Framework
The definitions and cross-cutting rules the tool is built on. Switch on Supplementary quotations in Settings to see the guideline text each one comes from.
Definitions
Rules
2026 ESC CVD–CKD guideline: HF therapy by eGFR
2026 ESC CVD–CKD guideline (Section 6, Recommendation Tables 15–18, 31; Figure 9): HF drug recommendations by eGFR. Key cut-offs: SGLT2i ≥20 (continue <20); steroidal MRA ≥30 (HFrEF), any MRA ≥25 if LVEF ≥40% (nsMRA); ACEI/ARNI/ARB and BB ≥30 Class I, 15–29 IIb (ACEI/ARB, BB), no data <15/dialysis; ARNI continue <30; glycosides >20; ivabradine ≥20; vericiguat ≥30; H-ISDN ≥30; GLP-1 RA/tirzepatide ≥15; MRA not recommended on dialysis (III). Thresholds differ in places from ESC HF 2026 supplementary tables (e.g. supplement S9 contraindicates SGLT2-I initiation at eGFR <20) and from FDA labels - drug-class agents reconcile.
| Therapy | Phenotype | eGFR | Class | Recommendation |
|---|---|---|---|---|
| Loop diuretics | any LVEF | any (higher doses at low eGFR) | I/A | “Treatment with loop diuretics is recommended in patients with HF and CKD to alleviate symptoms/signs of fluid overload and improve exercise capacity.” (p. 39) |
| SGLT2 inhibitor | any LVEF | ≥20 | I/A | “Treatment with an SGLT2 inhibitor is recommended in patients with HF and CKD with eGFR ≥20 mL/min/1.73 m2 irrespective of LVEF, to reduce the risk of (repeated) HF hospitalization and cardiovascular death.” (p. 39) |
| SGLT2 inhibitor (continuation) | any LVEF | <20 (continue if overall drop <50%, K ≤5.5) | IIa/C | “Continuation of a SGLT2 inhibitor should be considered in patients with HF and CKD in whom the eGFR progresses to <20 mL/min/1.73 m2” (p. 44) |
| SGLT2 inhibitor (in-hospital, DHF) | any LVEF | >20 | I/B1 | “Initiation of an SGLT2 inhibitor is recommended early during admission in patients with DHF and CKD with an eGFR >20 mL/min/1.73 m2 to improve signs and symptoms of congestion and reduce the risk of HF re-hospitalization.” (p. 42) |
| Steroidal MRA | HFrEF | ≥30 (text: >30) | I/A | “Treatment with a steroidal MRA is recommended in patients with HF and CKD with an eGFR ≥30 mL/min/1.73 m2 and HFrEF, to reduce the risk of HF hospitalization and death.” (p. 39) |
| MRA (steroidal or non-steroidal) | LVEF ≥40% | ≥25 (steroidal >30) | IIa/B1 | “Treatment with a MRA, either steroidal or non-steroidal, should be considered in patients with HF with LVEF ≥40% and CKD with an eGFRc ≥25 mL/min/1.73 m2 to reduce the risk of HF hospitalization and cardiovascular death.” (p. 39) |
| MRA in dialysis | any | dialysis | III/A | “Routine use of MRAs is not recommended in patients on dialysis because of the risk of serious hyperkalaemia without evidence of clear benefit on cardiovascular death or hospitalizations for heart failure.” (p. 69) |
| ACEI / ARNI / ARB | HFrEF | ≥30 | I/A | “Treatment with either ACEI, ARNI, or ARB (if ACEI or ARNI not tolerated) is recommended in patients with HFrEF and CKD with an eGFR ≥30 mL/min/1.73 m2 to reduce the risk of HF hospitalization and death.” (p. 39) |
| ARNI (vs ACEI/ARB for kidney protection) | HFrEF | ≥30 | IIa/B1 | “Treatment with an ARNI (sacubitril/valsartan) should be considered in patients with HFrEF and CKD with an eGFR ≥30 mL/min/1.73 m2 as an alternative to ACEI/ARB to reduce the risk of CKD progression (or slow the decline in eGFR).” (p. 39) |
| ARNI (continuation) | HF | <30 (continue if overall drop <50%, K ≤5.5) | IIa/C | “Continuation of an ARNI should be considered in patients with HF and CKD in whom the eGFR progresses to <30 mL/min/1.73 m2” (p. 44) |
| ACEI or ARB | HFrEF | 15–29 | IIb/C | “Treatment with an ACEI or ARB may be considered in patients with HFrEF and CKD with an eGFR 15–29 mL/min/1.73 m2 to reduce the risk of HF hospitalization and cardiovascular death.” (p. 39) |
