Guideline directed medical therapy in patients with heart failure with reduced ejection fraction undergoing renal replacement therapy: real world experience from a specialized cardiorenal unit
S Valdivielso, B Ayala-Borges, C Barrios Barrera, J Del Risco Zevallos, N Badosa-Merce, P Ruiz Rodriguez, A Linas Alonso, P Miletic, F Martinez Medina, F Barbosa Puig, I Galceran Herrera, E Tejeda Araez, M Illa Casellas, L C Belarte-Tornero, S Ruiz-BustilloAbstract
Introduction
Patients undergoing renal replacement therapy (RRT) are commonly excluded from randomized clinical trials and seldom receive comprehensive guideline-directed medical therapy (GDMT). Consequently, robust evidence informing the optimal management of heart failure with reduced ejection fraction (HFrEF) in this population is scarce, which contributes to undertreatment. Dedicated cardiorenal units (CRU) offer an integrated, multidisciplinary care model that may enhance the safe initiation and titration of GDMT in these particularly high-risk patients.
Purpose
To evaluate the efficacy and safety of initiating and titrating prognostic pharmacological therapies in patients with HFrEF who are undergoing RRT, within a specialized CRU.
Methods
We conducted a prospective, observational, single-center study including all patients with HFrEF and RRT who were referred to the CRU and initiated prognostic treatment from june 2023 to may 2025. Baseline characteristics, pharmacological treatment at 6-month follow-up and echocardiographic parameters at baseline and at 6-month follow-up were recorded. Safety outcomes included limiting factors for treatment initiation and titration, as well as the occurrence of adverse events.
Results
Twenty patients were included, predominantly male (90%), with a mean age of 66.4 ± 12.5 years. All patients had hypertension; 40% diabetes mellitus and 66.4% dyslipidemia. Regarding RRT, 14 (70%) patients were on hemodialysis and 6 (30%) on peritoneal dialysis. The main etiologies of chronic kidney disease were nephroangiosclerosis (35%) and diabetes (35%), while the predominant etiology of HF was ischemic heart disease (40%). At the end of follow-up, 95% of patients were receiving beta-blockers, 35% angiotensin–renin–aldosterone system inhibitors or angiotensin receptor blockers, 45% sacubitril-valsartan, 45% mineralocorticoid receptor antagonists, and 60% sodium–glucose co-transporter 2 inhibitors. Overall, 30% of patients were on quadruple therapy, 25% on triple therapy, 40% on dual therapy, and 5% on monotherapy. A significant increase in median LVEF was observed at the end of follow-up (35% [IQR 30–36.5] vs 50% [IQR 41–58.5], p = 0.002) with a Δ15% improvement. Hypotension was the main limiting factor for treatment optimization (50%), while hyperkalemia limited treatment in only two patients.
Conclusions
In patients with HFrEF undergoing renal replacement therapy, optimization of GDMT within a specialized CRU was achievable in a high proportion of cases, while also demonstrating a favorable safety profile. Treatment optimization was associated with a significant improvement in LVEF. These findings support the feasibility and potential benefit of implementing structured GDMT in this traditionally underrepresented population.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.