Chronic kidney disease (CKD) is common in patients with heart failure (HF) and
is associated with high morbidity and mortality. There has been remarkable
progress in the treatment of HF over recent years with the establishment of
guideline-directed medical therapies including: (1) Beta-blockers, (2) renal
angiotensin aldosterone system (RAAS) inhibition (i.e., angiotensin-converting
enzyme inhibitor [ACEi], aldosterone receptor blocker [ARB] or angiotensin
receptor-neprilysin inhibitor [ARNI]); (3) mineralocorticoid receptor antagonists
(MRA), and (4) sodium-glucose cotransporter-2 inhibitors (SGLT2i). However, there
are challenges to the implementation of these medications in patients with
concomitant CKD due to increased vulnerability to common side-effects (including
worsening renal function, hyperkalaemia, hypotension), and most of the pivotal
trials which provide evidence of the efficacy of these medications excluded
patients with severe CKD. Patients with CKD and HF often have regular healthcare
encounters with multiple professionals and can receive conflicting guidance
regarding their medication. Thus, despite being at higher risk of adverse
cardiovascular events, patients who have both HF and CKD are more likely to be
under-optimised on evidence-based therapies. This review is an updated summary of
the evidence available for the management of HF (including reduced, mildly
reduced and preserved left ventricular ejection fraction) in patients with
various stages of CKD. The review covers the evidence for recommended
medications, devices such as implantable cardioverter-defibrillator (ICD),
cardiac resynchronization therapy (CRT), intravenous (IV) iron, and discusses how
frailty affects the management of these patients. It also considers emerging
evidence for the prevention of HF in the cohort of patients with CKD. It
synthesises the available evidence regarding when to temporarily stop, continue
or rechallenge medications in this cohort. Chronic HF in context of CKD remains a
challenging scenario for clinicians to manage, which is usually complicated by
frailty, multimorbidity and polypharmacy. Treatment should be tailored to a
patients individual needs and management in specialised cardio-renal clinics with
a multi-disciplinary team approach has been recommended. This review offers a
concise summary on this expansive topic.
