#3198 Implementation of quadruple therapy in heart failure with reduce ejection fraction in patients with advance chronic kidney disease: challenges and experience in our cardiorenal unit

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Abstract Background and Aims The quadruple therapy has become the cornerstone of treatment for heart failure with reduced ejection fraction (HFrEF). It consists in the introduction of treatment with angiotensin receptor-neprilysin inhibitor (ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRA) and the sodium-glucose co-transporter 2 (SGLT2) inhibitors, with the aim to reduce the risk of cardiovascular death and worsening HF in patients with HFrEF. However, there is limited evidence to guide the medical treatment in patients with advanced chronic kidney disease (ACKD) (FG < 30 ml/min), often excluded in clinical trials, and due to the challenges that a reduced kidney function represent. We aim to analyze the changes in kidney function and left ventricular ejection fraction, after starting the quadruple therapy as prognostic modifying treatment in patients with ACKD and HFrEF. Method Single-center, observational, prospective study assessing clinical and analytical parameters, mainly renal function, and echocardiographic parameters in patients with ACKD and HFrEF visited in our Cardiorenal Unit for one year (June 2023-June 2024). Medication titration was performed according to clinical criteria and following our titration protocols. Each visit included clinical and analytical assessment and echocardiogram was performed at least once before and after introducing the prognostic modifying drugs. Results 22 patients were included, 4 of them did not complete the titration (2 due to rejection of the proposed treatments, and 2 died of cardiac causes). From the remaining 18, 15 (83.3%) were men aged 73 (40–89 years, SD 11.51). Heart disease main etiologies were non-ischemic dilated cardiomyopathy (8, 44%) and ischemic heart disease (7, 38.9%). CKD etiologies were: attributed to a combination of hypertension and cardiorenal syndrome (12, 66.7%), glomerular diseases (3, 16.7%), and diabetic kidney disease (2, 11.1%). Six participants were on renal replacement therapy (hemodialysis: 3 patients, kidney transplant: 2 patients and peritoneal dialysis: 1 patient). Upon titration, 83.3% received ARNI, 100% beta-blockers, 94.4% iSGLT2 and 61.1% MRA. The most frequent adverse events were hypotension (16.7%), hyperkalemia (11.1%) and the combination of both (11.1%). Ten patients (55.6%) experienced no adverse events. The mean initial FEV was 34.89 (20–40, SD 4.66) and the final one was 46.50 (34–58, SD 6.28). (P ˂ 0.001). Regarding the kidney function, the mean initial creatinine (Cr) was 2.65 mg/dl (1.71–3.8 mg/dl SD 0.69) with a GFR 23.21 ml/min (16–29ml/min, SD 5.65), and the mean final Cr was 2.68 mg/dl (1.77–4.32mg/dl) with a GFR of 23.08 ml/min (14–35ml/min, SD 6.76). There was no statistically significant difference between initial and final renal function (P = 0.413) Conclusion We found that despite the challenges, it is possible to introduce quadruple therapy even in patients with ACKD with a good safety profile and without significant changes in kidney function, achieving an improvement in left ventricular ejection fraction. Cardiorenal units are necessary for the close monitoring and follow-up of these patients and thus guarantee the results.

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