A 72-year-old woman with stage 4 CKD (eGFR 18 mL/min/1.73m²) secondary to hypertensive nephrosclerosis is admitted with acute dyspnea, orthopnea, and bilateral ankle edema. Physical examination reveals elevated jugular venous pressure, bibasal crackles, and 2+ pitting edema. Serum sodium 128 mEq/L, potassium 6.2 mEq/L, and bicarbonate 18 mEq/L. Chest X-ray shows bilateral pulmonary edema. Which of the following is the MOST appropriate immediate management?

Explanation

## Acute Decompensated Heart Failure in Advanced CKD **Key Point:** Loop diuretics are the first-line therapy for acute pulmonary edema in CKD patients. Fluid restriction and sodium restriction are essential adjuncts. Electrolyte monitoring is critical given the baseline hyperkalemia and hyponatremia. **High-Yield:** In CKD stage 4 with acute pulmonary edema: - **Loop diuretics** (IV furosemide) are the mainstay — they improve symptoms rapidly and reduce preload - **Fluid restriction** (<1000 mL/day) and **sodium restriction** (<2 g/day) prevent recurrent decompensation - **Electrolyte monitoring** is mandatory because CKD impairs potassium excretion and dilutional hyponatremia worsens with fluid restriction **Clinical Pearl:** This patient has: - Acute pulmonary edema (orthopnea, crackles, CXR findings) - Hyponatremia (Na 128) — likely dilutional from fluid overload - Hyperkalemia (K 6.2) — concerning in CKD; spironolactone is **contraindicated** - Metabolic acidosis (HCO~3~⁻ 18) — typical of CKD The combination of pulmonary edema + hyponatremia + hyperkalemia mandates **diuretic therapy with careful fluid/sodium restriction**, NOT potassium-sparing agents. **Warning:** Spironolactone in a patient with K 6.2 and eGFR 18 is **dangerous** — it will worsen hyperkalemia and precipitate cardiac arrhythmias. ### Management Algorithm 1. IV furosemide (40–80 mg bolus, then infusion if needed) 2. Strict fluid restriction (<1000 mL/day) 3. Sodium restriction (<2 g/day) 4. Monitor K, Na, Cr daily × 3–5 days 5. Consider dialysis if refractory pulmonary edema or worsening hyperkalemia [cite:Harrison 21e Ch 297; Robbins 10e Ch 7]