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Kidney Week

Abstract: PO1070

Point-of-Care Ultrasonography to Assess Venous Congestion and Guide Ultrafiltration: Another String to Our Bow?

Session Information

Category: Trainee Case Report

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Mahmud, Saqib, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
  • Koratala, Abhilash, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
Introduction

Point of care ultrasound (POCUS) is rapidly evolving as a valuable adjunct to bedside clinical examination in internal medicine and subspecialties. However, there is no single accurate sonographic application to determine fluid volume status. While sonographic assessment of inferior vena cava (IVC) is popular among novice POCUS users, its isolated use to determine and monitor volume status is subject to numerous limitations. Similarly, lung ultrasound gives an idea of left sided filling pressures but does cannot quantify venous congestion, which can have deleterious consequences in various organ systems including kidney. Novel scoring systems like venous excess ultrasound grading (VExUS) allow objective assessment of volume status using portal and hepatic venous Doppler waveforms in addition to IVC measurements. Herein, we demonstrate the natural history of these waveforms in a patient with advanced chronic kidney disease (CKD) during the course of ultrafiltration.

Case Description

A 39-year-old man with a history of CKD stage 5 presented with generalized weakness, shortness of breath on exertion, worsening leg edema and weight gain despite being compliant with prescribed diuretic therapy. He was admitted and initiated on hemodialysis for refractory volume overload. POCUS showed mild pericardial and pleural effusion as well as an enlarged IVC of ~3cm with <50% collapse. In addition, Doppler ultrasound showed 100% pulsatility of portal vein (normal <30%) with systolic flow reversal and hepatic vein with S wave reversal and only D wave below the baseline. These findings constitute VExUS grade 3, suggestive of severe congestion. While IVC continued to indicate high right atrial pressures, the Doppler waveforms showed parallel improvement with ultrafiltration reaching VExUS grade 1 (mild congestion) at discharge [Figure]. No episodes of intradialytic hypotension occured.

Discussion

POCUS-derived venous waveforms aid in monitoring the effectiveness of decongestive therapy and guide the amount of ultrafiltration.