Prise en charge pratique de l’aggravation de fonction rénale chez les patients ambulatoires atteints d’insuffisance cardiaque à fraction d’éjection altérée: position d’un groupe multidisciplinaire d’experts et du Groupe Insuffisance Cardiaque et Cardiomyopathie (GICC) de la Société Française de Cardiologie.
Nathan Mewton, Nicolas Girerd, Jean-Jacques Boffa, Cécile Courivaud, Richard Isnard, Laurent Juillard, Nicolas Lamblin, Matthieu Legrand, Damien Logeart, Christophe Mariat, Edith Meune, Pierre Sabouret, Laurent Sebbag, Patrick Rossignol
Summary
Renal function is often affected in patients with chronic heart failure with reduced ejection fraction (HFrEF). The complex interplay between heart and renal dysfunction makes renal function and potassium monitoring mandatory. Renin-angiotensin-aldosterone system (RAAS) blockers are a life-saving treatment for patients with HFrEF, regardless of worsening renal function. Uptitration to the maximum-tolerated dose should be a constant goal. This simple fact is all too often forgotten (only 30% of patients with heart failure receive the target dosage of RAAS blockers), and the RAAS blocker effect on renal function is sometimes misunderstood. RAAS blockers are not nephrotoxic drugs as they only have a functional effect on renal function. In many routine clinical cases, RAAS blockers are withheld or stopped because of this misunderstanding, combined with suboptimal assessment of the clinical situation and underestimation of the life-saving effect of RAAS blockers despite worsening renal function. In this expert panel, which includes heart failure specialists, geriatricians and nephrologists, we propose therapeutic management algorithms for worsening renal function for physicians in charge of outpatients with chronic heart failure. Firstly, the essential variables to take into consideration before changing treatment are the presence of concomitant disorders that could alter renal function status (e.g. infection, diarrhoea, hyperthermia), congestion/dehydration status, blood pressure and intake of nephrotoxic drugs. Secondly, physicians are invited to adapt medication according to four clinical scenarios (patient with congestion, dehydration, hypotension or hyperkalaemia). Close biological monitoring after treatment modification is mandatory. We believe that this practical clinically minded management algorithm can help to optimize HFrEF treatment in routine clinical practice.
Keywords
- Hyperkalemia
- Heart failure
- Systolic
- Chronic kidney disease
- Renal function
- Cardiorenal syndrome
- Cardiovascular disease
- Cardiac edema
Abbreviations
- ACE: angiotensin-converting enzyme
- ARB: angiotensin receptor blocker
- ARN: angiotensin receptor neprilysin
- CI: confidence interval
- CKD: chronic kidney disease
- CKD-EPI: Chronic Kidney Disease Epidemiology Collaboration
- eGFR: estimated glomerular filtration rate
- ESC: European Society of Cardiology
- GFR: glomerular filtration rate
- HFrEF: heart failure with reduced ejection fraction
- HR: hazard ratio
- NSAID: non-steroidal anti-inflammatory drug
- RAAS: renin-angiotensin-aldosterone system
- WRF: worsening renal function
© 2020 Elsevier Masson SAS. Tous droits réservés.