Management and outcomes of heart failure patients with CKD: experience from an inter‐disciplinary clinic

Nguyen, Mai Phuong; Rumjaun, Samir; Lowe-Jones, Racquel; Ster, Irina Chis; Rosano, Giuseppe M.C.; Anderson, Lisa; Banerjee, Debasish

doi:10.1002/ehf2.12796

Cited by 17 publications

(27 citation statements)

References 21 publications

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“…The outcome of HF patients with co‐morbidities is driven both by HF itself and by co‐morbidities 3–6,21 . The impact of co‐morbidities on outcome may vary depending upon both the stage of HF and the degree of HF pharmacotherapy and device therapy.…”

Section: Discussionmentioning

confidence: 99%

“…The outcome of HF patients with co-morbidities is driven both by HF itself and by co-morbidities. [3][4][5][6]21 The impact of co-morbidities on outcome may vary depending upon both the stage of HF and the degree of HF pharmacotherapy and device therapy. The higher risk of mortality or HF hospitalization was shown for DM in predominantly milder HF patients (72% NYHA I-II).…”

Section: Quality Of Lifementioning

confidence: 99%

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The effect of three major co‐morbidities on quality of life and outcome of patients with heart failure with reduced ejection fraction

et al. 2021

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Aims Diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease are prevalent in patients with heart failure with reduced ejection fraction (HFrEF). We have analysed the impact of co-morbidities on quality of life (QoL) and outcome. Methods and results A total of 397 patients (58.8 ± 11.0 years, 73.6% with New York Heart Association functional class ≥3) with stable advanced HFrEF were followed for a median of 1106 (inter-quartile range 379-2606) days, and 68% of patients (270 patients) experienced an adverse outcome (death, urgent heart transplantation, and implantation of mechanical circulatory support). Chronic obstructive pulmonary disease was present in 16.4%, diabetes mellitus in 44.3%, and chronic kidney disease in 34.5% of patients; 33.5% of patients had none, 40.0% had one, 21.9% had two, and 3.8% of patient had three co-morbidities. Patients with more co-morbidities reported similar QoL (assessed by Minnesota Living with Heart Failure Questionnaire, 45.46 ± 22.21/49.07 ± 21.69/47.52 ± 23.54/46.77 ± 23.60 in patients with zero to three co-morbidities, P for trend = 0.51). Multivariable regression analysis revealed that furosemide daily dose, systolic blood pressure, New York Heart Association functional class, and body mass index, but not the number of co-morbidities, were significantly (P < 0.05) associated with QoL. Increasing co-morbidity burden was associated with worse survival (P < 0.0001), lower degree of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker treatment (P = 0.001), and increasing levels of BNP (mean of 685, 912, 1053, and 985 ng/L for patients with zero to three co-morbidities, P for trend = 0.008) and cardiac troponin (sm-cTnI, P for trend = 0.0496), which remained significant (P < 0.05) after the adjustment for left ventricular ejection fraction, left ventricular end-diastolic diameter, right ventricular dysfunction grade, body mass index, and estimated glomerular filtration rate. Conclusions In stable advanced HFrEF patients, co-morbidities are not associated with impaired QoL, but negatively affect the prognosis both directly and indirectly through lower level of HF pharmacotherapy and increased myocardial stress and injury.

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Section: Discussionmentioning

confidence: 99%

Section: Quality Of Lifementioning

confidence: 99%

The effect of three major co‐morbidities on quality of life and outcome of patients with heart failure with reduced ejection fraction

et al. 2021

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“…We designed a multidisciplinary clinic with a cardiologist and nephrologist (Figure 3) attending the patient in the same room and the anaemia nurse providing intravenous iron and erythropoietin as necessary, as we know that intravenous iron improves symptoms in HFrEF patients, including patients with CKD 3 [42]. The first 124 relatively elderly patients [78.5 years (IQR 68.1-84.4)] over 234 days (IQR 121-441) had an improvement in RAASi therapy [43]. The proportions of HF-CKD patients on no RAASi decreased from 41.2% to 29.9% and those on single or dual RAASi therapy increased from 45.4% to 50.5% and from 13.4% to 19.6%, respectively (P ¼ 0.03).…”

Section: U L T I D I S C I P L I N a R Y M A N A G E M E N Tmentioning

confidence: 99%

“…Serum ferritin improved from 131.0 to 267.5 lg/L (P 0.001) and the number of patients with iron deficiency The delivery and benefits of a multidisciplinary clinic for CKD patients with HF. The figure shows the caregivers, therapy delivered and possible benefits of a multidisciplinary HF-CKD clinic in a tertiary care centre [43].…”

