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Cardiorenal Syndrome in the Hospitalized Patient: Targeting Venous Congestion and Pseudo-AKI with the VeXUS Protocol
In this episode of Hospital Medicine Unplugged, we blitz cardiorenal syndrome (CRS)—define fast, subtype smart, decongest early, protect kidneys, and tighten the cardio–nephro handshake.
We start with the frame: CRS = bidirectional heart–kidney dysfunction where trouble in one organ triggers or worsens the other. Know the five plays: Type 1 (acute cardiorenal), Type 2 (chronic cardiorenal), Type 3 (acute renocardiac), Type 4 (chronic renocardiac), Type 5 (secondary/systemic). Classification isn’t trivia—it drives workup and therapy.
Pathophys in one breath: venous congestion > low forward flow; RAAS/SNS surge, vasopressin, inflammation & endothelial dysfunction; sodium avidity → diuretic resistance. CKD stacks the deck toward higher mortality and rehospitalization.
Bedside diagnosis—do-firsts and don’t-miss:
• History + trend the eGFR, meds, and prior decompensations.
• UA + urine sediment to rule intrinsic renal disease; check albuminuria/proteinuria.
• BNP/NT-proBNP, Cystatin C for risk; watch electrolytes, BUN/Cr.
• TTE for LV/RV function and filling pressures; consider renal US/Doppler and VeXUS POCUS for systemic congestion; CMR selectively.
• True AKI vs pseudo-AKI: a small creatinine rise during effective diuresis can reflect hemoconcentration, not injury—don’t abort decongestion if the patient is clinically improving.
Risk & admit cues: refractory hypoxemia, rising JVP/edema, oliguria, shock/low MAP, refractory hyperK/acidosis, suspected Type 1 or 3 CRS, or diagnostic uncertainty.
Treatment—make decongestion the north star:
• First-line: IV loop diuretic (adequate dose & frequency) with daily weights, I/O, urine Na, and electrolyte/renal panels. Aim for complete decongestion.
• If resistance hits: sequential nephron blockade (add thiazide-type), consider MRA when safe, and natriuresis-guided up-titration.
• Vasodilators/afterload reduction for high filling pressures with preserved BP; inotropes for low-output states or shock—short and targeted.
• SGLT2 inhibitors & RAAS blockade: recommended in HF; initiate/continue with renal vigilance and pause only for hypotension, hyperK, or true AKI.
• Refractory congestion: ultrafiltration, peritoneal dialysis, or acute RRT—select carefully and match removal rate to plasma refill.
• Devices: consider CRT for dyssynchrony and mechanical circulatory support in advanced cases—heart help can be kidney help.
Monitoring that matters:
• Trend congestion (exam, weights, VeXUS, echo signs), urine output/Na, and CR/BUN/electrolytes.
• Expect and accept permissive creatinine bumps if hemodynamics and volume status are improving.
• Reassess daily: diuretic plan, RAAS/SGLT2 status, K/Mg, and hemodynamics (noninvasive first; invasive if shock/ambiguity).
Etiology threads—treat the cause:
• Sepsis (Type 5): source control + hemodynamics.
• Renal-first hits (Type 3/4): correct nephrotoxins, ischemia, or GN; manage afterload/arrhythmias.
• Cardiac-first (Type 1/2): guideline-directed HF therapy with congestion-first strategy.
Pitfalls to dodge: underdosing loops, stopping diuresis for mild Cr rise, ignoring RV failure/venous hypertension, delayed escalation to combo diuretics/UF, and premature RAAS/SGLT2 withdrawal without a clear reason.
We close with the hospital CRS bundle that sticks:
Classify type (1–5) and rule intrinsic kidney disease (UA/sediment, albuminuria, renal US).
Default to loop + natriuresis-guided titration; add thiazide-type early for resistance; consider MRA.
Track congestion multimodally (exam + weights + VeXUS ± TTE).
Guard rails: daily labs, K/Mg repletion, renal & hemodynamic checks.
RAAS/SGLT2 smart use—continue/initiate when safe; hold for hypotension, hyperK, true AKI.
Escalation pathway: UF/RRT for refractory overload or life-threatening derangements; CRT/MCS in select HF.
Team sport: cardiology + nephrology + ICU/pharmacy from day one; discharge with diuretic plan, labs, and early follow-up.
Bottom line: Congestion kills kidneys—decongest completely, use RAAS/SGLT2 wisely, monitor like a hawk, and move fast together.
