Mechanisms, Magnitude, and Consequence of Acute Estimated Glomerular Filtration Rate Change With Guideline-Directed Medical Therapy Initiation in Heart Failure

Estimated glomerular filtration rate (eGFR) is a key metric for assessing and monitoring kidney function. In heart failure management, guideline-directed medical therapy (GDMT) medications such as renin-angiotensin-aldosterone system inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors can initially cause a transient decrease in eGFR due to hemodynamic changes, such as a reduction in systemic and glomerular hypertension, reversal of hyperfiltration, and vasodilation in the glomerular vasculature. Despite the initial drop, long-term use of GDMT slows eGFR decline and, in the long-term, lowers the risk of developing chronic kidney disease. However, a significant decline in eGFR (≥20% to 30% reduction) may require closer monitoring and treatment adjustments. Additionally, the combined effect of these agents on eGFR, whether administered concurrently or sequentially, is not clearly understood and should be carefully considered. In conclusion, this review highlights the need for a collaborative approach between nephrologists and cardiologists to closely monitor and manage eGFR changes following GDMT initiation. Prompt alerts to clinicians via the electronic health record, patient education, regular assessment, and clinical review for sustained reduction in eGFR are strategies to maximize the use and subsequent reno-protective effect of GDMT in heart failure.