The role of sacubitril/valsartan in patients with advanced chronic kidney disease and heart failure

Chronic kidney disease and heart failure (HF) are closely related conditions that often coexist and complicate each other. Both conditions can exacerbate disease progression and influence treatment strategies. Angiotensin receptor- neprilysin inhibitors (ARNIs) are playing an increasingly important role in the treatment of HF. ARNIs combine two mechanisms of action: sacubitril is a neprilysin inhibitor that enhances natriuretic peptides, resulting in vasodilation, diuresis and reduced cardiac workload; valsartan is an angiotensin II receptor blocker that reduces the effects of the renin-angiotensin-aldosterone system, lowers blood pressure and reduces fluid retention. The PARADIGM-HF study (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) has shown that sacubitril/valsartan significantly reduces mortality and hospitalisation rates in patients with HF and reduced ejection fraction. In patients with advanced kidney disease, who have the highest prevalence of HF, the efficacy and safety of sacubitril/valsartan remains uncertain. However, evidence on the benefit of ARNI in HF patients with end-stage renal disease undergoing dialysis is limited.