Renal Responses to HF Medication

Renal Responses to HF
Medication- How to Treat
Dr. Nayan Ray
MBBS
Mymensingh Medical College and Hospital

Introduction
• Renal function is greatly important in risk stratification,
pharmacologic therapy, and the prognosis of patients with heart
failure (HF).
• The deterioration of heart function can result in the worsening renal
function (WRF) and vice versa.
• Besides the heart function itself, the Pharmacologic Treatment of HF
is closely related to renal function as regards initiation, titration, and
discontinuation, making the situation more complex.
Int J Heart Fail. 2022 Apr;4(2):75-9 https://doi.org/10.36628/ijhf.2021.0039 pISSN 2636-154X·eISSN 2636-1558
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Assessment of renal function
• Renal function evaluation helps
(i) to better understand the underlying cardio-renal physiology,
(ii) to improve initiation, adaptation or continuation of evidence-based heart
failure therapies,
(iii) to stratify patients at risk of adverse outcome, and
(iv) to identify the presence of systemic diseases or the coexistence of
independent renal disease.
European Journal of Heart Failure (2020) 22, 584–603 doi:10.1002/ejhf.1697
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Definition of changes in renal function in heart failure
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Overview of laboratory and urinary renal biomarkers in heart failure
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Distribution of estimated glomerular filtration rate (eGFR)
among 1216 patients with chronic stable heart failure.
Eur Heart J 2006;27:569–81
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Relationship between change in eGFR during hospitalisation and subsequent 60-day
hazard for adverse events
J Card Fail 2016;22:753–760. DOSE,
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Main factors inﬂuencing glomerular ﬁltration rate (GFR) in patients with chronic heart failure
Archives of Cardiovascular Disease (2020) 113, 660—670
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Grading of CKD deﬁnitions based on baseline eGFR (KDIGO CKD definition)
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Worsening Renal Function
Defined as ≥26.5μmol/L and ≥25% increase in
serum creatinine from baseline to 6 weeks
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Relationship between heart failure and renal failure
The bidirectional link between cardiac and renal function can lead to
clinical presentations that are termed cardio-renal syndrome (CRS)
There are ﬁve types of CRS
• Type 1: Acute heart failure causes acute kidney injury (AKI)
• Type 2: Chronic heart failure causes CKD
• Type 3: AKI or acute renal failure causes acute cardiac failure
• Type 4: CKD causes chronic cardiac dysfunction, including heart failure
• Type 5: An acute or chronic systemic disorder causes both cardiac and
renal failure (e.g. sepsis, diabetes mellitus, systemic lupus erythematosus)
Br J Clin Pharmacol (2018) 84 5–17
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Guideline Directed Medical Therapy for Heart Failure
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DOI:
https://doi.org/10.15420/usc.2020.29
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Characteristics of All Studies Reporting Sex-Speciﬁc Adverse Drug Reaction Data per Drug Class
J A C C : H E A R T F A I L U R E V O L . 7 , N O . 3 , 2 0 1 9
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Changes in kidney function after
initiation of drug treatment
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A decline in renal function is commonly seen in patients when they
start an ACEI, ARB or sacubitril/valsartan and is usually modest.
► A fall in eGFR (and rise in creatinine) is very common after initiation
of RAAS inhibitors but usually stabilises.
► A progressive fall in GFR on RAAS inhibition suggests primary renal
disease, including extrarenal and intrarenal vascular disease.
► For patients with HFrEF, the benefit of RAAS inhibitors is greater in
patients with worsening renal function during RAAS inhibition despite
their worse prognosis relative to those with no decline
► A moderate, asymptomatic decline in renal function is not an
indication to stop RAAS inhibitors.
Clark AL, Kalra PR, Petrie MC, et al. Heart 2019;105:904–910.
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Changes in kidney function
during intercurrent illness
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Changes in kidney function during intercurrent illness
• Regardless of whether patients are treated with RAAS inhibitors,
changes in renal function are common during acute intercurrent
illness; the incidence of AKI is between 7% and 18% of hospitalised
patients.
• AKI is a powerful risk marker for poor outcome and is strongly
associated with an increase in the risk of subsequent admission for
heart failure.
• Renal function often does not to return to baseline level in survivors
of AKI, especially in those with pre-existing CKD.
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• In patients on a RAAS inhibitor, intercurrent illness commonly causes
AKI, but there is no evidence that stopping the RAAS inhibitor is
beneficial.
► If a patient with HFrEF develops hyperkalaemia
– Potassium ≥5.5 mmol/L, monitor closely, medication review and consider
suspending RAAS inhibitor(s).
– Potassium ≥6.0 mmol/L, stop RAAS inhibitor(s).
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► If the patient with HFrEF has a rise in creatinine during intercurrent
illness:
– By less than 30%, continue RAAS inhibitor(s) but monitor closely.
– Stop any other medication that may worsen renal function, including diuretic
if clinically appropriate.
– If by ≥30%, RAAS inhibitor(s) should be stopped.
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Considerations when managing a patient with
heart failure who develops hyperkalaemia
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Management of patients with AKI
or worsening renal function who
are receiving RAAS inhibitor
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End-of-life care
• When a patient with HF is approaching end of life, symptom control
overrides treatment with potential prognostic impact.
• Deteriorating renal function is common.
• Diuretics should be titrated to prevent distress from fluid overload,
irrespective of renal function.
• If there is symptomatic hypotension, discontinuation of RAAS
blockade is appropriate.
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End-of-life care Management-
► Higher doses of diuretics than are commonly used are needed to
treat congestion in the fluid overloaded patient.
► A decline in renal function is not an indication to reduce diuretic
dose if the patient remains congested.
► Consider stopping RAAS inhibitors towards the end of life.
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Summary
• The interaction between treatment for heart failure and decline in
renal function is frequently misunderstood and commonly used as a
reason to withhold potentially life-prolonging therapy.
• The misunderstanding is not helped by referring to RAAS inhibitors as
‘nephrotoxic’ drugs, which they most emphatically are not.
• The combination is, of course, of vital importance to patients with
symptomatic HFrEF; however, close monitoring of renal function and
potassium is vital when using MRA and other RAAS inhibitor together.
1. National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management.
Clinical guideline [CG169]. London, 2013.
2. Sinnott SJ, Mansfield KE, Schmidt M, et al. Biochemical monitoring after initiation of aldosterone antagonist therapy
in users of renin-angiotensin system blockers: a UK primary care cohort study. BMJ Open 2017;7:e018153
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• There is a danger that concerns over renal function may prevent
patients receiving medication beneficial to their longterm outcome.
• While decline in renal function is important and may require drugs to
be stopped, that should only be after very careful consideration of the
risks and benefits to the individual patient.
1. National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management.
Clinical guideline [CG169]. London, 2013.
2. Sinnott SJ, Mansfield KE, Schmidt M, et al. Biochemical monitoring after initiation of aldosterone antagonist therapy
in users of renin-angiotensin system blockers: a UK primary care cohort study. BMJ Open 2017;7:e018153
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Renal Responses to HF Medication

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