ESC Recommends CKD Testing in All Patients With CVD

New guidelines from the European Society of Cardiology (ESC), in collaboration with the European Renal Association, for the first time provide recommendations for how to manage patients with cardiovascular disease and chronic kidney disease (CKD).

Defined as the presence of abnormalities of kidney structure or function for at least 3 months, CKD affects an estimated 800 million adults globally and increases the risk of CVD, with a broad range of implications. 

“The disability and lifetime lost to each disease are profound, but CKD can accelerate CVD and vice versa, resulting in cardiovascular events and the need for dialysis much earlier in life,” said Task Force Co-Chair Kevin Damman, MD, PhD (University Medical Centre Groningen, the Netherlands), in a press release. “The good news is that there have been major advances over the last few years, which mean there are now several simple treatments that can substantially lower the risk of both cardiovascular and kidney complications.” 

The new document, presented recently at the ESC Congress 2026 in Munich, Germany, was published online in the European Heart Journal. It follows the publication earlier this year of the first American guidelines for the prevention, detection, evaluation, and management of cardiovascular-kidney-metabolic (CKM) syndrome.

Speaking at the conference, nephrologist and Task Force Co-Chair William Herrington, MBBS (University of Oxford, England), stressed the need for more testing of kidney function and urine albumin in patients with CVD, noting that many cardiologists might not have thought much about the strong connection between the two disease pathways.

“You may have known since the first day you walked into wards as cardiologists that you need to think about pharmacokinetics of drugs,” he said. “You need to think about bleeding tendency and propensity for hyperkalemia and for acute kidney injury, but you may not know quite how close the bidirectional relationship is.”

In the first 6 months after being admitted for heart failure, patients have a 30-fold increased risk of developing kidney failure, Herrington explained. “That risk remains high and persists for at least 3 years. And in the absence of heart failure, if you have an instant myocardial infarction or stroke, then the risk is two- to threefold increased as well.”

With “actionable evidence” now in the literature, the time has come for the cardiology community to play a larger role here, he argued, calling for greater communication between cardiology and nephrology teams, as well as between physicians and patients, to avoid confusion for patients and improve care.

‘STAMP’ on CKD

The guidelines introduce the “STAMP” acronym to help physicians in caring for patients with CKD: Screen, Triage, Address CKD Risk, Modify CVD management, and Plan health services.

“We think that anyone with incident cardiovascular disease should be screened,” Herrington said. “You’ll be surprised how many patients will have disease.”

As for how this might be done, it’s likely that most patients are already having serum creatinine and estimated glomerular filtration rate (eGFR) measured, but he said it’s time to “bring urine into the cardiology clinics. Urine needs to be sent to the laboratory, not just dipsticks, and you need to measure albumin and creatinine.”

From there, patients with confirmed CKD need to be triaged through validated risk-scoring systems that can assess CVD risk.

“What is most important is the A,” Herrington said. “We didn’t say this was action, but I think it should be A for action [to] address risk. Don’t leave this to someone else. Everyone with CKD deserves to be initiated on treatment as soon as it is identified. All you need to know is their diabetes status, their eGFR, and their level of urinary albumin.”

General recommendations for reducing risk, including smoking cessation, weight loss, and statin therapy, should be encouraged for this population, he said. But drugs like sodium-glucose cotransporter 2 (SGLT2) inhibitors will be widely used, as will add-on therapies like finerenone (Kerendia; Bayer) and glucagon-like peptide-1 (GLP-1) receptor agonists, added Herrington. “You should be prioritizing the initiation, titration, and use of these treatments in combination urgently in those people at highest risk.”

Modification might be an “obvious” recommendation for some, Herrington acknowledged. “These drugs that we’ve been describing modify risk; you need to be modifying risk,” he said. “They lower blood pressure and they improve glycemic control, but you should establish people on these proven therapies which are cost-effective before then polishing glycemic control and blood pressure, et cetera.”

Planning Is Patient-Dependent

For patients with both CKD and CVD, planning will be key, emphasized Damman in his presentation of the guidelines. The specific therapies will vary depending on the conditions of a patient’s disease, but he highlighted a few key distinctions.

Heart failure and CKD are closely tied, and many of the recommendations in this document are similar to what have been published recently in the latest European heart failure guidelines, Damman explained.

“For most patients who have heart failure with chronic kidney disease, there’s an indication for loop diuretic therapy if the patient is congested,” he said. “And in all patients with heart failure and chronic kidney disease where the eGFR is above 20, there’s an indication for SGLT2 inhibitors as foundational medical treatment.”

In those with heart failure with reduced ejection fraction (HFrEF), renin-angiotensin-aldosterone-system (RAAS) inhibitors and beta-blockers are indicated. “And this is slightly different from the heart failure guidelines,” Damman said. “We split the recommendation for the type of mineralocorticoid receptor antagonist (MRA) based on ejection fraction, slightly.”

Specifically, steroidal MRAs are recommended if LVEF is below 40%, but if it’s 40% or higher, nonsteroidal or steroidal MRAs are indicated. “The reason for this slight diversion from the heart failure guideline is that there is meta-analytic evidence for heterogeneity based on the treatment effect of these drugs based on baseline eGFR and ejection fraction,” he explained.

Decompensated heart failure patients are high risk and diuretic-resistant, Damman emphasized. “And therefore, you need to adequately dose these patients. It means higher dose of loop diuretics if there is baseline chronic kidney disease. We want you to start SGLT2 inhibitors as early as possible,” he said.

Moving to ACS, “and this is really important, you need to avoid delays in the immediate and early invasive strategy,” Damman said. “This is something that comes back for many of our acute treatments in patients with chronic kidney disease. The efficacy of these potential lifesaving therapies is similar in patients with chronic kidney disease and those without.”

With respect to patients who need to undergo procedures with contrast, it’s true that they will be at a higher risk of developing contrast-induced acute kidney injury. But, Damman said, “it is important to realize that you should avoid delaying procedures and interventions to ensure timely diagnosis and treatment in these patients. Permanent harm associated with contrast-induced acute kidney injury is rare and nearly always outweighed by the benefit of doing these diagnostic and therapeutic procedures.”

However clinicians integrate these recommendations into their practice, it should be done with clear communication between physician team members as well as between the medical team and patients and caregivers, the guidelines stress.

“As you read these guidelines, you will see that you need to highly individualize your recommendation for a specific patient sitting in front of you,” Damman said.