Intrarenal Venous Doppler as a novel marker for optimal decongestion, management and prognosis in acute heart failure patients.

Abstract

An increase in right atrial pressure is a common feature of acute decompensated heart failure (ADHF). Such increased pressure leads to persistent kidney congestion. A marker to guide optimal diuretic therapy is missing. We aim to correlate intrarenal Doppler ultrasound (IRD) in ADHF patients with clinical outcomes to assess whether renal hemodynamic parameter changes are useful for monitoring kidney congestion. Between December 2018 and January 2020, ADHF patients requiring intravenous diuretic therapy for at least 48 hours were considered for study selection. IRD blinded examination was performed day on 1, 3, 5 and clinical and laboratory parameters were recorded. Venous Doppler profile (VDP) were classified as continuous (C), pulsatile (P), biphasic (B), or monophasic (M) according to congestion degree; B and M profiles were considered deranged. VDP improvement (VDPimp) was defined as a change of ≥ 1 pattern degree or maintenance of C or P patterns. Arterial resistive index (RI) > 0.8 was considered elevated. Outcomes of death and rehospitalization were gathered at 60 days. Data were assessed by regression and Kaplain Meier analyses. All 177 ADHF patients admitted were screened and 72 were enrolled (27 females - median age 81 [76-87] years - median EF 40% [30-52]). VDP derangement decreased from 79.2% on day 1 to 51.4% on day 5 (p < 0.05). RI elevation decreased from 60.6% on day 1 to 43.1% on day 5 (p < 0.05). At day 5, VDPimp was registered in over half of the patients (59.7%). At day 5, signs of congestion (dyspnea/edema/rales), fluid accumulation (pleural/peritoneal fluid), hematocrit, and BNP improved (p > 0.05).After 60 days, 12 (16.7%) patients were readmitted and 9 (12.5%) died. VDPimp was identified as the unique independent factor associated with readmission (OR 0.22 CI 95% 0.05-0.94, p = 0.04) and death (OR 0.07, CI 95% 0.01-0.68, p = 0.02), with significantly better outcomes identified in VDPimp patients (Log Rank test p < 0.05). Decongestion may be associated with improvements in many clinical and instrumental parameters, but only VDPimp was associated with better clinical outcome. VDPimp should be incorporated in ad hoc AHF clinical trials to better define its role in everyday practice.