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The 2026 ESC/ERA guidelines mandate early combined screening with SGLT2i and non-steroidal MRAs as Class I baseline therapies to stop cardio-renal disease progression.
The European Society of Cardiology (ESC), in collaboration with the European Renal Association (ERA), has released its first dedicated guideline for the management of cardiovascular disease (CVD) and chronic kidney disease (CKD). The guideline introduces the STAMP on CKD approach: Screen, Triage, Address CKD Risk, Modify CVD management, and Plan health services.
Key recommendations for clinical practice
1. Screen all patients with CVD for CKD
At CVD diagnosis, the guideline recommends assessment of creatinine-based estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (uACR). Two eGFR and uACR measurements over ≥3 months are advocated to establish CKD chronicity. Cystatin C-based eGFR must be considered when creatinine-based assessment may be inaccurate and an accurate kidney-function assessment is required for clinical decision-making.
2. Stratify cardiovascular (CV) and kidney-failure risk
CKD should be classified according to GFR and albuminuria to determine the risk of kidney failure and CKD complications, including CVD. For those with CKD categories G3–G5, a validated Kidney Failure Risk Equation (KFRE) is suggested to estimate the absolute risk of progression to kidney replacement therapy and support timely nephrology referral.
Where available, CV risk scores incorporating eGFR and/or albuminuria are recommended. Systematic COronary Risk Evaluation 2 (SCORE2)/SCORE2-Older Persons (SCORE2-OP) with the CKD Add-On is recommended for those with CKD without type 2 diabetes (T2D) or symptomatic ASCVD; SCORE2-Diabetes is advised for those with CKD and T2D without symptomatic ASCVD; and SMART2 is recommended for those with CKD and established atherosclerotic vascular disease.
3. Use maximally tolerated ACE inhibitor or ARB therapy
A maximally tolerated angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) is recommended in CKD to achieve target blood pressure and mitigate CKD progression and CV events. The potential exception is patients without albuminuria and with normal/low blood pressure who do not have heart failure (HF) as an indication for ACEI/ARB therapy. Combining an ACEI with an ARB is not recommended because the risks of acute kidney injury and severe hyperkalaemia outweigh additional cardiorenal benefit.
4. Use sodium-glucose cotransporter 2 inhibitors (SGLT2i) according to kidney function and albuminuria
An SGLT2i is recommended in patients with CKD and T2D with eGFR ≥20 mL/min/1.73 m², irrespective of glycemic control, to minimize kidney-failure and CV-event risk. For CKD without diabetes, an SGLT2i is recommended when eGFR ≥20 mL/min/1.73 m² and uACR ≥20 mg/mmol (≥200 mg/g). It should also be considered when eGFR is 20–44 mL/min/1.73 m² and uACR is <20 mg/mmol, to slow kidney-disease progression.
5. Add finerenone in eligible patients with T2D and CKD
A non-steroidal mineralocorticoid receptor antagonist (MRA), finerenone, is recommended for patients with CKD and with eGFR ≥25 mL/min/1.73 m² and uACR ≥3 mg/mmol (≥30 mg/g) to alleviate kidney-failure and CV-event risk. The FIDELIO-DKD and FIGARO-DKD trials required serum potassium ≤4.8 mmol/L at run-in and screening.
6. Use semaglutide in specified CKD populations with T2D
Subcutaneous semaglutide 1.0 mg/week after dose titration is advocated, irrespective of glycemic control, for patients with CKD and T2D with either eGFR 25–49 mL/min/1.73 m² and uACR ≥10 mg/mmol (≥100 mg/g) or eGFR 50–74 mL/min/1.73 m² and uACR ≥30 mg/mmol (≥300 mg/g), to reduce CKD progression and CV events.
7. Adapt CV treatment when CKD is present
The guideline highlights the need to modify CVD management according to kidney function across acute and chronic coronary syndromes, HF, arrhythmias, stroke, peripheral arterial disease, and sudden cardiac death. In coronary syndromes, this includes individualized approaches to diagnostic coronary imaging and dual antiplatelet therapy (DAPT).
8. Consider kidney function when prescribing medications
For CKD sufferers, assessment of benefits versus potential harms is advocated when prescribing potentially nephrotoxic medicines. Monitoring eGFR, relevant electrolytes, QT interval when indicated, and therapeutic drug levels where possible is recommended for renally excreted medicines with narrow therapeutic windows or potential adverse effects with reduced eGFR.
9. Strengthen multidisciplinary care in advanced CKD
Nephrology involvement in CVD multidisciplinary teams should be considered for those with eGFR <30 mL/min/1.73 m² or those receiving kidney replacement therapy, to incorporate CKD-related considerations into shared decision-making.
Clinical takeaway
The new ESC–ERA guidance places CKD screening, risk stratification, and early cardiorenal risk reduction within routine cardiovascular care. The overarching message is to identify CKD early, initiate protective therapies promptly, and adapt CVD care according to kidney function.
European Heart Journal
https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehag098/8766283?login=false
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA): Developed by the task force on the management of cardiovascular disease and chronic kidney disease of the European Society of Cardiology (ESC)
Kevin Damman et al.
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