Managing heart failure and CKD is NOT Mission Impossible!

The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS)

This podcast episode explores the intersection of chronic kidney disease (CKD) and heart failure, providing guidance for managing patients with both conditions. Hosts Prof Jeremy Levy and Andrew Frankel, consultant nephrologists, are joined by Dr Dominique Auger, a consultant cardiologist specialising in heart failure.

The discussion focuses on the shared pathophysiology of CKD and heart failure, optimising treatments, and addressing common clinical concerns in primary care.

Top Three Key Messages

1. CKD and Heart Failure Coexistence:

• CKD and heart failure frequently occur together, with CKD increasing the risk of cardiovascular disease and heart failure.
• Both conditions share overlapping treatments, including ACE inhibitors, ARBs, SGLT2 inhibitors, and MRAs, which improve survival, reduce symptoms, and decrease hospitalisations.

2. GFR Decline and Kidney Forgiveness:

• A decline in GFR is expected with effective therapies like RAS inhibitors and SGLT2 inhibitors.
• For heart failure with CKD, GFR reductions of up to 50% or creatinine increases to 260 µmol/L are acceptable, as kidneys often stabilise ("the kidneys forgive"). Therapy should continue with careful monitoring unless hyperkalaemia or other severe complications arise.

3. Role of Diuretics:

• Diuretics are essential for symptom control (e.g., relieving oedema and breathlessness) but have no prognostic benefit in heart failure.
• They are safe to use in CKD and heart failure, often requiring higher doses in CKD patients due to kidney resistance, and are useful for managing hyperkalaemia as well.

This episode underscores the importance of integrated, aggressive management of both CKD and heart failure, with a focus on optimising therapies that balance efficacy with patient safety.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

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Transcript

The Rest is Kidneys makes kidney disease management easy.  The Rest is Kidneys is for primary care clinicians.  The Rest is Kidneys is NICE consistent, short and sweet. Welcome to the Restless Kidneys brought to you by the Northwest London NHS Kidney Care Team.

Jeremy

So hello everyone. This podcast is one of our series of podcasts that aims to support people, professionals, healthcare systems in the management of chronic kidney disease, CKD. I'm Jeremy Levy. I'm a consultant nephrologist at Imperial College Healthcare NHS Trust. 

Andrew

Hello, Jeremy. Pleasure to be here again. And I'm Andrew Frankel, a consultant kidney doctor from Imperial College Healthcare NHS Trust. And today's episode is brought to you by Imperial College Healthcare NHS Trust. And today's episode is about not just CKD, but about CKD and heart failure. And we have a real pleasure to be joined today by Dr Dominique Auger. 

Dominique

Oh, the pleasure is all mine, Jeremy and Andrew. Thank you so much for inviting me. I'm Dominique Auger. I'm a consultant cardiologist at Imperial. And like Andrew said, I do mainly heart failure. 

Andrew 

So, In the real clinical world, patients very rarely have single clinical problems and increasingly frequently we see people with multiple long term conditions.

And this is particularly true for chronic kidney disease, which very frequently occurs in conjunction with the so called cardiometabolic conditions, such as cardiovascular disease and diabetes. 

Jeremy 

That's right, Andrew, isn't it? And that whole phrase cardiorenal metabolic or cardio kidney metabolic sort of syndrome has really come up in the last few years.

So in this podcast, we're going to review how the presence of heart failure influences the management of chronic kidney disease. And of course, it's a two way thing. Chronic kidney disease affects the management of heart failure. The two are very intertwined and we know from all of the queries we get that this causes loss of anxiety, a lot of difficulty in primary care and in secondary care actually.

Should we stop diuretics? Are renin angiotensin inhibitors harmful for the kidneys if they're used in heart failure? Can we continue RAAS’s if people have got chronic kidney disease and heart failure? What happens if their GFR drops from 48 to 42 when we're treating their heart failure? So all of those sorts of questions are very common in primary care.

When should you worry? So we hope in the next 10 minutes or so, we can answer all of those questions, given that we've got Dominique and you, Andrew here. Let's kick off. Increasingly in secondary care, we're seeing people with heart failure and chronic kidney disease. You are in primary care as well.

Andrew, what is the relationship between these two? Why do they occur so frequently? 

