The 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, developed with the European Renal Association, bring cardiovascular disease and chronic kidney disease into a single clinical framework.
The central idea is straightforward: CKD changes cardiovascular risk, treatment selection, drug safety, procedural planning and prognosis. Cardiovascular disease can also accelerate kidney dysfunction. The guideline therefore encourages clinicians to identify both conditions early, estimate both cardiovascular and kidney-failure risk, and treat them together rather than in parallel.
The overall strategy is summarised as “STAMP on CKD”: Screen, Triage and stage, Address CKD risk, Modify CVD management, and Plan health services.
When should patients with cardiovascular disease be screened for CKD?
The guideline recommends screening patients with cardiovascular disease using both estimated glomerular filtration rate and albuminuria. Creatinine or eGFR alone may miss early kidney disease. Albuminuria can appear before GFR falls and adds important cardiovascular and kidney-risk information.
A spot urine albumin-to-creatinine ratio (uACR) is therefore central to CKD detection. If reduced eGFR or increased albuminuria is newly detected, repeat testing is needed to distinguish chronic disease from an acute change.
Practical message: kidney screening is now part of cardiovascular risk assessment.
- eGFR
- uACR
What cardiovascular assessment is needed once CKD is identified?
The relationship is bidirectional. In patients with CKD, the ESC recommends assessment for symptoms and signs of the following conditions at each clinical encounter. CKD should prompt active cardiovascular surveillance rather than simply being documented as another comorbidity.
- Hypertension
- Atherosclerotic cardiovascular disease
- Heart failure
- Arrhythmias
- Valvular heart disease
How should cardiovascular and kidney-failure risk be assessed together?
Clinicians should estimate both cardiovascular risk and kidney-failure risk. For CKD categories G3–G5, the Kidney Failure Risk Equation is recommended to estimate progression to kidney replacement therapy. A five-year kidney-failure risk of approximately >3%–5% has been proposed as a threshold for nephrology referral.
| Clinical situation | Risk assessment |
|---|---|
| CKD without type 2 diabetes or established ASCVD | SCORE2/SCORE2-OP + CKD Add-On |
| CKD + type 2 diabetes without established ASCVD | SCORE2-Diabetes |
| CKD + established ASCVD | SMART2 |
| CKD G3–G5 | KFRE for kidney-failure risk |
Do not ask only, “What is this patient’s cardiovascular risk?” Also ask, “What is this patient’s risk of kidney failure?” These estimates influence treatment intensity, monitoring and referral.
What blood-pressure target should be used?
For many patients with CKD, the guideline supports intensive blood-pressure control with a systolic BP target of 120–129 mmHg when tolerated in appropriate populations. Targets should be more individualised in advanced CKD and when intensive lowering may not be tolerated.
Home or ambulatory measurements can be useful when white-coat, masked or nocturnal hypertension is suspected. The aim is to reduce cardiovascular events and CKD progression while accounting for individual tolerance.
Which therapies form the foundation of cardiorenal protection?
Several therapies sit at the centre of simultaneous cardiovascular and kidney protection.
| Therapy | Practical role |
|---|---|
| ACE inhibitor or ARB | BP control and reduction of CKD progression and cardiovascular risk in appropriate patients |
| SGLT2 inhibitor | Kidney and cardiovascular protection in defined CKD populations |
| Finerenone | Additional cardiorenal protection in albuminuric CKD with type 2 diabetes |
| GLP-1 receptor agonist | Cardiovascular and kidney benefit in selected patients with type 2 diabetes and CKD |
| Statin-based therapy | Reduction of atherosclerotic cardiovascular events |
SGLT2 inhibitors are recommended in CKD with type 2 diabetes when eGFR is ≥20 mL/min/1.73 m², irrespective of glycaemic control. They are also recommended in selected patients without diabetes according to eGFR and albuminuria criteria.
Finerenone reduces kidney and cardiovascular events in patients with CKD, albuminuria and type 2 diabetes. In type 2 diabetes with CKD, SGLT2 inhibitors and GLP-1 receptor agonists are recommended as first-line glucose-lowering agents because of their cardiovascular and kidney benefits.
Combined ACE inhibitor + ARB therapy is not recommended, because increased acute kidney injury and severe hyperkalaemia outweigh any additional cardiorenal benefit. These therapies should increasingly be viewed as organ-protective rather than only antihypertensive or glucose-lowering drugs.
How should lipid management change in CKD?
In patients with eGFR <60 mL/min/1.73 m² who are not on kidney replacement therapy, the guideline recommends an intensive statin-based regimen irrespective of baseline lipid levels to reduce major atherosclerotic events. Moderate- or high-intensity statins, with or without ezetimibe, are examples of regimens studied in CKD.
Once patients reach dialysis, evidence is less robust. Continuing statins may be considered, while starting therapy is more selective, particularly in patients with established ASCVD or planned transplantation.
In non-dialysis CKD, lipid-lowering decisions are driven largely by overall cardiovascular risk, not simply the LDL-C value.
How should heart failure be managed when CKD is present?
CKD should modify heart-failure treatment, not automatically limit it. SGLT2 inhibitors remain important across the heart-failure spectrum. In decompensated HF with CKD and eGFR >20 mL/min/1.73 m², early initiation during admission is recommended to improve congestion and reduce HF rehospitalisation.
