Practical management of worsening renal function in outpatients with heart failure and reduced ejection fraction: Statement from a panel of multidisciplinary experts and the Heart Failure Working Group of the French Society of Cardiology

Arch Cardiovasc Dis. 2020 Oct;113(10):660-670. doi: 10.1016/j.acvd.2020.03.018. Epub 2020 Jul 11.


Renal function is often affected in patients with chronic heart failure with reduced ejection fraction (HFrEF). The complex interplay between heart and renal dysfunction makes renal function and potassium monitoring mandatory. Renin-angiotensin-aldosterone system (RAAS) blockers are a life-saving treatment for patients with HFrEF, regardless of worsening renal function. Uptitration to the maximum-tolerated dose should be a constant goal. This simple fact is all too often forgotten (only 30% of patients with heart failure receive the target dosage of RAAS blockers), and the RAAS blocker effect on renal function is sometimes misunderstood. RAAS blockers are not nephrotoxic drugs as they only have a functional effect on renal function. In many routine clinical cases, RAAS blockers are withheld or stopped because of this misunderstanding, combined with suboptimal assessment of the clinical situation and underestimation of the life-saving effect of RAAS blockers despite worsening renal function. In this expert panel, which includes heart failure specialists, geriatricians and nephrologists, we propose therapeutic management algorithms for worsening renal function for physicians in charge of outpatients with chronic heart failure. Firstly, the essential variables to take into consideration before changing treatment are the presence of concomitant disorders that could alter renal function status (e.g. infection, diarrhoea, hyperthermia), congestion/dehydration status, blood pressure and intake of nephrotoxic drugs. Secondly, physicians are invited to adapt medication according to four clinical scenarios (patient with congestion, dehydration, hypotension or hyperkalaemia). Close biological monitoring after treatment modification is mandatory. We believe that this practical clinically minded management algorithm can help to optimize HFrEF treatment in routine clinical practice.

Keywords: Cardiac edema; Cardiorenal syndrome; Cardiovascular disease; Chronic kidney disease; Fonction rénale; Heart failure; Hyperkalemia; Hyperkaliémie; Insuffisance cardiaque; Maladie cardiovasculaire; Maladie rénale chronique; Renal function; Syndrome cardio-rénal; Systolic; systolique; Œdèmes d’origine cardiaque.

Publication types

  • Practice Guideline
  • Review

MeSH terms

  • Ambulatory Care / standards
  • Angiotensin Receptor Antagonists / adverse effects
  • Angiotensin Receptor Antagonists / therapeutic use*
  • Angiotensin-Converting Enzyme Inhibitors / adverse effects
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Cardio-Renal Syndrome / diagnosis
  • Cardio-Renal Syndrome / drug therapy*
  • Cardio-Renal Syndrome / physiopathology
  • Cardiology / standards
  • Chronic Disease
  • Consensus
  • Disease Progression
  • Heart Failure / diagnosis
  • Heart Failure / drug therapy*
  • Heart Failure / physiopathology
  • Humans
  • Kidney / drug effects*
  • Kidney / physiopathology
  • Kidney Diseases / diagnosis
  • Kidney Diseases / drug therapy*
  • Kidney Diseases / physiopathology
  • Mineralocorticoid Receptor Antagonists / adverse effects
  • Mineralocorticoid Receptor Antagonists / therapeutic use*
  • Nephrology / standards
  • Recovery of Function
  • Renin-Angiotensin System / drug effects
  • Stroke Volume / drug effects*
  • Treatment Outcome
  • Ventricular Function, Left / drug effects*


  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Mineralocorticoid Receptor Antagonists