| ACEI / ARB | HFrEF | <15 or dialysis | no data | “There are no data to support the use of these agents in patients with HFrEF with kidney failure (eGFR <15 mL/min/1.73 m2 or dialysis).” (p. 36) |
| ACEI (asymptomatic LVSD) | Stage B, LVEF ≤35% | ≥30 | I/B1 | “Treatment with an ACEI is recommended in patients with CKD with an eGFR ≥30 mL/min/1.73 m2 and asymptomatic left ventricular dysfunction (LVEF ≤35%) to reduce the risk of incident HF and HF-related hospitalizations.” (p. 39) |
| Beta-blocker | HFrEF | ≥30 | I/A | “Treatment with a beta-blocker is recommended in patients with HFrEF and CKD with an eGFR ≥30 mL/min/1.73 m2 to reduce the risk of HF hospitalization and death.” (p. 39) |
| Beta-blocker | HFrEF | 15–29 | IIb/C | “Treatment with a beta-blocker may be considered in patients with HFrEF and CKD with an eGFR 15–29 mL/min/1.73 m2 to” (p. 40) |
| Cardiac glycosides (digoxin/digitoxin) | HFrEF | >20 (text: ≥20) | IIa/B1 | “Additional medical therapy with cardiac glycosides (digoxin or digitoxin) should be considered in patients with HFrEF and CKD with eGFR >20 mL/min/1.73 m2 to reduce the risk of HF hospitalization and death.” (p. 40) |
| Vericiguat | HFrEF | ≥30 | IIb/B1 | “Additional medical therapy with vericiguat may be considered in patients with HFrEF and CKD with eGFR ≥30 mL/min/ 1.73 m2 to reduce the risk of HF hospitalization and cardiovascular death.” (p. 40) |
| Ivabradine | HFrEF, LVEF ≤35%, SR, HR >70 | ≥20 | IIa/B1 | “Additional medical therapy with ivabradined should be considered in patients with HFrEF and CKD with eGFR ≥20 mL/min/ 1.73 m2 to reduce the risk of cardiovascular and HF-related events.” (p. 40) |
| Hydralazine-ISDN | HFrEF, self-identified Black, dilated LV with LVEF <45% or LVEF ≤35% | ≥30 | IIa/B1 | “Treatment with a combination of hydralazine-isosorbide dinitrate should be considered in self-identified Black patients with HFrEF and CKD with an eGFR ≥30 mL/min/1.73 m2 and dilated left ventricle in combination with LVEF <45%, or LVEF ≤35%,” (p. 39) |
| GLP-1 RA (semaglutide) / tirzepatide | HFpEF, LVEF ≥45%, obese | ≥15 (text: >15) | IIa/B1 | “Treatment with a GLP-1RA (semaglutide) or glucose-dependent insulinotropic polypeptide and GLP-1RA (tirzepatide) should be considered in patients with HFpEF and CKD with an eGFR ≥15 mL/min/1.73 m2 and LVEF ≥45% with or without diabetes who are obese, to reduce weight and improve quality of life.” (p. 40) |
| IV iron | HFrEF with iron deficiency | any | IIa/B1 | “Treatment with intravenous iron supplementation using ferric carboxymaltose or ferric derisomaltose should be considered in patients with HFrEF with iron deficiency (with or without anaemia) and CKD to reduce the risk of HF hospitalization.” (p. 39) |
| IV iron (maintenance haemodialysis) | any | haemodialysis | I/B1 | “Proactive regular high-dose intravenous iron (e.g. iron sucrose) is recommended in patients on maintenance haemodialysis, unless the serum ferritin concentration is >700 μg/L or transferrin saturation is ≥40%, to reduce risk of” (p. 69) |
| Potassium binders | HF + CKD | any | text only | “Treatment with oral potassium binders (patiromer or sodium zirconium cyclosilicate) may be useful in patients with HF and CKD to decrease serum potassium, reduce the risk of hyperkalaemia, and avoid down-titration or withdrawal of risk-modifying therapies such as ACEI/ARBs, ARNIs, and MRAs.” (p. 39) |
| Devices (ICD, CRT, TEER) | HF | any | text only | “and mitral valve transcatheter edge-to-edge repair (TEER) indications in HF should not differ by CKD stage.” (p. 39) |