ESC / ERA · 2026

Cardiovascular Disease and Chronic Kidney Disease — Management Guideline

Source: 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA), European Heart Journal

✓ Edition checked 3 Oct 2026 — ESC / ERA 2026 is the current edition as of this date.

View the official source ↗

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria CKD is classified by GFR category and albuminuria category using a creatinine-based eGFR and a spot morning urine albumin-to-creatinine ratio; two measurements of eGFR and uACR over a period of about 3 months establish chronicity. The 2026 guideline follows a five-step framework: screen for disease, triage risk, address CKD progression factors, modify cardiovascular interventions, and plan multidisciplinary care.

⚠ Alarm features (investigate before diagnosing)

Rapid decline in eGFR or acute kidney injury
Severe albuminuria
eGFR below 20 mL/min/1.73 m2 or approaching kidney replacement therapy
Hyperkalaemia on a RAS inhibitor or MRA

Initial workup

Test	When to order
Creatinine-based eGFR	Class I: all patients with newly diagnosed cardiovascular disease, repeated to confirm chronicity over about 3 months. Cystatin C-based eGFR can refine estimates; see the guideline for the situations where it is advised.
Spot morning urine albumin-to-creatinine ratio (uACR)	Class I with eGFR in all patients with cardiovascular disease, at diagnosis and during follow-up, to classify CKD and guide drug choice (for example SGLT2 inhibitor and finerenone eligibility).

Decision Points

❓ Which situation applies?

Cardiovascular disease with no kidney assessment yet → Screening and classification (every patient with cardiovascular disease)

CKD confirmed, with or without diabetes → Slowing CKD progression and reducing cardiovascular events

Heart failure with CKD → Heart failure with CKD

Setting a blood pressure target in CKD → Blood pressure in CKD

Deciding on antiplatelet or anticoagulant therapy in CKD → Antithrombotic therapy in CKD

Treatment

Screening and classification (every patient with cardiovascular disease)

1 Screen with eGFR and uACR at diagnosis of cardiovascular disease Strong (Guideline recommendation) — Class I

Dose: —
Duration: At diagnosis, then repeated; confirm chronicity over about 3 months
Evidence level: High
Avoid if: —
If no response: If CKD is confirmed, move to the CKD pathway (RAS inhibitor, SGLT2 inhibitor, and statin-based therapy for most patients)

Slowing CKD progression and reducing cardiovascular events

1 ACE inhibitor or ARB (RAS inhibitor) Guideline recommendation — recommended for most patients with CKD, early in the course

Dose: Per product labeling, titrated as tolerated
Duration: Ongoing; monitor potassium and creatinine
Evidence level: High
Avoid if: Pregnancy; angioedema; hyperkalaemia; bilateral renal artery stenosis
If no response: Add an SGLT2 inhibitor

2 SGLT2 inhibitor Strong (Guideline recommendation) — Class I, level A in CKD with type 2 diabetes (eGFR 20 or above) or without diabetes (eGFR 20 or above and uACR 200 mg/g or above); Class IIa, level B1 without diabetes at eGFR 20-44 with uACR below 200 mg/g

Dose: Per product labeling
Duration: Ongoing; can be continued below eGFR 20 until kidney replacement therapy
Evidence level: High
Avoid if: Type 1 diabetes or ketoacidosis risk; recurrent genital or urinary infections; per labeling
If no response: Add statin-based therapy; in type 2 diabetes with albuminuria, add finerenone

3 Statin-based lipid therapy Guideline recommendation — recommended in CKD regardless of lipid levels; continuation on dialysis initiation may be considered

Dose: Per product labeling
Duration: Ongoing; continuation may be considered at dialysis initiation
Evidence level: High
Avoid if: Per statin labeling

4 Finerenone (non-steroidal MRA) in type 2 diabetes with albuminuria Strong (Guideline recommendation) — Class I, level A: CKD with type 2 diabetes, eGFR 25 or above, and uACR 30 mg/g or above

Dose: Per product labeling
Duration: Ongoing; monitor potassium
Evidence level: High
Avoid if: Hyperkalaemia; eGFR below 25
If no response: Add semaglutide in type 2 diabetes with eGFR 25-49 and uACR 100 mg/g or above

5 GLP-1 receptor agonist: subcutaneous semaglutide in type 2 diabetes with CKD Strong (Guideline recommendation) — Class I, level A in type 2 diabetes with eGFR 25-49 mL/min/1.73 m2 and uACR 100 mg/g (10 mg/mmol) or above; further eGFR and uACR strata were not seen in the text reviewed

Dose: Semaglutide 1.0 mg subcutaneously once weekly after dose titration
Duration: Ongoing
Evidence level: High
Avoid if: Personal or family history of medullary thyroid carcinoma or MEN2; history of pancreatitis; eGFR below 25

Heart failure with CKD

1 SGLT2 inhibitor irrespective of LVEF Strong (Guideline recommendation) — Class I, level A with eGFR 20 or above; continuation below 20 should be considered (Class IIa, level C)

Dose: Per product labeling
Duration: Ongoing; continue if eGFR falls below 20
Evidence level: High
Avoid if: Type 1 diabetes or ketoacidosis risk; per labeling
If no response: Manage the rest of heart failure therapy per the heart failure pathway

Blood pressure in CKD

1 Systolic blood pressure target of 120-129 mmHg if tolerated Guideline recommendation — systolic target 120-129 mmHg if tolerated in CKD with eGFR 30 mL/min/1.73 m2 or above; below eGFR 30 the target is individualized, and 120-129 mmHg appears reasonable for many such patients

Dose: Prioritize RAS inhibitors in the regimen
Duration: Ongoing
Evidence level: Moderate
Avoid if: Symptomatic hypotension; frailty or poor tolerance (individualize)

Antithrombotic therapy in CKD

1 Oral anticoagulation for atrial fibrillation in CKD: DOAC preferred over vitamin K antagonist, factor Xa inhibitor at eGFR 15-29 Guideline recommendation — an oral factor Xa inhibitor should be considered in preference to a VKA at eGFR 15-29 (Class IIa, level B1; only factor Xa inhibitor trials included patients with eGFR below 30); DOACs are preferred over VKA at higher eGFR (class per a second review, not seen in the excerpt); below eGFR 15 the decision is individualized (second review)

Dose: Per product labeling, dose adjusted to renal function
Duration: Ongoing
Evidence level: Moderate
Avoid if: Severe renal impairment below the labeled limit; active bleeding

✕ Treatments the guideline advises against

Routine antiplatelet therapy in CKD with eGFR below 60 and no symptomatic atherosclerotic cardiovascular disease: The 2026 ESC/ERA guideline states that routine antiplatelet therapy is not recommended in this population.

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.