16/ 🧵Take-home messages ‼️HF mortality is improving in advanced CKD, but HF morbidity is not. ⏳Between 2011–2021, HF hospitalizations⏫ while mortality⏬ more slowly than in the general population. ➡️ Advanced CKD ⏩ major and growing excess HF burden.

15/ ⚖️Study limitations ⚠️ HF identified from clinical/ICD diagnoses ⚠️ No data on LVEF or natriuretic peptides ⚠️ Study largely predates widespread SGLT2i use in CKD

14/ ⚖️Study strengths ✅ Nationwide, well-characterized CKD cohort ✅ No loss to follow-up through registry linkage ✅ Stage- & dialysis-specific HF outcomes, benchmarked against the general population

13/ ⚡How to interpret these findings? Despite advances in HF, two opposite trends emerged in advanced CKD: 🏥 HF hospitalizations steadily ⏫, especially in ND-CKD & HD 📉 HF-related mortality ⏬ across all CKD groups Both remained substantially ⏫compared to the general population.

12/ 📉 Meanwhile, HF-related mortality declined 💡From 2011 ➡️2021: HF mortality ⏬across all CKD cohorts: ⏬by almost 21% in CKD G4 ⏬by almost 66% in PD ‼️All-cause mortality also declined, but less markedly ⚠️ By 2021, HF-related mortality remained 11.4–32× ⏫in CKD than in the age-sex matched population

11/📈 HF outcome by CKD stage 💡From 2011 ➡️2021: ⏫51% in CKD G4 ⏫36% in CKD G5-ND ⏫30% in HD ❌PD: exception, with rates declining in later years ❓Should we do more PD than HD in this case? ‼️HF hospitalization rates were 5.5–11.8× ⏫in CKD than in matched controls.

10/ 📅 Trends from 2011 to 2021 ➡️Diabetes, BMI and HF prevalence ⏫across CKD cohorts (except in PD) ➡️RASi use: low and stable throughout the period of observation, while MRA use gradually ⏫ ➡️HF therapy: ⬇️2-10% ➡️2021: 6-16% received beta-blocker➕RASi/ARNI➕MRA

9/ 📈 HF risk across CKD stages ❤️‍🔥 HF hospitalization: 3.7–6.8× ↑ vs matched general population 🪦 HF-related mortality: 11.6–17× ↑ across CKD cohorts vs matched general population 🫘 Cardiorenal syndrome accounted for 64–71% of HF-related deaths

8/ Study population 📊 Study population ⏩CKD G4: 25,591 patients ⏩ CKD G5-ND: 13,968 ⏩HD: 10,635 | PD: 4,511 ⏩CVD burden was ⏫ all groups ⏩HF was the most common CVD: 27% in G4, 25% in G5-ND, 33% in HD & 25% in PD

7/ Study design 🌟Based on SRR, 4 cohorts of patients were created ➡️CKD stage4 ➡️CKD stage 5 ND ➡️Maintenance CKD HD and PD 🌟Follow-up until HF, death, CKD progression/dialysis modality switch 🌟CKD matched 1:10 by sex/birth year with general population

6/ Methods ➡️Current study uses the 🇸🇪Swedish Renal Registry (SRR) to explore temporal trends of HF-related hospitalizations and HF-related mortality among CKD patients ➡️SRR collects longitudinal information ➕transition from ND-CKD to kidney replacement modalities ⌛Inclusion from 2011 - 2021

4/ Intro ➡️Cardiovascular disease (CVD) ⏩leading cause of mortality in CKD ➡️Heart failure (HF) the most frequent complication ➡️HF 🔁CKD