GDMT in CKD — EECC MCQ

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ModerateHeart FailureGDMT in CKDEECC

A 58-year-old man with HFrEF develops chronic kidney disease with eGFR declining from 60 to 35 mL/min over 2 years. His nephrologist asks whether GDMT should be modified. What is the current approach to GDMT in CKD?

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Correct answer: B — Continue four-pillar GDMT with renal and potassium monitoring

CKD is highly prevalent in HF (>50% have eGFR <60) and complicates GDMT through: hyperkalaemia risk (RAAS inhibitors, MRA), eGFR decline, and altered drug clearance. The ESC 2023 HF and KDIGO 2024 Guidelines provide specific guidance: (1) ACEi/ARB/ARNI: continue with dose adjustment; tolerate eGFR dip up to 30-50%; (2) Beta-blockers: no renal dose adjustment needed (carvedilol/bisoprolol); (3) MRA: continue with frequent K⁺ monitoring (every 1-2 weeks initially); potassium binders enable continuation; (4) SGLT2i: can be initiated to eGFR 20 mL/min (DAPA-CKD), continued to dialysis; (5) Diuretics: may need higher doses in CKD (reduced tubular secretion). The key principle: do NOT withdraw life-saving GDMT for modest renal function changes — use monitoring, dose adjustment, and potassium binders to enable continuation.

Reference: ESC (2023): HF Guidelines; KDIGO 2024: https://bnf.nice.org.uk/