Pharmacologic therapy in patients with chronic heart failure and chronic kidney disease: a complex issue

Abstract

Chronic kidney disease is common in patients with chronic heart failure and has important clinical implications. The coexistence of these two syndromes is associated with a higher risk of adverse outcome and increases the difficulties of heart failure treatment because of the complex interplay between renal dysfunction and pharmacologic therapy. The underrepresentation of patients with chronic kidney disease in most heart failure trials contributes to the suboptimal treatment of this high-risk population in clinical practice. In the present review, we briefly examine the pathophysiologic mechanisms connecting chronic kidney disease and chronic heart failure and discuss the therapeutic approach to patients affected by both conditions.

Heart Failure in Patients with Chronic Kidney Disease: A Systematic Integrative Review

“…The use of ACEIs in patients with CKD and HF seems reasonable, given the well-established simultaneous cardio- and renoprotective effects of these drugs [118]. However, there is little evidence that treatment with ACEIs reduces CV morbidity and mortality in this particular population [12].…”

“…However, there is little evidence that treatment with ACEIs reduces CV morbidity and mortality in this particular population [12]. Furthermore, clinicians are often concerned about the possibly increased risk of adverse reactions from ACEI use in HF patients with impaired kidney function [118]. …”

“…A meta-analysis of 5 placebo-controlled RCTs with ACEIs in patients with HF showed that, although the rate of acute kidney injury was higher with ACEIs than with placebo, drug discontinuation was rarely necessary, and renal function returned to baseline in most cases, even without dose adjustment [118, 132]. Furthermore, a systematic review of 12 RCTs with ACEIs for renoprotection in patients with CKD showed that a mild increase in serum creatinine (up to 30% from baseline) was quite common within the first 2 weeks of therapy; however, this increase was followed by stabilization during the next few weeks [118, 133].…”

“…Furthermore, a systematic review of 12 RCTs with ACEIs for renoprotection in patients with CKD showed that a mild increase in serum creatinine (up to 30% from baseline) was quite common within the first 2 weeks of therapy; however, this increase was followed by stabilization during the next few weeks [118, 133]. In patients with both HF and CKD, a retrospective analysis of the SOLVD studies has shown that the use of ACEIs was associated with a reduction of mortality, even in those with severe renal insufficiency, and did not have an adverse effect on kidney function [134].…”

Renal Function and Peak Exercise Oxygen Consumption in Chronic Heart Failure With Reduced Left Ventricular Ejection Fraction

“…4 Furthermore, CKD may complicate the management of HF. 5 Cardiopulmonary exercise testing (CPET) has several clinical applications in HF, including investigation of the pathophysiology of exercise intolerance and symptoms, evaluation of functional capacity and response to therapeutic interventions, prognostic evaluation, and prescription of exercise training. Risk stratification is a major clinical application of CPET.…”