Venous Excess Doppler Ultrasound: A Visual Guide to Decongestion in Cardiorenal Syndrome

Promptly recognizing congestion, both clinical and hemodynamic, is paramount in the management of patients with heart failure. The pathophysiology of congestion involves a complex interplay of absolute fluid gain, volume redistribution from venous capacitance beds to the central venous circulation, inadequate excretion due to renal dysfunction, salt and water retention, and endothelial dysfunction. While congestive nephropathy is gaining wider recognition as a distinct variant of hemodynamic acute kidney injury (AKI), there are limited bedside diagnostic tools for proper evaluation of these patients. In this manuscript, we describe a case of AKI where POCUS helped us diagnose clinically silent congestion as well as monitor the response to therapy. A patient with heart failure with mildly reduced ejection fraction was initially administered intravenous fluids for rise in serum creatinine attributed to volume depletion. However, POCUS demonstrated a completely different scenario with severe venous congestion. Both sonographic stigmata of congestion and serum creatinine improved with diuretic therapy. Furthermore, serial venous excess Doppler ultrasound scans facilitated the visualization of decongestion in real time.