How do we treat patients with chronic kidney disease stages 4-5 and heart failure with reduced left ventricular ejection fraction? Impact on 1-year mortality and hospital admissions

Introduction Chronic kidney disease (CKD) is very prevalent in patients with HF, and makes the use of drugs with a favorable effect on patient prognosis more difficult, due to increased complications (hyperkalemia, impaired kidney function, hypotension). Pharmacological clinical trials in HFrEF have excluded cases with a glomerular filtration rate < 30 ml/min/m2 (CKD stages 4-5), so the effect of using these drugs in these patients is poorly understood. Purpose To analyze in a contemporary registry of HF patients followed in HF units in Spain the pharmacological treatment in patients with HFrEF and their relationship with outcomes at 1 year follow-up. Methods We analyzed data from the registry of the SEC-Excelente-IC quality accreditation program of the Spanish Society of Cardiology, with 2,245 patients with HF included between 2019 and 2024 by 68 specialized HF units. Of them, 1,144 (50.9%) were HFrEF, and 109 patients with HFrEF had CKD stages 4-5 (9.5%). Results Figure 1 shows the prescription of the various drugs in these 109 patients: 51.4% received ACEI, ARB or ARNI (ARNI 37.6%), 37.7% mineralcorticoid receptor antagonists (MRA), 78.9% betablockers, and 47.7% SGLT2 inhibitors (SGLT2i). Concomitant ACEI/ARB/ARNI+betablockers+MRA were used in 19.3% of patients, and ACEI/ARB/ARNI+betablockers+MRA+SGLT2i in 11.9%. Figure 2 shows the rates of 1-year mortality and HF admissions in patients with or without the different drugs. Numerically, the 1-year mortality and incidence of HF hospitalizations per year was lower with the use of the different drugs and combinations, but only the administration of ACEI or ARB or ARNI was significantly associated with a decreased mortality (RR 0.48, 95%CI 0.24-0.95, p=0.031) and HF hospitalizations rate (RR 0.33, 95%CI 0.20-0.56, p<0.001), probably due to the small sample size. Triple and quadruple therapy showed a trend to decrease both events (figure 2). Conclusions Despite the lack of evidence derived from clinical trials, the use of different drugs with proven prognostic effects and their combinations seems to reduce the incidence of death and HF hospitalizations in patients with HFrEF and CKD stages 4-5. It seems necessary to increase drug use to improve outcomes in these severely ill patients.