Key result
ARNIs may mitigate renal dysfunction in select HF patients but excessive hypotension risks exacerbating decline.
Why the study?
Renin-angiotensin system inhibitors are important for chronic kidney disease and hypertension, but their efficacy for advanced CKD remains uncertain, and direct evidence supporting ARNI's renal-protective effects is lacking.
Do angiotensin receptor-neprilysin inhibitors mitigate renal dysfunction in patients with chronic kidney disease and heart failure?
Do angiotensin receptor-neprilysin inhibitors mitigate renal dysfunction in patients with chronic kidney disease and heart failure?
While ARNIs show potential for renal protection in patients with heart failure, vigilant blood pressure monitoring is essential to prevent hypotension-induced renal decline, particularly in older patients with HFrEF and advanced CKD.
Answers are grounded in this paper and cite their sources.
Vigilant BP monitoring is needed with ARNIs in HF and CKD to avert hypotension-related renal harm; leaves open renal protection pending direct trials.
Background: Chronic kidney disease (CKD) and hypertension are significant global health challenges that often coexist and aggravate each other. Renin-angiotensin system inhibitors are important to the management of these conditions; however, their efficacy for advanced CKD remains uncertain. Summary: Angiotensin receptor-neprilysin inhibitors (ARNIs) have superior efficacy for heart failure (HF) management, as evidenced by landmark trials such as the PARADIGM-HF and PARAGON-HF, thus leading to its endorsement by various guidelines. Although direct evidence supporting the renal-protective effects of ARNI is lacking, post hoc analyses have suggested its potential to mitigate the decline of the estimated glomerular filtration rate and renal events, particularly in patients with HF with a relatively preserved ejection fraction. Mechanistically, ARNI augments the glomerular filtration rate by dilating glomerular arterioles, relaxing mesangial cells, and improving renal medullary blood flow, thereby mitigating interstitial fibrosis progression. ARNI also effectively addresses nondipper hypertension, particularly in salt-sensitive individuals, thereby reducing the cardiovascular risk. Key Messages: Uncertainties regarding the efficacy and safety of ARNI for advanced renal failure (estimated glomerular filtration rate <30 mL/min) exist. Excessive hypotension associated with ARNI use may exacerbate the renal function decline, especially in older patients with comorbid HF with a reduced ejection fraction. Hence, vigilant blood pressure monitoring is essential to optimizing the renal benefits of ARNI and minimizing adverse effects. Evidence supporting the renal benefits of ARNI continues to evolve; therefore, ARNI could mitigate renal dysfunction in select patient populations. Further research should be performed to clarify the efficacy of ARNI for advanced renal failure and refine its therapeutic application for patients with concurrent HF and renal dysfunction.
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Hishida et al. (2024) conducted a review in Chronic kidney disease. Angiotensin receptor-neprilysin inhibitors (ARNIs) was evaluated. Angiotensin receptor-neprilysin inhibitors may mitigate renal dysfunction in select patients with heart failure, though direct evidence is lacking and excessive hypotension may exacerbate renal decline.
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