Kidney Outcomes in Structural Heart and Cardiac Surgical Trials: The Case for Longitudinal Endpoint Reporting

The 2026 American Heart Association/American College of Cardiology/American Diabetes Association/American Society of Nephrology guideline on cardiovascular-kidney-metabolic syndrome establishes kidney function as a determinant of cardiovascular risk rather than an adjacent comorbidity. Endpoint architecture in structural heart and cardiac surgical research has not been revised accordingly. Valve Academic Research Consortium 3 standardized acute kidney injury reporting with considerable rigor, staging injury on Kidney Disease: Improving Global Outcomes serum creatinine criteria and requiring that new renal replacement therapy be reported discretely, but its scope is confined to the periprocedural window. No endpoint tracks filtration trajectory across follow-up, no threshold within the standard defines chronic kidney disease stage progression, and initiation of maintenance dialysis years after intervention has no reporting convention distinct from temporary replacement therapy in the immediate postoperative period. Pivotal trials consequently adjudicate cardiovascular outcomes for five years and kidney outcomes for 30 days. Registry evidence suggests the omission is consequential, with rapid filtration decline documented in more than a third of patients carrying preexisting kidney impairment within five years of cardiac surgery. This editorial argues for longitudinal reporting of estimated glomerular filtration rate, prespecification of stage progression and maintenance dialysis as adjudicated endpoints, and nephrology representation on trial steering committees with a defined role in kidney endpoint specification.