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The management of left ventricular systolic dysfunction in patients with advanced chronic kidney disease
Vera Dounaevskaia1, Andrew T Yan, David Charytan
1Division of Nephrology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Canada. vera.dounaevskaia@utoronto.ca
Insights
Many patients with advanced chronic kidney disease and left ventricular systolic dysfunction do not receive guideline-recommended therapies. This highlights a gap in care for this high-risk population, necessitating further investigation into treatment barriers.
Area of Science:
- Cardiology
- Nephrology
- Pharmacology
Background:
- Left ventricular systolic dysfunction (LVSD) is common in advanced chronic kidney disease (CKD) and linked to poor outcomes.
- Standard care for LVSD involves renin-angiotensin system (RAS) inhibition and beta-adrenergic blockade.
- Guideline adherence for LVSD management in CKD patients is not well understood.
Purpose of the Study:
- To assess the utilization of recommended pharmacotherapies for LVSD in advanced CKD patients.
- To identify factors influencing the application of optimal medical therapy for LVSD in this cohort.
Main Methods:
- A cross-sectional study of 387 patients with advanced CKD (dialysis or pre-dialysis).
- Echocardiographic and pharmacotherapy data were analyzed.
- Optimal therapy for moderate-severe LVSD (ejection fraction <40%) was defined as receiving both a beta-blocker and a RAS inhibitor.
Main Results:
- 34 patients (8.8%) had moderate-severe LVSD.
- Optimal therapy was administered to 23 of these patients (67.7%).
- Reasons for non-adherence were not explained by hypotension, hyperkalemia, drug sensitivities, or pill burden.
Conclusions:
- A significant proportion (approximately one-third) of advanced CKD patients with LVSD do not receive optimal pharmacotherapy.
- Barriers to optimal care must be identified and addressed to improve management in this high-risk group.
Background:
Left ventricular systolic dysfunction (LVSD) is frequently observed in patients with advanced chronic kidney disease (CKD) and its presence is associated with a poor prognosis. Renin-angiotensin system (RAS) inhibition and beta-adrenergic blockade are the cornerstones of medical management for LVSD. Current guidelines advocate that CKD patients with advanced LVSD should receive these therapies. The extent to which these recommendations are followed is unclear. The goal of this study was to evaluate practice patterns for LVSD management across the spectrum of patients with advanced CKD, and to determine the rate of utilization of recommended therapies for LVSD.
Methods:
This cross-sectional study encompassed all long-term dialysis patients (n=299) and patients with advanced pre-dialysis CKD who were followed in a multidisciplinary clinic (n=176) at a tertiary care center in Toronto, Canada. Echocardiographic and pharmacotherapy data were sought for each patient. In patients with moderate-severe LVSD (ejection fraction <40%), we evaluated the extent to which optimal pharmacotherapy, defined as the receipt of a beta-adrenergic receptor blocker and a RAS inhibitor (an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker), was applied. We then sought to identify factors to explain the usage of these therapies.
Results:
Of the 475 eligible patients, 387 had echocardiographic data available for analysis. Among these individuals, 34 (8.8%) had moderate-severe LVSD, of whom 23 (67.7%) were receiving optimal therapy. Non-receipt of optimal therapy could not be explained by hypotension, hyperkalemia, known drug sensitivities, or pill burden.
Conclusions:
Approximately one-third of patients with advanced CKD and significant LVSD were not receiving optimal pharmacotherapy, in the absence of known contraindication or intolerance. Identifying and overcoming barriers to care will be crucial in order to enhance the management of this high-risk population.
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