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What to do with key cardiovascular drugs when kidney function worsens?
Karin Bergen1,2,3, Jonas Spaak1,3,4
1Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
Clinical Kidney Journal
|January 14, 2026
Summary
Guideline-directed medical therapies (GDMT) for cardiovascular disease are underutilized in advanced chronic kidney disease (CKD). This review examines GDMT benefits and risks in CKD stages 4-5, emphasizing heart failure management.
Area of Science:
- Cardiology
- Nephrology
- Metabolic Syndrome
Background:
- Patients with advanced cardiovascular kidney metabolic syndrome have high cardiovascular complication risks.
- Guideline-directed medical therapies (GDMT) are crucial for mitigating risks but often excluded in advanced chronic kidney disease (CKD) trials.
- This leads to underutilization of GDMT in CKD stages 4-5 due to concerns about side effects like hyperkalemia and creatinine increase.
Purpose of the Study:
- To review evidence on cardiovascular drug use in advanced CKD.
- To emphasize GDMT for heart failure in patients with CKD.
- To outline an integrated heart-nephrology-diabetes clinic treatment approach.
Main Methods:
- Clinical review of accumulating evidence.
- Emphasis on GDMT in heart failure patients with CKD stages 4-5.
- Discussion of treatment approaches in an integrated clinic setting.
Main Results:
- Evidence for cardiovascular drug benefits and risks in advanced CKD is often unclear.
- Underutilization of GDMT is common, driven by clinical inertia and fear of side effects.
- Individualized treatment, clinical judgment, and shared decision-making are essential.
Conclusions:
- Optimizing GDMT in advanced CKD requires careful consideration of patient-specific factors.
- Treatment goals must align with patient preferences and adapt to increasing frailty.
- Integrated care models are vital for managing complex cardiovascular and kidney conditions.
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