---
title: Chronic kidney disease and the heart
description: How chronic kidney disease and heart disease make each other worse, why kidney disease raises the risk of heart attack, heart failure and heart rhythm disorders, why high potassium is dangerous, how the kidneys and the heart are checked, which treatment approaches clinical guidelines describe, and when to call an ambulance.
type: disease
aliases:
  - chronic kidney disease
  - CKD
  - kidney disease and the heart
  - kidneys and the heart
  - cardiorenal syndrome
  - cardiorenal continuum
  - chronic renal failure
  - hyperkalaemia
  - hyperkalemia
sources:
  - tier: guideline
    org: esc
    title: 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA)
    year: 2026
    doi: 10.1093/eurheartj/ehag098
    url: https://doi.org/10.1093/eurheartj/ehag098
  - tier: guideline
    org: minzdrav-rf
    title: Хроническая болезнь почек (ХБП)
    year: 2024
    url: https://cr.minzdrav.gov.ru/view-cr/469_3
  - tier: reference
    org: msd-manuals
    title: Chronic Kidney Disease (MSD Manual Professional Version)
    year: 2026
    url: https://www.msdmanuals.com/professional/genitourinary-disorders/chronic-kidney-disease/chronic-kidney-disease
  - tier: reference
    org: msd-manuals
    title: Chronic Kidney Disease (MSD Manual Consumer Version)
    year: 2026
    url: https://www.msdmanuals.com/home/kidney-and-urinary-tract-disorders/kidney-failure/chronic-kidney-disease
  - tier: reference
    org: msd-manuals
    title: Hyperkalemia (MSD Manual Professional Version)
    year: 2025
    url: https://www.msdmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/hyperkalemia
  - tier: reference
    org: msd-manuals
    title: Hyperkalemia (High Level of Potassium in the Blood) (MSD Manual Consumer Version)
    year: 2026
    url: https://www.msdmanuals.com/home/hormonal-and-metabolic-disorders/electrolyte-balance/hyperkalemia-high-level-of-potassium-in-the-blood
  - tier: reference
    org: statpearls
    title: Cardiorenal Syndrome
    year: 2025
    url: https://pubmed.ncbi.nlm.nih.gov/31194445/
  - tier: reference
    org: statpearls
    title: Hyperkalemia
    year: 2025
    url: https://pubmed.ncbi.nlm.nih.gov/29261936/
sources_checked: 2026-10-14
review: null
---

Chronic kidney disease (CKD) is kidney damage that does not go away but lasts a long time.<Cite n={[1, 2]} /> "Chronic" means "long-term", not "severe".<Cite n={1} /> CKD is a common condition.<Cite n={2} />

Kidney disease and heart and blood vessel disease are closely linked: one makes the other more likely and makes it worse.<Cite n={[1, 2]} /> Heart and blood vessel disease is the most common direct cause of death in people with impaired kidney function.<Cite n={2} />

This article is about how the kidneys and the heart affect each other. Blood pressure, diabetes and cholesterol are covered in more detail in the articles on [hypertension](../hypertension/), [diabetes and the heart](../diabetes-and-heart/) and [dyslipidaemia](../dyslipidemia/).

<Diagram name="chronic-kidney-disease-and-heart">
  <p slot="normal">
    The diagram shows the heart and a kidney joined by an artery. The kidneys filter the blood all
    the time: they remove waste products, which leave in the urine, and control the amount of salt
    and water in the body.<Cite n={1} /> Healthy kidneys also do a good job of removing extra
    potassium.<Cite n={6} />
  </p>
  <p slot="disease">
    In chronic kidney disease the kidneys do not work as well as they should, and waste products
    build up in the body.<Cite n={1} /> Diseased kidneys cannot get rid of extra salt and water: this
    raises blood pressure and can lead to heart failure.<Cite n={4} /> Less potassium is removed, its
    level in the blood rises, and high potassium increases the risk of heart rhythm
    disorders.<Cite n={4} /> Raised triglycerides together with high blood pressure increase the risk
    of atherosclerosis.<Cite n={4} /> The link also works the other way: heart and blood vessel
    disease is another cause of CKD.<Cite n={1} />
  </p>
</Diagram>

## Why it happens

<Patient>

Common causes of CKD are diabetes, high blood pressure, inflammation in the kidneys and inherited kidney conditions.<Cite n={[1, 4]} /> Many factors that harm the kidneys harm the heart as well: high blood pressure, diabetes, abnormal blood fats, obesity and smoking.<Cite n={2} />

