Venous Excess Doppler ultrasound assessment and loop diuretic efficiency in acute cardiorenal syndrome

Cardiorenal syndrome poses significant diagnostic and therapeutic challenges. The Venous Excess Ultrasound (VExUS) grading system based on the combination of venous Doppler assessments has shown potential in predicting acute kidney injury and cardiovascular outcomes, but its relevance regarding the management of acutely decompensated heart failure (ADHF) remains to be fully understood.

In this prospective study, patients with ADHF and acute kidney injury (AKI) were enrolled from a medical intensive care unit over 20 months. The study involved echocardiography and VExUS grading at admission and 72 h later. Data collection included clinical parameters, diuretic dosages, urine output, and fluid balance. Statistical analyses focused on exploring the relationships between VExUS grades and its components, including the renal venous stasis index (RVSI), diuretic efficiency, and renal function improvement.

The cohort of 43 patients showed varied VExUS grades at admission. Higher VExUS grades were significantly associated with lower diuretic efficiency. Specifically, the mean urine output per 40 mg of furosemide was 368 ± 213 mL, with patients having VExUS grade 2 or 3 exhibiting reduced diuretic efficiency compared to those with grade 0-1 (Grade 2 vs. Grade 0-1: 333 ± 214 mL vs. 507 ± 189 mL, p = 0.02; Grade 3 vs. Grade 0-1: 270 ± 167 mL vs. 507 ± 189 mL, p = 0.004). The relationship between VExUS grade and diuretic efficiency was independent of admission creatinine and prior use of loop-diuretics (β = -106 CI: -180; -32 p = 0.006). Among the components of venous congestion assessment, the RVSI had the best ability to predict low diuretic efficiency (AUROC: 0.76 (0.60; 091) p = 0.001). Improvement in VExUS grade at 72 h was correlated with significant renal function improvement (84.6% vs. 47.1% for improved vs. non-improved VExUS grades, p = 0.03).

High VExUS and RVSI grades at admission are independently associated with reduced diuretic efficiency in ADHF patients with AKI. The findings emphasize the clinical value of venous congestion assessment in cardiorenal syndrome management including the selection of an initial diuretic dose.