Management of Chronic Kidney Disease with Heart Failure and Reduced Ejection Fraction

Immediate Management

The American College of Cardiology recommends administering intravenous loop diuretics immediately to address anasarca, pulmonary congestion, and decreased urine output in patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) superimposed on chronic kidney disease (CKD) 1
Monitor strict intake/output, daily weights, and clinical signs of congestion in patients with HFrEF and CKD to ensure proper volume management 1
Target euvolemia before making changes to other medications, as volume overload can cause acute-on-chronic kidney injury in patients with CKD and HFrEF 1
Tolerate acute eGFR decreases up to 30% during diuresis in patients with CKD and HFrEF, and do not discontinue diuretics prematurely unless eGFR drops >30% 1

The American Heart Association recommends SGLT2 inhibitors (dapagliflozin or empagliflozin) for patients with HFrEF and CKD, as they have been proven to reduce mortality and hospitalization 1
The American College of Cardiology recommends ACE inhibitors or ARBs (ARNI preferred if available) for patients with HFrEF and CKD, and titrate to maximum tolerated dose for both heart failure and kidney protection 1, 4
The American Heart Association recommends beta-blockers for patients with HFrEF, as they are essential for mortality reduction 1
The National Kidney Foundation recommends mineralocorticoid receptor antagonists (MRAs) for patients with CKD and type 2 diabetes, and monitor potassium closely to avoid hyperkalemia 1, 4

The American College of Cardiology recommends high-intensity statin therapy for all patients with CKD and coronary artery disease (CAD) 2, 4
The American Heart Association recommends low-dose aspirin (75-100 mg daily) for secondary prevention of CAD in patients with CKD 2

The National Kidney Foundation recommends immediate nephrology consultation for patients with CKD stages 4-5, as they require close monitoring and potential renal replacement therapy planning 6, 4
The American Society of Nephrology recommends referral to nephrology for patients with abrupt sustained decrease in eGFR >20% after excluding reversible causes 6

With creatinine 5.7 mg/dL (estimated CrCl approximately 15-25 mL/min), many medications require dose adjustment or are contraindicated, and metformin is contraindicated at this level of kidney function 9, 4
Anticoagulants (if needed for atrial fibrillation) require significant dose reduction or alternative agents in patients with CKD and HFrEF 9, 8