Optimising heart failure treatment in patients receiving renal replacement therapy: the role of a cardiorenal unit

Introduction

The therapeutic approach to cardiorenal syndrome (CRS) is evolving. There is currently no consensus on the benefit of heart failure (HF) prognostic therapies in patients receiving renal replacement therapy.

Purpose

We aimed to assess the impact of HF prognostic therapies in patients with CRS undergoing renal replacement therapy.

Methods

We conducted a retrospective, observational study including patients with CRS receiving renal replacement therapy at our Cardiorenal Unit (CRU). We collected data on comorbidities, laboratory parameters, echocardiographic findings, and HF treatment. We performed subgroup analyses according to left ventricular ejection fraction (LVEF) and renal replacement therapy modality. We then assessed their impact on functional class, drug up-titration, hospital admissions, and mortality.

Results

We included 58 patients (69% men) with a mean age of 65.6 ± 12.5 years. The main comorbidities were arterial hypertension (86.2%), dyslipidaemia (72.4%), and diabetes mellitus (51.7%). The mean Charlson comorbidity index was 5.83 ± 2.04.

According to LVEF, 25.9% of patients had an ejection fraction below 40%, 20.7% between 40% and 49%, and 53.4% of 50% or higher. Regarding renal replacement therapy, 62.1% received haemodialysis, 25.9% peritoneal dialysis for ultrafiltration, and 12.1% automated peritoneal dialysis. Haemodialysis was more frequent in patients with an ejection fraction of 40% or higher, whereas peritoneal dialysis for ultrafiltration predominated in those with an ejection fraction below 40% (p = 0.042).

At baseline, patients with an ejection fraction below 40% had worse functional class. NYHA functional class improved in all groups, regardless of ejection fraction.

We observed up-titration of HF prognostic therapies irrespective of ejection fraction and renal replacement therapy modality. This was accompanied by a significant reduction in furosemide dose, suggesting improvement in clinical congestion. The use of potassium binders increased significantly, particularly in patients with an ejection fraction of 50% or higher.

During follow-up, 20.7% of patients were admitted for HF and 10.3% died. Non-cardiovascular admissions were more frequent in patients receiving haemodialysis (27.8%). No significant differences were observed in the evolution of N-terminal pro–B-type natriuretic peptide or cancer antigen 125 between groups (Figures 1 and 2).

Conclusion

Despite limited evidence on the use of prognostic therapies in CRS among patients receiving renal replacement therapy, this study provides supportive evidence of their safety and potential benefit. Close follow-up within CRU allows treatment optimisation, with improvement in functional class and a reduction in heart failure admissions. These findings highlight the importance of an individualised, multidisciplinary approach in this patient population.Baseline characteristicsFor image description, please refer to the figure legend and surrounding text.HF therapy in cardiorenal patientsFor image description, please refer to the figure legend and surrounding text.