Severe kidney disease and heart failure therapy: a conundrum only partially resolved

This Editorial Comment refers to ‘SGLT2 inhibitor use in severe eGFR deterioration across cardiovascular-kidney-metabolic conditions: a pooled analysis of randomized trials', by J.P. Ferreira et al., https://doi.org/10.1002/ejhf.70093. Managing patients with heart failure (HF) and severely impaired kidney function remains one of the most complex and unresolved challenges in contemporary cardiovascular medicine. Unfortunately, most HF drugs have very limited evidence for their use in those with severe kidney disease. This leaves a significant unmet treatment gap, with many high-risk patients left without therapy options. Uncertainty also surrounds what to do when patients on established HF therapies develop severe impairment of kidney disease during the course of their treatment. Reduced estimated glomerular filtration rate (eGFR) is not only a marker of chronic kidney disease (CKD) but also a powerful predictor of adverse outcomes in both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF).1–4 Patients with HF and concomitant CKD experience disproportionately higher rates of many adverse outcomes, including mortality and HF hospitalizations than those without CKD.5 At any given B-type natriuretic peptide/N-terminal pro–B-type natriuretic peptide concentration, patients with HF and lower eGFR have a higher risk of HF-related events than those with better kidney function.6