The document discusses the treatment of heart failure in patients with chronic kidney disease. It notes that CKD is a common comorbidity in heart failure patients and that the coexistence of the two conditions increases health risks. The main treatments discussed are: 1. ACE inhibitors and ARBs to improve ventricular function, though they can worsen kidney function. Close monitoring of kidney function and electrolytes is needed. 2. Beta blockers like bisoprolol and carvedilol to improve ventricular function, though they can cause hypotension and kidney dysfunction. 3. Aldosterone antagonists to reduce heart failure worsening and increase survival, though they can cause hyperkalemia and worsen kidney function.

1. Heart Failure with CKD: How to Treat ?
by
Prof. M. Thomas Mathew, MD, DM, FRCP.
Senior Consultant Nephrologist,
Calicut

2. Kidneys are amazing organs of our body

3. Functions of the Kidneys
• Removal of waste products of metabolism like urea,
creat, uric acid, acids, Alkalies, water etc
• Maintain salt and water balance
• Maintain Acid – Base balance
• Maintain the Blood Pressure
• Maintain calcium, phosphorus balance
• Produces active Vit D3
• Produces Erythropoietin
• ? Associated with longevity - Klotho Gene
• ? Associated with brain function - KIBRA Gene .

4. Chronic Kidney Disease (CKD) is defined as
abnormality of kidney structure or function, present
for >3months, with implications for health.
Very often asymptomatic or silent

5. • Markers of Kidney damage (one or more)
- Proteinuria - AER > 30mg/24hrs
- Urinary Sediments
- Electrolyte abnormalities
- Structural abnormalities on imaging
• Decreased GFR
- GFR < 60ml/min1.73m2
- Sr. Creatine > 1.4mg/dl
Criteria for CKD

7. Heart failure (HF) continues to be a National
Epidemic with increasing prevalence affecting
almost 2.5% of Adult population - an incidence
that has not declined in the past 2 decades.

9. Chronic Kidney Disease (CKD) is also a
National epidemic with increasing
prevalence affecting almost 16.8% of adult
population, an incidence that continued to
rise during the past 2 decades.

10. • CKD is now pandemic and affects more than 16% of
adult population.
• CKD is a common co-morbidity in patients with
Heart Failure.
• The co-existence of HF and CKD will increase the
toxic manifestation of various diagnostic and
therapeutic measures, accelerates atherosclerosis
and increases the risk of death.

11. - Slight increase in renal dysfunction correlates with substantial increase in
CVD risk and mortality independent of standard risk factors .
- In those with GFR of 45 -59 ml/min/1.732 meter the risk is increased by 43%
- In those with GFR of < 15ml/min/1.732 meter, the risk is increased by 343 %.
- 43 % of deaths in ESRD is due to cardiac disease.
- Death in cardiac disease is 10-20times more common in those with CKD.
- 50% of ESRD patients will suffer from MI within 2 yrs after initiating
Dialysis.
All patients with CKD have to be considered at accelerated
risk for Cardiovascular disease.

12. • The ‘cross- talk’ between the heart and the kidneys
occurring through the atrial and renal reflexes is
important to control the BP, Renal sodium and water
excretion, arterial perfusion and oxygenation of
tissues.
• When one organ becomes dysfunctional the other
may well be affected as well.
- Arthur Guyton-

13. Prof. Arthur Guyton – (1919-2003)
One of the great cardiovascular
Physiologists of the 20th century.
His book on Human Physiology is
studied by all medical students.
Outstanding contribution on -
cardiac output, role of kidneys
In hypertension and the
‘cross-talk’ between the heart
and kidneys .

14. • CKD exposes the heart to 3 main mechanisms leading to
cardiomyopathy and cardiac failure.
- Pressure overload
- Volume overload
- CKD associated non hemodynamic factors.
• Hemodialysis is associated with repetitive hemodynamic
instability and subsequent myocardial ischemia leading
to LV systolic dysfunction and HF.
• AVF and grafts will further aggravate LV dysfunction.
•

15. Many patients with HF
have underlying CKD and
patients with CKD are
prone to cardiac failure.This
has led to the concept of
Cardio-Renal/Reno-Cardiac
syndromes.

