Sodium-glucose cotransporter-2 inhibition in a CKD patient with severe heart failure treated by high-dose diuretics and peritoneal ultrafiltration: lesson for the clinical nephrologist

Excerpt

In August 2021, a 69-year-old male patient with insulin-requiring diabetes mellitus and chronic heart failure with reduced systolic function was referred to the nephrology outpatient clinic because of chronic kidney disease (CKD) stage 4 and oedema. He complained of severe dyspnoea at rest, making him unable to walk or carry out any physical activity. The patient reported acute myocardial infarction treated by percutaneous transluminal coronary angioplasty in 2016, and coronary artery bypass graft in 2018. Furthermore, a cardioverter-defibrillator was positioned. In the six months prior to nephrology referral, the patient had been admitted four times to the emergency department because of acute heart failure. At the clinical visit blood pressure (BP) was 80/60 mmHg, there was significant ascites, and remarkable lower limb oedema despite high-dose diuretics (furosemide 250 mg twice a day, spironolactone 50 mg/day, and metolazone 5 mg/day). The patient was being treated with bisoprolol 2.5 mg/day and sacubitril 24 mg/valsartan 26 mg twice a day. …