Kidney disease and heart failure: recent advances and current challenges: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Heart failure (HF) and chronic kidney disease (CKD) frequently coexist, which elevates the risks of hospitalization, disease progression, and death. Despite advances in treating each condition independently, many challenges remain in diagnosing and managing them in combination. In March 2024, Kidney Disease: Improving Global Outcomes (KDIGO) held the Controversies Conference on Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Discussions highlighted the complex, bidirectional relationship between HF and CKD, including shared risk factors and overlapping pathophysiology as well as nuances in interpreting biomarkers such as natriuretic peptides and serum creatinine. Sodium-glucose cotransporter-2 inhibitors, renin-angiotensin-aldosterone system inhibitors, and emerging agents such as finerenone and glucagon-like peptide-1 receptor agonists can have benefits in both populations of patients with HF and CKD, though evidence in advanced CKD remains limited. Importantly, small declines in kidney function after initiating guideline-directed HF therapies generally do not require discontinuation, as these declines are often hemodynamic in nature and not associated with poor outcomes. The group highlighted the need for CKD-specific HF diagnostic thresholds and refined acute kidney injury definitions in HF. It is important for future cardiovascular and kidney trials to include relevant end points, such as kidney function trajectories, symptom burden, and quality of life. To improve care for individuals with HF and CKD, a more integrated approach to management, rooted in individualization, clinical context, and shared therapeutic goals, is needed.