What does this research mean for the field?

Initiating intermediate-dose sacubitril/valsartan improved ejection fraction from 38% to 71% and reduced NT-proBNP from 113,883 pg/mL to 2,005 pg/mL over six months in a young hemodialysis patient with high-output heart failure. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

To explore the effectiveness of angiotensin receptor-neprilysin inhibitors in a young hemodialysis patient experiencing high-output heart failure due to a high-flow AVF.

January 10, 2026Cureus0 citationsOpen Access

Use of Angiotensin Receptor-Neprilysin Inhibitors (ARNis) in High-Output Heart Failure in a Young Hemodialysis Patient: Synergistic or Cumulative Effect?

SSSara R SilvaCentro Hospitalar de Lisboa Ocidental ESElsa SoaresAdministração Regional de Saúde de Lisboa e Vale do Tejo ANAna NatárioAdministração Regional de Saúde de Lisboa e Vale do Tejo

Key Result

Initiating intermediate-dose sacubitril/valsartan improved ejection fraction from 38% to 71% and reduced NT-proBNP from 113,883 pg/mL to 2,005 pg/mL over six months.

Key Points

To explore the effectiveness of angiotensin receptor-neprilysin inhibitors in a young hemodialysis patient experiencing high-output heart failure due to a high-flow AVF.
Case evaluation of a 32-year-old female hemodialysis patient with refractory hypertension and symptoms of heart failure.
Utilization of transthoracic echocardiography for cardiac function assessment and monitoring of hemodynamics.
Administration of intermediate-dose sacubitril/valsartan as antihypertensive therapy over a two-month period.
Significant improvement in blood pressure control and heart function within two weeks of treatment.
Ejection fraction improved from 38% to 71% and pulmonary artery systolic pressure reduced from 46 mmHg to 23 mmHg after two months.
N-terminal pro-BNP levels decreased from 113,883 pg/mL to 2,005 pg/mL, indicating clinical improvement.

Structured PICO

Does sacubitril/valsartan improve cardiac function and blood pressure in a hemodialysis patient with high-output heart failure?

Population

1 32-year-old female patient on hemodialysis for five years with end-stage chronic kidney disease, presenting with refractory hypertension and high-output heart failure (LVEF 38%, PASP 46 mmHg, NT-proBNP 113,883 pg/mL) secondary to a high-flow arteriovenous fistula (Qa >3000 mL/min).

Intervention

Intermediate-dose sacubitril/valsartan replacing all previous antihypertensive therapy, followed by surgical closure of the arteriovenous fistula two months later.

Outcome

Improvement in blood pressure, clinical symptoms (resolution of pleural effusion), and echocardiographic parameters (LVEF, PASP) and NT-proBNP levels at 6 months.surrogate

Sacubitril/valsartan, combined with arteriovenous fistula closure, safely and effectively improved left ventricular function and controlled refractory hypertension in a young hemodialysis patient with high-output heart failure.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

In hemodialysis patients, an arteriovenous fistula (AVF) is the preferred option for vascular access. High-output heart failure (HOHF) due to a high-flow AVF can be an underrecognized complication, and arterial hypertension is among the most prevalent comorbidities in this population. Consequently, these patients are closely monitored during hemodialysis and routinely evaluated for cardiovascular pathology. A 32-year-old woman on hemodialysis for five years presented with hypertension refractory to triple pharmacologic therapy and dialysis, pleural effusion, exertional dyspnea, peripheral edema, and jugular venous distention. She was evaluated at an internal medicine day hospital to investigate the underlying cause of recurrent pleural effusion. She was found to have a concomitant high-flow AVF (Qa >3000 mL/min), which had undergone multiple banding procedures. Thoracentesis with cytobiochemical analysis revealed a transudative pleural effusion. Transthoracic echocardiography (TTE) demonstrated HF with reduced ejection fraction (38%) and pulmonary artery systolic pressure (PASP) of 46 mmHg; N-terminal pro-BNP (NT-proBNP) was 113,883 pg/mL. After multidisciplinary discussion, all antihypertensive therapy was replaced with intermediate-dose sacubitril/valsartan (SAC/VAL), aiming to control blood pressure and improve ejection fraction, with close monitoring of serum potassium and hemodynamics. Within two weeks, blood pressure control and symptoms improved significantly, with resolution of the pleural effusion. Two months after initiating SAC/VAL, the AVF was surgically closed, and dialysis access was switched to a long-term catheter. At six-month follow-up, repeat TTE showed recovery of ejection fraction to 71% and reduction of PASP to 23 mmHg. NT-proBNP decreased to 2,005 pg/mL, corroborating clinical improvement. The patient remains clinically stable. Continuous clinical assessment and individualized management are essential for addressing complex conditions in dialysis patients. Further research is warranted to establish the efficacy and safety of SAC/VAL in this population.

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