There is always a huge challenge in navigating CHF and CKD in our patients. Use of diuretics and ACE inhibitors can be life altering in a very good way for patients who have fluid overload. The difficulty lies in keeping an adequate perfusion to the kidney.

A 69 year old male presents to the emergency department with increasing shortness of breath.  He has a very high BNP indicating acute heart failure.  He also has a substantially reduced ejection fraction.  He reports that he has been out of the house the previous few days so he didn’t want to take his furosemide because it makes him have to go to the bathroom all day.  He has been getting furosemide in the hospital and is discharged on 40 mg twice daily and also had an increase in his lisinopril to 20 mg per day.

At 2 week post-hospital checkup, the patient reports that he has had some significant shoulder pain from an old injury.  He has been taking Ibuprofen 800 mg three times per day.  Upon assessment of his labs, his creatinine has risen from 1.2 to 2.8.

The increase in the diuretic, lisinopril, and the patient adding to the problem by taking the ibuprofen all potentially added to the worsening kidney function.  The lisinopril and diuretic are incredibly important medications for heart failure, but we have to recognize the potential for kidney impairment.  This is a big challenge in navigating care in patients with CHF and CKD.

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