Impact of chronic kidney disease on treatment implementation and prognosis of patients with heart failure: A large retrospective observational analysis from the Italian Network-Heart Failure (IN-HF) registry.

Abstract

Chronic kidney disease (CKD) commonly coexists with heart failure (HF), negatively impacting prognosis. We analyzed temporal trends in clinical characteristics, HF medications use and outcomes in outpatients with chronic HF and CKD, KDIGO stage 3b and stages 4-5, in a nationwide HF registry. We retrospectively analyzed patients stratified by CKD levels (3b: eGFR 30-44; 4-5: eGFR <30 ml/min/1.73 m²) and enrolment period (2007-2016 vs 2017-2023) Outcomes were major adverse cardiovascular (CV) events (MACE) and CV death or heart failure hospitalization (CVd-HFH). Among 2003 patients, 1450 (72.4%) had stage 3b and 553 (27.6%) stage 4-5 CKD. HF drugs prescription rates were 73.7% for renin-angiotensin system inhibitors/angiotensin receptor-neprilysin inhibitors (RASI/ARNI) (79.3% vs 59%, p<0.001), 52.7% for mineralocorticoid receptor antagonist (MRA) (56.4% vs 43%, p<0.001), 81.5% for betablockers (BB) (81.6% vs 81.4%, p=0.949), respectively. Over time, use and target-dose achievement of RASI/ARNI declined, while BB and MRA uptake increased. Among HFrEF patients 47% (stage 3b) and 31% (stage 4-5) received triple therapy (RASI/ARNI+BB+MRA). Stage 4-5 patients had a higher risk of MACE (adjHR 1.280, 95%CI 1.078-1.519, p=0.005) Outcomes did not improve over time (CKD stage*enrolment period interaction, p=0.277). In HF outpatients with moderate-to-severe CKD, we observed higher contemporary use of BB, MRA, and triple therapy than previously reported. Prognosis did not substantially improve over time, likely due to increasing patient complexity. Integrated cardio-renal care and prospective studies to optimize treatment and improve outcomes in this population are needed.