Management and outcomes of heart failure patients with CKD: experience from an inter-disciplinary clinic

CKD-HF patients suffer excess hospitalization and mortality, often under-treated with life-prolonging medications due to fear of worsening renal function and hyperkalaemia. Yet, role of inter-disciplinary working in improving therapy is unknown, which this study aims to investigate.

Clinical, biochemical data, and medications at first and last clinic visit were obtained from patient records for 124 patients seen in kidney failure-heart failure clinic (23 March 2017 to 11 April 2019). Medication dose groups (none, low, and high dose), number of RAASi agents, and blood test results were compared between first and last visit in patients with at least two clinic visits (n = 97). Patient characteristics were age 78.5 years (IQR 68.1-84.4 years), male 67.7%, diabetes 51.6%, moderate (45.2%) vs. severe (39.5%) CKD, HF with reduced ejection fraction (HFrEF) (49.2%), follow-up 234 days (IQR 121-441 days). HFrEF was associated with increased risk of death (adjusted OR 4.49, 95% CI 1.43-14.05; P = 0.01). Distributions of patients according to number of RAASi agents they were on differed between first and last visit (P = 0.03). Dosage was increased in 25.9% for beta-blockers, 33.0% for ACEi/ARBs, and 17.5% for MRAs. Distributions of patients across MRA dosage groups was different (P = 0.03), with higher proportions on higher dosages at last visit, without significant changes in serum potassium or creatinine. Serum ferritin improved (131.0 vs. 267.5 microg/L; P < 0.001), and fewer patients had iron deficiency (56.7% vs. 26.8%; P = 0.002) at last visit compared to the first.

This inter-disciplinary clinic improved guideline-recommended medication prescription, MRA dosages in CKD-HF patients without significant biochemical abnormality, and iron status. A prospectively designed study with medication titration protocol and defined patient-centred outcomes is needed to further assess effectiveness of such clinic.