Renal Considerations in Sacubitril/Valsartan Uptitration for Heart Failure Patients
論文ID: CJ-25-0187
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論文ID: CJ-25-0187
To the Editor:
We read with interest the article by Doi et al. reporting outcomes with different doses of sacubitril/valsartan in the REVIEW-HF registry.1 Their identification of eGFR <30 mL/min/1.73 m2 as a negative predictor for achieving high-dose sacubitril/valsartan merits critical examination.
The exclusion of patients with advanced kidney disease from pivotal trials such as PARADIGM-HF constrains our understanding of sacubitril/valsartan’s efficacy in this population.2 The REVIEW-HF cohort, with 20% having eGFR <30 mL/min/1.73 m2, represents a real-world population typically excluded from clinical trials.
The bidirectional relationship between heart failure therapy and kidney function warrants careful consideration.3 Although declining renal function limits sacubitril/valsartan uptitration, the study could not determine whether lower doses resulted from renal dysfunction or if reduced kidney function merely reflects advanced heart failure. The time-updated Cox models addressed immortal time bias but could not resolve this confounding.
The identification of GNRI as a predictor of successful uptitration aligns with established relationships between nutritional status and cardiovascular pharmacokinetics in kidney disease.4 This finding has significant clinical implications, as nutritional assessment may identify patients likely to tolerate higher doses. The intersection of nutrition, renal function, and heart failure pharmacotherapy demands attention in clinical decision-making.
These observations underscore the need for targeted studies in heart failure patients with renal dysfunction. Until such evidence emerges, vigilant monitoring of renal function and nutritional status may guide optimal dosing in this challenging population.
All the authors declared no competing interests.
