Advances in Heart Failure Therapy: Improved Survival in Patients with Advanced CKD

Background: Advanced chronic kidney disease (CKD) is a significant subpopulation of heart failure (HF) patients but is underrepresented in clinical trials. This study aims to evaluate mortality trends among advanced CKD patients with HF over the past decade.

Methods: We conducted a retrospective analysis of HF patients treated between 2014 and 2024 in a single tertiary center. Advanced CKD (eGFR < 45 ml/min/1.73 m²) patients were compared across two time periods: before and after January 2019. Kaplan-Meier survival analysis and Cox proportional hazards models were used, stratified by time. Sensitivity analyses confirmed robustness.

Results: The final cohort included 21,815 patients, median age 74±13.6 years (IQR 65-83), 12,369 (56.7%) of whom were male, and 4,664 (21%) had advanced CKD—2,336 before January 2019 and 2,298 after. Over a median follow-up of 3.5 years (IQR 1.6-6.1), 9,643 (44%) patients died. Kaplan-Meier analysis showed a 5-year mortality rate of 69%±0.77% for advanced CKD patients versus 44.5%±0.5% for non-advanced CKD patients (Log-rank p < 0.001). Treatment strategies evolved during the study period with increased use of sodium-glucose cotransporter-2 inhibitors (3% vs 15.9%), Entresto (5% vs 13%), and mineralocorticoid receptor antagonists (23% vs 27%). Cox regression analysis, adjusted for guideline-directed therapy and mortality predictors, showed reduced mortality risk associated with advanced CKD over time. The early period demonstrated an 89% increased risk (HR 1.89, 95% CI 1.78-2.007), decreasing to 67% in the later period (HR 1.67, 95% CI 1.54-1.81; p for interaction = .001)

Conclusions: Although advanced CKD remains a strong predictor of HF mortality, survival outcomes have improved in recent years, coinciding with the adoption of new therapies. This highlights the importance of modern HF management in advanced CKD patients.