Progressive renal insufficiency

Chronic renal insufficiency is very common in patients with heart failure and is usually only clinically important from a creatinine clearance < 60 ml/min.

In the earlier stages of mild renal insufficiency (GFR < 90 ml/min and/or an increased albumin/creatinine ratio, ACR), it may already be necessary to identify the cause and discuss preventive measures (see: general points of interest).

Correct monitoring and treatment is very important in patients with chronic renal insufficiency to prevent progression to end-stage renal insufficiency and renal dialysis.

Classification according to the severity of chronic renal failure ( KDIGO classification)

How often to check kidney function?

Recommendation for the frequency of monitoring creatinine and creatinine clearance during chronic follow-up:

Stage 3a (GFR <60 ml/min): every 6 months.
Stage 3b (GFR <45 ml/min): every 4 months.
Stage 4 (GFR <30 ml/min): every 3 months.
Stage 5 (GFR <15 ml/min): monthly.

Determine the albumin/creatinine ratio (ACR) on a first morning urine sample.

Microalbuminuria is a sign of kidney damage and kidney disease, sometimes present even before a clear decrease in creatinine clearance occurs.

Normal < 30 mg/g.
Moderately increased: 30-299 mg/g.
Severely increased: ≥ 300 mg/g.

General points of interest in progressive or chronic renal insufficiency

Treat hypotension until systolic blood pressure > 95 mmHg.
Discontinue and avoid NSAIDs and other nephrotoxic drugs (iodine-containing contrast, aminoglycoside antibiotics, etc.).
If necessary, reduce the dose of drugs according to renal function.
Aim for the lowest dose of diuretics that maintains euvolemia. Sometimes the diuretic can also be stopped completely after starting good heart failure therapy.
Rule out other causes of renal insufficiency:
- Excluding postrenal renal insufficiency with abdominal ultrasound: hydronephrosis? Urinary retention, globus vesicalis?
- Intrinsic kidney disease (glomerulonephritis,...)
  - Check urinary sediment (proteinuria, leukocyturia, hematuria with dysmorphic red blood cells, pathological cylinders,... ?).
  - Determine the albumin/creatinine ratio (ACR) (normal value < 30 mg/g).
Optimal cardiovascular prevention: good blood pressure control, good diabetes control (if applicable), no smoking, sufficient physical activity, healthy diet, losing weight (if applicable).

Further approach according to the clinical scenario

1. Chronic heart failure and increasing renal insufficiency

Actions to be taken in case of deterioration of renal function during therapy with an ACE inhibitor, ARB or ARNI:

* Reimbursement criteria for Finerenon in Belgium, 2024:

Diabetes mellitus type 2.
and a decreased GFR between 25 and 60 ml/min.
and an ACR ≥ 300 mg/g or an ACR 30-299 mg/g with a history of diabetic retinopathy.
and > 4 weeks of therapy with ACE inhibitor or ARB at maximum dose.
and no HFrEF – NYHA II-IV.
and no concomitant therapy with an MRA.
and potassium ≤ 4.8 mmol/l when starting finerenon.

2. Acute heart failure and increasing renal insufficiency

3. Referral to the nephrologist

According to the guidelines of the chronic renal insufficiency care pathway.

Indications:

Serum creatinine clearance, eGFR persistently < 30 ml/min.
Serum creatinine clearance, eGFR persistently < 60 ml/min with also significant proteinuria with a moderately to severely increased albumin-creatinine ratio (ACR) on a fresh urine sample > 30-300 mg/g, especially in diabetes mellitus and with a history of diabetic retinopathy.
Rapid, unexplained decline in kidney function.
Pathological urine sediment.
Persistent frequent episodes of fluid retention and cardiac decompensation in poor renal function, with a need for dialysis expected in the future.

BWGHF

Progressive renal insufficiency

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Progressive renal insufficiency

Classification according to the severity of chronic renal failure ( KDIGO classification)

How often to check kidney function?

General points of interest in progressive or chronic renal insufficiency

Further approach according to the clinical scenario

1. Chronic heart failure and increasing renal insufficiency

Actions to be taken in case of deterioration of renal function during therapy with an ACE inhibitor, ARB or ARNI:

2. Acute heart failure and increasing renal insufficiency

3. Referral to the nephrologist