QW70-August 2026 – Nephro Critical Care Society

QW70 August 2026

Question: Select each option to validate with explanations

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.

Wrong Answer: ❌ A is incorrect: Grade 1 implies normal or mild flow abnormalities. This patient has severe flow abnormalities (Reversal and high pulsatility).

Wrong Answer: ❌ B is incorrect: Grade 2 is defined as IVC > 2cm plus a severe abnormality in only 1 vein. This patient has severe abnormalities in 2 veins (Hepatic and Portal).

Right Answer: ✅ The correct answer is C (VExUS Grade 3).

Explanation
• Prerequisite Met: The IVC is > 2cm (Plethoric) and non-collapsing, which allows for VExUS grading.
• Vein 1 (Hepatic): The presence of Systolic (S) Reversal constitutes a severe abnormality in the Hepatic Vein. * Vein 2 (Portal): A Pulsatility Index > 50% constitutes a severe abnormality in the Portal Vein.
• Grading Calculation: A VExUS Grade 3 is defined as an IVC > 2 cm plus severe abnormalities in 2 or more veins. * Clinical Implication: Even though the renal vein was not visualized, the presence of two other severe venous markers (Hepatic and Portal) confirms Grade 3. This indicates the heart cannot manage the current venous return, and the AKI is likely exacerbated by venous congestion (venous excess) rather than hypovolemia.

Modified VExUS

Modified VExUS (mVExUS) focuses more directly on venous Doppler abnormalities and can be particularly useful when the IVC is difficult to interpret or is not markedly dilated.
The commonly assessed venous Doppler patterns remain:
• Hepatic vein: systolic flow reversal → severe congestion
• Portal vein: pulsatility >50% → severe congestion
• Intrarenal vein: discontinuous/biphasic or monophasic flow → increasing severity of congestion
In the modified VExUS approach, venous Doppler abnormalities can be considered without making a plethoric IVC an absolute prerequisite, making it potentially more applicable in patients in whom IVC assessment is unreliable—for example, those on mechanical ventilation, with altered intra-abdominal pressure, or with challenging echocardiographic windows.

💎NephroCC Pearl

💥 VExUS (Venous Excess Ultrasound Score) Grade 3, defined by a plethoric IVC (> 2 cm) plus severe flow abnormalities in two or more visceral veins (e.g., Hepatic Vein Reversal and Portal Pulsatility Index > 50%), signifies severe systemic venous congestion.
💥Clinical Implication: In a patient with oliguric AKI and equivocal physical exam, VExUS Grade 3 strongly suggests that the kidney injury is driven by congestive nephropathy (venous hypertension) rather than volume depletion. These finding mandates volume-removing strategies (diuretics/dialysis) rather than fluid administration.
💥Supporting Evidence & Development The protocol was developed by a multidisciplinary team of experts in intensive care, nephrology, and cardiology (including Dr. Philippe Rola and Dr. William Beaubien-Souligny). Key milestones in the literature include:
• Original Validation: The 2020 study demonstrated that a VExUS Grade 3 had a specificity of 96% for predicting Acute Kidney Injury (AKI) in post-cardiac surgery patients.
• Heart Failure Applications: Recent prospective studies (e.g., Longino et al., 2025) and trials in emergency departments have shown that VExUS is superior to Central Venous Pressure (CVP) and physical exams for predicting heart failure readmissions and mortality.
• Expansion to General ICU: Meta-analyses (e.g., PubMed Central, 2025) have confirmed its utility in non-cardiac critically ill patients, specifically in managing "congestive nephropathy" where high venous pressure—rather than low arterial flow—is the driver of kidney failure.

Wrong Answer: ❌ D is incorrect: While the renal vein adds data, Grade 3 only requires severe abnormalities in "2 or more veins". Since Hepatic and Portal are already confirmed severe, the score is Grade 3 regardless of the renal finding.

This field is for validation purposes and should be left unchanged.