Peritoneal Dialysis Versus Extracorporeal Ultrafiltration Modalities in the Management of Acute Cardiorenal Syndrome with Diuretic Resistance

In cardiorenal Syndrome (CRS), diuretic resistance is frequent and congestion predominates in acute forms. In refractory cases, non-pharmacological ultrafiltration therapies have shown effectiveness on fluid removal, improved diuresis, and reduced rehospitalizations. However, the choice of modality remains individualized and resource-dependent. Both continuous renal replacement therapy (CRRT) and peritoneal dialysis (PD) offer hemodynamic advantages, but CRRT carries risks such as infection, bleeding, and high cost. PD has also demonstrated benefits in acute settings, providing effective sodium removal, and no need for anticoagulation, though it is not considered first-line therapy. There are few studies comparing different renal replacement therapies (RRT) in patients with acute CRS and there is no evidence on diuretic resistance. So, the question arises: could there be an advantage of a modality beyond fluid removal? The scarcity of comparative studies underscores the need for randomized trials that move beyond the cardiocentric perspective and include patients at risk of diuretic resistance.