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ARNI in Advanced CKD — EECC MCQ

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ModerateHeart FailureARNI in Advanced CKDEECC

A 65-year-old man with HFrEF on GDMT develops stage 4 CKD (eGFR 22 mL/min). His nephrologist asks whether sacubitril/valsartan should be continued at this eGFR. What is the recommendation?

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Correct answer: E — Continue reduced-dose ARNI with close biochemical monitoring

Sacubitril/valsartan dosing in CKD per ESC HF and product guidance: (1) eGFR ≥30: standard dosing/titration; (2) eGFR 15-30: start at 24/26 mg bd or reduce to this dose; careful monitoring every 1-2 weeks; (3) eGFR <15: limited data, use with extreme caution. The UK-HARP-III trial specifically assessed sacubitril/valsartan in CKD (eGFR 20-60) and showed: no additional renal safety concerns compared with irbesartan. The key principle: do NOT withdraw life-saving GDMT for CKD unless truly intolerable (K⁺ persistently >6.0 mmol/L despite potassium binders, symptomatic hypotension unresponsive to dose adjustment, or AKI attributable to the drug). The creatinine rise of up to 30-50% from baseline should be tolerated. Potassium binders (patiromer, SZC) enable MRA and RAAS inhibitor continuation in CKD.

Reference: ESC (2023): HF Guidelines; UK-HARP-III Trial: https://bnf.nice.org.uk/