Management of Patients with CKD and CHF

Core Pharmacologic Strategy

The American College of Cardiology recommends initiating quadruple therapy with SGLT2 inhibitor, ACE inhibitor or ARB, beta-blocker, and mineralocorticoid receptor antagonist, uptitrated to maximally tolerated doses, to address both cardiac and renal protection while reducing mortality and hospitalization in patients with CKD and CHF 1
The Kidney International guidelines suggest starting an SGLT2 inhibitor immediately in all patients with CKD stages G1-G4 and heart failure, regardless of diabetes status, to reduce heart failure hospitalizations, slow CKD progression, and decrease cardiovascular mortality 2, 1
The Journal of the American College of Cardiology recommends initiating ACE inhibitor or ARB therapy in all patients with CKD and heart failure, targeting maximal tolerated doses, to provide cardio-renal protection 3, 1
The Kidney International guidelines suggest accepting transient increases in serum creatinine up to 30% and mild hyperkalemia when initiating or uptitrating ACE inhibitors or ARBs, and not discontinuing prematurely 1

The Kidney International guidelines recommend prescribing high-intensity statin therapy to all patients ≥50 years with eGFR <60 mL/min/1.73 m², and to patients 18-49 years with coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% 2, 4
The Kidney International guidelines suggest using low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease 2, 4
The American Journal of Kidney Diseases guidelines recommend targeting blood pressure <140/90 mmHg in all CKD patients to prevent progression and reduce cardiovascular events 5

The Journal of the American College of Cardiology guidelines recommend administering intravenous iron to patients with heart failure and iron deficiency, regardless of anemia status, to improve functional status and quality of life 3
The American Journal of Hematology guidelines suggest not using erythropoietin-stimulating agents in patients with heart failure and anemia, as they do not improve morbidity or mortality and may cause harm 3

The Kidney International guidelines recommend prioritizing intensive medical therapy over immediate invasive procedures for stable ischemic heart disease with CKD 2, 4
The Praxis Medical Insights guidelines suggest using iso-osmolar contrast agents and minimizing contrast volume to prevent contrast-induced nephropathy 7

The Kidney International guidelines recommend prescribing non-vitamin K antagonist oral anticoagulants preferentially over warfarin for thromboprophylaxis in atrial fibrillation with CKD stages G1-G4 2, 4
The Praxis Medical Insights guidelines suggest adjusting NOAC doses based on eGFR and exercising caution in CKD stage G4 4, 1

The Kidney International guidelines recommend a plant-based Mediterranean-style diet to reduce both cardiovascular and kidney disease risk 2, 4, 1
The American Journal of Kidney Diseases guidelines suggest limiting dietary sodium intake to <2 grams per day 5, 7
The Praxis Medical Insights guidelines recommend restricting protein intake to 0.8 g/kg body weight/day to slow CKD progression 7

The Praxis Medical Insights guidelines suggest monitoring eGFR, serum creatinine, potassium, and hemoglobin at baseline, 1-2 weeks after medication changes, then every 3-6 months 1
The American Journal of Hematology guidelines recommend assessing iron status at baseline and periodically 6, 3

The Praxis Medical Insights guidelines suggest not discontinuing ACE inhibitors/ARBs prematurely for mild creatinine elevations or potassium 5.0-5.5 mEq/L, as these medications provide critical cardio-renal protection 1
The Kidney International guidelines recommend not withholding SGLT2 inhibitors due to concerns about kidney function, as they are beneficial across CKD stages G1-G4 2
The Kidney International guidelines suggest not using NSAIDs for pain management, as they worsen renal function and increase cardiovascular risk 2
The Journal of the American College of Cardiology guidelines recommend not prescribing ESAs for anemia in heart failure, and instead focusing on IV iron replacement 3