Andrew 

The co-location of CKD, chronic kidney disease, and heart failure is increasingly recognised. And I think one of the reasons is that we're taking a much more proactive approach to both of these disorders. Now, chronic kidney disease itself is a very powerful predictor for the development of all types of cardiovascular [00:03:00] disease, which include heart failure.

And it's increasingly recognised. that a heart failure in itself can cause CKD and worsen its prognosis likely not just from renal under perfusion when the cardiac output is low. Furthermore, we know that people with cardiovascular disease, including heart failure, who also have CKD, fall into the group of people with cardiovascular disease who have the worst prognosis.

The pathophysiology of that relationship is poorly understood, but we do know that up to 40 per cent of people with CKD stages 3, 4, or 5 will have some degree of cardiovascular disease, including heart failure, both from preserved and reduced ejection fraction. Now the positive side of the coin is that treatments for both heart failure and CKD have actually advanced [00:04:00] enormously in the last 10 years. But those treatments do have an impact on kidney function or the EGFR, which does often necessitate cardiac failure team, primary care teams and nephrologists to work together more closely and collaboratively so that we can give people a coherent approach to how to manage those changes in kidney function.

Jeremy

Yeah, that's right, Andrew, isn't it? And we're seeing this both in primary care, secondary care, a big challenge, but I'm delighted, as we've said earlier, we've got Dominique with us, who's a consultant, the heart failure doctor who works very closely with us in our kidney teams. And Dominique, we're going to ask you, tell us a bit more about the core management for people with heart failure initially and some of what's changed.

Dominique 

Thank you very much for this interesting question. People with heart failure, we know have a significant mortality risk, and they suffer from very important symptoms, and they have very [00:05:00] affected quality of life by these symptoms. Over the last decade, we have learned from large-scale studies that there are now very effective treatments that can significantly impact both their survival, so the time that live with the diagnosis, but also their symptoms of heart failure.

The treatment options do differ a little bit in patients with heart failure where the ejection fraction of the left ventricle is reduced. That means an ejection fraction equal or below 35%, and where the heart failure is associated with a preserved ejection fraction, where the ejection fraction is around 45, 50%, and more.

For those individuals with reduced ejection fraction, we know that effective therapies are present. We have our fab four therapies, which are mainly composed of the ACE inhibitors and its new little cousin, the sacubitril valsartan, beta blockers the MRA inhibitors and the new kid on the block, the SGLT2 inhibitors. So these are the four pillars of treatment for heart failure with reduced ejection fraction. And we introduce them and tailor them according to the patient's symptoms, blood pressure, and tolerance to the medication. For people with heart failure and preserved ejection fraction, the options are fewer, but there is definite evidence of the benefits of the SGLT2.

So ensuring that patients receive optimal therapy for their heart failure, a significant impact, and with our heart failure clinics, our frequent MDTs, so we get the therapy it doesn't just have impact on their quality of life, as we've said, but also on their length of life and on their risk of attending hospital with a heart failure decompensation.

And this is critical. 

Andrew 

That is really helpful. And of course, it's so exciting that you now have multiple treatments for heart failure. From the perspective of management of chronic kidney disease, of course, one of the other really exciting aspects is that our treatment options are really very much aligned in the management of chronic kidney disease, because this also includes Maximisation of RAAS inhibitors, ACE inhibitors, angiotensin 2 blockers, the use of SGLT2 inhibitors and the use of MRA inhibitors in conjunction, as I'm sure you do, with lifestyle changes, and blood pressure control.

So the two treatment management plans are really very aligned. 

Jeremy

Andrew, you're doing yourself out of a job. Yeah, you've talked about identical treatments. We don't need you. We'll just keep Dominique. So that's all well and good, Andrew, particularly but these drugs do affect kidney function, don't they? We do.

Primary care certainly starts to worry about these and think about these, but when should primary care clinicians be? be concerned about changes in kidney function with these drugs. 

Andrew

So we know that many of these really effective interventions, both for heart failure and actually chronic kidney disease, will result in a drop in GFR.

And nephrologists highlight to primary care that they need to monitor kidney function and potassium when starting or adjusting GFR. the dose of any form of RAAS inhibitor. And we do give actually clear guidance on our North West London site, which is nice consistent as to when you should stop the medication and speak specialist advice.

