A Pragmatic Approach to Acute Cardiorenal Syndrome:  Diagnostic Strategies and Targeted Therapies to Overcome Diuretic Resistance

Patrick Tran; Laith Khweir; Michael Kuehl; Mithilesh Joshi; Krishna Appunu; Waqar Ayub; Prithwish Banerjee

doi:10.3390/jcm14092996

A Pragmatic Approach to Acute Cardiorenal Syndrome: Diagnostic Strategies and Targeted Therapies to Overcome Diuretic Resistance

Patrick Tran
, Laith Khweir
, Michael Kuehl
, Mithilesh Joshi
, Krishna Appunu
, Waqar Ayub
, Prithwish Banerjee

University Hospitals Coventry and Warwickshire NHS Trust
University of Warwick

Research output: Contribution to journal › Review article › peer-review

4 Citations (Scopus)

124 Downloads (Pure)

Abstract

Cardiorenal syndrome (CRS) is a challenging condition characterised by interdependent dysfunction of the heart and kidneys. Despite advancements in understanding its pathophysiology, clinical management remains complex due to overlapping mechanisms and high rates of diuretic resistance. Relevant literature was identified through a comprehensive narrative review of PubMed, Embase, and Cochrane Library databases, focusing on pivotal trials relating to CRS from 2005 to 2024. This review aims to provide a pragmatic, evidence-based approach to acute CRS management by addressing common misconceptions, outlining diagnostic strategies, and proposing a structured algorithm to manage diuretic resistance. We discuss the role of thoracic and venous excess ultrasound (VeXUS) in providing reliable measures of systemic congestion, natriuresis-guided sequential nephron blockade, and more targeted therapies, including ultrafiltration in refractory cases. In addition, we explore emerging trials that target renal hypoperfusion and venous congestion in CRS. Designed for a broad audience, including general physicians, cardiologists, and nephrologists, this review integrates clinical evidence with practical guidance to support effective and timely decision-making in the care of patients with CRS.

Original language	English
Article number	2996
Number of pages	13
Journal	Journal of Clinical Medicine
Volume	14
Issue number	9
Early online date	26 Apr 2025
DOIs	https://doi.org/10.3390/jcm14092996
Publication status	E-pub ahead of print - 26 Apr 2025

Bibliographical note

This article is an open access article distributed under the terms and
conditions of the Creative Commons Attribution (CC BY) license
(https://creativecommons.org/licenses/by/4.0/)

Keywords

ultrasound
inotropes
cardiorenal syndrome
ultrafiltration
diuretic resistance

Access to Document

10.3390/jcm14092996Licence: CC BY

Tran2025VoRFinal published version, 2.62 MBLicence: CC BY

Cite this

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title = "A Pragmatic Approach to Acute Cardiorenal Syndrome: Diagnostic Strategies and Targeted Therapies to Overcome Diuretic Resistance",

abstract = "Cardiorenal syndrome (CRS) is a challenging condition characterised by interdependent dysfunction of the heart and kidneys. Despite advancements in understanding its pathophysiology, clinical management remains complex due to overlapping mechanisms and high rates of diuretic resistance. Relevant literature was identified through a comprehensive narrative review of PubMed, Embase, and Cochrane Library databases, focusing on pivotal trials relating to CRS from 2005 to 2024. This review aims to provide a pragmatic, evidence-based approach to acute CRS management by addressing common misconceptions, outlining diagnostic strategies, and proposing a structured algorithm to manage diuretic resistance. We discuss the role of thoracic and venous excess ultrasound (VeXUS) in providing reliable measures of systemic congestion, natriuresis-guided sequential nephron blockade, and more targeted therapies, including ultrafiltration in refractory cases. In addition, we explore emerging trials that target renal hypoperfusion and venous congestion in CRS. Designed for a broad audience, including general physicians, cardiologists, and nephrologists, this review integrates clinical evidence with practical guidance to support effective and timely decision-making in the care of patients with CRS.",

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T2 - Diagnostic Strategies and Targeted Therapies to Overcome Diuretic Resistance

AU - Tran, Patrick

AU - Khweir, Laith

AU - Kuehl, Michael

AU - Joshi, Mithilesh

AU - Appunu, Krishna

AU - Ayub, Waqar

AU - Banerjee, Prithwish

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N2 - Cardiorenal syndrome (CRS) is a challenging condition characterised by interdependent dysfunction of the heart and kidneys. Despite advancements in understanding its pathophysiology, clinical management remains complex due to overlapping mechanisms and high rates of diuretic resistance. Relevant literature was identified through a comprehensive narrative review of PubMed, Embase, and Cochrane Library databases, focusing on pivotal trials relating to CRS from 2005 to 2024. This review aims to provide a pragmatic, evidence-based approach to acute CRS management by addressing common misconceptions, outlining diagnostic strategies, and proposing a structured algorithm to manage diuretic resistance. We discuss the role of thoracic and venous excess ultrasound (VeXUS) in providing reliable measures of systemic congestion, natriuresis-guided sequential nephron blockade, and more targeted therapies, including ultrafiltration in refractory cases. In addition, we explore emerging trials that target renal hypoperfusion and venous congestion in CRS. Designed for a broad audience, including general physicians, cardiologists, and nephrologists, this review integrates clinical evidence with practical guidance to support effective and timely decision-making in the care of patients with CRS.

AB - Cardiorenal syndrome (CRS) is a challenging condition characterised by interdependent dysfunction of the heart and kidneys. Despite advancements in understanding its pathophysiology, clinical management remains complex due to overlapping mechanisms and high rates of diuretic resistance. Relevant literature was identified through a comprehensive narrative review of PubMed, Embase, and Cochrane Library databases, focusing on pivotal trials relating to CRS from 2005 to 2024. This review aims to provide a pragmatic, evidence-based approach to acute CRS management by addressing common misconceptions, outlining diagnostic strategies, and proposing a structured algorithm to manage diuretic resistance. We discuss the role of thoracic and venous excess ultrasound (VeXUS) in providing reliable measures of systemic congestion, natriuresis-guided sequential nephron blockade, and more targeted therapies, including ultrafiltration in refractory cases. In addition, we explore emerging trials that target renal hypoperfusion and venous congestion in CRS. Designed for a broad audience, including general physicians, cardiologists, and nephrologists, this review integrates clinical evidence with practical guidance to support effective and timely decision-making in the care of patients with CRS.

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