Change in renal function associated with drug treatment in heart failure: national guidance

Clark, A. L., Kalra, P. R., Petrie, M. C. , Mark, P. B. , Tomlinson, L. A. and Tomson, C. R.V. (2019) Change in renal function associated with drug treatment in heart failure: national guidance. Heart, 105(12), pp. 904-910. (doi: 10.1136/heartjnl-2018-314158) (PMID:31118203) (PMCID:PMC6582720)

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Inhibitors of the renin–angiotensin–aldosterone (RAAS) system are cornerstones of the management of patients with heart failure with reduced left ventricular ejection fraction (HFrEF). However, RAAS inhibitors may cause decline in renal function and/or hyperkalaemia, particularly during initiation and titration, intercurrent illness and during worsening of heart failure. There is very little evidence from clinical trials to guide the management of renal dysfunction. The Renal Association and British Society for Heart Failure have collaborated to describe the interactions between heart failure, RAAS inhibitors and renal dysfunction and give clear guidance on the use of RAAS inhibitors in patients with HFrEF. During initiation and titration of RAAS inhibitors, testing renal function is mandatory; a decline in renal function of 30% or more can be acceptable. During intercurrent illness, there is no evidence that stopping RAAS inhibitor is beneficial, but if potassium rises above 6.0 mmol/L, or creatinine rises more than 30%, RAAS inhibitors should be temporarily withheld. In patients with fluid retention, high doses of diuretic are needed and a decline in renal function is not an indication to reduce diuretic dose: if the patient remains congested, more diuretics are required. If a patient is hypovolaemic, diuretics should be stopped or withheld temporarily. Towards end of life, consider stopping RAAS inhibitors. RAAS inhibition has no known prognostic benefit in heart failure with preserved ejection fraction. Efforts should be made to initiate, titrate and maintain patients with HFrEF on RAAS inhibitor treatment, whether during intercurrent illness or worsening heart failure.

Item Type:Articles
Glasgow Author(s) Enlighten ID:Mark, Dr Patrick and Petrie, Professor Mark and Kalra, Dr Paul
Authors: Clark, A. L., Kalra, P. R., Petrie, M. C., Mark, P. B., Tomlinson, L. A., and Tomson, C. R.V.
College/School:College of Medical Veterinary and Life Sciences > Institute of Cardiovascular and Medical Sciences
College of Medical Veterinary and Life Sciences > School of Medicine, Dentistry & Nursing
Journal Name:Heart
Publisher:BMJ Publishing Group
ISSN (Online):1468-201X
Published Online:22 May 2019
Copyright Holders:Copyright © 2019 The Authors
First Published:First published in Heart 105(12):904-910
Publisher Policy:Reproduced under a Creative Commons License

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