Guideline Recommendations for Managing Heart Failure with CKD Stage 3b and Nephrotic‑Range Proteinuria

1 SGLT2‑Inhibitor Therapy

Initiate an SGLT2 inhibitor immediately in patients with heart failure and chronic kidney disease stage 3b (eGFR ≥ 20 mL/min/1.73 m²) who have nephrotic‑range albuminuria; this is a Class 1 A recommendation. 1
Continue the SGLT2 inhibitor even if eGFR falls below 20 mL/min/1.73 m² during treatment, provided the drug is tolerated. 5
Do not change monitoring frequency or stop the SGLT2 inhibitor solely because of the expected reversible decline in eGFR that occurs after initiation. 3

Initiate or uptitrate an ACE inhibitor or ARB to the maximum tolerated dose in patients with severely increased albuminuria (ACR > 2000 mg/g); this carries a Class 1 B recommendation. 6
Maintain RAS inhibition even when eGFR declines below 30 mL/min/1.73 m². 4
Check blood pressure, serum creatinine, and potassium 2–4 weeks after any RAS‑inhibitor start or dose change. 5
Accept a rise in serum creatinine of up to 30 % within the first 4 weeks before considering dose reduction. 5
Manage hyper‑kalemia with potassium‑lowering strategies rather than reducing or stopping RAS inhibition. 2
Reduce or discontinue RAS inhibition only for symptomatic hypotension or refractory hyper‑kalemia despite optimal medical measures. 5

Add a second diuretic (thiazide‑type or metolazone) or switch to continuous IV furosemide infusion when loop diuretic requirements exceed ~240 mg furosemide‑equivalent per day. Evidence: observational cohort (The Canadian Journal of Cardiology, 2007). 8

Re‑measure serum creatinine, potassium, and blood pressure 2–4 weeks after any new medication or dose adjustment. 4
Use potassium‑lowering interventions rather than stopping RAS inhibitors when hyper‑kalemia occurs. 4

Consider adding a non‑steroidal MRA in patients with type 2 diabetes, normal potassium, and persistent albuminuria despite maximally tolerated RAS inhibition; eligibility requires eGFR > 25 mL/min/1.73 m². This is a Class 2 A recommendation. 9
The non‑steroidal MRA may be combined with both RAS inhibition and SGLT2‑inhibitor therapy. 10
Ensure serum potassium remains within normal limits and monitor potassium regularly after MRA initiation. 9

Systematically evaluate for reversible factors such as NSAID use, hypovolemia, hypotension, or urinary obstruction when kidney function declines. 8
Perform daily medication review in the setting of oliguria or rising creatinine. 8

Do not discontinue SGLT2 inhibitors or RAS inhibitors solely because of modest eGFR declines; mortality and morbidity benefits persist. 1
Do not use the transient eGFR dip after SGLT2‑inhibitor initiation as a reason to stop therapy. 4
Avoid combining an ACE inhibitor, an ARB, and a direct renin inhibitor, as this combination is contraindicated. 3

Nephrotic‑range albuminuria (ACR ≈ 4000 mg/g) warrants investigation for primary glomerular disease beyond diabetic or hypertensive nephropathy; referral to nephrology and possible kidney biopsy should be considered. 1