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renal.cardiorenal.v1PRODUCTION
renal.cardiorenal.v1

Cardiorenal Syndromes (Ronco 1-5)

nephrologyacutechronicadult
Hard-required inputs
0 / 9
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
2
Actions
0
Advance rule
Set
Advance when

Type classified (Ronco JACC 2008)

Patient inputs (13)

Frailty + GDMT tolerability + transplant candidacy (Ronco JACC 2008; KDIGO 2024)

eGFR + AKI staging are core to cardiorenal classification (Ronco JACC 2008; KDIGO 2012 AKI)

RAS + spironolactone + finerenone tolerability driven by K+ (KDIGO 2024; FIDELIO 2020)

GDMT titration ceiling + cardiogenic shock detection (HFSA 2018)

GDMT reconciliation; finerenone + spironolactone + RAS K+ stacking risk (KDIGO 2024)

HF severity + congestion marker; BNP suppression by sacubitril (use NT-proBNP) (HFSA 2018; AHA cardiorenal 2020)

AKI subtype — bland (prerenal/HRS) vs casts (ATN) vs RBC casts (GN) (KDIGO 2012 AKI)

LVEF determines GDMT pillar selection + cardiogenic shock detection (HFSA 2018)

Daily weight is core volume-tracking signal (HFSA 2018)

Routes to cardio.ascvd.chronic.v1 sibling for primary/secondary prevention (ACC/AHA Lipid 2026)

HRS subtype if cirrhosis + AKI — routes renal.hepatorenal.v1 (ICA 2019 HRS-AKI)

Cardiac injury marker — Type-3 reno-cardiac surveillance; CSA-AKI screen (AHA cardiorenal 2020)

Pulmonary congestion / cardiomegaly / interstitial edema (AHA cardiorenal 2020)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (11)

11 need judgement
  • informationalseveretype_1_acute_cardiorenal
    Type-1 acute cardiorenal — acute HF (de novo or decompensation) precipitates AKI; diuretic + vasodilator + inotrope per shock (Ronco JACC 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretype_3_acute_reno_cardiac
    Type-3 acute reno-cardiac — acute AKI (e.g., contrast, ATN, AIN) precipitates cardiac dysfunction (uremic cardiomyopathy, hyperkalemia, volume) (Ronco JACC 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretype_5_systemic_cardiorenal
    Type-5 systemic cardiorenal — sepsis/SLE/diabetes/amyloid affects both organs simultaneously; source control + supportive (Ronco JACC 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehrs_aki_subtype
    HRS-AKI subtype — cirrhosis + ascites + AKI; route to renal.hepatorenal.v1 for vasoconstrictor protocol (ICA 2019 HRS-AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretransplant_evaluation_combined
    Combined heart-kidney transplant evaluation — end-stage HF + ESRD (cardiorenal Type-2/4); UNOS 2023 allocation policy + multidisciplinary review (HFSA 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelvad_renal_recovery
    LVAD implantation with renal-recovery potential — advanced HF + reversible AKI/CKD; multidisciplinary evaluation (HFSA 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecardiac_surgery_associated_aki
    Cardiac surgery-associated AKI (CSA-AKI) — risk score-driven nephroprotection; CABG/valve repair with intraop AKI risk (AHA cardiorenal 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetype_2_chronic_cardiorenal
    Type-2 chronic cardiorenal — chronic HF + chronic CKD with progressive bidirectional decline; GDMT optimization + SGLT2i + transplant/RRT planning (Ronco JACC 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetype_4_chronic_reno_cardiac
    Type-4 chronic reno-cardiac — chronic CKD contributes to CAD/LVH/arrhythmia/sudden cardiac death; ICD criteria adjusted for CKD (Ronco JACC 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateuf_role_post_carress_hf
    Ultrafiltration not superior to step-up diuresis for acute cardiorenal Type-1 — reserve UF for true diuretic resistance (CARRESS-HF Bart NEJM 2012 PMID 24716680)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildsglt2i_cardiorenal_benefit
    SGLT2i cardiorenal protection — empagliflozin or dapagliflozin reduce CV death + HF + eGFR decline across diabetic and non-diabetic CKD (DAPA-CKD NEJM 2020; EMPA-KIDNEY NEJM 2023 PMID 36331190)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