Those criteria are very clear for people with just CKD and we accept that it's physiologically normal for people to see a reduction in their GFR when starting RAAS inhibitors and also when starting SGLT2 inhibitors. For SGLT 2 inhibitors, that change in GFR is not considered to be clinically significant, and we actually don't recommend monitoring.

However, following the introduction of RAAS inhibitors, we accept a serum creatinine rise of up to 30 percent or a GFR fall of 25%. Changes that are greater than this should prompt the need to review the patient and seek specialist advice. And changes that are borderline, we also suggest that you repeat the test to ensure that the patient is at a new baseline.

It's really important to understand that a drop in GFR from 50 to 35 is just a number to a patient. But in the context of heart failure, the situation is different. Because RAAS inhibitors provide that significant life expectancy and quality of life benefit. Dominique, perhaps you can highlight how the approach differs in people who've got both heart failure and CKD.

Dominique

Yes, of course. Of course, Andrew. Thank you. So that's right. In cardiology and heart failure, we are a little bit more, I wouldn't say relaxed, but we tend to accept drops in the GFR of about 50 percent and creatinines up to 260. Sometimes when we want to introduce these therapies that are lifesaving and that improve quality of life, just like you've said.

It's not rare in my clinical practice that I do see early drop in GFR when I start these therapies, but the kidneys do forgive and the EGFR re stabilizes and gets better a little bit over time as the heart failure gets treated. So this is also something that we see and that we can monitor.

Jeremy

I love your phrase, the kidneys forgive. I think that's exactly right. That drop in GFR. So that drop in GFR up to 50 percent it's acceptable and the kidneys forgive it. They'll forgive you in primary care if they, if the GFR looks a bit lower. So that's a really important point. Now we haven't mentioned potassiums at all so far, but we do know that these drugs tend to exacerbate, exaggerate potassiums and can lead to hyperkalaemia.

And for those of you listening to this as a first podcast, we've talked about this in previous episodes. So if you want to know more about hyperkalaemia, listen to our potassium special, but we do know combining particularly the RASI drugs uh, angiotensin converting enzyme inhibitors or angiotensin blockers.

With MRAs, especially, and in the setting of CKD, chronic kidney disease, can lead to hyperkalaemia. So that often needs managing in its own right, which might not mean stopping these really important drugs. There are other things we can do. And we need to continue these drugs because they improve symptoms.

They save lives. They stop people being admitted to hospital. But the other tool we've got is diuretics and we should talk about these a bit. Dominic, shouldn't we? Because diuretics can have multiple purposes. They can be useful to help control potassium. Actually, we know that they can get rid of potassium, but they've been used in heart failure for a slightly different reason than the FAB 4 that you mentioned earlier.

And in primary care, people suddenly get obsessed about them being nephrotoxic, which they're really not at all. But can you tell us something about diuretics and their role in heart failure? 

Dominique

So yes, diuretics are vital to us they help out with symptom control, they help out relieving the edema and helping with the breathing, but unfortunately they don't have any prognostic impact in heart failure.

Andrew

Diuretics are not nephrotoxic but they are actually helpful for symptoms and they need to be used just for those symptomatology treatment. It's important to appreciate also that when you're using diuretics in people with CKD for heart failure, you often have to use bigger doses because the kidneys are more resistant. To the diuretics, 

Jeremy

A really helpful discussion. Dominique and Andrew. I think I've remembered four things. Actually, usually we say three, but heart failure and chronic kidney disease are very commonly linked. They occur together their coexistence. I've learned that we must still treat the heart failure really aggressively and that's a fab four that Dominique's been banging on about because this will save lives and in the end protect kidneys, reduce admissions and improve symptoms and all the standard drugs that we use in heart failure.

Without CKD, we use in CKD. And then lastly, we can accept really quite significant drops in GFR of up to 50%, but of course need to monitor kidney function. But the GFR can fall by up to 50% in the setting of heart failure and CKD and that fantastic phrase. The kidneys forgive small early drops in GFR, but kidneys actually in the end will be better off.

If you've had a drop in GFR at the beginning and it just needs monitoring, it does not need us to stop the drugs. Have I got that right? Yes, totally. Fantastic. Dominique, Andrew, that's been a great session. 

Andrew

Thank you so much, Jeremy. And thank you, Dominique. 

Dominique 

Thank you both. And thank you everyone for listening.