State-of-the-Art Paper
Current Evidence on Treatment of Patients With Chronic Systolic Heart Failure and Renal Insufficiency: Practical Considerations From Published Data

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Chronic kidney disease (CKD) is increasingly prevalent in patients with chronic systolic heart failure. Therefore, evidence-based therapies are more and more being used in patients with some degree of renal dysfunction. However, most pivotal randomized clinical trials specifically excluded patients with (severe) renal dysfunction. The benefit of these evidence-based therapies in this high-risk patient group is largely unknown. This paper reviews data from randomized clinical trials in systolic heart failure and the interactions between baseline renal dysfunction and the effect of randomized treatment. It highlights that most evidence-based therapies show consistent outcome benefit in patients with moderate renal insufficiency (stage 3 CKD), whereas there are very scarce data on patients with severe (stage 4 to 5 CKD) renal insufficiency. If any, the outcome benefit might be even greater in stage 3 CKD compared with those with relatively preserved renal function. However, prescription of therapies should be individualized with consideration of possible harm and benefit, especially in those with stage 4 to 5 CKD where limited data are available.

Key Words

evidence-based treatment
heart failure
pharmacological treatment
renal insufficiency

Abbreviations and Acronyms

ACEi
angiotensin-converting enzyme inhibitor
ARB
angiotensin II receptor blocker
CKD
chronic kidney disease
CRT
cardiac resynchronization therapy
CV
cardiovascular
eGFR
estimated glomerular filtration rate
ICD
implantable cardioverter defibrillator
HF
heart failure
H-ISDN
hydralazine and isosorbide-dinitrate
HFPEF
heart failure with preserved ejection fraction
HFREF
heart failure with reduced ejection fraction
KDOQI
Kidney Disease Outcomes Quality Initiative
LV
left ventricular
MRA
mineralocorticoid receptor antagonist
MI
myocardial infarction
sCr
serum creatinine
WRF
worsening renal function

Cited by (0)

Dr. Damman is supported by the Netherlands Heart Institute (ICIN) and European Society of Cardiology Heart Failure Association Research Grant. Dr. Felker has received grant support from and consulted for Novartis, Amgen, Roche Diagnostics, and Otsuka. Dr. Zannad has served on the steering committees of Pfizer, Bayer, Janssen, and Takeda; and the advisory boards of Novartis, Servier, and CardioRenal Diagnostics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.