Management of Heart Failure With Chronic Kidney Disease

MANAGEMENT OF HEART
FAILURE WITH CHRONIC

KIDNEY DISEASE
Nadya Meilinar Samson
Yudi Her Oktaviono
Introduction
• Heart failure is very common, projected to affect more than 8 million Americans by
2030, and currently is implicated in 1 of every 9 deaths in the United States
• Chronic kidney disease (CKD) is a very common disease with an estimated 500
million people worldwide having a glomerular filtration rate (GFR) of 4.5% of the
general population with GFR <60 mL / min / 1.73m2, while 50% of patients with acute
heart failure and chronically (including preserved and reduced ejection fraction) have
the same decrease in GFR
• The incidence and prevalence of chronic heart failure and CKD increases with
increasing elderly population, hypertension, diabetes, and other risk factors for kidney
and cardiovascular disease.
House AA. Management of Heart Failure in Advancing CKD: Core Curriculum 2018. Am J Kidney Dis. 2018;72(2):284-295. doi:10.1053/j.ajkd.2017.12.006
Damman K, Testani JM. The kidney in heart failure: An update. Eur Heart J. 2015;36(23):1437-1444. doi:10.1093/eurheartj/ehv010
HEART FAILURE
Heart Failure
• Definition (ESC 2016) :
 Heart failure is a clinical syndrome characterized by typical symptoms (e.g.
breathlessness, ankle swelling and fatigue) that may be accompanied by signs
(e.g. elevated jugular venous pressure, pulmonary crackles and peripheral
oedema) caused by a structural and/or functional cardiac abnormality, resulting
in a reduced cardiac output and/or elevated intracardiac pressures at rest or during
stress.
• The terminology used in heart failure is currently based on the left ventricle
ejection fraction (LVEF), the onset of heart failure, and the severity of the NYHA
classification.
Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;37(27):2129-2200m.
doi:10.1093/eurheartj/ehw128
Terminology
1. Based on LVEF
Terminology
2. Based on its onset
• patients who have had heart failure before are called 'chronic heart failure’,
• patients who have received heart failure treatment with signs and symptoms that generally
do not change in at least 1 month are called 'stable’
• Patients with chronic heart failure who experience a decrease in condition can be called
‘decompensation’
Terminology
3. Based on severity (NYHA classification)
Diagnosis
Diagnosis
Algorithm
Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the
diagnosis and treatment of acute and chronic heart failure. Eur Heart J.
2016;37(27):2129-2200m. doi:10.1093/eurheartj/ehw128
CHRONIC KIDNEY
DISEASE
Chronic Kidney Disease (CKD)
• KDIGO 2012 :
 CKD is defined as abnormalities of kidney structure or function, present for >3
months, with implications for health.
National Kidney Foundation. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2012;Supp:2(5):337-414.
doi:10.1038/kisup.2012.7
Category
doi:10.1038/kisup.2012.7
Category
doi:10.1038/kisup.2012.7
Prognosis
doi:10.1038/kisup.2012.7
End stage renal disease (ESRD)
• ESRD, also known as End Stage Kidney Disease (ESKD), is a term commonly used for
kidney failure receiving dialysis or transplant therapy, regardless of the degree of kidney
function, and this term is used for administrative purposes.
• The ESRD limitation is CKD with kidney function which is greatly reduced to the stage
that requires renal replacement therapy (RRT).
• Kidney Disease Stage 5 is not the same as ESRD because not all patients with GFR <15
ml/min/1.73 m2 need RRT, some patients with GFR > 15 ml/min/1.73 m 2 already show
symptoms and need RRT, kidney transplant recipients often has GFR > 15 ml/min/1.73
m2.
Reutens A, Atkins R. Chronic kidney duisease (CKD): the scope of the global problem. In: Nahas M, Levin A, eds. Chronic Kidney Disease a Practical Guide to Understanding and
Management. 1st ed. Oxford: Oxford university press; 2009:39-75.
HEART FAILURE AND
CHRONIC KIDNEY
DISEASE
Heart Failure and CKD
• The heart and kidneys are essential for cardiovascular homeostasis.
What happen to heart in uremic conditions?
1. Atherosclerotic plaques grow faster in uremic conditions.
2. Growth of micro-vessels is less than the process of hypertrophy of cardiac myocytes
