# HFpEF and the Kidney: Shared Risk, Distinct Phenotypes

Confirm HFpEF, identify the dominant comorbid phenotype, and read each treatment result by population and endpoint.

![Infographic: HFpEF and the Kidney: Shared Risk, Distinct Phenotypes](https://urinenephrology.org/visual-reference/images/hfpef-kidney.png?v=20261003c)

## Preserved EF is not the diagnosis

HFpEF generally requires symptoms/signs of HF, LVEF ≥50%, and objective evidence of elevated filling pressures or cardiac dysfunction. HFmrEF has EF 41–49%. A normal EF with dyspnea also demands consideration of lung disease, anemia, obesity, and deconditioning.

## Establish the phenotype

Combine examination, echocardiography, natriuretic peptides, ECG/rhythm, kidney function, and UACR. Obesity can lower natriuretic peptides; CKD and atrial fibrillation can raise them. If resting tests are inconclusive, specialist exercise or hemodynamic assessment may clarify exertional symptoms.

## Treat congestion and common drivers

Use diuretics for fluid retention and address hypertension, atrial fibrillation, ischemia, obesity, sleep-disordered breathing, diabetes, and CKD. Follow weight, symptoms, BP, creatinine, and electrolytes. Do not apply the HFrEF four-drug framework automatically to every preserved-EF patient.

## Know the SGLT2 outcome

EMPEROR-Preserved and DELIVER support SGLT2 therapy to reduce worsening-HF outcomes across relevant preserved/mildly reduced EF populations, including people without diabetes. Check agent-specific kidney eligibility, volume status, and sick-day precautions; HbA1c is not the eligibility gate.

## Interpret finerenone accurately

FINEARTS-HF enrolled EF ≥40% and reduced total worsening-HF events plus cardiovascular death: rate ratio 0.84, a 16% relative rate reduction. Cardiovascular death alone was not significantly reduced. Potassium and kidney monitoring remain essential; recurrent-event results do not yield a simple NNT.

## Use comorbidity to select the next step

For obesity-related HFpEF, evidence-based weight treatment may improve symptoms and function. For diabetes with albuminuric CKD, apply kidney-protective eligibility rules. Avoid universal claims that HFpEF is a kidney disease or that one MRA is superior to another across unmatched trials.

## Supporting evidence

- [Official clinical guidance](https://professional.heart.org/en/guidelines-statements/2022-ahaacchfsa-guideline-for-the-management-of-heart-failure-a-report-of-thecir0000000000001063)
- [PubMed 34449189](https://pubmed.ncbi.nlm.nih.gov/34449189/)
- [PubMed 36027570](https://pubmed.ncbi.nlm.nih.gov/36027570/)
- [PubMed 39225278](https://pubmed.ncbi.nlm.nih.gov/39225278/)

## Source lessons

- [index](https://urinenephrology.org/2025_UDPA_Lectures_Live/hfpef-roundtable/index.html)
- [supplemental materials](https://urinenephrology.org/2025_UDPA_Lectures_Live/hfpef-roundtable/supplemental-materials.html)
- [comprehensive cardiorenal report](https://urinenephrology.org/2025_UDPA_Lectures_Live/hfpef-roundtable/reports/comprehensive-cardiorenal-report.html)
- [neurohormonal heart failure report](https://urinenephrology.org/2025_UDPA_Lectures_Live/hfpef-roundtable/reports/neurohormonal-heart-failure-report.html)

Read alongside the full lessons; the findings and decisions shown here require the stated clinical context.