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)
axis: cardiorenal_gdmt_sglt2i_diureticstep tier_1_gdmt_4_pillar - Tier 1 — GDMT 4-pillar (ACEi/ARNI + beta-blocker + MRA + SGLT2i)
Selected step "Tier 1 — GDMT 4-pillar (ACEi/ARNI + beta-blocker + MRA + SGLT2i)" — HFrEF or HFmrEF + cardiorenal Type-1/2; titrate per K+ + BP + Cr tolerance (HFSA 2018; KDIGO 2024)
  • lisinopril
    first line
    acei
    5-10 mg PO daily, titrate to max tolerated (40 mg) • PO • daily
    triggers: hfref, cardiorenal_type1_or_2
    HFSA 2018 — ACEi foundation; up to 30% Cr rise from baseline is acceptable per RAAS guidance (do not withhold)
    rxcui 29046
  • losartan
    first line
    arb
    50-100 mg PO daily, titrate to max tolerated • PO • daily
    triggers: acei_intolerant
    HFSA 2018 — ARB equivalent first-line if ACEi cough/angioedema
    rxcui 52175
  • sacubitril_valsartan
    first line
    arni
    24/26 mg PO BID, titrate to 97/103 mg BID (use NT-proBNP not BNP) • PO • BID
    triggers: hfref_tolerating_acei_or_arb
    PARADIGM-HF 2014; HFSA 2018 — ARNI superior to enalapril; substitute ACEi/ARB after 36h washout
    rxcui 1656339
  • carvedilol
    first line
    beta_blocker
    3.125 mg PO BID, double q2wks to 25-50 mg BID • PO • BID
    triggers: hfref, euvolemic
    COPERNICUS 2001; HFSA 2018 — carvedilol/metoprolol succinate/bisoprolol are 4-pillar BB
    rxcui 20352
  • spironolactone
    first line
    mra
    12.5-25 mg PO daily • PO • daily
    triggers: hfref_egfr_gte_30, k_le_5
    EMPHASIS-HF 2011; HFSA 2018 — MRA 4-pillar; monitor K+ q1-2wk after start
    rxcui 9997

outpatient playbook — drug actions (5)

  1. 1. GDMT titration — ACEi/ARNI + BB + MRA + SGLT2i
    Up-titrate q2-4 wk to target or max tolerated • PO • daily-BID
    trigger: Tolerable BP + Cr + K+
    HFSA 2018 — GDMT optimization is core
  2. 2. SGLT2i (empagliflozin or dapagliflozin)
    10 mg PO daily • PO • daily
    trigger: eGFR ≥20-25 + cardiorenal context
    EMPA-KIDNEY 2023; DAPA-CKD 2020
  3. 3. Finerenone (if T2DM + CKD + albuminuric)
    10-20 mg PO daily • PO • daily
    trigger: eGFR ≥25 + K+ ≤4.8
    FIDELIO + FIGARO 2020/2021
  4. 4. Statin per ASCVD
    Per Lipid 2026 • PO • daily
    trigger: ASCVD coexistent
    ACC/AHA Lipid 2026
  5. 5. Loop diuretic + adjuncts
    Per outpatient titration • PO • daily
    trigger: Residual congestion
    HFSA 2018

