A fictional 69-year-old with heart failure and reduced ejection fraction remains breathless with raised JVP, pulmonary crackles and oedema after admission. Creatinine has risen from 128 to 174 micromol/L after intravenous diuretic treatment; blood pressure is 108/68 mmHg and potassium is 5.0 mmol/L.
Listen for the assumption.
The creatinine has risen, so I was going to stop the diuretic and all disease-modifying heart-failure medicines.
Before changing everything, what do the examination, urine output, weight trend, electrolytes and perfusion tell us about congestion and immediate harm?
They remain congested without shock. I need specialist heart-failure input, continued monitored decongestion and an indication-by-indication medicine review.
Choose an answer below and reveal the reasoning to see consultant feedback at every checkpoint. The full consultant-led synthesis follows after all three decisions.
Go to the first decision ↓The picture develops.
- Weight remains 3.1 kg above the recorded euvolaemic weight
- Urine output has fallen but the patient is not anuric
- No symptomatic hypotension, severe hyperkalaemia or new conduction disturbance
Commit before you reveal.
After you select an option, reveal the model reasoning and the consultant’s feedback.
Hear the senior team refine the plan.
The registrar tests the plan, the consultant synthesises the key principle, and the SHO confirms the safer next steps.
Confirm the diuretic dose and delivery, look for precipitants, reassess perfusion and congestion, and involve the specialist heart-failure team early.
Do not equate every creatinine rise with intrinsic kidney injury or assume it is harmless. Continue decongestion only with close clinical and biochemical surveillance, and escalate poor response through the local specialist pathway.
I will hand over the weight, urine output, creatinine and potassium trajectories, congestion findings, response target and medicine-reconciliation plan.
What must remain explicit.
- Seek specialist heart-failure input early and continuously.
- Monitor renal function, electrolytes, weight, urine output and haemodynamics.
- Escalate shock, severe electrolyte disturbance, anuria or respiratory deterioration immediately.
Where reasoning fails.
- Stopping therapy because of one laboratory result
- Ignoring residual congestion
- Escalating diuretics without a response target
Acute heart failure with congestion [findings/trend], weight [trend], urine output [trend], creatinine/potassium [trend], intravenous diuretic [dose/response] and medicines [continued/held/review owner].
When renal function changes during decongestion, which bedside findings prevent you from treating the creatinine in isolation?