Section: U L T I D I S C I P L I N a R Y M A N A G E M E N Tmentioning

confidence: 99%

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Personalizing heart failure management in chronic kidney disease patients

Banerjee

Wang²

2021

Nephrology Dialysis Transplantation

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CKD in heart failure patients is common, present in 49%, associated with higher mortality [Hazard ratio, 2.34 (95% CI2.20–2.50, P < 0.001) and multiple hospital admissions. The management of heart failure in CKD can be challenging due to drug induced electrolyte and creatinine changes; resistance to diuretics and infections related to device therapy. Evidence for improvement in mortality and heart failure hospitalisations exists in HFrEF stage 3 CKD patients from randomised controlled trials of ACE-inhibitor and mineralocorticoid receptor antagonist therapy; but not in dialysis patients where higher doses can cause hyperkalaemia. Evidence on improvement of cardiovascular death and heart failure hospitalisations has emerged with angiotensin blocker-neprilysin inhibitor, ivabradine and more recently with sodium-glucose cotransporter inhibitors in HFrEF patients with CKD stages 1,2, and 3. However these studies have excluded CKD 4,5 patients. Evidence for betablocker therapy exists in CKD stages 1,2 and 3 and separately in haemodialysis patients. Cardiac resynchronisation therapy reduces heart failure hospitalisations and mortality in patients with CKD 1,2,3 but not in CKD stages 4,5 or dialysis patients. Internal cardioverter and defibrillator therapy in HFrEF patients have been shown to be beneficial in CKD 3 patients, not in dialysis patients where it is associated with high rates of infection. For HFpEF patients with CKD therapy is symptomatic as there is no proven therapy for improvement in survival or hospitalisations. Heart failure patients with end-stage-kidney disease with fluid overload may benefit from peritoneal dialysis. A multidisciplinary, personalised approach has been associated with better care and improved patient satisfaction.

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Heart Failure—Together We Go Farther—Reply

Tang,

Brownell,

Fonarow

2024

JAMA Cardiol

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COMMENT & RESPONSEIn Reply We thank Van der Linden and Mullens for their interest in our recent Review article 1 on quality improvement interventions for optimization of guideline-directed medical therapy (GDMT). We agree that interdisciplinary efforts with nurses and pharmacists are often a key component to successful interventions in both the inpatient and outpatient setting. Regarding country-level differences, we found most interventions were conducted in the US with several others performed in high-income countries, including the United Kingdom, Germany, Spain, Italy, and Australia. This raises an interesting point regarding global disparities in GDMT use and how interventions may differ both in terms of implementation and effectiveness across various settings. One observational study 2 in the country of Georgia reported that the development of a new heart failure management program that incorporated both local clinician and patient education was extremely efficacious, resulting in a roughly 5-to-10-fold increase in the prescription of β-blockers and renin-angiotensinaldosterone system inhibitors. Notably, baseline rates of prescriptions were low at 7.4% and 18.4%, respectively. This example highlights substantial variation in the efficacy of certain interventions depending on the setting in which they are performed, as well as the potential for significant impact in regions with low levels of baseline GDMT use.Given the large heterogeneity in methodology across different interventions assessed, it is challenging to ascertain the comparative benefits of different types of initiatives. In general, multifactorial interventions are more likely to be efficacious, but additional randomized studies are needed for further evaluation. For instance, 1 randomized study that integrated performance audits with clinician education showed no difference in a composite quality score between groups. 3 However, several observational studies that incorporated audits with direct feedback and training for clinicians demonstrated significant increases in GDMT prescription rates. 4,5 On the other hand, educational sessions alone were consistently ineffective in changing prescribing behaviors.Additionally, patient complexity presents a challenge for optimization of GDMT, especially among patients in whom polypharmacy is already present. Chronic kidney disease is a common comorbidity among patients with heart failure and can result in health care professional hesitancy in initiation or uptitration of GDMT due to concerns over worsening kidney function or risk of hyperkalemia. An observational study 6 in the United Kingdom implemented a multidisciplinary clinic for patients with concomitant heart failure and kidney disease and found overall improvements in GDMT use and titration without significant changes in creatinine or potassium levels. These findings suggest that collaboration with different specialties may be helpful in patients with multiple comorbidities. Overall, it is evident that substantial barriers persist to optimizati...

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Management and outcomes of heart failure patients with CKD: experience from an inter‐disciplinary clinic

Cited by 17 publications

References 21 publications

The effect of three major co‐morbidities on quality of life and outcome of patients with heart failure with reduced ejection fraction

The effect of three major co‐morbidities on quality of life and outcome of patients with heart failure with reduced ejection fraction

Personalizing heart failure management in chronic kidney disease patients

Heart Failure—Together We Go Farther—Reply

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