The kidneys affect the heart through salt and water retention, high potassium and faster atherosclerosis; these pathways are shown in the diagram above.<Cite n={4} /> Heart valve problems are also more common in CKD: calcium can build up on the valves, particularly the aortic and mitral valves, and make them stiff.<Cite n={1} />

The heart affects the kidneys too. High blood pressure damages the kidneys.<Cite n={1} /> People with heart failure are particularly prone to CKD, and the risk of CKD is also high after a recent heart attack.<Cite n={1} />

As a result, people with CKD have a higher risk of heart attack, stroke, heart failure, atrial fibrillation and peripheral artery disease, and after a first such event another one is more likely.<Cite n={1} /> The lower the kidney function and the more protein in the urine, the higher this risk.<Cite n={1} /> It is particularly high when CKD comes together with diabetes, and in people on dialysis.<Cite n={1} /> After a successful kidney transplant the cardiovascular risk is lower than with continued dialysis.<Cite n={1} />

</Patient>

<Student>

The Russian Ministry of Health guideline describes the mutual dependence of cardiovascular and kidney damage and the bidirectional action of risk factors as the cardiorenal continuum.<Cite n={2} /> Besides the "traditional" risk factors, non-traditional (renal) ones act: albuminuria/proteinuria, systemic inflammation, oxidative stress, anaemia, hyperhomocysteinaemia; cardiovascular disease is therefore much more common in kidney patients than traditional risk factors would predict.<Cite n={2} /> The risk of cardiovascular death in patients on kidney replacement therapy is tens of times higher than in the general population.<Cite n={2} />

The prevalence of CKD in the general population in a meta-analysis of cohort studies averaged 13.4%; according to Russian studies, signs of CKD are present in more than a third of patients with chronic heart failure.<Cite n={2} /> According to MSD, hypertension is present in more than 80% of patients with advanced CKD and is usually related to hypervolaemia; heart failure can occur due to sodium and water overload, particularly with decreased cardiac reserve.<Cite n={3} />

Cardiorenal syndrome is defined as any acute or chronic problem in the heart or kidneys that could result in an acute or chronic problem in the other; it is classified into 5 subtypes by pathophysiology and chronicity.<Cite n={7} />

</Student>

<HeartModel highlight={['aortic-valve', 'mitral-valve']} />

## Symptoms

<Patient>

In its early stages CKD usually causes few or no symptoms; clear signs usually mean the disease is advanced.<Cite n={[2, 3]} /> Later there may be urinating at night, tiredness, nausea, itching, muscle twitching and cramps, loss of appetite, confusion, difficulty breathing and swelling, most often of the legs.<Cite n={4} />

Shortness of breath, tiredness and swollen legs can be caused by either heart failure or kidney disease.<Cite n={1} /> People with CKD should report chest pain, palpitations or an irregular heartbeat, shortness of breath, finding their usual level of exercise harder, and swollen legs to their doctor.<Cite n={1} /> Atrial fibrillation is more common in CKD, and the risk grows as kidney disease progresses; its signs are described in the article on [atrial fibrillation](../atrial-fibrillation/).<Cite n={1} />

High potassium in the blood often causes no symptoms; sometimes there is muscle weakness.<Cite n={6} /> When potassium rises further, heart rhythm disorders appear, and at a very high level the heart can stop.<Cite n={6} /> High potassium is usually found by a blood test or an ECG, not by how a person feels.<Cite n={6} /> The risk of sudden cardiac death rises as CKD becomes more severe and is particularly high on dialysis, because of rapid changes in body fluid, potassium and other blood electrolytes, and underlying heart disease.<Cite n={1} />

</Patient>

<Student>

According to the Russian Ministry of Health guideline, the early stages of CKD (C1–C3a) typically have few symptoms.<Cite n={2} /> Hyperkalaemia is a serum potassium concentration > 5.5 mmol/L, usually due to decreased renal potassium excretion; it is usually asymptomatic until cardiac arrhythmias develop, and flaccid paralysis occasionally occurs.<Cite n={5} /> Severe hyperkalaemia can precipitate life-threatening arrhythmias, muscle weakness or paralysis.<Cite n={8} />

ECG changes as hyperkalaemia increases: tall, peaked T waves and a shortened QT interval, then QRS widening and loss of the P wave, then a sine-wave pattern and ventricular fibrillation or asystole.<Cite n={[2, 5]} /> The potassium level at which the same ECG changes appear varies widely between patients.<Cite n={5} />

