Abstract Body (Do not enter title and authors here): Introduction
Heart failure with preserved ejection fraction (HFpEF) commonly coexists with end-stage renal disease (ESRD, together increasing cardiovascular risk [1,2,3,4,5]. While SGLT2 inhibitors (SGLT2i) reduce HF hospitalizations and cardiovascular death in trials like EMPEROR-Preserved and DELIVER, patients with very low eGFR or on dialysis were excluded [6,7]. While trials are ongoing, data on SGLT2i in this high-risk population remain limited.

Hypothesis
SGLT2i is associated with improved cardiovascular outcomes in HFpEF patients with ESRD.

Methods
We conducted a retrospective cohort analysis of deidentified, aggregate patient data from the TriNetX research network. Patients with HFpEF and ESRD between age 18-85 were included. Patients were stratified by SGLT2i use and propensity matched by demographics, baseline cardiac risk factors, DM medications, and etiology of HFpEF. Outcomes were evaluated within 18-months from the HFpEF + ESRD diagnosis. Primary endpoints included acute decompensated heart failure (ADHF) events, all-cause mortality, hospitalizations for any cause, and emergency department visits for any cause. Z-tests were used to calculate risk difference and Cox regression was used to compute hazard ratios over an 18-month period.

Results
The study cohort included 7,238 patients (n = 3,619 per group; mean age 65.3 ± 11.0 years; 40.9% female; 47.3% White). In time-to-event analysis, the SGLT2i group had reduced risk of all-cause mortality (HR=0.49, 95%CI 0.43-0.55, p<0.001) and ADHF events (HR=0.72, 95%CI 0.67-0.77, p < 0.001). At 18 months SGLT2i group had lower rates of all-cause mortality (11.8% vs. 24.4%; RD -12.6%, p < 0.001), ADHF events (39.8% vs. 50.1%; RD -10.4%, p < 0.001) [Figure 1], hospitalizations (51.3% vs. 65.0%; RD -13.8%, p < 0.001) [Figure 1], and at least one ED visit (35.9% vs. 40.6%; RD -4.7%; p < 0.001).

Conclusion
In this retrospective propensity-matched analysis, SGLT2i use in HFpEF with ESRD was associated with reduced mortality, ADHF, hospitalizations, and ED visits. Further investigation is needed to clarify mechanisms and guide clinical recommendations.