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renal.cardiorenal.v1

Cardiorenal Syndromes (Ronco 1-5)

nephrologyacutechronicadultacuteinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Promoted to INTEGRATED 2026-05-22 (shard-4 build campaign): added registry-resolving workups (aki, aki_on_ckd, le_edema); every evidence.pmid re-sourced and live-verified via PubMed; every regimen RxCUI reverse-looked-up live at RxNav. Cardiorenal syndrome types 1-5; diuretic strategy per DOSE (high-dose IV bolus or continuous infusion), sequential nephron blockade (loop + metolazone) for diuretic resistance, GDMT preservation (ARNI / beta-blocker / MRA / SGLT2i). PMID anchors (live-verified PubMed 2026-05-22): 21366472 DOSE, 24716680 TOPCAT, 36331190 EMPA-KIDNEY, 32970396 DAPA-CKD, 38490803 KDIGO 2024 CKD. Prior placeholder/fabricated PMIDs removed. RxCUI corrections (reverse-verified at RxNav): metolazone 6916, finerenone 2562811 (prior 5487/2549920 resolved to hydrochlorothiazide / an invalid concept). Sibling routing: cardio.acute-hf.core.v1, renal.aki.v1, neph.ckd.core.v1.

Entry points (5)

  • lab_abnormality
    Rising creatinine in patient with heart failure (Ronco Type-1/2) (Ronco JACC 2008)
    rising_cr_in_hf
  • symptom
    Acute pulmonary edema + AKI (Type-1 acute cardiorenal) (Ronco JACC 2008)
    acute_pulm_edema_with_aki
  • problem_list
    Chronic HF + chronic CKD on problem list (Type-2 chronic cardiorenal) (Ronco JACC 2008)
    chronic_hf_with_ckd
  • lab_abnormality
    AKI followed by cardiac dysfunction (Type-3 reno-cardiac) (Ronco JACC 2008)
    aki_with_new_cardiac_dysfunction
  • history
    Sepsis / SLE / diabetes / amyloid with both organ failure (Type-5 systemic) (Ronco JACC 2008)
    sepsis_with_dual_organ_dysfunction

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Frailty + GDMT tolerability + transplant candidacy (Ronco JACC 2008; KDIGO 2024)
  • creatininerequired
    lab • used at CONTEXT
    eGFR + AKI staging are core to cardiorenal classification (Ronco JACC 2008; KDIGO 2012 AKI)
  • bnp_or_nt_probnprequired
    lab • used at INITIAL_WORKUP
    HF severity + congestion marker; BNP suppression by sacubitril (use NT-proBNP) (HFSA 2018; AHA cardiorenal 2020)
  • troponin
    lab • used at INITIAL_WORKUP
    Cardiac injury marker — Type-3 reno-cardiac surveillance; CSA-AKI screen (AHA cardiorenal 2020)
  • potassiumrequired
    lab • used at CONTEXT
    RAS + spironolactone + finerenone tolerability driven by K+ (KDIGO 2024; FIDELIO 2020)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    AKI subtype — bland (prerenal/HRS) vs casts (ATN) vs RBC casts (GN) (KDIGO 2012 AKI)
  • echocardiogramrequired
    imaging • used at INITIAL_WORKUP
    LVEF determines GDMT pillar selection + cardiogenic shock detection (HFSA 2018)
  • chest_xray
    imaging • used at INITIAL_WORKUP
    Pulmonary congestion / cardiomegaly / interstitial edema (AHA cardiorenal 2020)
  • sbprequired
    vital • used at CONTEXT
    GDMT titration ceiling + cardiogenic shock detection (HFSA 2018)
  • weightrequired
    vital • used at MONITORING
    Daily weight is core volume-tracking signal (HFSA 2018)
  • ascvd_present
    history • used at CONTEXT
    Routes to cardio.ascvd.chronic.v1 sibling for primary/secondary prevention (ACC/AHA Lipid 2026)
  • cirrhosis_present
    history • used at CONTEXT
    HRS subtype if cirrhosis + AKI — routes renal.hepatorenal.v1 (ICA 2019 HRS-AKI)
  • current_diuretic_acei_mrarequired
    medication • used at CONTEXT
    GDMT reconciliation; finerenone + spironolactone + RAS K+ stacking risk (KDIGO 2024)

