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Management of Heart Failure Patient with CKD

Debasish Banerjee, Giuseppe Rosano and Charles A. Herzog
CJASN January 2021, CJN.14180920; DOI: https://doi.org/10.2215/CJN.14180920
Debasish Banerjee
1Renal and Transplantation Unit, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom
2Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St Georges, University of London, London, United Kingdom
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Giuseppe Rosano
2Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St Georges, University of London, London, United Kingdom
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Charles A. Herzog
3Cardiology Division, Department of Internal Medicine, Hennepin Healthcare/University of Minnesota, Minneapolis, Minnesota
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Abstract

CKD is common in patients with heart failure, associated with high mortality and morbidity, which is even higher in people undergoing long-term dialysis. Despite increasing use of evidence-based drug and device therapy in patients with heart failure in the general population, patients with CKD have not benefitted. This review discusses prevalence and evidence of kidney replacement, device, and drug therapies for heart failure in CKD. Evidence for treatment with β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and sodium-glucose cotransporter inhibitors in mild-to-moderate CKD has emerged from general population studies in patients with heart failure with reduced ejection fraction (HFrEF). β-Blockers have been shown to improve outcomes in patients with HFrEF in all stages of CKD, including patients on dialysis. However, studies of HFrEF selected patients with creatinine <2.5 mg/dl for ACE inhibitors, <3.0 mg/dl for angiotensin-receptor blockers, and <2.5 mg/dl for mineralocorticoid receptor antagonists, excluding patients with severe CKD. Angiotensin receptor neprilysin inhibitor therapy was successfully used in randomized trials in patients with eGFR as low as 20 ml/min per 1.73 m2. Hence, the benefits of renin-angiotensin-aldosterone axis inhibitor therapy in patients with mild-to-moderate CKD have been demonstrated, yet such therapy is not used in all suitable patients because of fear of hyperkalemia and worsening kidney function. Sodium-glucose cotransporter inhibitor therapy improved mortality and hospitalization in patients with HFrEF and CKD stages 3 and 4 (eGFR>20 ml/min per 1.73 m2). High-dose and combination diuretic therapy, often necessary, may be complicated with worsening kidney function and electrolyte imbalances, but has been used successfully in patients with CKD stages 3 and 4. Intravenous iron improved symptoms in patients with heart failure and CKD stage 3; and high-dose iron reduced heart failure hospitalizations by 44% in patients on dialysis. Cardiac resynchronization therapy reduced death and hospitalizations in patients with heart failure and CKD stage 3. Peritoneal dialysis in patients with symptomatic fluid overload improved symptoms and prevented hospital admissions. Evidence suggests that combined cardiology-nephrology clinics may help improve management of patients with HFrEF and CKD. A multidisciplinary approach may be necessary for implementation of evidence-based therapy.

  • chronic kidney disease
  • heart failure
  • dialysis
  • Copyright © 2021 by the American Society of Nephrology
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Clinical Journal of the American Society of Nephrology: 16 (2)
Clinical Journal of the American Society of Nephrology
Vol. 16, Issue 2
February 08, 2021
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Management of Heart Failure Patient with CKD
Debasish Banerjee, Giuseppe Rosano, Charles A. Herzog
CJASN Jan 2021, CJN.14180920; DOI: 10.2215/CJN.14180920

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Management of Heart Failure Patient with CKD
Debasish Banerjee, Giuseppe Rosano, Charles A. Herzog
CJASN Jan 2021, CJN.14180920; DOI: 10.2215/CJN.14180920
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  • Article
    • Abstract
    • Epidemiology of CKD in Heart Failure
    • The Interdependence of the Heart and Kidney
    • AKI in Patients with Heart Failure and CKD
    • Heart Failure Therapy in Patients with CKD
    • Diuretic Therapy
    • Renin-Angiotensin-Aldosterone System Inhibitor Therapy in Patients with Heart Failure with Reduced Ejection Fraction and CKD
    • Angiotensin Receptor and Neprilysin Inhibitor Therapy in Patients with Heart Failure with Reduced Ejection Fraction and CKD
    • Ivabradine and β-Blocker Therapy in Patients with Heart Failure with Reduced Ejection Fraction and CKD
    • Sodium Glucose Cotransporter 2 Inhibitor Therapy in Patients with Heart Failure with Reduced Ejection Fraction and CKD
    • Management of Iron Deficiency and Anemia in Patients with Heart Failure with Reduced Ejection Fraction and CKD
    • KRT
    • Device Therapy
    • Heart Failure with Preserved Ejection Fraction in Patients with CKD
    • Multidisciplinary Care
    • The Way Forward
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More in this TOC Section

  • Euglycemic Ketoacidosis as a Complication of SGLT2 Inhibitor Therapy
  • Mass Disasters and Burnout in Nephrology Personnel
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