Managing Kidney Medication Issues in Heart Failure Patients

Medication Issues in Renal Management for Heart Failure Patients

Dear Doctor,
My father is suffering from moderate to severe heart failure, and due to severe leg edema, he needs to limit his fluid intake.
He has been on diuretics for 14 consecutive months, which has resulted in poor kidney function.
On December 5, blood tests showed UA: 9.3 mg/dL, urine pH: 5.5, Albumin (Dipstick): 150 mg/L, Creatinine (Dipstick): 100 mg/dL, Protein (Dipstick): 30 mg/dL.
On January 4, blood tests indicated eGFR: 57.8, CRE: 1.3 mg/dL, and urine tests showed CRE: 158.5 mg/dL, TP (urine): 70.0 mg/dL.
The nephrologist prescribed Forflow SR, Feburic, and Folic Acid from December 10 to January 7, and Forflow SR and Feburic from January 10 to March 7, with a follow-up appointment for 18 tests scheduled for March 7.
He was hospitalized from February 14 to February 28 due to heart issues, during which urine tests on February 14 showed pH (Dipstick): 5.0, Albumin (Dipstick): 30 mg/dL, Protein (Dipstick): 15, Creatinine (Dipstick): 50 mg/dL, and blood tests on February 25 showed BUN: 49 mg/dL, eGFR: 70.1, CRE: 1.1 (UA was not tested).
I have two questions for you:
1.
My father did not return for his nephrology appointment on March 7 and continued taking Concor, diuretics, and Feburic until April 2.
Should he have tested UA first before deciding whether to continue taking Feburic? Is it insufficient for him to only take Feburic for his kidney issues? (Although this is from April, I still seek clarification for a correct understanding of his kidney condition.)
2.
He was hospitalized again from April 9 to May 6 due to heart failure, and on April 25, blood tests showed eGFR: 117.8, UN: 25, CRE: 0.7, Alb: 3.0.
During his hospitalization, he occasionally took Potassium Gluconate: Radi-K for his kidneys.
After being discharged on May 6, he did not see a nephrologist and has been taking only the medications prescribed by his cardiologist: COZZAR, diuretics, and CONCOR.
Is this sufficient for his kidney issues? Should he consider taking FEBURIC or other medications? (On June 4, blood tests showed UN: 59 mg/dL, eGFR: 48.9, UA: 11.6, CRE: 1.5, Alb: 3.2, fasting blood glucose: 102, and HbA1c: 5.3.)
I look forward to your valuable advice.
Thank you!

Miss Lin, 30~39 year old female. Ask Date: 2020/08/08

Dr. Huang Yaoxuan reply Internal Medicine

Dear Ms.
Lin,
Regarding your father's condition, it is recommended that you consult with a nephrologist to discuss his situation.
Additionally, if you are concerned about kidney function, you may want to know about kidney care methods that are applicable regardless of whether kidney function is normal or impaired.
These are also things that the nephrologist would like you to assist your father with:
1.
Measure blood pressure daily and, if possible, record it on paper.
When you accompany your father to follow-up appointments with the nephrologist or cardiologist, bring this record for the doctor’s reference (to help manage blood pressure).

2.
Dietary management; for details, you can consult a renal case manager (health educator) or a nutritionist.
3.
Engage in moderate, tolerable exercise.
Given your father's heart failure, it is important to discuss with the cardiologist what types of exercise are appropriate and to what extent he can participate.
Wishing you peace and well-being.

Reply Date: 2020/08/08

More Info

Managing kidney issues in patients with heart failure is a complex task that requires careful consideration of medications, kidney function, and overall health. Your father's situation, characterized by severe heart failure and the need for diuretics, presents a common but challenging scenario in clinical practice.

Understanding the Context
Heart failure often leads to fluid retention, which is why diuretics are commonly prescribed. However, prolonged use of diuretics can adversely affect kidney function, as evidenced by your father's declining eGFR and rising creatinine levels. The medications he is currently taking, including Concor (a beta-blocker), diuretics, and Feburic (used to lower uric acid levels), need to be evaluated in light of his renal function.

Addressing Your Questions
1. Should uric acid levels be checked before continuing Feburic?
Yes, it is prudent to monitor uric acid levels before continuing Feburic. Given that your father has been on diuretics for an extended period, his renal function may fluctuate, impacting uric acid levels. If his uric acid levels are within the normal range, continuing Feburic may not be necessary. However, if levels are elevated, it may be beneficial to continue treatment. Regular monitoring of kidney function and uric acid levels is essential in managing his medications effectively.

2. Is the current medication regimen sufficient for kidney health?
After your father's hospitalization and the subsequent changes in his kidney function, it is crucial to reassess his medication regimen. While Cozaar (an angiotensin receptor blocker) and diuretics are beneficial for heart failure, they may not be sufficient alone for managing kidney health, especially considering the recent decline in eGFR. The addition of Feburic or other nephroprotective agents may be warranted, depending on his specific kidney issues and uric acid levels.

Recommendations for Management
- Regular Monitoring: Regular blood tests to monitor kidney function (eGFR, creatinine, BUN) and uric acid levels are essential. This will help in making informed decisions about medication adjustments.

- Consultation with a Nephrologist: Given the complexity of your father's condition, a follow-up with a nephrologist is advisable. They can provide specialized insights into managing his kidney health in the context of heart failure.

- Dietary Considerations: A renal dietitian can help tailor a diet that supports both heart and kidney health. This may include managing protein intake, sodium restriction, and ensuring adequate hydration without overloading the kidneys.

- Fluid Management: Since your father has significant fluid retention, careful management of fluid intake is necessary. This should be balanced with the need to maintain kidney perfusion.

- Medication Review: A comprehensive review of all medications is essential. Some medications may need to be adjusted or changed based on kidney function. For instance, if kidney function continues to decline, certain medications may need to be avoided or used with caution.

- Lifestyle Modifications: Encourage your father to engage in light physical activity as tolerated, which can improve overall health and potentially benefit both heart and kidney function.

Conclusion
Managing kidney issues in heart failure patients requires a multidisciplinary approach. Regular monitoring, medication adjustments, dietary management, and consultations with specialists are key components of effective care. Your proactive approach in seeking clarification and understanding of your father's condition is commendable and will contribute to better health outcomes. Always consult with healthcare providers before making any changes to medication or treatment plans.

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