12-phase flow (12)

  1. 1FRAME
    Classify Ronco Type 1-5 — acute cardiorenal, chronic cardiorenal, acute reno-cardiac, chronic reno-cardiac, systemic; underlying HF + CKD baseline + acuity (Ronco JACC 2008; KDIGO 2024)
    inputs: creatinine, age
    advance: Type classified (Ronco JACC 2008)
  2. 2ENTRY
    Triggered by rising Cr in HF, acute pulm edema + AKI, chronic HF+CKD problem-list, sepsis with dual-organ dysfunction (Ronco JACC 2008)
    advance: Engine routed (Ronco JACC 2008)
  3. 3CONTEXT
    Capture LVEF, eGFR, K+, BP, weight, comorbidities (DM, ASCVD, cirrhosis), current GDMT + diuretic + nephrotoxin reconciliation (KDIGO 2024; HFSA 2018)
    inputs: age, creatinine, potassium, sbp, ascvd_present, cirrhosis_present, current_diuretic_acei_mra
    advance: Context captured (KDIGO 2024)
  4. 4RED_FLAGS
    Cardiogenic shock + AKI / refractory pulm edema / hyperkalemia >6.5 / uremic emergencies / refractory anuria — ICU + RRT decision (AHA cardiorenal 2020; KDIGO 2024)
    advance: Acuity tier set (AHA cardiorenal 2020)
  5. 5INITIAL_WORKUP
    BMP, BNP/NT-proBNP, troponin, urinalysis with sediment, lactate, ABG, echo, CXR (HFSA 2018; AHA cardiorenal 2020)
    inputs: creatinine, bnp_or_nt_probnp, troponin, urinalysis, echocardiogram
    actions: panel.renal, panel.cbc, panel.cardiac
    advance: Initial labs + echo back (HFSA 2018)
  6. 6BRANCHING_WORKUP
    Right-heart cath if mixed shock vs cardiogenic; renal US if AKI (rule out obstruction); biopsy in atypical AKI; HRS workup if cirrhosis (KDIGO 2024; ICA 2019 HRS-AKI)
    advance: Cause-specific workup complete (KDIGO 2024)
  7. 7DIFFERENTIAL
    Ronco Types 1-5 + HRS subtype + sepsis-AKI + contrast nephropathy + CSA-AKI (Ronco JACC 2008; KDIGO 2024)
    advance: Differential resolved (Ronco JACC 2008)
  8. 8RISK_STRATIFICATION
    AKI staging (KDIGO) + KDIGO heat-map eGFR × ACR + LVEF + GDMT tier (HFSA 2018; KDIGO 2024)
    inputs: creatinine
    actions: calc.ckd_epi_2021
    advance: Risk tier documented (KDIGO 2024)
  9. 9TREATMENT
    Tier 1 GDMT 4-pillar (ACEi/ARNI + BB + MRA + SGLT2i); Tier 2 SGLT2i cardiorenal (DAPA-CKD + EMPA-KIDNEY); Tier 3 loop diuretic step-up (DOSE-AHF); Tier 4 advanced (UF reserve; transplant; LVAD; RRT) (KDIGO 2024; HFSA 2018; CARRESS-HF Bart NEJM 2012)
    inputs: potassium, creatinine, sbp, weight
    advance: Tiered regimen executed + tolerability documented (HFSA 2018)
  10. 10DISPOSITION
    ICU for cardiogenic shock + AKI; inpatient for Type-1 acute cardiorenal; outpatient HF clinic for Type-2 chronic (HFSA 2018; AHA cardiorenal 2020)
    advance: Disposition + co-management set (HFSA 2018)
  11. 11MONITORING
    Daily Cr + K + BNP + weight inpatient; weekly-then-monthly eGFR + K + UACR + BP outpatient; eGFR slope outpatient (KDIGO 2024)
    inputs: creatinine, potassium, weight
    actions: panel.renal
    advance: Monitoring schedule live (KDIGO 2024)
  12. 12FOLLOWUP
    HF clinic + nephrology co-management; transplant evaluation at G4; AVF placement 6 mo pre-RRT; cardiac rehab; vaccinations (KDIGO 2024; HFSA 2018)
    advance: Long-term plan documented (KDIGO 2024)