#1988 VExUS score as a method to guide diuretic treatment in CKD patients with congestive nephropathy by right heart failure

Abstract

Abstract Background and Aims Congestive nephropathy is a kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics and most of all it is due to right heart failure. Venous congestion can lead to a circulation vicious hormonal activation, increased intra-abdominal pressure, excessive renal tubular reabsorption of sodium and volume overload. In CKD with right heart failure, management of the patient is difficult because may be hard to identify a condition of fluid overload and when to stop intravenous diuretic treatment. Inferior caval vein (ICV) diameter and ICV index (reduction of diameter with respiration) have been used to identify fluid overload and guide diuretic treatment. However, in CKD patients with heart failure the ICV may not change rapidly and could overestimate the need of intravenous diuretics. This is why VExUS has been useful in both diagnosis and monitoring therapeutic. The VExUS method is a new approach, documented in the literature for the first time once in 2020. In this study we report the usefulness of the VExUS (Venous Excess Ultrasound Score) method for the diagnosis of overload volume and venous congestion and in setting an adequate therapy. It consists of Doppler evaluation of the abdominal veins: hepatic, portal and intrarenal. In fact, the acute renal failure, in the patients studied, is to be attributed in the first instance to venous congestion rather than underfilling, resulting from decompensation and therefore requiring diuretic therapy. Method This retrospective study was conducted in CKD patients (stages 3-4) with acute kidney injury (creatinine level: 6.3-2.6 mg/dl) due to right heart failure admitted at the U.O.C. Nephrology at the S. Maria della Pietà Hospital in Nola and UOC Nephrology of Univ. of Campania. The VExUS method defines 3 degrees (score 0-3) of congestion based on the severity of the anomalies on hepatic, portal and intrarenal venous Doppler. All patients have been treated with diuretics i.v. based on a VEXUS score>1, and then returned to oral treatment when VEXUS score returned to 0. VExUS assessment was performed at admission, repeated every 48 hours and the last score has been considered here (on average 1 week). The relationship between change in VExUS score and ICV index vs creatinine levels was studied by correlation analysis. Lung POCUS (point of care pulmonary ultrasonography) has also been used for all patients to identify a possible contemporary overload caused by LV failure. Results Thirty patients have been included. The use of diuretics reduced the VExUS score and the ICV diameter. However, diuretic treatment changed the ICV diameter by a smaller extent (−30%) compared to the VExUS score (−80%), and one patient showed clear reduction of VExUS score, without any modification of the ICV diameter, suggesting that the latter is a slower indicator of recovery compared to VExUS. Indeed, the change of VExUS score was highly correlated to the improvement of creatinine levels (Pearson's correlation 0.837, p < 0.001). The change of IVC diameter explained in comparison a smaller amount of variability of the creatinine improvement (Pearson's correlation 0.65, p = 0.008). Conclusion VExUS is a promising and reliable tool in the management of congestive nephropathy in patients with CKD and right heart failure. VExUS is superior to VCI diameter and should be used routinely, along with clinical, laboratory, and other ultrasound parameters, because of its usefulness, repeatability, low cost and ease of execution.