</Student>

## How it is diagnosed

<Patient>

Everyone with heart or blood vessel disease should be tested for CKD.<Cite n={1} /> This needs a blood test and a urine test.<Cite n={1} /> From blood creatinine, together with age, sex and body size, doctors estimate how well the kidneys filter the blood: the estimated glomerular filtration rate (eGFR).<Cite n={1} /> A spot urine sample is tested for the protein albumin: albumin in the urine is an early sign of kidney damage.<Cite n={1} /> To confirm that the disease is chronic, the tests are repeated after a while.<Cite n={1} /> From the results the doctor determines the CKD stage and the risk category: the likelihood of kidney failure and complications, including cardiovascular ones.<Cite n={1} />

At each visit the doctor checks people with CKD for signs of high blood pressure, atherosclerosis, heart failure, rhythm disorders and valve disease.<Cite n={1} /> The heart is assessed with an ECG and echocardiography, an ultrasound scan of the heart.<Cite n={[1, 2]} /> A blood test for natriuretic peptides helps detect heart failure, but in CKD their levels are often higher even without it, so the result is interpreted together with symptoms, examination and echocardiography.<Cite n={1} /> Blood potassium is tested and monitored in everyone with CKD.<Cite n={2} />

</Patient>

<Student>

According to the Russian Ministry of Health guideline, one criterion of CKD is a GFR < 60 mL/min/1.73 m² persisting for three months or more, regardless of other signs of kidney damage.<Cite n={2} /> GFR stages (mL/min/1.73 m²): C1 > 90, C2 60–89, C3a 45–59, C3b 30–44, C4 15–29, C5 < 15; albuminuria grades (mg/day): A1, optimal or raised, given in the table as "< 10–29"; A2, high, 30–299; A3, very high, 300–1999; A4, nephrotic, ≥ 2000.<Cite n={2} />

ESC 2026: screening for CKD using eGFR and albuminuria is recommended in patients with CVD; albuminuria is assessed by the urine albumin-to-creatinine ratio (uACR) in a spot morning urine sample; two measurements of eGFR and uACR over at least 3 months are needed to establish chronicity.<Cite n={1} /> Patients with severe CKD (eGFR < 30 with any albuminuria; eGFR 30–44 and uACR 3–30 mg/mmol; uACR > 30 mg/mmol with any eGFR) are recommended to be considered at relatively very high CVD risk, and those with moderate CKD (eGFR 30–44 and uACR < 3 mg/mmol; eGFR 45–59 and uACR 3–30 mg/mmol) without other major risk factors at relatively high risk.<Cite n={1} /> Risk scores incorporating eGFR and albuminuria are recommended for risk assessment.<Cite n={1} /> The Russian Ministry of Health guideline recommends echocardiography in patients with CKD C1–C5D to detect structural changes and myocardial dysfunction.<Cite n={2} />

</Student>

## How it is treated

<Patient>

Some medicines have been shown to reduce the risk of CKD progressing to kidney failure and to lower cardiovascular risk; starting them in the early stages and taking them long-term is recommended.<Cite n={1} /> The guidelines name these drug classes:

- ACE inhibitors or angiotensin receptor blockers (ARBs): they lower blood pressure and protect both the heart and the kidneys;<Cite n={[1, 2]} />
- SGLT2 inhibitors (gliflozins): recommended for most people with CKD, best together with an ACE inhibitor or ARB;<Cite n={[1, 2]} />
- in CKD with type 2 diabetes, also non-steroidal mineralocorticoid receptor antagonists (especially when there is protein in the urine)<Cite n={[1, 2]} /> and GLP-1 receptor agonists;<Cite n={1} />
- statins: for most people with CKD, even if cholesterol is not very high.<Cite n={1} />

Blood pressure control is especially important: high blood pressure damages the kidneys and increases the risk of heart attack, stroke and heart failure.<Cite n={1} /> The target blood pressure depends on age, the stage of CKD, symptoms and other conditions; the doctor discusses it with the patient.<Cite n={1} /> Stopping smoking, being physically active and choosing, together with the doctor, a diet low in salt and high in vegetables are recommended.<Cite n={1} /> In CKD, vegetables and fruits that are low in potassium are the best choice.<Cite n={1} /> There is no single "kidney diet": the doctor or a dietitian helps choose a diet that suits the stage of CKD.<Cite n={1} /> Some salt substitutes contain potassium and may not be safe in CKD: ask your doctor before using them.<Cite n={[1, 4]} />

Some medicines needed in CKD, above all ACE inhibitors and ARBs, raise potassium, so potassium and kidney function are monitored during treatment.<Cite n={2} /> A rise in potassium is usually not a reason to stop this treatment: stopping these medicines is linked to more cardiovascular events and faster worsening of kidney function.<Cite n={2} /> If potassium becomes too high, it is lowered with medicines, and sometimes emergency dialysis is needed.<Cite n={4} />

Heart failure in people with CKD is treated in much the same way as in people without it.<Cite n={1} /> If kidney function changes slightly after treatment starts, these medicines are not stopped automatically.<Cite n={1} /> CKD is not a reason to delay urgent treatment of a heart attack or tests that use contrast agents.<Cite n={1} /> More in the articles on [heart failure](../heart-failure/) and [myocardial infarction](../myocardial-infarction/).

