Effect of GDMT Optimization on KDIGO Risk Categories in HFrEF: Analysis of the VIENNA-HF Registry

Concerns about worsening renal function often limit the use of guideline-directed medical therapy (GDMT) in heart failure (HF) with reduced ejection fraction (HFrEF). Although changes in estimated glomerular filtration rate (eGFR) are commonly monitored during GDMT up-titration, the added value of urine albumin-to-creatinine ratio (UACR) and Kidney Disease: Improving Global Outcomes (KDIGO) risk categories remains less studied.

The objectives of the study were to assess changes in eGFR, UACR, and KDIGO risk categories following GDMT optimization in HFrEF and to evaluate their association with renal and HF outcomes.

Consecutive HFrEF (n = 234) outpatients with baseline and 12-month follow-up data were analyzed from the VIENNA-HF registry. KDIGO risk trajectories and their association with renal and HF outcomes were assessed.

At follow-up, GDMT dosages significantly increased. eGFR declined (60 vs 56 mL/min/1.73 m²; P = 0.007), whereas UACR improved (31 vs 24 mg/g; P = 0.003). 56%, 24%, and 20% of patients exhibited stable, worsening, or improved KDIGO trajectories. UACR contributed to over half of all reclassifications and was the sole determinant in 35% of cases. Event rates increased stepwise across baseline KDIGO risk classes (renal events: 4% vs 12% vs 15% vs 27%; P < 0.001; HF events: 19% vs 29% vs 37% vs 56%; P < 0.001, 2-years estimate). Similarly and worsening KDIGO trajectories were associated with higher event rates (renal events: 6% vs 15% vs 21%; P = 0.034; HF events: 11% vs 43% vs 46%; P = 0.007, 2-year estimate).

KDIGO risk trajectories vary substantially during GDMT optimization in HFrEF. UACR provides complementary information beyond eGFR and may improve risk stratification for renal and HF outcomes.