Top Things to Know: Evaluation and Management of Kidney Dysfunction in Advanced Heart Failure
Published: September 10, 2024
Prepared by Nisha Bansal, MD, MS and W.H. Wilson Tang, MD
- Kidney dysfunction in advanced heart failure (HF) is reflected by the kidneys’ inability to maintain fluid and electrolyte homeostasis, waste excretion, and endocrine functions.
- Estimated glomerular filtration rate (eGFR) is a strong predictor of outcomes in advanced HF.
- HF-related kidney dysfunction is largely reflected as fluctuations in eGFR via impaired perfusion or congestion, driven by hemodynamic and neurohormonal factors, in the absence of prominent features of intrinsic kidney disease.
- Longitudinal trajectories of kidney dysfunction in advanced HF present in distinct profiles that may warrant different levels of invasive diagnostic evaluation and interventions.
- Systematic evaluation of kidney function in advanced HF includes eGFR, urine biomarker profile, kidney imaging, and responses to drug therapy and/or hemodynamic support, thus allows for assessing the degree of irreversible intrinsic kidney disease before selection for advanced HF therapies.
- Acute kidney injury following left ventricular assist device relates to preoperative, perioperative, and postoperative insults which could be mitigated by appropriate patient selection and preemptive interventions aimed at preventing complications (e.g., oliguria, bleeding, right ventricular failure).
- All advanced HF patients with eGFR <45 ml/min could be considered and counseled for potential simultaneous heart-kidney transplantation eligibility or potential downstream need for kidney transplant, especially if there is evidence of intrinsic kidney disease.
- Post-operative hemodynamic optimization and reversal of anemia are key for kidney recovery, while calcineurin inhibitor nephrotoxicity is a contributing factor that can be minimized.
- Multidisciplinary team-based approaches can be effective in addressing the social needs of patients with advanced HF from underrepresented races and ethnicities and lower socioeconomic status who face disparities in kidney disease burden, access to treatment, and health care outcomes.
- Palliative care is crucial for patients with advanced HF and comorbidities like kidney dysfunction to improve quality of life, and can assist in illness understanding, prognosis, treatment decision-making, and advance care planning.
Citation
Tang WHW, Bakitas MA, Cheng XS, Fang JC, Fedson SE, Fiedler AG, Martens P, McCallum WI, Ogunniyi MO, Rangaswami J, Bansal N; on behalf of the American Heart Association Council on the Kidney in Cardiovascular Disease; Council on Cardiopulmonary Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Hypertension; and Council on Quality of Care and Outcomes Research. Evaluation and management of kidney dysfunction in advanced heart failure: a scientificstatement from the American Heart Association. Circulation. Published online September 10, 2024. doi: 10.1161/CIR.0000000000001273