Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study

Abstract

A bstract Background Fluid overload is deleterious in critically ill patients. It can lead to venous congestion, thereby increasing venous pressure, theoretically increasing the backpressure, and thereby reducing renal blood flow. Venous congestion thus can be an important contributor to acute kidney injury (AKI), with no validated tools to objectively identify venous congestion bedside. Materials and methods Patients above 18 years admitted in ICU with a provisional diagnosis of cardiorenal syndrome were included in the study. Those with inadequate window, inferior vena cava (IVC) thrombus, and known case of cirrhosis with portal hypertension were excluded from the study. Patients underwent ultrasound examination with serial determination till AKI resolved or patient is initiated on dialysis. Venous excess ultrasound score (VEXUS) comprising inferior vena cava, hepatic vein waveform, and portal vein pulsatility was assessed. Results Thirty patients were enrolled for the study. The mean age was 59.53 ± 16.47 with 21 (70%) males. Mean sequential organ failure assessment (SOFA) score was 5.03 ± 1.97. Fourteen patients (46.7%) were in AKI stage 1, while eight patients (26.7%) were in AKI stage 2 and stage 3 each. Twenty patients (66.7%) had VEXUS grade III. Resolution of AKI injury showed significant correlation with improvement in VEXUS grade ( p value 0.003). Similarly, there was significant association between changes in VEXUS grade and fluid balance ( p value 0.006). There was no correlation between central venous pressure (CVP), left ventricular function, and right ventricular function with change in VEXUS grade. Conclusion The study shows that a combined grading of IVC, hepatic vein, and portal vein might reliably demonstrate venous congestion and aid in the clinical decision to perform fluid removal. How to cite this article Bhardwaj V, Vikneswaran G, Rola P, Raju S, Bhat RS, Jayakumar A, et al. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med 2020;24(9):783–789.

Forced diuresis oriented by point‐of‐care ultrasound in cardiorenal syndrome type 5 due to light chain myeloma—The role of hepatic venogram: A case report

“…The Venous Excess UltraSound (VExUS) score was purposed, for grading systemic congestion by combination of IVC diameter and venous Doppler waveforms at aforementioned sites. VExUS independently predicted the risk of rehospitalization among patients admitted to intensive care unit after cardiac surgery 4 and was further applied, for guiding fluid removal by dialysis and diuretics among adult patients affected by CRS and AKI 5,17 …”

“…Noninvasive grading of venous congestion by point‐of‐care ultrasound (POCUS) predicted the risk of acute kidney injury (AKI) 4 and oriented diuretic therapy in CRS 5 . In 2016, European Society of Cardiology categorized the clinical phenotypes of HF, according to signs of congestion and peripheral perfusion, represented by the combination of wet‐dry and warm‐cold patterns 6 .…”

SARS‐CoV‐2–related ARDS in a maintenance hemodialysis patient: case report on tailored approach by daily hemodialysis, noninvasive ventilation, tocilizumab, anxiolytics, and point‐of‐care ultrasound

“…In April 2020, when the patient's clinical trend was improving, the venous excess ultrasound score (VEXUS) was purposed for assessing venous congestion in cardiorenal syndrome, including US examination of IVC diameter and waveforms of hepatic, portal and renal veins, in patients admitted to ICU after cardiac surgery, excluding patients with critical illness, eGFR < 15 mL/min, or renal transplantation 26 . VEXUS score was associated with the risk of acute kidney injury, and subsequently adopted by Bhardwaj et al, 27 for tailoring fluid removal by diuretics and ultrafiltration in patients with cardiorenal syndrome associated with acute kidney injury stage 1 to 3. On May 2020 Tri‐POCUS approach, including bedside assessment of lungs, heart, and venous system, was suggested for critically ill patients with COVID‐19 28 …”

Síndrome cardiorrenal: clasificación, fisiopatología, diagnóstico y tratamiento. Una revisión de las publicaciones médicas

“…Esto presupone que el incremento del volumen venoso estresado o cualquier suceso con elevación de la presión auricular derecha hace que la VCI alcance la parte plana de la curva de distensibilidad; con ello, la presión retrógrada dilata el árbol venoso hepático y luego el renal 41 . En 2020, Bhardwaj, et al publicaron una cohorte prospectiva de 30 pacientes con SCR en la cual el grado de VEXUS mostró correlación con la resolución de la LRA y el balance acumulado, aunque no hubo correlación con los signos clínicos periféricos de sobrecarga, PVC y función ventricular izquierda o derecha 42 . Si bien este método es accesible y carece de riesgo, se requiere más evidencia que sustente los beneficios de su empleo.…”