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Treatment of Chronic Heart Failure in Advanced Chronic Kidney Disease: The HAKA Multicenter Retrospective Real-World
Borja Quiroga1,2, Alberto Ortiz2,3, Sara Núñez4
1Nephrology Department, IIS-La Princesa, Hospital Universitario de la Princesa, Madrid, Spain.
Insights
Treatment for chronic heart failure (HF) in advanced chronic kidney disease (aCKD) patients is suboptimal. Real-world data show low uptake of guideline-recommended quadruple therapy, highlighting an unmet need for improved care and targeted clinical trials.
Area of Science:
- Nephrology
- Cardiology
- Pharmacology
Background:
- Advanced chronic kidney disease (aCKD) significantly increases mortality and hospitalization risk in patients with chronic heart failure (HF).
- Randomized clinical trials often exclude patients with aCKD, limiting evidence-based treatment guidelines for this population.
- Current HF therapy in patients under specialized aCKD care requires investigation.
Purpose of the Study:
- To evaluate the adherence to European Society of Cardiology (ESC) guidelines for HF treatment in patients with aCKD.
- To assess the utilization of foundational HF medications, including renin-angiotensin system inhibitors (RASi), angiotensin receptor/neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i).
Main Methods:
- The Heart And Kidney Audit (HAKA) study analyzed real-world data from 5,012 aCKD outpatients with HF across 29 Spanish centers.
- A cross-sectional and retrospective design was employed to examine treatment patterns.
- Compliance with ESC guidelines for HF management was assessed, focusing on key drug classes.
Main Results:
- Only 9.3% of aCKD patients with heart failure with reduced ejection fraction (HFrEF) received guideline-recommended quadruple therapy (RASi/ARNI, BB, MRA, SGLT2i), often not at maximum doses.
- No patients with HFrEF and advanced CKD (G5) were on quadruple therapy.
- Treatment patterns for heart failure with mildly reduced ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) also showed suboptimal use of guideline-recommended therapies, particularly newer agents like ARNI and SGLT2i.
Conclusions:
- Real-world treatment of HF in aCKD patients is suboptimal, falling short of current clinical guidelines.
- There is a critical need for increased clinician awareness of HF guidelines in this population.
- Pragmatic clinical trials specifically designed for aCKD patients with HF are essential to address this unmet medical need.
Introduction:
Chronic heart failure (HF) has high rates of mortality and hospitalization in patients with advanced chronic kidney disease (aCKD). However, randomized clinical trials have systematically excluded aCKD population. We have investigated current HF therapy in patients receiving clinical care in specialized aCKD units.
Methods:
The Heart And Kidney Audit (HAKA) was a cross-sectional and retrospective real-world study including outpatients with aCKD and HF from 29 Spanish centers. The objective was to evaluate how the treatment of HF in patients with aCKD complied with the recommendations of the European Society of Cardiology Guidelines for the diagnosis and treatment of HF, especially regarding the foundational drugs: renin-angiotensin system inhibitors (RASi), angiotensin receptor blocker/neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i).
Results:
Among 5,012 aCKD patients, 532 (13%) had a diagnosis of HF. Of them, 20% had reduced ejection fraction (HFrEF), 13% mildly reduced EF (HFmrEF), and 67% preserved EF (HFpEF). Only 9.3% of patients with HFrEF were receiving quadruple therapy with RASi/ARNI, BB, MRA, and SGLT2i, but the majority were not on the maximum recommended doses. None of the patients with HFrEF and CKD G5 received quadruple therapy. Among HFmrEF patients, approximately half and two-thirds were receiving RASi and/or BB, respectively, while less than 15% received ARNI, MRA, or SGLT2i. Less than 10% of patients with HFpEF were receiving SGLT2i.
Conclusions:
Under real-world conditions, HF in aCKD patients is sub-optimally treated. Increased awareness of current guidelines and pragmatic trials specifically enrolling these patients represent unmet medical needs.
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