Debasish Banerjee

Background and aim: Hospital admissions are common in patients with heart failure (HF), particularly in those with concomitant chronic kidney disease (HF-CKD). Hospitalisation is often driven by fluid overload, requiring intravenous furosemide. Subcutaneous furosemide is emerging as an alternative which may facilitate at-home treatment. This study will assess the feasibility of conducting a randomised controlled trial (RCT) to evaluate whether subcutaneous furosemide can reduce hospital admissions in people with HF-CKD. Methods: Stage one – Recruitment and monitoring of at-risk patients: We aim to recruit 200 people with HF-CKD with at least one hospital admission within the preceding year. These participants will be monitored for signs of fluid accumulation. Stage two - Treatment: The second stage will run contemporaneously to the first stage. The first 80 participants to develop fluid accumulation will be randomised to usual care (attend hospital and receive standard treatment) or at-home furosemide. The participants allocated to home treatment will administer SQIN-furosemide via a patch infusor device, 80 mg daily for five days, then be reviewed in a final clinic appointment. These participants will monitor their weight and observations daily, as well as receive a check-in call from the research team. Potassium levels will be checked twice over five days. The primary outcome of this feasibility study will be recruitment and retention of participants, as well as adherence to the intervention. Discussion: Findings from this feasibility trial will inform the planning of a definitive RCT to evaluate whether subcutaneous furosemide can reduce hospital admissions in people living with HF-CKD.

Renin-angiotensin-aldosterone inhibitors (RAASi) improve outcomes in patients with heart failure with reduced ejection fraction (HFrEF), but their use is often limited by hyperkalaemia in chronic kidney disease (CKD) patients. This double-blind, placebo-controlled, randomised trial evaluated whether sodium zirconium cyclosilicate (SZC) enables RAASi up-titration in HFrEF patients with CKD stages 3–5 and serum potassium of 5.0–5.5 mmol/L over 14 weeks. The primary binary outcome was defined as achieving the target dose of RAAS inhibition therapy without reaching hyperkalaemia (serum potassium ≥5.6 mmol/L) over 14 weeks or otherwise. Participants ( n = 112) were randomised 1:1 to receive sodium zirconium cyclosilicate (SZC) or placebo. The per-protocol (PP) analyses included 43 out of 53 (81%) in the SZC arm and 53 out of 59 participants (90%) in the placebo arm; the intention-to-treat (ITT) analyses included all 112. At the end of the trial, 24 of 43 participants (56%) in the SZC group achieved the target RAASi dose without developing hyperkalaemia compared with 15 of 53 patients (28%) in the placebo group (PP analysis, p = 0.006, ITT analysis, p = 0.007,). Participants in the SZC group were 3 times more likely to reach the target dose without reaching potassium 5.6 mmol/L (OR = 3.16; 95% CI 1.35–7.39; p = 0.008) than in the placebo group (ITT analysis). No significant differences in adverse events between the two groups were observed. SZC appears to safely support rapid RAASi optimisation in HFrEF patients with CKD. This trial was funded by AstraZeneca via Externally Sponsored Scientific Research grant ESR-19-20174. Trial Registration: Clinicaltrials.gov NCT05004363 and EudraCT number 2020-002946-18.

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Cardiovascular–kidney–metabolic (CKM) syndrome represents the complex interplay between cardiovascular disease (CVD), chronic kidney disease (CKD), and metabolic disorders such as type 2 diabetes and obesity. These conditions share overlapping risk factors, pathophysiological mechanisms, and clinical outcomes, leading to progressive organ dysfunction, as well as increased morbidity and mortality. Traditional disease-specific care models, in which cardiology, nephrology, and endocrinology operate in separate clinics, are increasingly inadequate for addressing the integrated nature of CKM syndrome. Patients often experience fragmented care, with different specialties prioritizing different medications and communicating slowly via letters, which delays important guideline-directed medical therapy (GDMT) for each organ system, potentially leading to higher rates of hospital admissions and mortality. New models of care are urgently needed to improve outcomes through coordinated, patient-centered, and multidisciplinary approaches. Future integrated CKM care models should emphasize cross-specialty collaboration, data sharing, and shared decision-making to optimize treatment and deliver comprehensive care plans that consider all three specialty domains. Advances in digital health, precision medicine, and population health analytics can support these models by enabling more accurate risk stratification, personalized interventions, and continuous monitoring across the care continuum. This review, originating from an International Society of Nephrology Transplant Sister Center Meeting, synthesizes the available evidence on multispecialty clinics and other interventions designed to improve care for patients with multiple CKM comorbidities.

