A Pragmatic Approach to Acute Cardiorenal Syndrome: Diagnostic Strategies and Targeted Therapies to Overcome Diuretic Resistance.

Cardiorenal syndrome (CRS) is a challenging condition characterised by interdependent dysfunction of the heart and kidneys. Despite advancements in understanding its pathophysiology, clinical management remains complex due to overlapping mechanisms and high rates of diuretic resistance. Relevant literature was identified through a comprehensive narrative review of PubMed, Embase, and Cochrane Library databases, focusing on pivotal trials relating to CRS from 2005 to 2024. This review aims to provide a pragmatic, evidence-based approach to acute CRS management by addressing common misconceptions, outlining diagnostic strategies, and proposing a structured algorithm to manage diuretic resistance. We discuss the role of thoracic and venous excess ultrasound (VeXUS) in providing reliable measures of systemic congestion, natriuresis-guided sequential nephron blockade, and more targeted therapies, including ultrafiltration in refractory cases. In addition, we explore emerging trials that target renal hypoperfusion and venous congestion in CRS. Designed for a broad audience, including general physicians, cardiologists, and nephrologists, this review integrates clinical evidence with practical guidance to support effective and timely decision-making in the care of patients with CRS.