The following are key points to remember from a scientific statement on the evaluation and management of kidney dysfunction in advanced heart failure (HF):

1. Optimal management of kidney function is crucial in the comprehensive care of patients with advanced HF to improve clinical outcomes and quality of life. Abnormal kidney function, either chronic kidney disease or acute kidney injury, leads to retention of uremic solutes, which can have direct cardiotoxic effects.
2. Early identification of kidney dysfunction in patients with advanced HF is crucial for timely interventions. In addition to elevations in serum creatinine, kidney dysfunction encompasses inadequate maintenance of sodium and volume homeostasis, retention of uremic solutes, and disrupted endocrine functions.
3. Hemodynamic derangements and maladaptive neurohormonal upregulations contribute to fluctuations in kidney indices and electrolytes that may recover with guideline-directed medical therapy.
4. Quantifying the extent of underlying irreversible intrinsic kidney disease is crucial in predicting whether optimization of congestion and guideline-directed medical therapy can stabilize kidney function.
5. A comprehensive kidney evaluation may include kidney ultrasound and urine studies. There should be a low threshold to perform kidney biopsies in these patients who have persistent signs of kidney dysfunction, and treatable causes (e.g., BK virus infection) need to be ruled out.
6. This scientific statement focuses on clinical management of patients experiencing kidney dysfunction through the trajectory of advanced HF, with specific focus on:
• The conceptual framework for appropriate evaluation of kidney dysfunction within the context of clinical trajectories in advanced HF, including in the consideration of advanced HF therapies;
• Preoperative, perioperative, and postoperative approaches to evaluation and management of kidney disease for advanced surgical therapies (durable left ventricular assist device/heart transplantation) and kidney replacement therapies; and
• The key concepts in palliative care and decision-making processes unique to individuals with concomitant advanced HF and kidney disease.
7. For optimal decision-making and comanagement of advanced HF and kidney dysfunction, the core elements include:
• Engaging the patient and their family/caregivers, cardiologist/nephrologists, and all team members;
• Focusing on information and knowledge sharing and building consensus about treatment options;
• Clarifying goals of care and reaching agreement on treatment implementation; and
• Adapting care models within the context of health equity and consideration of social determinants of health.
8. Furthermore, clinical evidence of kidney dysfunction in advanced HF calls for an interdisciplinary approach with longitudinal assessments to ensure individualized care.
9. This may require careful evaluation of reversibility of heart and kidney dysfunction through timely drug and device therapies, appropriate considerations for risk-benefit assessment of advanced therapies, and early involvement of palliative care to aid in patient-centered decision-making.
10. Given clear knowledge gaps and the lack of standardization in diagnosing and managing kidney dysfunction in patients with advanced HF, additional research efforts are needed to serve this vulnerable patient population.

Clinical Topics: Acute Heart Failure, Cardiovascular Care Team, Heart Failure and Cardiomyopathies

Keywords: Acute Kidney Injury, Advanced Heart Failure, Kidney Diseases

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