Tumelty Ella, Chung Isaac, Hussain Sabba, Ali Mahrukh Ayesha, Addada Harshavardhani, Banerjee Debasish
Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust London, SW17 0QT London, UK.
Cardiovascular and Genetics Research Institute St George's University of London, SW17 0QT London, UK.
Rev Cardiovasc Med. 2024 Apr 11;25(4):144. doi: 10.31083/j.rcm2504144. eCollection 2024 Apr.
Chronic kidney disease (CKD) is common in patients with heart failure (HF) and is associated with high morbidity and mortality. There has been remarkable progress in the treatment of HF over recent years with the establishment of guideline-directed medical therapies including: (1) Beta-blockers, (2) renal angiotensin aldosterone system (RAAS) inhibition (i.e., angiotensin-converting enzyme inhibitor [ACEi], aldosterone receptor blocker [ARB] or angiotensin receptor-neprilysin inhibitor [ARNI]); (3) mineralocorticoid receptor antagonists (MRA), and (4) sodium-glucose cotransporter-2 inhibitors (SGLT2i). However, there are challenges to the implementation of these medications in patients with concomitant CKD due to increased vulnerability to common side-effects (including worsening renal function, hyperkalaemia, hypotension), and most of the pivotal trials which provide evidence of the efficacy of these medications excluded patients with severe CKD. Patients with CKD and HF often have regular healthcare encounters with multiple professionals and can receive conflicting guidance regarding their medication. Thus, despite being at higher risk of adverse cardiovascular events, patients who have both HF and CKD are more likely to be under-optimised on evidence-based therapies. This review is an updated summary of the evidence available for the management of HF (including reduced, mildly reduced and preserved left ventricular ejection fraction) in patients with various stages of CKD. The review covers the evidence for recommended medications, devices such as implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), intravenous (IV) iron, and discusses how frailty affects the management of these patients. It also considers emerging evidence for the prevention of HF in the cohort of patients with CKD. It synthesises the available evidence regarding when to temporarily stop, continue or rechallenge medications in this cohort. Chronic HF in context of CKD remains a challenging scenario for clinicians to manage, which is usually complicated by frailty, multimorbidity and polypharmacy. Treatment should be tailored to a patients individual needs and management in specialised cardio-renal clinics with a multi-disciplinary team approach has been recommended. This review offers a concise summary on this expansive topic.
慢性肾脏病（CKD）在心力衰竭（HF）患者中很常见，且与高发病率和死亡率相关。近年来，随着包括以下内容的指南指导药物治疗的建立，心力衰竭的治疗取得了显著进展：（1）β受体阻滞剂；（2）肾素血管紧张素醛固酮系统（RAAS）抑制（即血管紧张素转换酶抑制剂[ACEi]、醛固酮受体阻滞剂[ARB]或血管紧张素受体脑啡肽酶抑制剂[ARNI]）；（3）盐皮质激素受体拮抗剂（MRA）；以及（4）钠-葡萄糖协同转运蛋白2抑制剂（SGLT2i）。然而，由于更容易出现常见副作用（包括肾功能恶化、高钾血症、低血压），在合并CKD的患者中应用这些药物存在挑战，并且大多数提供这些药物疗效证据的关键试验都排除了重度CKD患者。CKD和HF患者经常与多个专业人员进行定期医疗接触，并且可能会收到关于其用药的相互矛盾的指导。因此，尽管发生不良心血管事件的风险更高，但同时患有HF和CKD的患者在循证治疗方面更有可能未得到充分优化。本综述是关于CKD各阶段患者心力衰竭（包括射血分数降低、轻度降低和保留）管理的现有证据的最新总结。该综述涵盖了推荐药物、植入式心脏复律除颤器（ICD）、心脏再同步治疗（CRT）、静脉铁剂等设备的证据，并讨论了虚弱如何影响这些患者的管理。它还考虑了CKD患者队列中预防HF的新证据。它综合了关于该队列中何时暂时停药、继续用药或重新挑战用药的现有证据。CKD背景下的慢性HF仍然是临床医生管理中具有挑战性的情况，通常因虚弱、多病共存和多重用药而变得复杂。治疗应根据患者的个体需求进行调整，建议在专门的心肾诊所采用多学科团队方法进行管理。本综述对这个广泛的主题提供了简明总结。