Purpose of review: Cardiorenal syndrome is common, increasing in prevalence mainly due to increases in obesity, diabetes, hypertension and chronic kidney disease. The patients with cardiorenal syndrome are often frail and elderly suffering from poor quality of life, multiple hospital admissions, and death. There has been an increase in the number of evidence-based medications available for prevention and treatment of cardiorenal syndrome; however, implementation remains a challenge. Recent findings: In ambulatory patients, we discuss emerging evidence-based therapies such as nonsteroidal mineralocorticoid antagonists and glucagon-like peptide-1 receptor agonists for cardiorenal syndrome across all stages of chronic kidney disease, alongside the challenges of electrolyte imbalance and kidney function decline. In admitted patients, recent advances focus on optimization of volume status, including saline replacement during diuresis when appropriate and the use of adjuncts to loop diuretics (e.g. thiazide-type diuretics) to overcome diuretic resistance. Summary: These findings highlight the growing range of novel therapies expanding the cardiorenal physician's armamentarium, offering greater flexibility in managing cardiorenal syndrome across its spectrum to improve outcomes and improve the quality of life of patients suffering from cardiorenal syndrome.

Dialysis patients with heart failure with reduced ejection fraction (HFrEF) are frequently excluded from kidney transplantation due to high perioperative risk. We evaluated whether a multidisciplinary cardiorenal clinic could optimise guideline-directed medical therapy (GDMT), improve cardiac function, enable transplantation, and reduce healthcare costs. Eleven dialysis patients were treated. Median LVEF improved from 30% to 47% (p < 0.01). After 29 months follow-up, 7 patients underwent transplantation and 4 remained active on the waiting list. Five-year estimated costs were £166,338 for dialysis versus £47,908 following transplantation. HFrEF optimisation may restore transplant eligibility while substantially reducing long-term healthcare expenditure.

Hospital admissions to treat fluid overload are common in patients with both heart failure and chronic kidney disease (CKD-HF). This is a population with high levels of frailty. Recurrent hospital admissions are costly to both patients and healthcare systems. We designed a proof-of-concept, multidisciplinary quality improvement project to deliver at-home subcutaneous furosemide to treat fluid overload in patients with CKD-HF. This project involved collaboration between a hospital, community remote monitoring hub and hospital-at-home team, including general practitioners, secondary care physicians, nurses and pharmacists. Patients were considered suitable for the intervention if they had CKD-HF, fluid overload and were haemodynamically stable. Following review, suitable patients were treated at-home with 80 mg subcutaneous furosemide over 5 hours, for 5 days. This was administered by the hospital-at-home team in liaison with hospital specialists, with continuous patient monitoring provided by the remote monitoring hub. Renal function and weight were assessed daily. Following treatment, patients were reviewed by the secondary-care team to adjust their maintenance medications. Data collected and analysed included daily weights, renal function and observations, as well as the number of hospitalisations and/or death at 30 days following the intervention. 10 patients successfully completed treatment. All potentially required hospitalisation at baseline and all avoided hospitalisation during the 5-day course of subcutaneous furosemide. One patient was admitted to the hospital following their final hospital review, and two patients were hospitalised for 4 and 14 days respectively, after their final dose of subcutaneous furosemide. Renal function and potassium did not significantly change throughout the treatment. No major safety concerns were identified. Patients welcomed the intervention. This quality improvement project demonstrates that it is logistically feasible, with primary care collaboration, to treat fluid overload in patients with CKD-HF at-home using subcutaneous furosemide.