This handout is for acute hf — type-1 cardiorenal syndrome (adhf + aki). Your care team identified this based on: cr rise ≥0.3 mg/dl or ≥50% from baseline during adhf treatment → type-1 crs (ronco 2008; kdigo aki).
Other reasons your team may use this plan: adhf + oliguria <0.5 ml/kg/h despite adequate diuretic dose → cardiorenal phenotype; persistent congestion + escalating loop diuretic + worsening renal function → sequential blockade indication.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| furosemide | IV bolus 2-2.5× home dose; if naïve 80 mg IV, then 80-160 mg IV q6-12h or continuous 10-20 mg/h | IV | q6-12h or continuous | DOSE PMID 21366472 — high-dose IV bolus or continuous infusion equivalent; assess UOP at 2h; do NOT default to UF per CARRESS-HF PMID 23131078 |
| acetazolamide | 500 mg IV daily × 3 days | IV | daily × 3 | ADVOR PMID 36027564 — adjunct to IV loop improves decongestion at 3 days without worsening renal function |
| hydrochlorothiazide | 25-50 mg PO daily | PO | daily | CLOROTIC PMID 36461706 — HCTZ + IV loop improves decongestion vs loop alone; sequential nephron blockade |
| metolazone | 2.5-10 mg PO 30 min before loop | PO | daily or BID | Sequential nephron blockade alternative; longer half-life than HCTZ; monitor K + Mg closely |
| empagliflozin | 10 mg PO daily — CONTINUE if eGFR >20 | PO | daily | EMPULSE PMID 35347356 — reno-cardiac protective; continue in CRS if eGFR >20 unless DKA risk; do NOT discontinue for moderate Cr rise |
| sacubitril-valsartan | HOLD if Cr rise >50% from baseline; restart at 24/26 BID at 50% lower dose once Cr stable | PO | BID | Hold during severe Cr rise; restart at lower dose once euvolemic — preserves long-term cardiorenal benefit |
| enalapril | HOLD if Cr rise >50% from baseline; restart at 2.5 mg BID once Cr stable | PO | BID | Same hold-then-restart approach; ACEi/ARB withdrawal during severe AKI is appropriate |
| spironolactone | 12.5 mg PO daily once Cr stable + K <5 | PO | daily | RALES PMID 10471456 — start cautiously after CRS resolution; lower starting dose given K + Cr risk |
| carvedilol | CONTINUE home dose if hemodynamically tolerant; do not reduce solely for AKI | PO | BID | COPERNICUS PMID 11386262 — chronic BB withdrawal during ADHF associated with worse outcomes; continue unless hypotensive or bradycardic |
| dobutamine | 2.5 µg/kg/min IV titrate | IV | continuous | Inotropic support to enable diuresis when low CO drives renal hypoperfusion; arrhythmia risk |
Plan: Type-1 CRS — sequential nephron blockade to achieve euvolemia while tolerating ≤30% Cr rise (CARRESS-HF; ADVOR; CLOROTIC)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Restart ACEi/ARB or ARNI at lower dose once euvolemic + Cr stable; STRONG-HF cadence; nephrology clinic if AKI did not fully resolve; SGLT2i continuation
Guideline: 2022 ACC/AHA HF + 2023 Focused Update + KDIGO AKI 2026 draft