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Updates in the management of heart failure for the chronic kidney disease patient.

ABSTRACT: PURPOSE OF REVIEW:Heart failure is highly prevalent in patients with chronic kidney disease (CKD) and a leading cause of morbidity and mortality in this population. Heart failure therapies proven to benefit the general population may have different risk-benefit profiles in patients with concurrent CKD, plausibly because of the unique pathophysiology of heart failure in this population. The present review highlights recent advances in heart failure treatment as they apply to patients with CKD. RECENT FINDINGS:Several recent publications have shown possible benefits of established heart failure therapies to improve clinical outcomes in patients with CKD; while others conclude neutral or even harmful effects of heart failure therapies in CKD patients. Novel heart failure therapies show promise to improve outcomes in the general population and should be evaluated in future studies to further elucidate the efficacy and safety of these novel therapies specifically in patients with CKD. SUMMARY:Knowledge of heart failure treatment to improve clinical outcomes in the CKD population remains limited. Future studies should focus on patients with CKD to evaluate the generalizability of heart failure therapies to this patient population.

SUBMITTER: Hsu S

PROVIDER: S-EPMC6625663 | biostudies-literature | 2019 May

REPOSITORIES: biostudies-literature

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Updates in the management of heart failure for the chronic kidney disease patient.

Hsu Simon S Bansal Nisha N

Current opinion in nephrology and hypertension 20190501 3

<h4>Purpose of review</h4>Heart failure is highly prevalent in patients with chronic kidney disease (CKD) and a leading cause of morbidity and mortality in this population. Heart failure therapies proven to benefit the general population may have different risk-benefit profiles in patients with concurrent CKD, plausibly because of the unique pathophysiology of heart failure in this population. The present review highlights recent advances in heart failure treatment as they apply to patients with ...[more]

PMID: 30946179

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Project description:BackgroundThe management of heart failure (HF) is challenging because of the complexities in recommended therapies. Integrated disease management (IDM) is an effective model, promoting guideline-directed care, but the impact of IDM in the community setting requires further evaluation.MethodsA retrospective evaluation of community-based IDM. Patient characteristics were described, and outcomes using a pre- and post-intervention design were HF-related health-service use, quality of life, and concordance with guideline-directed medical therapy (GDMT).Results715 patients were treated in the program (2016 to 2023), 219 in a community specialist-care clinic, and 496 in 25 primary-care clinics. The overall cohort was predominantly male (60%), with a mean age of 73.5 years (± 10.7), and 60% with HF with reduced ejection fraction. In patients with ≥ 6 months of follow-up (n = 267), pre vs post annualized rates of HF-related acute health-service use decreased from 36.3 to 8.5 hospitalizations per 100 patients per year, P < 0.0001, from 31.8 to 13.1 emergency department visits per 100 patients per year, P < 0.0001, and from 152.8 to 110.0 urgent physician visits per 100 patients per year, P = 0.0001. The level of concordance with GDMT improved; the number of patients receiving triple therapy and quadruple therapy increased by 10.1% (95% confidence interval [CI], 2.4%,17.8%) and 19.6% (95% CI, 12.0%, 27.3%), respectively. Within these groups, optimal dosing was achieved in 42.5% (95% CI, 32.0%, 53.6%) and 35.0% (95% CI, 23.1%, 48.4%), respectively. In patients with at least one follow-up visit (n = 286), > 50% experienced a clinically relevant improvement in their quality of life.ConclusionsA community-based IDM program for HF, may reduce HF-related acute health-service use, improve quality of life and level of concordance with GDMT. These encouraging preliminary outcomes from a real-world program evaluation require confirmation in a randomized controlled trial.

Project description: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.

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Updates in the management of heart failure for the chronic kidney disease patient.

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Updates in the management of heart failure for the chronic kidney disease patient.

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