17. Though there is a continuous improvement in
the treatment of HF all over the world, when the
HF is combined with CKD, the effective therapies
are dramatically underused.

18. Treatment of Heart Failure with CKD
Although there are many landmark clinical
guidelines for managing HF as well as CKD, there
are no agreed guidelines for managing patients with
cardio-renal and/or reno-cardiac syndromes.

19. Treatment of Heart Failure with CKD
• KDOQI–has suggested that ‘the level of care of heart
failure offered to people with CKD should be the
same as is offered to those without CKD’.

20. Angiotensin –Converting Enzyme Inhibitors (ACEIs)
• Should be used in all patients with symptomatic HF & LVEF  40%.
Ventricular function and patient well being improves.
Contraindications
• History of angioedema, bilateral renal artery stenosis,
Sr K+ >5.0mmol/L, Sr creat. >2.5mg/dl, Severe aortic stenosis .
Before starting ACEIs
• Check renal function and Sr. Electrolytes.
• Re-check renal function and Electrolytes within 1-2 weeks.

21. Dosage of commonly used ACEIs
Starting dose (mg) Target dose (mg)
Captopril
Enalapril
Lisinopril
Ramipril
Trandolapril
6.25 t.i.d.
2.5 b.i.d.
2.5-5.0 o.d.
2.5 o.d.
0.5 o.d.
50-100 t.i.d.
10-20 b.i.d
20-35 o.d.
5 b.i.d.
4 o.d.

22. While on ACEI
Worsening of renal function –
• Mild increase in blood urea and sr.creat after initiation.
• Check for nephrotoxic drugs, NSAIDS.
Reduce ACEI dose or discontinue.
• An increase in creat. upto 50% from baseline or upto
3mg/dl is acceptable.
• If creat rises above 3 mg/dl but below 3.5mg/dl, halve
the dose of ACEI .
• If creat rises to morethan3.5mg/dl or above, stop ACEI.

23. While on ACEI
Hyperkalemia –
• If potassium rises above 5.5mmoI/L, halve the dose of ACEI
• If potassium rises over 6.0mmoi/L, stop ACEI.
• Check use of other agents causing hyperkalemia.
eg: K+ supplements , K sparing diuretics etc.
Symptomatic hypotension –
• Is common , might decrease renal function but is transient.

24. Angiotensin Receptor Blockers (ARBs)
• In all patients with LVEF  40% who remain
symptomatic despite optimal treatment with an ACEI
and β-blockers .
• May cause worsening of renal function, hyperkalemia &
hypotension.
• Renal function to be checked.
• If there is rise in creat or K+ - reduce the dose.

25. Dosage of commonly used Angiotensin Receptor Blockers
Starting dose(mg) Target dose (mg)
Telmisartan
Candesartan
Valsartan
20-40 o.d.
4-8 o.d.
40 b.i.d.
80 o.d.
32 o.d
160 b.i.d.

26. Betablockers
• Should be used in all pts with symptomatic HF & LVEF  40%.
• Ventricular function and patient well being will improve.
• Bisoprolol or Carvedilol can be used.
• Can cause symptomatic hypotension and mild increase in
renal dysfunction.

27. Dosage of commonly used β-Blocker
Starting dose(mg) Target dose (mg)
Bisoprolol
Carvedilol
Metoprolol
Nebivolol
1.25 o.d.
3.125 b.i.d.
12.5/25 o.d.
1.25 o.d.
10 o.d.
25-50 b.i.d
200 o.d.
10 o.d.