→ myocytes’s oxygen supply↓ → ischemia → stimulates myocardial cell apoptosis
and accumulation of extracellular and collagen matrix → interstitial fibrosis →
promotes left ventricular stiffness, increased left ventricular filling pressure, weak
diastolic filling → diastolic dysfunction. Myocardial fibrosis also worsens ischemia
by reducing capillary density and capillary reserve, and greatly increases the risk of
ventricular arrhythmias and sudden cardiac death.
3. Failure of coronary artery vasodilation as a result of endothelial dysfunction.
Alshahrani SMS, Alghamdi SAS, Kadasah AS, et al. Congestive Heart Failure in Patients with Chronic Kidney Disease on Dialysis. Egypt J Hosp Med. 2017;69:2730-2735.
doi:10.12816/0042256
Heart Failure and CKD
4. Studies of cardiac metabolism in uremic conditions have shown energy-rich
nucleotide decay, especially ATP → energy saving reduction.
5. Sympathetic activity increases, as does apoptosis. The chemoreceptors and
baroreceptors in the damaged kidney are activated → cause a greater burden on the
heart with a response to increasing heart rate and contraction, and predisposing to the
occurrence of arrhythmias. Apoptosis occurs because of an imbalance of sympathetic
activity of the heart muscle. Sympathetic overactivity → concentric remodeling of the
left ventricle.
6. Uremia causes several abnormalities in heart muscle function, including abnormal
calcium cycles that affect contractility function.
Alshahrani SMS, Alghamdi SAS, Kadasah AS, et al. Congestive Heart Failure in Patients with Chronic Kidney Disease on Dialysis. Egypt J Hosp Med. 2017;69:2730-2735.
doi:10.12816/0042256
MANAGEMENT OF
HF WITH CKD
Therapeutic goals
1. Reduce preload and afterload and reduce left ventricular hypertrophy
2. Management of myocardial ischemia, if present
3. Inhibit neurohormonal hyperactivity, especially the sympathetic
nervous system and renin-angiotensin-aldosterone system (RAAS)
1. Lifestyle Modification
Lifestyle modification
Sodium intake must be limited to control volume status in heart failure patients with CKD.
1D According to the 2012 ESC and KDIGO 2012, sodium intake <2.0 g / day (<90 mmol / day),
equal to the recommended sodium intake for patients CKD
1D Reducing or maintaining normal weight (BMI 20-25)
Physical exercise programs that are suitable for cardiovascular conditions and patient tolerance,
1D
towards 30 minutes per day, 5 times a week
Giving fluids per 24 hours is adjusted to urine production, ie total urine production in 24 hours
1D
plus 500 ml And based on ESC, <1.5 l/day
Reducing alcohol consumption and smoking
doi:10.1038/kisup.2012.7
2. Pharmacotherapy
Angiotensin Converting Enzyme (ACE) inhibitor
Cardioprotective and renoprotective
Recommended for all HFrEF patients if there are no contraindications. Can reduce the risk of
1A death and the rate of hospitalization in HFrEF patients, mainly used in conjunction with beta
blockers
Recommended for adult patients with CKD and urinary albumin excretion 30-300 mg / 24 hours
2D
(or equivalent)
Recommended for adult patients with CKD and urinary albumin excretion >300 mg / 24 hours
1B
(or equivalent)
ACE inhibitors are used with caution, close monitoring of serum creatinine and potassium
levels is needed, and are stopped if there is a decrease in GFR> 25% or the onset of
hyperkalemia (> 5.5 mmol / L)
doi:10.1038/kisup.2012.7
Beta blocker
Out of 8 meta-analysis studies in stage 3-5 CKD patients found that beta blockers
reduce cardiovascular mortality and other causes in heart failure patients but with an
increased risk of hypotension and bradycardia
It is recommended that patients with HFrEF heart failure be used with ACE inhibitors
1A
in stable HFrEF patients, to reduce the risk of death and hospitalization
Atenolol and bisoprolol can accumulate in patients with chronic kidney disease and
cause bradyarrhythmias, while carvedilol, metoprolol and propranolol do not
doi:10.1038/kisup.2012.7
Mineralocorticoid Receptor Antagonist (MRA)
When used in conjunction with ACE inhibitors and ARBs, MRA increase the
reduction in mortality and cardiovascular events on a long-term basis
It is recommended in patients with HFrEF who remain symptomatic with ACE

