Sacubitril/Valsartan in Patients with HFrEF Undergoing Maintenance Hemodialysis, Evidence of Cardiac Reverse Remodeling During 12-Month Follow-Up: Case Series

Background and Clinical Significance: Heart failure with reduced ejection fraction (HFrEF) is highly prevalent among patients with end-stage kidney disease (ESKD) undergoing maintenance hemodialysis (MHD) and is associated with poor clinical outcomes. Sacubitril/valsartan (SV) is a cornerstone therapy for HFrEF; however, its use in dialysis patients remains limited due to safety concerns and lack of robust evidence. This case series describes the clinical response and safety of SV in patients with HFrEF receiving MHD; Case Presentation: Four male patients with HFrEF undergoing MHD were treated with SV and followed for 12 months. Baseline evaluation showed a left ventricular ejection fraction (LVEF) of 35.5%, left ventricular end-systolic volume (LVESV) of 118.5 mL, left ventricular end-diastolic volume (LVEDV) of 185.7 mL, pulmonary artery systolic pressure (PASP) of 52.7 mmHg, and NT-proBNP levels above 35,000 pg/mL in all patients. After 12 months of SV therapy, LVEF improved to 53.7%, corresponding to a 51.4% relative increase from baseline. Reverse cardiac remodeling was observed, with LVESV decreasing to 58.2 mL and LVEDV to 110 mL, together with reductions in left ventricular dimensions. PASP decreased to 32 mmHg, and NT-proBNP levels declined to 7261.7 pg/mL. Blood pressure improved, serum potassium remained stable at 4.95 mmol/L, and no severe hyperkalemia, intradialytic hypotension, post-dialysis hypotension, or heart failure-related hospitalization occurred; Conclusions: In this case series, SV was associated with improved cardiac function, reverse remodeling, pulmonary pressure reduction, and an acceptable safety profile in patients with HFrEF undergoing MHD. These findings suggest a potential therapeutic role for SV in selected dialysis patients and support further investigation.