Table 3:

General considerations to be included in standard operating procedures.

Referral criteria
Inpatient	Outpatient
1. Patients with CKD stages ≤G3bA2 or CKD progression prior to admission who are discharged with uncorrected or persistent cardiovascular conditions 2. Patients discharged with uncorrected or persistent cardiovascular conditions who developed persistent stage 2–3 AKI according to the KDIGO definition or stage 2–3 AKD during the 7- to 90-day period after the initial AKI 3. Patients who required transient aquapheresis procedures due to refractory congestion during the index admission	1. Patients with prior history of uncorrected or persistent cardiovascular conditions with concomitant CKD stages ≤G3bA2 or CKD progression 2. Patients with CKD stages ≤G3bA2 or CKD progression who develop either acute or progressive high-risk cardiovascular conditions 3. Patients with refractory congestion who might be considered for KRT or intermittent aquapheresis programs 4. Patients with cardiorenal disease who require transplant workup (heart, kidney, or combined) 5. Patients who require consensus decision-making regarding pharmacological or device therapy in ‘gray-zone’ areas (e.g. eGFR <30 ml/min/1.73 m2)
Follow-up and monitoring
1. Early follow-up visit (7–30 days) • Patients recently discharged from the hospital (ideally within the first 7–10 days post-discharge) • AKI/AKD • Worsening symptoms/persistent congestion • Cardio- or nephroprotective treatment initiation/up-titration 2. Short follow-up intervals (1–3 months) • Patients included in KRT programs or transplant workup • Rapidly progressive CKD or CKD stages G4–G5 • More than two worsening HF events within the last year despite optimal medial and device therapy • Patients refractory/intolerant to GDMT 3. Long follow-up intervals (6 months) • Stable eGFR (if eGFR >30 ml/min/1.73 m2) and UACR • Improving heart/kidney function and biomarker profile • Stable symptoms/signs • Optimal GDMT	Systematic checklist evaluation to be performed in each follow-up clinical visit Multiparametric assessment of congestion Kidney function, electrolyte, and acid-base monitoring Assess drug-related adverse events Medication reconciliation Initiation or up-titration of GDMT Monitoring and treatment of CKD-related complications (i.e. anaemia, iron deficiency, mineral and bone disorder) Reinforce patient and caregiver education Risk stratification and care planning Provide non-pharmacological advice Identify the need for, coordinate and provide palliative care
Flexibility to modify the frequency of follow-up as needed based on the patient's trajectory, needs and stage of the disease

AKD: acute kidney disease; GDMT: guideline-directed medical therapy.