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Rising creatinine in patient with heart failure (Ronco Type-1/2) (Ronco JACC 2008); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiorenal Syndromes (Ronco 1-5)** (renal.cardiorenal.v1).
Phenotype framing: Ronco Types 1-5 + HRS subtype + sepsis-AKI + contrast nephropathy + CSA-AKI (Ronco JACC 2008; KDIGO 2024)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Tier 1 — GDMT 4-pillar (ACEi/ARNI + beta-blocker + MRA + SGLT2i)".
1. lisinopril 5-10 mg PO daily, titrate to max tolerated (40 mg) PO daily (acei, first line) — HFSA 2018 — ACEi foundation; up to 30% Cr rise from baseline is acceptable per RAAS guidance (do not withhold)
2. losartan 50-100 mg PO daily, titrate to max tolerated PO daily (arb, first line) — HFSA 2018 — ARB equivalent first-line if ACEi cough/angioedema
3. sacubitril_valsartan 24/26 mg PO BID, titrate to 97/103 mg BID (use NT-proBNP not BNP) PO BID (arni, first line) — PARADIGM-HF 2014; HFSA 2018 — ARNI superior to enalapril; substitute ACEi/ARB after 36h washout
4. carvedilol 3.125 mg PO BID, double q2wks to 25-50 mg BID PO BID (beta_blocker, first line) — COPERNICUS 2001; HFSA 2018 — carvedilol/metoprolol succinate/bisoprolol are 4-pillar BB
5. spironolactone 12.5-25 mg PO daily PO daily (mra, first line) — EMPHASIS-HF 2011; HFSA 2018 — MRA 4-pillar; monitor K+ q1-2wk after start

Setting playbook (outpatient) — Chronic cardiorenal Type-2/4 management; GDMT optimization; SGLT2i + finerenone titration; eGFR slope tracking; transplant + RRT planning (HFSA 2018; KDIGO 2024)
6. GDMT titration — ACEi/ARNI + BB + MRA + SGLT2i Up-titrate q2-4 wk to target or max tolerated PO daily-BID — Tolerable BP + Cr + K+ (HFSA 2018 — GDMT optimization is core)
7. SGLT2i (empagliflozin or dapagliflozin) 10 mg PO daily PO daily — eGFR ≥20-25 + cardiorenal context (EMPA-KIDNEY 2023; DAPA-CKD 2020)
8. Finerenone (if T2DM + CKD + albuminuric) 10-20 mg PO daily PO daily — eGFR ≥25 + K+ ≤4.8 (FIDELIO + FIGARO 2020/2021)
9. Statin per ASCVD Per Lipid 2026 PO daily — ASCVD coexistent (ACC/AHA Lipid 2026)
10. Loop diuretic + adjuncts Per outpatient titration PO daily — Residual congestion (HFSA 2018)

Non-pharmacologic actions:
- Cardiac rehab participation (HFSA 2018)
- Salt + fluid restriction reinforcement (HFSA 2018)
- Vaccinations per ACIP 2026 (flu, pneumococcal, COVID-19, RSV, shingles)
- Transplant referral evaluation at eGFR <30 (G4) (KDIGO 2024)
- AVF placement 6 months pre-anticipated RRT (KDOQI 2019)
- Pre-RRT shared decision-making — dialysis vs conservative (KDIGO 2015)
- Nutrition + low-Na + protein 0.8 g/kg/d counseling (KDIGO 2024)

AVOID / contraindication checks:
- K_above_5_no_mra_or_finerenone (HFSA 2018; FIDELIO 2020)
- Cr_rise_gt_30pct_review_acei (HFSA 2018)
- Sglt2i_egfr_lt_20_hold_or_dose adjust (EMPA KIDNEY 2023)
- Dual_raas_acei_plus_arb_avoid_except_specialist (HFSA 2018)
- Bb_titrate_only_when_euvolemic (HFSA 2018)
- Uf_reserve_not_first_line_per_carress_hf (Bart NEJM 2012)

