The following are key points to remember on contemporary management of severe acute kidney injury (AKI) and refractory cardiorenal syndrome (CRS) from the Critical Care Cardiology Working Group of the Heart Failure and Transplant Section Leadership Council:

1. AKI and CRS are increasingly seen in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. In fact, AKI occurs in approximately one in four patients hospitalized with cardiovascular disease, including up to 47% of patients with acute decompensated heart failure and 15-30% of patients with acute coronary syndrome (ACS).
2. CRS can be conceptually distinguished from other forms of AKI based on its intrinsic relationship with worsening cardiac function and often presents with a reversible decrease in kidney function without overt tubular injury.
3. At this time, there are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Management of AKI and CRS generally involve optimization of hemodynamics and fluid balance, and avoidance or discontinuation of potential nephrotoxins.
4. Loop diuretics are useful for patients with CRS and AKI to prevent or treat fluid overload, and successful diuresis can potentially lead to improved renal function by relieving renal venous congestion with a stepped diuretic regimen as needed. The addition of a second diuretic, frequently a thiazide-type diuretic, to ongoing loop diuretic therapy may potentially overcome diuretic resistance and increase urine output.
5. Isolated ultrafiltration (aquapheresis) is a potential option for management of diuretic-resistant heart failure and refractory CRS, although patients with severe kidney dysfunction (e.g., serum creatinine >2.5 mg/dl) may benefit from another renal replacement therapy (RRT) modality that provides clearance.
6. Acute RRTs, including ultrafiltration, intermittent hemodialysis, and continuous RRT, are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal function recovers.
7. The most common indication for continuous RRT (CRRT) initiation in cardiac intensive care unit (CICU) patients is medically refractory volume overload with hemodynamic instability.
8. Multidisciplinary CICU teams caring for patients receiving CRRT should ideally include providers with expertise in critical care medicine, cardiovascular medicine, critical care nursing, pharmacy, nutrition, and nephrology.
9. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, underscoring the importance of appropriate patient selection.
10. Additional research is indicated to evaluate the optimal approach to management of the increasing number of cardiac patients with AKI-D and refractory CRS, including new therapies for AKI and CRS, and improved strategies for CRRT initiation, management, and transitions.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Acute Heart Failure, Chronic Heart Failure

Keywords: Acute Coronary Syndrome, Acute Kidney Injury, Cardio-Renal Syndrome, Creatinine, Critical Care, Diuretics, Heart Failure, Hyperemia, Metabolic Syndrome, Nephrology, Renal Dialysis, Renal Replacement Therapy, Secondary Prevention, Sodium Potassium Chloride Symporter Inhibitors, Ultrafiltration

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