Patient handout

Cardiorenal Syndromes (Ronco 1-5)

PRODUCTION

1. Your condition

This handout is for cardiorenal syndromes (ronco 1-5). Your care team identified this based on: rising creatinine in patient with heart failure (ronco type-1/2) (ronco jacc 2008).

Other reasons your team may use this plan: acute pulmonary edema + aki (type-1 acute cardiorenal) (ronco jacc 2008); chronic hf + chronic ckd on problem list (type-2 chronic cardiorenal) (ronco jacc 2008); aki followed by cardiac dysfunction (type-3 reno-cardiac) (ronco jacc 2008).

2. Your medications

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
lisinopril	5-10 mg PO daily, titrate to max tolerated (40 mg)	PO	daily	HFSA 2018 — ACEi foundation; up to 30% Cr rise from baseline is acceptable per RAAS guidance (do not withhold)
losartan	50-100 mg PO daily, titrate to max tolerated	PO	daily	HFSA 2018 — ARB equivalent first-line if ACEi cough/angioedema
sacubitril_valsartan	24/26 mg PO BID, titrate to 97/103 mg BID (use NT-proBNP not BNP)	PO	BID	PARADIGM-HF 2014; HFSA 2018 — ARNI superior to enalapril; substitute ACEi/ARB after 36h washout
carvedilol	3.125 mg PO BID, double q2wks to 25-50 mg BID	PO	BID	COPERNICUS 2001; HFSA 2018 — carvedilol/metoprolol succinate/bisoprolol are 4-pillar BB
spironolactone	12.5-25 mg PO daily	PO	daily	EMPHASIS-HF 2011; HFSA 2018 — MRA 4-pillar; monitor K+ q1-2wk after start

Plan: Cardiorenal tiered regimen — GDMT 4-pillar (Tier 1) → SGLT2i cardiorenal (Tier 2) → loop diuretic step-up (Tier 3) → advanced UF/transplant/LVAD/RRT (Tier 4) (KDIGO 2024; HFSA 2018; DAPA-CKD 2020; EMPA-KIDNEY 2023; CARRESS-HF 2012)

3. When to call your provider

Contact your care team if any of the following happen:

Rising Cr >30% on RAS → reduce dose or hold; rule out volume loss + nephrotoxin (HFSA 2018)
K+ >5.5 → reduce MRA / finerenone / RAS; binder (patiromer / SZC) if persistent (KDIGO 2024)
Acute volume overload → ED for IV diuretic (HFSA 2018)
Cardiogenic shock signs → ED → ICU (AHA cardiorenal 2020)
eGFR <30 → transplant evaluation + AVF planning + pre-RRT education (KDIGO 2024)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Type-1 acute cardiorenal — acute HF (de novo or decompensation) precipitates AKI; diuretic + vasodilator + inotrope per shock (Ronco JACC 2008)
Type-3 acute reno-cardiac — acute AKI (e.g., contrast, ATN, AIN) precipitates cardiac dysfunction (uremic cardiomyopathy, hyperkalemia, volume) (Ronco JACC 2008)
Type-5 systemic cardiorenal — sepsis/SLE/diabetes/amyloid affects both organs simultaneously; source control + supportive (Ronco JACC 2008)
HRS-AKI subtype — cirrhosis + ascites + AKI; route to renal.hepatorenal.v1 for vasoconstrictor protocol (ICA 2019 HRS-AKI)
Combined heart-kidney transplant evaluation — end-stage HF + ESRD (cardiorenal Type-2/4); UNOS 2023 allocation policy + multidisciplinary review (HFSA 2018)
LVAD implantation with renal-recovery potential — advanced HF + reversible AKI/CKD; multidisciplinary evaluation (HFSA 2018)
Cardiac surgery-associated AKI (CSA-AKI) — risk score-driven nephroprotection; CABG/valve repair with intraop AKI risk (AHA cardiorenal 2020)

5. Follow-up

HF clinic + nephrology co-management; transplant evaluation at G4; AVF placement 6 mo pre-RRT; cardiac rehab; vaccinations (KDIGO 2024; HFSA 2018)

6. Sources

Guideline: KDIGO 2024 CKD + DOSE diuretic strategy (NEJM 2011) + TOPCAT MRA (NEJM 2014) + SGLT2i renal-cardiac protection (EMPA-KIDNEY 2023, DAPA-CKD 2020)