The role of Venous Excess Ultrasound Score (VExUS Score) in Predicting acute kidney injury and optimizing fluid management in Patients with Cardio-renal Syndrome / By Eslam Mohamed Abdelmaksoud Abu-Naeima; Supervised By Dr. Ahmed Mohamed Ahmed Hussein Fayed, Dr. Moataz Fatthy Mohamed Abdelnaeem, Dr. Ghada Mohamed Abdou Ayeldeen, Dr. Mahmoud Amin Abu-Sheaishaa Shalaby

Thesis (Ph.D)-Cairo University, 2023.

Bibliography: pages 216-248.

Background: Systemic congestion develops in patients with heart failure,
pulmonary hypertension and in patients with fluid overload. It is a mediator of
adverse outcomes in critically ill patients and is a key target in their
management. A reduction of the arteriovenous gradient across vital organs may
hamper adequate perfusion. This phenomenon may be worsened with the
development of interstitial edema. In encapsulated organs such as the kidneys,
interstitial edema may result in decreasing the renal blood flow and the
development of AKI.
Studies have shown that physical exam is not efficient in this setting and routine
methods for more accurate assessment of volume status (e.g., body weight and
chest radiography) have significant disadvantages, even CVP measurement
requires invasive intervention and has many pitfalls. Point-Of-Care ultrasound
(POCUS) is a widely available noninvasive bedside diagnostic tool, could
enable clinicians to visualize the vascular anatomy, assess blood velocity using
Doppler imaging and detect vascular congestion. It also can aid in monitoring
the efficacy of decongestive therapy and bears prognostic significance.
In this study, we are going to evaluate the role of Venous excess ultrasound
score (VEXUS) which consists of hepatic vein Doppler, portal vein Doppler,
intra-renal venous Doppler and inferior vena cava (IVC) ultrasound in the
detection of venous congestion, monitoring of AKI and monitoring the efficacy
of decongestive therapy (by diuretics or ultrafilteration) in patients with cardio-
renal syndrome especially type 1.
Aim of work : To assess the correlation between change in VEXUS score and
AKI, fluid balance and clinical signs of fluid overload in patients with cardio-
renal syndrome.
Subjects and methods: Patients above 18 years admitted in ICU with a
provisional diagnosis of cardiorenal syndrome were included in the study. Those
with end stage kidney disease, Patients on vasopressors/inotropes/mechanical
ventilation, inadequate window, inferior vena cava (IVC) thrombus, and known
case of cirrhosis were excluded from the study. A formal echocardiography was
done on admission, Patients then underwent serial evaluation by body weight,
fluid balance, CVP, NT-proBNP, and Venous excess ultrasound score (VEXUS)
comprising inferior vena cava, hepatic vein waveform, portal vein pulsatility and
interlobar renal venous flow, on admission and after 48-72 hours.
Due to the short interval between the first and second VExUS evaluations, and
to decrease the number of patients with unchanged VExUS grading, we
proposed a new scoring system that was more detailed and can be more
reasonable for the serial daily evaluation of venous congestion.
Results: 51 patients were enrolled in our study, 28 males and 23 females, with
mean age 51±15 years, 25 patients were diabetic, 37 patients were hypertensive,
26 patients were obese (BMI >30 kg/m2), Only 8 paients were chronic kidney
disease, 6 of them were stage 3, 2 were stage 4.
Most of them were admitted due to non-compliance to their medications, 22 out
of 51 included patients, 15 patients were admitted due to chest infection.
Ascites was found in 8 patients, pleural effusion was found in 30 patients. 31
patients were admitted with AKI stage 1, 11 with stage 2, 9 with stage 3, with
mean serum creatinine was 2.6±1.6 mg/dl, sepsis was found in 27 patients,
median SOFA score was 3, Mean NT-pro BNP level was 1148 ±346 pmol/L.
Mean LVEF was 39.9 ±13.7, mean TAPSE was 1.7 ±0.4 cm,11 patients had
severe tricuspid regurgitation, 5 had severe mitral regurgitation. Mean value of
IVC maximum diameter was 2.5 ±0.3 cm, 19 patients had severe HVD
waveform, 20 patients had severe PVD waveform, 17 patients had severe IRVD
waveform, 16 patients had VExUS grade 3, 18 patients had VExUS grade 2.
All the patients received IV loop diuretics, IV shots in 20, IV infusion in 31,
with average daily IV loop diuretic dose 240 mg/day, Metolazone was added in
9 patients,10 patients required ultrafiltration, and 4 patients were indicated for
hemodialysis.
AKI after 72 hours of admission, improved in 38 patients and didn‘t improve in
13 patients. NT proBNP improved in 50 patients, worsened in 1 patient. IVC
maximum diameter improved in 39 patients, worsened in 12 patients. HVD
waveform improved in 25 patients, worsened in 3 patients. PVD waveform
improved in 33 patients, worsened in 1 patients. PVD PI improved in 44
patients, worsened in 7 patients. IRVD waveform improved in 15 patients,
worsened in 2 patients. RVSI improved in 26 patients, worsened in 4 patients.
The VExUS grading system improved in 31 patients, worsened in 2 patients.
On discharge, AKI improved on 34 patients, didn‘t improve in 8 patients,
median duration of hospital stay was 12 days, 9 patients died during hospital
stay, another 3 patients died in the first 90 days after discharge, chest infection
was the most common cause of death.
There was a significant correlation between VExUS grading on day1 with
number of peripheral signs, diuretic effect on UOP, mean serum creatinine on
admission, TV E/A, TAM É/Ấ , TAPSE, MV E/A, LA diameter, TV E velocity,
RA endsystolic area, RA length, MV A velocity, LV IVCT, LV IVRT, LV ET,
and LV MPI. There was no significant correlation between VExUS grading on
day1 with CVP, NT proBNP values, lung US, AKI staging.
There was no significant correlation between AKI response on day3 with the
change in number of peripheral signs, change in NT proBNP, change in body
weight, change in CVP, the presence of sepsis, change in IVC diameter, change
in HVD waveform, change in PVD waveform, change in IRVD waveform,
change in RVSI, change in renal artery parameters.
There was a significant correlation between AKI response on day3 with change
in VExUS grading system, cumulative IV loop diuretic dose, hospital stay,
change in HVD S/D ratio, change in number of B lines in lung US, 3 months
rehospitalization, and 3 months mortality. There was a highly significant
correlation between AKI response on day3 with diuretic effect on UOP and body
weight, Cumulative negative balance, PVD pulsatility index and the new
VExUS numerical scoring.
There was a significant correlation between the change in the new VExUS
numerical scoring on day3 and the change in CVP, need for UF in the first 3
days, RRT during hospital stay and discharge on RRT. There was a highly
significant correlation between the change in the new VExUS numerical scoring
with the AKI response day3 and on discharge.
Conclusion: Our study suggests a strategy of using VExUS grading system as a
complementary tool to physical examination, to determine venous congestion
and aid in the clinical decision to perform fluid removal.