1A
inhibitors and beta blockers, to reduce the risk of death and hospitalization
In stage 3 CKD patients, it can be used with caution, with a maximum dose of 25 mg
/ day with close monitoring of potassium levels.
In patients with stage 4 and 5 CKD, MRA is not recommended
doi:10.1038/kisup.2012.7
Angiotensin Receptor Blocker (ARB)
It is recommended to reduce the risk of hospitalization related to heart failure and
1B death in patients who cannot tolerate ACE-i (patients must receive beta blocker and
MRA therapy)
Can be given to patients who remain symptomatic after administration of beta

2b/C blockers who cannot tolerate MRA to reduce the risk of hospitalization related to
heart failure and death
Recommended for use in adult patients with CKD and urinary albumin excretion
1B 30-300 mg / 24 hours (or equivalent) (2D) and urinary albumin excretion > 300
mg / 24 hours (or equivalent)
doi:10.1038/kisup.2012.7
Diuretic
Diuretics are used to improve symptoms and physical exercise capacity in patients
1B
with / without signs of congestion
Diuretics are also recommended to reduce the risk of hospitalization in patients with /
2a/B
without signs of congestion
Loop diuretics are used as first-line agents in CKD patients because the use of the
thiazide group is relatively ineffective when used alone. Loop diuretics are given to
patients with GFR <30 mL/ min/1,73m2 (stage 4-5 CKD)
In patients who are resistant to loop diuretics, total daily dose can be increased or the
frequency is increased, or combined with other diuretics
doi:10.1038/kisup.2012.7
Diuretic
Potassium-sparing diuretics are administered with caution in patients with GFR <30
mL /min/1.73m2 (stage 4-5 CKD), patients with ACE inhibitor therapy or ARBs, and
patients with risk factors for hyperkalemia
Patients with diuretic therapy must be monitored for volume depletion signs in the form
of hypotension or decreased GFR, potassium levels and other electrolyte abnormalities
Use of bolus diuretics in patients with acute heart failure can be used along with
optimization of volume and blood pressure status. If persistent oligouria / anuria persists
or acute kidney failure occurs, continuous furosemide, bumetanide, or a combination of
furosemide and metalozone can be used. If there is no improvement, continuous renal
replacement therapy (CRRT) can be used
Digoxin
Can be used by monitoring digoxin concentrations in stage 3-5 CKD patients
Can be considered in symptomatic patients with sinus rhythm in addition to ACE-I (or ARB)
therapy, beta blockers and MRA to reduce the risk of hospitalization
Ivabradine
It should be considered to reduce the risk of cardiovascular death and hospitalization rates in
2a/B patients with LVEF ≤35% with sinus rhythm and heart rate ≥70 x / m in patients who have
received optimal therapy with beta blockers (up to the maximum dose), ACE-i, and MRA
In CKD patients no dose adjustment is needed but it is not recommended if GFR <15
mL /min/1.73m2 due to the lack of data
doi:10.1038/kisup.2012.7
Angiotensin Receptor Neprilysin Inhibitor (ARNI)
Sacubitril / valsartan is recommended as ACE-i treatment and reduces hospitalization rates due
1B to heart failure and risk of death in outpatient HFrEF patients who remain symptomatic despite
optimal therapy with ACE-i, beta blockers, and MRA
Hydralazine dan isosorbid dinitrate (H-ISDN)

