The most appropriate next step in this patient's treatment would be to start IV loop diuretics promptly, using an aggressive, goal-directed strategy. She had clear clinical evidence of acute decompensated heart failure (ADHF) with congestion: dyspnea, JVD, crackles, and peripheral edema. Her worsening kidney function represented congestion-related (functional) cardiorenal syndrome, not intrinsic kidney injury. In the setting of ADHF, withholding diuretics due to a modest Cr level rise delays decongestion and worsens outcomes. Small increases in Cr levels during diuresis are common and often benign (permissive acute kidney injury). The appropriate response is to remove congestion, not to either restrict or administer fluids. Early, adequate IV loop diuretics (often ≥2-2.5 times the home-dose IV) improve symptoms, kidney function over time, and survival.

IV fluids will worsen pulmonary edema and raise filling pressures, further impairing kidney perfusion. Low-dose dopamine has no proven benefit in kidney protection and increases arrhythmia risk; as such, it is no longer recommended. Withholding diuretics perpetuates congestion—the primary driver of her kidney dysfunction—and delays appropriate therapy. Dialysis would not be indicated unless there were refractory hyperkalemia, acidosis, anuria, or severe volume overload unresponsive to diuretics. She had not yet had an adequate diuretic trial.

This patient case quiz is part of the larger Managing HF Across the Spectrum: From Recognizing Symptoms to Implementing Appropriate Treatment initiative, supported by Bayer. To visit the Managing HF Across the Spectrum page and access additional educational activities on this topic, click here.

References

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