View all episodes
By Roger Musa, MDIn this episode of Hospital Medicine Unplugged, we blitz cardiorenal syndrome (CRS)—define fast, subtype smart, decongest early, protect kidneys, and tighten the cardio–nephro handshake.
We start with the frame: CRS = bidirectional heart–kidney dysfunction where trouble in one organ triggers or worsens the other. Know the five plays: Type 1 (acute cardiorenal), Type 2 (chronic cardiorenal), Type 3 (acute renocardiac), Type 4 (chronic renocardiac), Type 5 (secondary/systemic). Classification isn’t trivia—it drives workup and therapy.
Pathophys in one breath: venous congestion > low forward flow; RAAS/SNS surge, vasopressin, inflammation & endothelial dysfunction; sodium avidity → diuretic resistance. CKD stacks the deck toward higher mortality and rehospitalization.
Bedside diagnosis—do-firsts and don’t-miss:
• History + trend the eGFR, meds, and prior decompensations.
• UA + urine sediment to rule intrinsic renal disease; check albuminuria/proteinuria.
• BNP/NT-proBNP, Cystatin C for risk; watch electrolytes, BUN/Cr.
• TTE for LV/RV function and filling pressures; consider renal US/Doppler and VeXUS POCUS for systemic congestion; CMR selectively.
• True AKI vs pseudo-AKI: a small creatinine rise during effective diuresis can reflect hemoconcentration, not injury—don’t abort decongestion if the patient is clinically improving.
Risk & admit cues: refractory hypoxemia, rising JVP/edema, oliguria, shock/low MAP, refractory hyperK/acidosis, suspected Type 1 or 3 CRS, or diagnostic uncertainty.
Treatment—make decongestion the north star:
• First-line: IV loop diuretic (adequate dose & frequency) with daily weights, I/O, urine Na, and electrolyte/renal panels. Aim for complete decongestion.
• If resistance hits: sequential nephron blockade (add thiazide-type), consider MRA when safe, and natriuresis-guided up-titration.
• Vasodilators/afterload reduction for high filling pressures with preserved BP; inotropes for low-output states or shock—short and targeted.
• SGLT2 inhibitors & RAAS blockade: recommended in HF; initiate/continue with renal vigilance and pause only for hypotension, hyperK, or true AKI.
• Refractory congestion: ultrafiltration, peritoneal dialysis, or acute RRT—select carefully and match removal rate to plasma refill.
• Devices: consider CRT for dyssynchrony and mechanical circulatory support in advanced cases—heart help can be kidney help.
Monitoring that matters:
• Trend congestion (exam, weights, VeXUS, echo signs), urine output/Na, and CR/BUN/electrolytes.
• Expect and accept permissive creatinine bumps if hemodynamics and volume status are improving.
• Reassess daily: diuretic plan, RAAS/SGLT2 status, K/Mg, and hemodynamics (noninvasive first; invasive if shock/ambiguity).
Etiology threads—treat the cause:
• Sepsis (Type 5): source control + hemodynamics.
• Renal-first hits (Type 3/4): correct nephrotoxins, ischemia, or GN; manage afterload/arrhythmias.
• Cardiac-first (Type 1/2): guideline-directed HF therapy with congestion-first strategy.
Pitfalls to dodge: underdosing loops, stopping diuresis for mild Cr rise, ignoring RV failure/venous hypertension, delayed escalation to combo diuretics/UF, and premature RAAS/SGLT2 withdrawal without a clear reason.
We close with the hospital CRS bundle that sticks:
Classify type (1–5) and rule intrinsic kidney disease (UA/sediment, albuminuria, renal US).
Default to loop + natriuresis-guided titration; add thiazide-type early for resistance; consider MRA.
Track congestion multimodally (exam + weights + VeXUS ± TTE).
Guard rails: daily labs, K/Mg repletion, renal & hemodynamic checks.
RAAS/SGLT2 smart use—continue/initiate when safe; hold for hypotension, hyperK, true AKI.
Escalation pathway: UF/RRT for refractory overload or life-threatening derangements; CRT/MCS in select HF.
Team sport: cardiology + nephrology + ICU/pharmacy from day one; discharge with diuretic plan, labs, and early follow-up.
Bottom line: Congestion kills kidneys—decongest completely, use RAAS/SGLT2 wisely, monitor like a hawk, and move fast together.