Heart Failure Medicines in Kidney Disease

Heart failure and kidney disease worsen each other, and most heart failure therapy gives benefit across the range of kidney function. A modest rise in creatinine after starting a renin-angiotensin blocker or during decongestion is acceptable and should not by itself lead to stopping therapy.

Acceptable change. Creatinine rise up to 30 percent, or eGFR fall up to about 25 percent, with stable potassium.

Residual risk. Hyperkalaemia and hypotension limit therapy, and potassium binders can allow continuation.

Four pillars.

• ACE inhibitor, angiotensin receptor blocker or sacubitril with valsartan.

• Evidence-based beta blocker (bisoprolol, carvedilol, metoprolol succinate).

• Mineralocorticoid receptor antagonist (spironolactone or eplerenone).

• SGLT2 inhibitor (dapagliflozin or empagliflozin).

Alternatives and additions. Hydralazine with isosorbide dinitrate when renin-angiotensin blockers cannot be used; loop diuretic for congestion; digoxin with reduced dose.

Special groups.

• Pregnancy: avoid renin-angiotensin blockers, mineralocorticoid receptor antagonists and SGLT2 inhibitors.

• Older adults: titrate slowly.

• Dialysis: beta blockers and careful fluid management; use of other pillars is by specialist decision.

• East Africa: rheumatic heart disease and cardiomyopathy are common causes, so check for anticoagulation indications as well.

• Ramipril: start 1.25 to 2.5 mg once daily, target 10 mg once daily; maximum 5 mg daily if eGFR is under 30.

• Sacubitril with valsartan: start 24/26 mg twice daily at eGFR under 30, target 97/103 mg twice daily.

• Bisoprolol: start 1.25 mg once daily, increase every 2 weeks, target 10 mg once daily. Carvedilol: start 3.125 mg twice daily, target 25 mg twice daily.

• Spironolactone: 12.5 to 25 mg once daily, start only if potassium is 5.0 mmol/L or under and eGFR is 30 or over. Eplerenone: 25 mg once daily, target 50 mg.

• Dapagliflozin or empagliflozin: 10 mg once daily, dapagliflozin from eGFR 25 and empagliflozin from eGFR 20.

• Furosemide: higher doses are needed as function falls; oral 40 to 80 mg, intravenous 40 to 80 mg, doubled if there is no response in 1 to 2 hours. Add a thiazide-like diuretic, for example metolazone 2.5 to 5 mg, for resistance under specialist care.

• Digoxin: 62.5 to 125 micrograms once daily (62.5 micrograms if eGFR is under 30), aiming for a level of 0.5 to 0.9 micrograms/L.

• Hydralazine 25 mg three times daily with isosorbide dinitrate 20 mg three times daily, increased to 75 mg and 40 mg three times daily.

Monitoring. Check creatinine and potassium at 1 to 2 weeks after each renin-angiotensin blocker or antagonist change, then at 4 weeks, and every 3 months. Weigh daily.

Stop rules. Halve spironolactone for potassium 5.5 mmol/L, stop it at 6.0 mmol/L. Reduce a renin-angiotensin blocker for a creatinine rise over 30 percent. Hold all four pillars during acute kidney injury, hypotension or sepsis, and restart in turn.

Referral and escalation. Refer when potassium or creatinine prevents optimal therapy, when diuretic resistance persists, or for dialysis or ultrafiltration decisions.

Common errors. Stopping therapy for a small creatinine rise, giving a mineralocorticoid antagonist without potassium checks, and under-dosing loop diuretics.