Monitoring

Regimen monitoring:
- K+ q1-2 wk after MRA / finerenone / RAS titration (HFSA 2018)
- Cr q1-2 wk after RAS titration; ≤30% rise acceptable (HFSA 2018)
- BNP/NT-proBNP trend at outpatient HF clinic visits (HFSA 2018)
- Daily weight + UOP inpatient + outpatient log (HFSA 2018)
- BP trend q1-2 wk during titration; ≥90 systolic minimum (HFSA 2018)
- eGFR slope q3-6 mo outpatient — flag >5/y as rapid progressor (KDIGO 2024)
- A1c + UACR q3-6 mo if diabetic (KDIGO 2022 Diabetes-in-CKD)

Setting (outpatient) monitoring:
- BMP + UACR + BNP q3-6 mo (HFSA 2018; KDIGO 2024)
- eGFR slope quarterly (KDIGO 2024)
- A1c q3-6 mo if DM (KDIGO 2022 Diabetes-in-CKD)
- K+ q1-2 wk after RAS / MRA / finerenone titration; q3-6 mo stable (HFSA 2018; FIDELIO 2020)

Follow-up plan: HF clinic + nephrology co-management; transplant evaluation at G4; AVF placement 6 mo pre-RRT; cardiac rehab; vaccinations (KDIGO 2024; HFSA 2018)
- Close-out criterion: Long-term plan documented (KDIGO 2024)

Monitoring phase: Daily Cr + K + BNP + weight inpatient; weekly-then-monthly eGFR + K + UACR + BP outpatient; eGFR slope outpatient (KDIGO 2024)

Disposition

Current setting: outpatient — Chronic cardiorenal Type-2/4 management; GDMT optimization; SGLT2i + finerenone titration; eGFR slope tracking; transplant + RRT planning (HFSA 2018; KDIGO 2024)

Disposition criteria:
- Continue HF clinic + nephrology co-management q1-3 mo if stable (HFSA 2018; KDIGO 2024)
- Admit if cardiogenic shock OR AKI-on-CKD OR refractory pulm edema (HFSA 2018)

Escalation triggers (move to higher acuity):
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Type-1 acute cardiorenal — acute HF (de novo or decompensation) precipitates AKI; diuretic + vasodilator + inotrope per shock (Ronco JACC 2008)
- [SEVERE] Type-3 acute reno-cardiac — acute AKI (e.g., contrast, ATN, AIN) precipitates cardiac dysfunction (uremic cardiomyopathy, hyperkalemia, volume) (Ronco JACC 2008)
- [SEVERE] Type-5 systemic cardiorenal — sepsis/SLE/diabetes/amyloid affects both organs simultaneously; source control + supportive (Ronco JACC 2008)

Citations

- KDIGO 2024 CKD + DOSE diuretic strategy (NEJM 2011) + TOPCAT MRA (NEJM 2014) + SGLT2i renal-cardiac protection (EMPA-KIDNEY 2023, DAPA-CKD 2020) [PMID:21366472](https://pubmed.ncbi.nlm.nih.gov/21366472/)
- Cited evidence (PMID 24716680) [PMID:24716680](https://pubmed.ncbi.nlm.nih.gov/24716680/)
- Cited evidence (PMID 36331190) [PMID:36331190](https://pubmed.ncbi.nlm.nih.gov/36331190/)
- Cited evidence (PMID 32970396) [PMID:32970396](https://pubmed.ncbi.nlm.nih.gov/32970396/)
- Cited evidence (PMID 38490803) [PMID:38490803](https://pubmed.ncbi.nlm.nih.gov/38490803/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2024 CKD + DOSE diuretic strategy (NEJM 2011) + TOPCAT MRA (NEJM 2014) + SGLT2i renal-cardiac protection (EMPA-KIDNEY 2023, DAPA-CKD 2020) — PMID:21366472
  • Cited evidence (PMID 24716680) — PMID:24716680
  • Cited evidence (PMID 36331190) — PMID:36331190
  • Cited evidence (PMID 32970396) — PMID:32970396
  • Cited evidence (PMID 38490803) — PMID:38490803