Tell every new doctor that you have CKD: the doses of some medicines have to be adjusted, and some medicines damage the kidneys.<Cite n={1} /> Most experts recommend avoiding non-steroidal anti-inflammatory drugs (NSAIDs) in CKD: they may worsen kidney function and raise blood pressure.<Cite n={3} /> Your doctor decides which medicines you need and which treatment targets suit you; do not start, stop or change medicines on your own.

</Patient>

<Student>

ESC 2026: maximally tolerated ACEI or ARB is recommended in CKD to achieve target blood pressure and reduce the risk of CKD progression and cardiovascular events; combined use of an ACEI with an ARB is not recommended, as the risk of AKI and severe hyperkalaemia outweighs any added benefit.<Cite n={1} /> In CKD with type 2 diabetes, an SGLT2 inhibitor is recommended with eGFR ≥ 20 mL/min/1.73 m² irrespective of glycaemic control, and a non-steroidal MRA with eGFR ≥ 25 mL/min/1.73 m² and uACR ≥ 3 mg/mmol; SGLT2 inhibitors and GLP-1 receptor agonists are first-line glucose-lowering agents in type 2 diabetes with CKD.<Cite n={1} /> The Russian Ministry of Health guideline recommends, in non-diabetic CKD with GFR ≥ 20 mL/min/1.73 m², an SGLT2 inhibitor with proven efficacy in addition to an ACEI or ARB; the hyperkalaemia risk with a non-steroidal MRA is lower than with other aldosterone antagonists but should be taken into account.<Cite n={2} />

ESC 2026 recommends an intensive statin-based regimen with eGFR < 60 mL/min/1.73 m² not on kidney replacement therapy, irrespective of lipid levels; routine antiplatelet therapy with eGFR < 60 without symptomatic ASCVD is not recommended because of the risk of major bleeding; routine use of MRAs in patients on dialysis is not recommended because of the risk of serious hyperkalaemia.<Cite n={1} />

The sources give different blood pressure targets in CKD. ESC 2026: with eGFR ≥ 30 mL/min/1.73 m² and confirmed office BP ≥ 130/80 mm Hg, intensified BP control is recommended, with a systolic target of 120–129 mm Hg if tolerated.<Cite n={1} /> Russian Ministry of Health guideline: in CKD with albuminuria grades A1–A2 and hypertension, systolic BP should be lowered to 130–139 mm Hg.<Cite n={2} />

Russian Ministry of Health guideline: a rise in serum potassium should generally not lead to stopping RAS blockade unless the hyperkalaemia is acute or, when chronic, cannot be corrected; hyperkalaemia leads to dose reduction or withdrawal of ACEI or ARB in about 50% of patients on maximal doses, and stopping these drugs is associated with more cardiovascular events, faster CKD progression and higher mortality.<Cite n={2} /> Immediate treatment is recommended for potassium > 6.0 mmol/L, or > 5.5 mmol/L with typical ECG changes or ventricular rhythm and conduction disorders.<Cite n={2} /> In cardiorenal syndrome, optimal use of neurohormonal blockade is often limited by concerns about worsening kidney function and hyperkalaemia.<Cite n={7} />

</Student>

## When to call an ambulance

CKD itself usually develops gradually, but its heart complications can be life-threatening. Severe hyperkalaemia can cause life-threatening heart rhythm disorders, often without warning symptoms, and needs immediate treatment.<Cite n={[2, 5, 8]} /> People with CKD have a much higher risk of heart attack.<Cite n={1} /> Heart failure sometimes worsens rapidly, with increasing breathlessness and fluid build-up in the body, and may need hospital care.<Cite n={1} />

Call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK) if you have chest pain or pressure, sudden or rapidly increasing severe shortness of breath, fainting, a strong pounding or irregular heartbeat, or sudden severe weakness: this is the site's general safety rule for heart disease. Signs of a heart attack are described in the article on [myocardial infarction](../myocardial-infarction/), and signs of acute heart failure in the article on [heart failure](../heart-failure/).