Optimizing meds in patients with HFrEF and CKD

Few patients with chronic kidney disease (CKD) are on optimized meds for heart failure with reduced ejection fraction (HFrEF). It’s a delicate balance...

Hyperkalemia can occur with an ACEI or ARB, Entresto (sacubitril/valsartan), or an aldosterone antagonist. Plus, these meds or SGLT2 inhibitors (Forxiga, etc) can cause an initial bump in serum creatinine (SCr). But suboptimal HFrEF treatment can worsen kidney function.

• Continue to start with an ACEI, ARB, or Entresto PLUS an evidence-based beta-blocker (carvedilol, etc) for HFrEF, and be cautious with diuretics.
• Work with your nephrologist colleagues, especially when eGFR is below 30 mL/min/1.73 m² or potassium is above 5 mEq/L. Studies exclude patients with these low eGFRs. But it’s often okay to use an ACEI or ARB with close monitoring even in patients on dialysis and beta-blockers are okay at any eGFR.
• Start with a LOW dose (lisinopril 2.5 mg daily, etc) and titrate to typical target doses if labs and BP are stable. After that, consider adjusting the usual stepwise approach.
• Think of adding an SGLT2 inhibitor as the THIRD med. These improve HFrEF and CKD outcomes regardless of diabetes and can be started down to 20 mL/min/1.73 m².
• Consider lowering diuretic doses when starting an SGLT2 inhibitor due to the risk of hypovolemia and acute kidney injury.
• If eGFR is above 30 mL/min/1.73 m² and potassium is below 5 mEq/L, add an aldosterone antagonist (spironolactone, etc) a few weeks later as the FOURTH med. These also improve HFrEF outcomes.
• Monitor electrolytes and kidney function closely especially when adding or titrating meds. For example, check labs at baseline, 1 to 2 weeks later and at least quarterly.
• If SCr bumps up over 50%, hold SGLT2 inhibitors and halve doses of other meds except beta-blockers. Hold meds that raise potassium for levels above 5.5 mEq/L.
• Try retitrating meds in 2 to 4 weeks once labs improve.

References

• Beldhuis IE, Lam CSP, Testani JM, et al. Evidence-Based Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Chronic Kidney Disease. Circulation. 2022;145(9):693-712. Available at: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.121.052792

  Mullens W, Martens P, Testani JM, et al. Renal effects of guideline-directed medical therapies in heart failure: a consensus document from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2022;24(4):603-619. Available at: https://onlinelibrary.wiley.com/doi/10.1002/ejhf.2471

  Patel RB, Fonarow GC, Greene SJ, et al. Kidney Function and Outcomes in Patients Hospitalized With Heart Failure. J Am Coll Cardiol. 2021;78(4):330-343. Available at: https://pubmed.ncbi.nlm.nih.gov/33989713