Background: Heart failure (HF) therapy has been disrupted by the introduction of 2 new prognostic-relevant drugs: Sacubitril/Valsartan and SGLT2i. However, the amount of evidence for guideline-directed HF therapies in the context of chronic kidney disease (CKD) is relatively modest, especially in advanced stages (e.g., on haemodialysis). Aim of this report is to describe the feasibility and the efficacy of HF medical therapy in a patient with naive HFrEF and CKD on haemodialysis.
Case report: A woman in her 40’s, with no cardiovascular history, affected by polycystic kidney disease end end-stage CKD placed on hemodialysis for the previous 9 months, underwent a echocardiography (TTE) in 09/2021, as part of investigations for kidney transplantation. The TTE showed a picture consistent with dilated cardiomyopathy with reduced EF, severe left atrium (LA) dilation and moderate-to-severe mitral regurgitation (MR). Thus, the patient was temporarily suspended from the transplant list. She was on chronic diuretic therapy with high dose of furosemide (250mg b.i.d.), with a residual diuresis of 400-500 mL per day. An elective coronary angiography showed normal coronary arteries. A Cardiac Magnetic Resonance (CMR) confirmed the diagnosis of DCM with severe dilation of the left ventricle (LV), reduced EF and severe MR. A cardiopulmonary exercise test (CPET) showed mild functional limitation with no pulmonary vascular limitation. After a multidisciplinary evaluation involving HF specialists and nephrologists, the recommended quadruple HF therapy was started and gradually up-titrated during the following 10 months. Neither the hemodialysis protocol nor the diuretic therapy was changed throughout this period. No adverse events were observed (e.g., increased sessions or dialysis schedule, hyperkalemia, hypotension). During this timeframe, the patients was asymptomatic and a progressive and sustained decrease in N-terminal pro B-type natriuretic peptide (NT-proBNP) from 26356 to 1556 ng/ml was observed. We documented a significant amelioration in CPET and other laboratory parameters (sST2), as well as a consistent reverse remodeling of the left heart chambers and a significant reduction in MR grade.
Conclusions: We described a case of significant left heart chambers reverse remodeling and disease regression in a patient with end-stage CKD presenting with HFrEF treated with off-label optimized HF medical therapy. Further studies on hemodialyzed HF patients will be needed.