الخلفية: يتطور الاحتقان الجهازي عند المرضى الذين يعانون من قصور القلب وارتفاع ضغط الدم الرئوي والمرضى الذين يعانون من زيادة السوائل. إنه وسيط للنتائج السلبية لدى المرضى المصابين بأمراض خطيرة وهو هدف رئيسي في إدارتهم. قد يؤدي انخفاض التدرج الشرياني الوريدي عبر الأعضاء الحيوية إلى إعاقة التروية الكافية. قد تتفاقم هذه الظاهرة مع تطور الوذمة الخلالية. في الأعضاء المغلفة مثل الكلى، قد تؤدي الوذمة الخلالية إلى انخفاض تدفق الدم الكلوي وتطور الفشل الكلوي الحاد.
أظهرت الدراسات أن الفحص البدني ليس فعالاً في هذا الإعداد وأن الطرق الروتينية لتقييم أكثر دقة لحالة الحجم (على سبيل المثال، وزن الجسم والتصوير الشعاعي للصدر) لها عيوب كبيرة، حتى قياس CVP يتطلب تدخلاً جراحيًا وله العديد من المخاطر. تعد الموجات فوق الصوتية في نقطة الرعاية (POCUS) أداة تشخيصية غير جراحية متاحة على نطاق واسع، ويمكن أن تمكن الأطباء من تصور تشريح الأوعية الدموية، وتقييم سرعة الدم باستخدام تصوير دوبلر واكتشاف تقييمات الأوعية الدموية الثانية VExUS، وتقليل عدد المرضى الذين لم يتغيروا. تصنيف VExUS، اقترحنا نظام تسجيل جديد أكثر تفصيلاً ويمكن أن يكون أكثر منطقية للتقييم اليومي التسلسلي للازدحام الوريدي.
النتائج: تم تسجيل 51 مريضا في دراستنا، 28 ذكرا و 23 أنثى، بمتوسط عمر 51 ± 15 سنة، 25 مريضا مصابين بالسكري، 37 مريضا يعانون من ارتفاع ضغط الدم، 26 مريضا يعانون من السمنة المفرطة (مؤشر كتلة الجسم> 30 كجم / م 2)، 8 مرضى فقط كانوا من أمراض الكلى المزمنة، 6 منهم في المرحلة 3، 2 في المرحلة 4.
تم إدخال معظمهم بسبب عدم الالتزام بأدويتهم، حيث تم إدخال 22 مريضاً من أصل 51 مريضاً، وتم إدخال 15 مريضاً بسبب التهاب في الصدر.
تم العثور على الاستسقاء في 8 مرضى، وتم العثور على الانصباب الجنبي في 30 مريضا. تم قبول 31 مريضًا في المرحلة 1 من AKI، و11 في المرحلة 2، و9 في المرحلة 3، وكان متوسط كرياتينين المصل 2.6 ± 1.6 ملغم / ديسيلتر، وتم العثور على تعفن الدم في 27 مريضًا، وكان متوسط درجة SOFA 3، ومتوسط مستوى NT-pro BNP كان 1148 ± 346 بمول / لتر.
كان متوسط LVEF 39.9 ±13.7، وكان متوسط TAPSE 1.7 ±0.4 سم، وكان 11 مريضًا يعانون من قلس ثلاثي الشرفات شديد، وكان 5 منهم يعانون من قلس تاجي شديد. كان متوسط قيمة القطر الأقصى لـ IVC 2.5 ± 0.3 سم، وكان 19 مريضًا لديهم شكل موجة HVD شديد، و20 مريضًا لديهم شكل موجة PVD شديد، و17 مريضًا لديهم شكل موجة IRVD شديد، و16 مريضًا لديهم شكل موجة VExUS من الدرجة 3، و18 مريضًا لديهم شكل موجة VExUS من الدرجة 2.
تلقى جميع المرضى مدرات البول في الحلقة الوريدية، وحقنًا في الوريد في 20 حالة، وتسريبًا في الوريد في 31 حالة، بمتوسط جرعة يومية من مدر البول في الحلقة الوريدية 240 ملغ / يوم، وأضيف ميتولازون في 9 مرضى، وتطلب 10 مرضى الترشيح الفائق، وتمت الإشارة إلى 4 مرضى لغسيل الكلى.

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Text in English and abstract in Arabic & English.