How should I approach the management of a patient with heart failure who also presents with acute kidney injury?

When managing a patient with heart failure who also presents with acute kidney injury (AKI), close monitoring and careful adjustment of treatment are essential. Start by assessing the severity of both conditions and identifying the cause of AKI through clinical evaluation and investigations such as serum creatinine, urine output, and urine dipstick testing. Temporarily stop ACE inhibitors and ARBs if the patient has diarrhoea, vomiting, or sepsis until clinical stability is achieved to reduce further kidney injury risk ¹.

For acute heart failure, intravenous diuretic therapy should be offered, with consideration of higher doses if the patient was already on diuretics prior to admission, but renal function, weight, and urine output must be closely monitored during therapy to avoid worsening AKI ². Discuss with the patient strategies to manage increased urine output ².

Do not routinely use nitrates, sodium nitroprusside, inotropes, or vasopressors unless there is cardiogenic shock with reversible causes, in which case these should be administered in a high-dependency setting ². Avoid routine ultrafiltration unless there is confirmed diuretic resistance ².

Consult a nephrologist early, ideally within 24 hours of AKI detection, especially if the cause is unclear, the AKI is severe (stage 3), or there is inadequate response to treatment ¹. This multidisciplinary approach ensures optimisation of both cardiac and renal management.

Finally, provide information and support to the patient and carers about the treatment plan, monitoring, and prognosis of both heart failure and AKI ¹.