Effective Heart Failure Management Strategies in Chronic Kidney Disease

In chronic kidney disease (CKD), managing medication for heart failure with reduced ejection fraction (HFrEF) presents significant challenges. The delicate balance required is complicated by potential issues like hyperkalemia from ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), Entresto (sacubitril/valsartan), or aldosterone antagonists. Additionally, SGLT2 inhibitors such as Forxiga can initially elevate serum creatinine levels, necessitating careful oversight to prevent exacerbating kidney dysfunction.

For effective HFrEF management, initiate therapy with an ACEI, ARB, or Entresto alongside an evidence-based beta-blocker like carvedilol. Diuretics should be used cautiously. Collaboration with nephrology specialists is crucial, particularly with eGFR below 30 mL/min/1.73 m² or potassium levels exceeding 5 mEq/L.

• Although clinical trials often exclude patients with these conditions, ACEIs or ARBs can generally be used with careful monitoring, even in dialysis patients, while beta-blockers are suitable across all eGFR levels.
• Start with a low initial dose (e.g., lisinopril 2.5 mg daily) and adjust gradually based on stable lab results and blood pressure readings.

Consider adding an SGLT2 inhibitor as the third medication, which improves outcomes for both HFrEF and CKD, independent of diabetes, and can be initiated with an eGFR as low as 20 mL/min/1.73 m². When starting an SGLT2 inhibitor, reduce diuretic doses to mitigate the risk of hypovolemia and acute kidney injury.

If eGFR is above 30 mL/min/1.73 m² and potassium levels are below 5 mEq/L, consider adding an aldosterone antagonist like spironolactone as a fourth medication a few weeks later to further enhance HFrEF management. Monitor electrolytes and kidney function closely, especially when initiating or adjusting medications. Regularly check labs initially, within 1 to 2 weeks post-initiation, and quarterly thereafter. If serum creatinine rises by more than 50%, pause SGLT2 inhibitors and adjust other medications' doses, except beta-blockers. Cease medications that elevate potassium levels if levels exceed 5.5 mEq/L. Consider retitrating medications 2 to 4 weeks after stabilization of lab values.

Take-home points

1. Initiate HFrEF treatment with ACE inhibitors, ARBs, or Entresto alongside beta-blockers like carvedilol, with cautious diuretic use.
2. Collaborate closely with nephrologists for CKD patients with eGFR < 30 mL/min/1.73 m² or potassium > 5 mEq/L.
3. Start ACEIs or ARBs at low doses and titrate gradually based on stable labs and BP.
4. Consider adding SGLT2 inhibitors as the third medication to improve HFrEF and CKD outcomes, even at eGFR 20 mL/min/1.73 m².
5. Adjust diuretic doses when initiating SGLT2 inhibitors to mitigate hypovolemia and AKI risks.
6. Add aldosterone antagonists like spironolactone for eGFR > 30 mL/min/1.73 m² and potassium < 5 mEq/L, improving HFrEF management.
7. Monitor electrolytes and kidney function closely, adjusting medications as needed based on lab results and clinical response.

References

Keywords: HFrEF management ACE inhibitors ARBs Entresto, CKD and heart failure treatment guidelines, SGLT2 inhibitors in HFrEF and CKD, Nephrologist collaboration in heart failure care, Managing hyperkalemia in heart failure, Beta-blockers in renal impairment, Aldosterone antagonists and eGFR thresholds, Serum creatinine monitoring in heart failure therapy, Diuretic adjustment in SGLT2 inhibitor therapy, Hypovolemia risks with diuretics