28. Aldosterone antagonists
• In all patients with LVEF  35% and with severe symptoms.
• Reduces worsening of HF and increases survival.
• To be used along with optimal dose of a  - blocker and ACEI or
ARB.
Contraindications
• Sr K + > 5.0mmoI/L, Sr.creat >2.5mg/dl, concomitant K+
sparing diuretic or supplements, combination of ACEI & ARB.

29. Dosage of commonly used Aldosterone antagonist
Starting dose(mg) Target dose (mg)
Spironolactone
Eplerenone
25 o.d.
25 o.d.
25-50 o.d.
50 o.d

30. Adverse effects of Aldosterone Antagonists
Hyperkalemia –
•If potassium rises above 5.5mmoI/L, halve the dose.
•If potassium rises over 6.0mmoi/L, stop the drug.
Worsening of renal function –
• If sr. creat rises to >2.5mg/dlL, halve the dose
• If sr. creat rises to > 3.5mg/dL, stop the drug

31. Hydralazine and isosorbide dinitrate (H- ISDN)
In all patients with LVEF  40% as an alternative if intolerance
to ACEI or ARB.
Add H –ISDN in patients with persistence symptoms despite
treatment with ACEI, ARB, β-blockers or Aldosterone
antagonists.
Will improve ventricular function.
Contra indicated in hypotension, lupus syndrome and
severe CKD.

32. Digoxin
In all patients with symptomatic HF and AF and also
to slow a rapid ventricular rate.
In presence to CKD, the dose has to be reduced to
0.125 or 0.0625mg o.d.

33. Diuretics
• Recommended in all patients with HF and clinical
signs or symptoms of congestion.
• Loop diuretics in moderate or severe HF.
Thiazides to be used in combination with loop
diuretics for resistant oedema.
• Be alert to check hypotension, hyponatremia,
hypokalemia, dehydration and deterioration of
renal function.

34. Diuretics
• If an ACEI/ARB/Aldosterone antagonist is used
with diuretic, potassium replacement will
usually not be required.
• Serious Hyperkalemia can result if K+ sparing
diuretics are used including Aldosterone
antagonist in combination of ACEI/ARB.
• Combination of Aldosterone antagonist and an
ACEI/ARB should only be used under careful
supervision.

37. Anaemia
• Aim for Hb%>10gm/dl. This will reduce LVH in CKD.
• EPO and IV iron supplements will be needed.

38. Minimize Vascular Calcification
• Control Calcium and Phosphate concentration.
• Use non-calcium containing phosphate binders.
• Achieve adequate Vitamin D status.

39. Haemodialysis/Ultrafiltration
• In patients with CKD stage 5 with HF, Adequate
Dialysis/Ultrafiltration and dietary salt and
water restriction to be achieved.
• Ultrafiltration in refractory HF is very useful.

40. Inotropic Therapy
• Dobutamine, milrinone, levosimendan in
worsening renal function secondary to fall in
cardiac output.
• Levosimendan will improve cardiac function,
reduce congestion and improves renal function.

41. Aquaretics
• Arginine Vasopressin antagonists.
Tolvaptan- In significant hypervolemic state
along with persistent hyponatremia.
HF and renal function will improve.

42. Al- Adenosine antagonists
• Promising new class of drugs.
• Reduces vasoconstriction, improves renal
function.
• Improves diuretic response.

43. Diet
Very important for patients with HF and CKD.
• 1500-2000 Kcal diet (veg-non veg)
• Fluid restricted to 1000 – 1500ml
• Proteins restricted to 0.5gm /kg BW
• Salt restricted to 5 – 8gms
• Fat restricted to 20-25gms
• Low Phosphors, Low Potassium adequate Vitamins

44. • Current clinical studies and evidence based medicine
have contributed significantly to our understanding
of treatment strategies of HF combined with CKD.
• As new data emerges, we have to update our clinical
practices and treatment guidelines which may
involve modifying old Paradigms and Prescriptions
and embracing new ones.

45. Ladies & Gentlemen,
The Future Is Bright

46. Thank you very much for your patient listening -