Managing Heart Failure With Reduced Ejection Fraction in Patients With Chronic Kidney Disease: A Case-Based Approach and Contemporary Review

Patients with heart failure with reduced ejection fraction (HFrEF) often have concurrent chronic kidney disease (CKD), which can make initiating and titrating the 4 standard pharmacologic therapies a challenge. Drug dosing is often based on a calculation of the patient’s creatine clearance or estimated glomerular filtration rate (eGFR), but it should also incorporate the trend in their renal function over time and the risk of toxicity of the drug. The presence of CKD in a patient should not preclude the use of a renin-angiotensin system inhibitor, although patients should be monitored frequently for worsening renal function and hyperkalemia. Sacubitril/valsartan is not recommended in patients with an eGFR < 30 mL/min per 1.73 m2. Of the 3 ß-blockers recommended in the management of HFrEF, only bisoprolol may accumulate in patients with renal impairment; however, patients should still be titrated to the target dose (10 mg daily) or the maximally tolerated dose, depending on their clinical response. The sodium-glucose cotransporter 2 inhibitors are effective at reducing adverse cardiovascular and renal outcomes in patients with HFrEF and CKD (eGFR ≥ 25 mL/min per 1.73 m2 with dapagliflozin or ≥ 20 mL/min per 1.73 m2 with empagliflozin), although declining kidney function is a risk, due to the osmotic diuretic effect. Finally, mineralocorticoid receptor antagonist therapy should be considered in all patients with HFrEF and an eGFR ≥ 30 mL/min per 1.73 m2. The starting dose should be low (eg, 6.25-12.5 mg daily or 12.5 mg every other day) and can be uptitrated based on the patient’s renal function and serum potassium. Les patients atteints d’insuffisance cardiaque avec fraction d’éjection réduite (ICFER) présentent souvent une néphropathie chronique (NC) concomitante, ce qui peut compliquer l’instauration et l’ajustement du traitement par les quatre types de médicaments principaux. La posologie repose souvent sur le calcul de la clairance de la créatine ou du débit de filtration glomérulaire estimé (DFGe), mais l’évolution de la fonction rénale du patient et le risque de toxicité du médicament devraient également être pris en compte. Une NC chez un patient ne devrait pas empêcher l’utilisation d’un inhibiteur du système rénine-angiotensine, mais il convient alors d’effectuer un suivi fréquent de ces patients pour détecter un éventuel déclin de la fonction rénale ou une hyperkaliémie. L’association sacubitril-valsartan n’est pas recommandée chez les patients ay