Barry Arden R
Associate Professor (Partner), Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada.
Clinical Pharmacy and Research Specialist (Cardiology), Jim Pattison Outpatient Care and Surgery Centre, Lower Mainland Pharmacy Services, Surrey, British Columbia, Canada.
CJC Open. 2022 Jun 26;4(9):802-809. doi: 10.1016/j.cjco.2022.06.007. eCollection 2022 Sep.
Patients with heart failure with reduced ejection fraction (HFrEF) often have concurrent chronic kidney disease (CKD), which can make initiating and titrating the 4 standard pharmacologic therapies a challenge. Drug dosing is often based on a calculation of the patient's creatine clearance or estimated glomerular filtration rate (eGFR), but it should also incorporate the trend in their renal function over time and the risk of toxicity of the drug. The presence of CKD in a patient should not preclude the use of a renin-angiotensin system inhibitor, although patients should be monitored frequently for worsening renal function and hyperkalemia. Sacubitril/valsartan is not recommended in patients with an eGFR < 30 mL/min per 1.73 m. Of the 3 ß-blockers recommended in the management of HFrEF, only bisoprolol may accumulate in patients with renal impairment; however, patients should still be titrated to the target dose (10 mg daily) or the maximally tolerated dose, depending on their clinical response. The sodium-glucose cotransporter 2 inhibitors are effective at reducing adverse cardiovascular and renal outcomes in patients with HFrEF and CKD (eGFR ≥ 25 mL/min per 1.73 m with dapagliflozin or ≥ 20 mL/min per 1.73 m with empagliflozin), although declining kidney function is a risk, due to the osmotic diuretic effect. Finally, mineralocorticoid receptor antagonist therapy should be considered in all patients with HFrEF and an eGFR ≥ 30 mL/min per 1.73 m. The starting dose should be low (eg, 6.25-12.5 mg daily or 12.5 mg every other day) and can be uptitrated based on the patient's renal function and serum potassium.
射血分数降低的心力衰竭（HFrEF）患者常并发慢性肾脏病（CKD），这使得启动和滴定4种标准药物治疗成为一项挑战。药物剂量通常基于患者的肌酐清除率或估算肾小球滤过率（eGFR）计算，但也应考虑其肾功能随时间的变化趋势以及药物毒性风险。患者患有CKD不应排除使用肾素 - 血管紧张素系统抑制剂，尽管应频繁监测患者肾功能恶化和高钾血症情况。eGFR<30 mL/（min·1.73 m²）的患者不建议使用沙库巴曲/缬沙坦。在HFrEF管理中推荐的3种β受体阻滞剂中，只有比索洛尔可能在肾功能损害患者中蓄积；然而，仍应根据患者的临床反应将其滴定至目标剂量（每日10 mg）或最大耐受剂量。钠 - 葡萄糖协同转运蛋白2抑制剂可有效降低HFrEF和CKD患者（达格列净治疗时eGFR≥25 mL/（min·1.73 m²）或恩格列净治疗时eGFR≥20 mL/（min·1.73 m²））的不良心血管和肾脏结局，尽管由于渗透性利尿作用，肾功能下降是一种风险。最后，所有eGFR≥30 mL/（min·1.73 m²）的HFrEF患者均应考虑使用盐皮质激素受体拮抗剂治疗。起始剂量应较低（例如，每日6.25 - 12.5 mg或隔日12.5 mg），并可根据患者的肾功能和血钾水平上调剂量。
