Managing Heart Failure with Chronic Kidney Disease on ACE Inhibitors or ARBs
Continue ACE inhibitors or ARBs in patients with heart failure and CKD unless specific safety thresholds are exceeded, and optimize guideline-directed medical therapy (GDMT) with beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors according to kidney function stage. 1
Continuation of ACE Inhibitors/ARBs
Continue ACE inhibitors or ARBs even when eGFR falls below 30 mL/min/1.73 m², as these medications reduce mortality in heart failure patients with CKD. 1, 2 The KDIGO 2024 guidelines explicitly state that ACEi/ARB therapy should be continued in people with CKD even when eGFR drops below 30 mL/min/1.73 m². 1
Safety Thresholds for ACEi/ARB Management
Monitor creatinine and potassium within 2-4 weeks after initiation or dose increase. 1, 3 For patients already on these medications, check renal function every 3 months if stable. 1
Continue therapy unless creatinine rises >30% within 4 weeks of initiation or dose increase. 1, 3 A 25% decrease in eGFR or 30% increase in creatinine from pretreatment levels is the maximum permitted change. 1
Reduce dose or discontinue if potassium rises to >6.0 mmol/L despite medical management. 1 For potassium 5.5-5.9 mmol/L, consider halving the MRA dose rather than stopping the ACEi/ARB. 1
Consider dose reduction in symptomatic hypotension or when eGFR <15 mL/min/1.73 m² with uremic symptoms. 1
Optimizing Guideline-Directed Medical Therapy
Beta-Blockers (All CKD Stages)
Beta-blockers reduce death by approximately 31% in heart failure patients with CKD and should be used in all stages including dialysis. 1, 4 Titrate metoprolol, carvedilol, or bisoprolol to target doses every 2 weeks if tolerated. 2 Only bisoprolol may accumulate in renal impairment, but patients should still be titrated to target dose (10 mg daily) or maximally tolerated dose. 5
Mineralocorticoid Receptor Antagonists
Start MRAs in patients with eGFR ≥30 mL/min/1.73 m² and potassium ≤5.0 mmol/L. 1
Begin with low doses: spironolactone 12.5 mg daily or eplerenone 25 mg daily. 1, 5 In patients with significant CKD, consider starting at 6.25-12.5 mg daily or 12.5 mg every other day. 5
Monitor potassium and creatinine at 1 week, then at 1,2,3,6 months, then 6-monthly if stable. 1
Halve the dose if potassium reaches 5.5-5.9 mmol/L; stop if ≥6.0 mmol/L. 1, 2
MRAs increase hyperkalaemia risk (RR 2.91) but this can often be managed with potassium-lowering measures rather than discontinuing therapy. 1, 6
SGLT2 Inhibitors
Add SGLT2 inhibitors for patients with eGFR ≥20 mL/min/1.73 m² (dapagliflozin or empagliflozin). 1 These agents reduce cardiovascular death and heart failure hospitalization in patients with CKD stages 3-4. 4, 5
Continue SGLT2i even if eGFR falls below 20 mL/min/1.73 m² after initiation, unless not tolerated or kidney replacement therapy is started. 1
Withhold during prolonged fasting, surgery, or critical illness due to ketosis risk. 1
The reversible eGFR decrease on initiation does not necessitate discontinuation. 1
Monitoring Schedule
Implement structured monitoring based on medication changes and CKD stage: 1
After any medication initiation or dose increase: Check renal function and electrolytes at 1-2 weeks, then at 4 weeks. 1
During stable therapy: Monitor at 3 months for patients on ACEi/ARB, then at 6,9, and 12 months, then every 4-6 months thereafter. 1
For MRA therapy: More intensive monitoring at 1 week, 1,2,3,6 months, then 6-monthly. 1
Critical Pitfalls to Avoid
Do NOT combine ACE inhibitors with ARBs or direct renin inhibitors—this triple RAAS blockade increases adverse effects without benefit. 1, 3, 7 The ESC guidelines explicitly state this combination is NOT recommended. 1
Avoid NSAIDs, which cause sodium retention, worsen renal function, and exacerbate heart failure. 1, 2, 8 NSAIDs may reduce the natriuretic and antihypertensive effects of diuretics and ACEi/ARBs. 8
Do not withhold evidence-based therapies based solely on CKD presence. 1, 9 Patients with CKD are systematically undertreated despite being at higher risk and having strong evidence for benefit in eGFR ≥20-30 mL/min/1.73 m². 4, 9
Manage hyperkalemia with potassium-lowering strategies rather than automatically stopping ACEi/ARB or MRA. 1 Consider dietary counseling, avoiding potassium-sparing diuretics, discontinuing potassium supplements, and using potassium binders if needed. 1
Diuretic Management
Use loop diuretics instead of thiazides when eGFR <30 mL/min/1.73 m². 1, 7 Furosemide combined with ACEi/ARB may lead to severe hypotension and deterioration in renal function; monitor closely and adjust doses as needed. 8
Separate furosemide and sucralfate administration by at least 2 hours to avoid reduced diuretic effect. 8