From the Guidelines
Entresto (sacubitril/valsartan) should not be used in patients with End-Stage Renal Disease (ESRD). The use of sacubitril/valsartan in patients with severe renal impairment (eGFR <30 mL/min/1.73 m2) requires a reduced starting dose, but even with dose adjustment, the risk of worsening renal function and hyperkalemia remains a concern 1.
- Key considerations for using sacubitril/valsartan in patients with renal impairment include:
- Reduced starting dose to 24/26 mg twice daily for patients with severe renal impairment (eGFR <30 mL/min/1.73 m2)
- Close monitoring of renal function and electrolyte levels
- Avoidance of concomitant use with other medications that may increase the risk of hyperkalemia or worsening renal function In patients with ESRD, alternative therapies, such as ACE inhibitors or beta blockers, may be considered for the management of heart failure, under close monitoring of renal function and electrolyte levels 1.
From the Research
Use of Entresto (Sacubitril/Valsartan) in End-Stage Renal Disease (ESRD)
- Entresto (sacubitril/valsartan) is a combination of neprilysin inhibitor and angiotensin II receptor blocker that has proven efficacy and safety in heart failure patients 2.
- However, the use of sacubitril/valsartan in end-stage renal disease (ESRD) patients is still controversial due to the potential risk of hypotension and hyperkalemia 2.
- Some studies suggest that sacubitril/valsartan may be beneficial for patients with chronic kidney disease (CKD), including those with ESRD, by improving cardiovascular outcomes and reducing the risk of cardiovascular death or heart failure hospitalization 3, 4, 5, 6.
- A meta-analysis of six trials with a total of 6217 patients with CKD found that sacubitril/valsartan attenuated the risk of cardiovascular death or heart failure hospitalization and prevented the incidence of serum creatinine elevation among patients with CKD 3.
- A retrospective cohort study of 2860 patients with heart failure with reduced ejection fraction (HFrEF) and coexisting ESRD found that sacubitril/valsartan treatment was associated with significantly lower 5-year all-cause mortality and greater left ventricular ejection fraction (LVEF) improvement compared to candesartan or valsartan 4.
- A study of 12 hemodialysis patients with HFrEF found that administration of sacubitril/valsartan for six months improved ejection fraction and quality of life, with no major adverse effects reported 5.
- Another study found that sacubitril/valsartan improved left ventricular systolic and diastolic function in patients with HFrEF and end-stage kidney disease, with no increase in serum potassium levels 6.
Key Findings
- Sacubitril/valsartan may be beneficial for patients with ESRD by improving cardiovascular outcomes and reducing the risk of cardiovascular death or heart failure hospitalization.
- The use of sacubitril/valsartan in ESRD patients is still controversial due to the potential risk of hypotension and hyperkalemia.
- Further large-scale randomized controlled trials are needed to confirm the efficacy and safety of sacubitril/valsartan in ESRD patients 2, 3, 4, 5, 6.