QW70 August 2026 – Nephro Critical Care Society

Clinical Case Scenario

A 65-year-old male with a history of hypertension for 10 years, is admitted to the ICU with lower respiratory tract infection on oxygen support. The patient has now developed oliguric, Acute Kidney Injury (AKI) and rising values of creatinine from 0.9 mg/dl to 2 mg/dl with metabolic acidosis in a span of 24 hours. The clinical team is debating whether the patient is "dry" (pre-renal) or "wet" (congested), as the physical exam is equivocal. You perform a VExUS assessment to guide management.

Ultrasound Findings:

IVC: Diameter is 3.02 cm and non-collapsing.
Hepatic Vein: Shows Systolic (S) wave reversal (flow above the baseline).
Portal Vein: Pulsatility Index is calculated at 60%.
Renal Vein: Not visualized due to bowel gas.

Question: Based on the VExUS grading criteria provided, how would you classify this patient's venous congestion, and what is the physiological implication?

A) VExUS Grade 1; The findings suggest mild congestion, and fluids can likely be given safely.

B) VExUS Grade 2; There is a severe abnormality in only one vein (Hepatic), suggesting moderate congestion.

C) VExUS Grade 3; The patient has severe congestion, suggesting the AKI may be driven by venous hypertension (congestive nephropathy).

D) Indeterminate; You cannot calculate a VExUS score because the Renal Vein was not visualized.

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