1B There is no interaction between the effects of H-ISDN and renal disturbances
Must be considered in black race patients with LVEF ≤35% or LVEF <45% with dilatation of
2a/B left ventricle in NYHA class III-IV in addition to therapy with ACE-i, beta blockers and MRA
to reduce the risk of hospitalization due to heart failure and death
doi:10.1038/kisup.2012.7
Add a Slide Title - 1
3. Implantable Cardioverter Defibrillator (ICD)
Implantable Cardioverter Defibrillator (ICD)

1A Recommended in patients with HFrEF
Use in patients with CKD especially stage 4-5 has a large advantage and decreases
cardiovascular mortality
4. Anemia
• In patients with heart failure with CKD, anemia is associated with LV dilatation
and hypertrophy. Anemia in patients with renal replacement therapy (RRT) is
associated with an increased risk of left ventricular hypertrophy
• There has been no RCT about serum hemoglobin targets in heart failure patients
with CKD.
• The expected Hb target does not exceed 12 g/dl (in HF) and 10-12 g/dl (in CKD
patients).
5. Ultafilration
Ultrafiltration
In patients with acute heart failure, ultrafiltration can be considered in patients with
2b/B
refractory congestion, who do not respond to diuretics
2a/C RRT is considered in patients experiencing refractory overload and acute renal failure
Adequate use of ultrafiltration in heart failure patients with CKD is useful in

controlling overhydration, controlling blood pressure, preventing and reducing
hypertrophy and dilation of the left ventricle
Ultrafiltration used must be with a low sodium and cooled dialysate and avoid
ultrafiltration in large volumes to prevent myocardial stunning, and avoid the use of
high-flow arteriovenous fistulas (increase cardiac output and induce left ventricular
eccentric hypertrophy)
Ultrafiltration
Shortened frequency with a short duration (eg 4-6 times per week) has a more
significant result in reducing the left ventricular mass index
CRRT can be considered in conditions of severe acute heart failure and fluid overload
condition, which do not respond to diuretics, oligouria, and / or the occurrence of
kidney failure.
CRRT has neutral hemodynamic properties and a minimal effect on the mean arterial
pressure (MAP), especially in overload conditions. CRRT can also eliminate toxic
substances in the cardiopulmonary system and myocardial depressant factors
6. Monitoring
• Laboratories
 CBC, urinalysis, electrolyte serum, BUN, creatinine serum, liver function test
• BNP or NT pro BNP

• 12 leads ECG
• Thorax photo
• Echocardiography
• Coronary artheriography (if indicated)
• Volume status
TAKE HOME POINTS
• There is no published guideline for heart failure with CKD
• The usage of ACE-I/ARB is highly recommended in heart failure patients with CKD
with close monitoring for serum electrolyte and renal function
• The therapeutic goals :
1. Reduce preload and afterload and reduce left ventricular hypertrophy
2. Management of myocardial ischemia, if present
3. Inhibit neurohormonal hyperactivity, especially the sympathetic nervous system
and renin-angiotensin-aldosterone system (RAAS)
• Tailored therapy is considered the best way for treating heart failure patients with
CKD.
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MANAGEMENT OF HEART

FAILURE WITH CHRONIC

1D Reducing or maintaining normal weight (BMI 20-25)

Reducing alcohol consumption and smoking

It is recommended in patients with HFrEF who remain symptomatic with ACE

Can be given to patients who remain symptomatic after administration of beta

Hydralazine dan isosorbid dinitrate (H-ISDN)

Implantable Cardioverter Defibrillator (ICD)

Adequate use of ultrafiltration in heart failure patients with CKD is useful in

• BNP or NT pro BNP

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