Heart Failure in Kidney Transplant Recipients: Narrative Review of Risk Factors, Therapy, and Current Gaps in Management

Among kidney transplant recipients (KTR), cardiovascular disease remains the leading cause of mortality, with heart failure (HF) being especially common in this population. Risk factors for HF in KTR can be categorized as traditional (risks relevant to the general population) versus nontraditional (unique to kidney disease and transplantation). Despite the substantial burden of cardiovascular disease, KTR have been excluded from large clinical trials in cardiovascular medicine and from landmark studies looking at the kidney-protective effects of novel cardiorenal metabolic agents, including sodium-glucose cotransporter 2 inhibitors (SGLT2i). Thus, there is uncertainty about the safety and efficacy of the use of guideline directed medical therapy (GDMT) for HF in this population. Long-term optimal use of GDMT in KTR is limited by various barriers, including the risk of hyperkalemia from concomitant use of renin-angiotensin inhibitors and mineralocorticoid receptor antagonists, fears about genitourinary infections from SGLT2i, and lack of evidence for kidney-protective effects from GDMT agents among KTR. Overcoming these barriers will require a multifaceted approach that involves evidence generation to understand the efficacy and safety of GDMT among KTR, implementation-based strategies to increase uptake of GDMT, and development of multispecialty combined clinical care approaches to care for KTR with HF.