Mineralocorticoid Receptor Antagonists can be Used Safely in Heart Failure Patients with Chronic Kidney Disease

Introduction The mineralocorticoid receptor antagonists (MRAs) have been shown to be beneficial in heart failure (HF), improving survival and reducing hospitalizations. The AHA/ACC guidelines now give a Class 1A recommendation to use MRAs in NYHA class II-IV HFrEF. There are concerns about the risk for hyperkalemia and renal injury for patients (pts) with HF and chronic kidney disease (CKD). Previous trials have excluded pts with a serum creatinine (Cr) >2.5 mg/dL or an eGFR of Hypothesis We hypothesize that MRAs can be used safely in patients with HF and CKD when followed closely. Methods This is a retrospective study of pts whose data are in our EMR and started a MRA between January 2012 to September 2017. Eligible pts were age ≥18 years with HF followed in cardiology clinic. Selected pts were receiving MRAs and stratified by CKD based on a Cr ≥2.5 and/or eGFR Results Average follow up intervals were 2.1, 3.4 and 1.9 months for CKD (total 7.4±6.0 months) vs. 2.3, 2.5 and 3.4 months in HF (total 8.1±5.2 months). At the first follow up, there were no DCs in Group CKD compared with 1 in Group HF. At the final visit, there were 8 DCs in Group CKD vs. 2 in Group HF (p=0.06). Of the 8 total DCs in the CKD arm, 5 were for worsening renal function and 2 for hyperkalemia. There were 18 hospitalizations in the CKD arm through the final visit; only 2 were for worsening renal failure, but 9 were for HF. There were 11 hospitalizations in group HF. Average Cr and eGFR were 0.9±0.2 and 98.2±31.4 at baseline and 1.0±0.3 and 89.7±32.5 at the final visit in Group HF (p=NS for both). Conversely, Cr and eGFR in Group CKD were 1.5±0.5 and 40.4±14.4 at baseline and 1.6±0.6 and 37.1±13.0 at the final visit (p=0.08 and p=0.05). Conclusions There was a trend towards higher DCs of MRAs in the CKD group, mostly due to worsening renal function, with good recovery after DC. However there were only 2 hospitalizations cited for worsening renal failure compared with 9 for worsening HF. There was no significant change in eGFR from baseline to the final visit in the HF group. There was a small, significant decrease in eGFR in the CKD arm. Our data indicate that MRAs can be used safely in patients with both HF and CKD, when monitored closely.