What is the best treatment approach for a patient with Acute Decompensated Heart Failure (ADHF) and End-Stage Renal Disease (ESRD)?

Management of Acute Decompensated Heart Failure with End-Stage Renal Disease

In patients with ADHF and ESRD, ultrafiltration should be strongly considered as the primary decongestion strategy when diuretics fail to achieve adequate fluid removal, while maintaining guideline-directed medical therapy unless hemodynamic instability exists. 1

Immediate Assessment and Risk Stratification

Upon presentation, rapidly assess for high-risk features that mandate ICU-level care: 1, 2

• Respiratory rate >25 breaths/min or SpO2 <90%
• Systolic blood pressure <90 mmHg with signs of hypoperfusion
• BUN ≥43 mg/dL or creatinine ≥2.75 mg/dL (though ESRD patients will exceed this)
• Altered mental status, oliguria, or cold peripheries

Obtain immediate ECG and cardiac troponin to rule out acute coronary syndrome as a precipitant, as this requires urgent revascularization. 3, 2

Decongestion Strategy: The Critical Difference in ESRD

Initial Diuretic Approach

Standard ADHF protocols recommend IV loop diuretics at doses equal to or exceeding chronic oral doses (or 40 mg furosemide if diuretic-naïve). 3, 2 However, in ESRD patients, loop diuretics have severely diminished efficacy due to minimal residual renal function, making standard doses inadequate. 4

If attempting diuretics in ESRD: 1

• Use very high doses of IV loop diuretics (often 2-4 times standard doses)
• Consider adding metolazone for synergistic effect
• Monitor hourly urine output initially—if <100-200 mL/hour after 2-6 hours, diuretics are failing

Ultrafiltration: The Preferred Strategy

When diuretics fail to achieve adequate decongestion in ADHF with ESRD—which is the expected scenario—ultrafiltration (continuous veno-venous hemofiltration) becomes necessary and should be implemented without delay. 1, 5, 6

Ultrafiltration advantages in this population: 1, 6

• Achieves predictable, controlled fluid removal independent of renal function
• Avoids further electrolyte derangements (hypokalemia, hyponatremia) common with escalating diuretic doses
• May restore diuretic responsiveness if residual renal function exists
• Reduces sympathetic activation and improves hemodynamics

The CARRESS-HF trial specifically studied ultrafiltration versus stepped pharmacologic care in cardiorenal syndrome, demonstrating that ultrafiltration provides superior decongestion when renal function is severely impaired. 5, 6

Hemodynamic Management Based on Blood Pressure

If SBP >110 mmHg (Hypertensive ADHF)

Add IV vasodilators (nitroglycerin or nitroprusside) to reduce preload and afterload, which improves cardiac output and symptom relief. 3, 2

• Start nitroglycerin 10-20 mcg/min, titrate to symptom relief and BP response
• Target initial BP reduction of 30 mmHg systolic over minutes to hours, not to normal values 1

If SBP 90-110 mmHg (Normotensive ADHF)

Continue ultrafiltration as primary therapy without vasodilators. 3, 2

If SBP <90 mmHg with Hypoperfusion Signs

Hold all diuretics and vasodilators immediately. Consider inotropic support (dobutamine 2.5-5 mcg/kg/min) to restore perfusion before resuming decongestion. 3, 2, 7

Critical caveat: Inotropes increase mortality risk and should ONLY be used when hypotension coexists with end-organ hypoperfusion (altered mentation, oliguria, cold extremities, lactate >2 mmol/L). 2, 7

Guideline-Directed Medical Therapy Management

Continue ACE inhibitors/ARBs and beta-blockers during ADHF hospitalization unless SBP <90 mmHg with end-organ dysfunction. 1, 3, 2

The common pitfall is reflexively stopping these medications in ESRD patients due to elevated creatinine—but in ESRD, creatinine is chronically elevated and not a reason to discontinue GDMT. 1

Hold GDMT only if: 1

• SBP <85 mmHg persistently
• Heart rate <50 bpm (for beta-blockers)
• Potassium >5.5 mmol/L (for ACE-I/ARB/MRA)
• Cardiogenic shock

Respiratory Support

Administer supplemental oxygen if SpO2 <90%, targeting 94-96%. 2

For severe dyspnea with pulmonary edema, initiate non-invasive positive pressure ventilation (CPAP or BiPAP) immediately—this reduces work of breathing and improves oxygenation while awaiting fluid removal. 2, 4

Reserve intubation for patients failing non-invasive ventilation. 4

Essential Monitoring During Hospitalization

Daily monitoring must include: 1, 3, 2

• Daily weights (target 0.5-1.0 kg loss daily until euvolemic)
• Strict intake/output records
• Daily electrolytes (especially potassium), BUN, creatinine
• Continuous telemetry for arrhythmias
• Clinical assessment of perfusion (mentation, urine output, extremity warmth) and congestion (JVP, edema, lung exam)

In ESRD, creatinine changes are less meaningful than volume status and perfusion markers. 4

Additional Critical Interventions

Administer venous thromboembolism prophylaxis (low molecular weight heparin or unfractionated heparin) unless already anticoagulated or contraindicated. 3, 2

Evaluate for precipitating factors specific to ESRD: 4, 8

• Missed dialysis sessions
• Dietary sodium/fluid non-compliance
• Anemia from erythropoietin deficiency
• Metabolic acidosis
• Infection (obtain cultures if febrile or leukocytosis)

Discharge Criteria and Follow-Up

Do not discharge until the patient is hemodynamically stable, euvolemic, and established on oral GDMT for at least 24 hours. 1, 2

Arrange: 1, 2

• Telephone follow-up within 3 days
• Outpatient visit within 7-14 days with heart failure specialist or nephrologist
• Coordination with dialysis center for ongoing volume management

The key to preventing readmission in ADHF with ESRD is achieving complete decongestion before discharge—patients sent home with residual volume overload have high early readmission rates. 1