Patients with CKD may require more aggressive diuretic strategies because reduced kidney function contributes to diuretic resistance.
- Appropriately higher loop-diuretic doses
- Early assessment of diuretic response
- Acetazolamide added to loop diuretics in selected patients
- Thiazide combination therapy in selected cases
What if creatinine rises during decongestion?
In a congested patient with decompensated HF and CKD who is responding well to diuresis, decongestive treatment should continue despite a rise in creatinine of up to 50%, provided there are no other concerning features.
A transient decline in eGFR during effective decongestion does not necessarily indicate structural kidney injury or a worse prognosis. Treat the congestion, monitor carefully, and interpret creatinine in clinical context rather than stopping effective therapy reflexively.
How should coronary disease be approached in CKD?
Kidney dysfunction can lead to delayed investigation or undertreatment. The guideline argues against this therapeutic inertia.
For chronic coronary syndromes, diagnostic testing and revascularisation should be individualised according to symptoms, ischaemia, coronary anatomy, kidney function and procedural risk. Invasive angiography remains appropriate when it is likely to influence treatment. In acute coronary syndromes, CKD should not become a reason to delay indicated cardiovascular care.
Reduce kidney risk while still delivering appropriate cardiac treatment.
How should contrast be used safely in CKD?
Necessary contrast-based procedures should not be delayed solely because a patient has CKD. For patients with eGFR <30 mL/min/1.73 m² who are not on dialysis, iso-osmolar or low-osmolar iodinated contrast with contrast-sparing techniques is recommended during coronary angiography or vascular procedures.
| Strategy | Recommendation |
|---|---|
| Avoid delaying an indicated procedure | Recommended |
| Low- or iso-osmolar iodinated contrast | Recommended |
| Contrast-sparing techniques | Recommended |
| IV hydration at eGFR <30 | May be considered |
| Prophylactic haemodialysis | Not recommended |
Periprocedural IV hydration may be considered in selected high-risk patients. Prophylactic haemodialysis is not recommended because it has been associated with harm.
Protect the kidney, but do not delay necessary care.
How should atrial fibrillation anticoagulation change with kidney function?
CKD increases both thromboembolic and bleeding risk. For AF with eGFR ≥30 mL/min/1.73 m², a DOAC is recommended in preference to a vitamin K antagonist. For eGFR 15–29, an oral factor Xa inhibitor should be considered in preference to VKA. For eGFR <15, including kidney replacement therapy, anticoagulation should be individualised.
| Kidney function | Preferred approach |
|---|---|
| eGFR ≥30 | DOAC preferred over VKA |
| eGFR 15–29 | Factor Xa inhibitor should be considered |
| eGFR <15 / KRT | Individualised decision |
Existing stroke and bleeding risk scores are not recommended in AF with eGFR <30 mL/min/1.73 m² because predictive performance is poor in severe CKD. Choose the right drug and dose for kidney function and reassess renal function over time.
What changes when a patient reaches dialysis?
Evidence becomes less certain in maintenance dialysis because many cardiovascular trials excluded this population.
Proactive regular high-dose intravenous iron is recommended in maintenance haemodialysis unless serum ferritin is >700 μg/L or transferrin saturation is ≥40%, to reduce cardiovascular events including heart failure.
Routine MRA therapy is not recommended in dialysis because of serious hyperkalaemia risk without clear evidence of benefit on cardiovascular death or HF hospitalisation. Cardiovascular care in dialysis therefore requires more individualised decision-making.
How should kidney-transplant candidates undergo cardiovascular assessment?
All kidney-transplant candidates should undergo the following baseline assessment. More advanced coronary testing should be risk based rather than universal.
Myocardial perfusion imaging or coronary CT angiography should be considered in high-risk asymptomatic candidates. Routine pre-operative CAD screening is not recommended in candidates with a low probability of obstructive CAD, because unnecessary testing may cause complications and delay transplantation.
Screen selectively and avoid creating unnecessary barriers to transplantation.
- Clinical history and examination
- Resting ECG
- Transthoracic echocardiography
When should cardiology and nephrology manage patients together?
Nephrology team members should be considered as part of cardiovascular multidisciplinary care for patients with eGFR <30 mL/min/1.73 m² or those receiving kidney replacement therapy, so CKD-related issues are incorporated into shared decisions.
This is particularly important for complex heart failure, advanced coronary disease, difficult anticoagulation decisions, dialysis and transplantation.
The STAMP on CKD framework
The framework uses kidney information to change risk assessment, treatment selection, monitoring, procedural planning and referral—not merely to document abnormal kidney function.
| Step | Action |
|---|---|
| S | Screen for CKD |
| T | Triage and stage CKD |
| A | Address kidney and cardiovascular risk |
| M | Modify cardiovascular management according to CKD |
| P | Plan coordinated health services |
Final clinical takeaway
The 2026 ESC guideline treats cardiovascular disease and CKD as an integrated cardiorenal problem. Measure eGFR and uACR, estimate both cardiovascular and kidney-failure risk, use proven cardiorenal therapies early, and adapt cardiovascular treatment to kidney function without allowing CKD to become a reason for undertreatment.
Protect the heart. Protect the kidneys. Treat both together.
Full reference
Damman K, Herrington WG, Mayne KJ, et al. 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA). European Heart Journal. Published 28 August 2026. doi:10.1093/eurheartj/ehag098.