart rate 59-63 bpm is acceptable but could be optimized further 1
• Beta-blockers are proven effective across all CKD stages including dialysis 4

SGLT2 Inhibitor Addition

• Strongly recommend adding SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily) for patients with HFpEF and CKD 1
• SGLT2 inhibitors improve mortality and hospitalization in HFpEF with CKD stages 3-4 (eGFR >20 ml/min per 1.73 m²) 4, 5
• These agents provide additional diuretic effect, improve cardiac remodeling, and reduce HF hospitalizations 1
• Safe to use with current GFR 52 ml/min 1

Mineralocorticoid Receptor Antagonist Consideration

• Consider adding spironolactone 12.5-25 mg daily for additional RAAS blockade in HFpEF with CKD 1
• Monitor potassium closely (current K 4.4 is acceptable baseline) 1
• If hyperkalemia (K >5.0 mEq/L) develops, consider potassium binder to facilitate ongoing use rather than discontinuing therapy 1

Atrial Fibrillation Management

Rate Control

• Continue flecainide and metoprolol for rhythm and rate control 1, 3
• Target resting heart rate 55-60 bpm to optimize diastolic filling 2
• Consider adding digoxin 0.125 mg daily if rate control inadequate, using reduced dose given age and renal function 1

Anticoagulation

• Continue current anticoagulation regimen (likely apixaban or warfarin based on CKD stage 3B) 6
• Anticoagulation is essential in HF with atrial fibrillation regardless of ejection fraction 6

Renal Function Monitoring

Acceptable Changes

• Tolerate creatinine increases up to 30% from baseline during diuretic or RAAS inhibitor therapy 1, 7
• Current stable Cr 1.06 with GFR 52 indicates appropriate management 1
• These changes are often short-lived and reversible with volume optimization 7

Red Flags Requiring Intervention

• If creatinine increases >30% or GFR declines >30%: ensure euvolemia by adjusting diuretic dosage, discontinue nonessential nephrotoxic agents (NSAIDs, certain antibiotics), and evaluate alternative etiologies 1
• Avoid nephrotoxic agents including NSAIDs, aminoglycosides, and contrast dye when possible 1

Monitoring Frequency

• Check BMP weekly initially, then every 2-4 weeks once stable 1
• Monitor BUN, creatinine, GFR, electrolytes (particularly potassium) 1

Anemia Management

Current Status Assessment

• Hemoglobin 10.4 g/dL with normocytic indices (MCV 87.7) represents chronic anemia of CKD and chronic disease 6
• No acute intervention indicated at current level 6

Iron Evaluation and Treatment

• Check iron studies (serum iron, TIBC, ferritin, transferrin saturation) to assess for iron deficiency 6, 4
• If ferritin 100-300 ng/mL with TSAT <20%, this represents functional iron deficiency requiring treatment 6
• Intravenous iron is preferred over oral iron in HF patients with GFR <60 ml/min due to impaired absorption from intestinal edema and hepcidin upregulation 6, 4
• IV iron improves symptoms and reduces HF hospitalizations by 44% in patients with CKD 4

Nutritional Management

Protein-Calorie Malnutrition

• Low prealbumin (9 mg/dL) despite stable weight indicates inadequate protein synthesis 6
• Continue nutritional supplementation with high-protein supplements 6
• Target prealbumin >15 mg/dL with reassessment in 2-4 weeks 6
• Reinforce low-sodium (<2 grams daily), heart-healthy diet while ensuring adequate protein intake 1, 2

Vitamin D Deficiency

• Continue cholecalciferol supplementation (typically 1000-2000 IU daily) 6
• Current level 24.5 ng/mL is insufficient; target >30 ng/mL 6
• Recheck in 3 months 6

Blood Pressure Management

Current Status

• Blood pressures show variability (112/58 to 179/79 mmHg) requiring optimization 2
• Target BP <130/80 mmHg consistently 2

Medication Adjustment

• Continue metoprolol and minoxidil 2
• The elevated reading (179/79) suggests need for medication adjustment or adherence assessment 2
• Monitor BP every shift in skilled nursing facility 2

Obesity and Functional Status

Weight Management

• Current BMI approximately 41 kg/m² (morbid obesity) contributes to HF burden, hypertension, and reduced functional endurance 2
• Weight trend shows appropriate reduction from hospital discharge (214.6 to 206-208 lb) representing successful diuresis 2
• Continue dietary counseling emphasizing low-sodium, heart-healthy diet 2

Physical Therapy

• Continue PT/OT with focus on endurance and balance training 2
• Encourage moderate dynamic exercise (walking with walker, seated exercises) 2
• Discourage intense physical exertion and isometric exercises 2
• Elevate legs when seated to reduce dependent edema 2

Critical Medications to AVOID

• Do NOT use positive inotropic agents (dobutamine, milrinone) as systolic function is preserved and these may worsen diastolic dysfunction 2
• Avoid NSAIDs due to fluid retention, hypertension, and nephrotoxicity 1
• Avoid calcium channel blockers (except potentially verapamil for rate control if needed) as dihydropyridines cause peripheral edema 1

Common Management Pitfalls

Excessive Diuresis

• Most frequent error is over-diuresis leading to hypotension and reduced cardiac output 2, 3
• Diastolic HF requires adequate preload to maintain stroke volume 2
• Monitor for orthostatic hypotension, dizziness, and worsening renal function 1

Premature Discontinuation of RAAS Inhibitors

• Do not stop ACE inhibitors/ARBs for creatinine increases <30% or potassium <5.5 mEq/L 1, 7
• These medications are essential for long-term outcomes 2, 3
• Use potassium binders if needed to continue therapy 1

Inadequate Heart Rate Control

• Failure to optimize beta-blocker dosing perpetuates inadequate diastolic filling time 2
• Target heart rate 55-60 bpm at rest 2

Monitoring Parameters

Weekly Labs

• BMP (sodium, potassium, chloride, CO2, BUN, creatinine, glucose) 1
• CBC (hemoglobin, hematocrit) 6
• Calculate GFR from creatinine 1

Monthly Labs

• Comprehensive metabolic panel 1
• Magnesium, phosphorus 1
• Iron studies if anemia management initiated 6
• Prealbumin to assess nutritional status 6

Clinical Monitoring

• Daily weights (report changes >2-3 lbs in 24 hours or >5 lbs in one week) 1, 2
• Blood pressure every shift 2
• Edema assessment daily 2
• Orthostatic vital signs with medication changes 1

Biomarker Monitoring

• Consider NT-proBNP or BNP measurement to assess HF status and guide therapy 1
• Natriuretic peptides help identify worsening HF and determine prognosis 1
• Note that obesity may cause falsely low levels 1

Prognosis and Goals of Care

• Diastolic HF with CKD stage 3B carries substantial mortality risk requiring aggressive evidence-based management 2, 3
• Current clinical compensation represents optimal window for medication optimization 2
• Focus on preventing HF hospitalizations through medication adherence, volume management, and comorbidity control 1