Clinical Case Scenario
A 72-year-old man with diabetes mellitus, hypertension, coronary artery disease with PCI 10 years ago, HFrEF with an EF of 37%, CKD on medical management with a baseline creatinine of 1.8 mg/dL, and COPD requiring occasional home BiPAP presents with acute respiratory distress.He has had progressively reduced mobility and bilateral lower-limb edema for the past 6 months. For the last 3 days, he has developed cough with expectoration associated with intermittent fever.On examination, he is tachypneic with bilateral crackles, elevated JVP, and bilateral pitting pedal edema. Chest radiograph shows bilateral pulmonary edema.
Initial Assessment
Echocardiography shows LV systolic dysfunction with EF 37%, grade II diastolic dysfunction, mild RV dysfunction, moderate-to-severe tricuspid regurgitation, PASP approximately 52 mmHg, and a dilated IVC with no respiratory collapse.POCUS demonstrates extensive bilateral B-lines involving all lung fields with small bilateral pleural effusions.
The patient is diagnosed with AECOPD, likely precipitated by community-acquired pneumonia, with concurrent acute decompensated HFrEF. He is started on NIV, IV loop-diuretic infusion, and appropriate treatment for the suspected infective exacerbation. Over the next 48 hours, his respiratory distress and oxygen requirement improve considerably, with reduction in pulmonary edema.
Day 3
The patient is significantly more comfortable from a respiratory standpoint but continues to have elevated JVP and peripheral edema. Urine output has decreased and his response to further loop-diuretic doses is becoming poor.
Wrong Answer: ❌ A. Escalate loop diuretics to target VExUS Grade 0 — Incorrect: Grade 0 is not a universal endpoint; TR and pulmonary hypertension may cause persistent abnormalities. Further diuresis risks electrolyte depletion and alkalosis.
Wrong Answer: ❌ B. Initiate hemodialysis with ultrafiltration — Incorrect: There is no urgent KRT indication, and pulmonary congestion has already improved.
Wrong Answer: ❌ C. Initiate SCUF — Incorrect: SCUF is reserved for selected refractory congestion; residual VExUS abnormality alone is insufficient.
Right Answer: ✅ D: Hold further escalation of diuretics and correct the associated electrolyte and acid–base abnormalities. Explaination • Initial congestion: At presentation, pulmonary edema, extensive bilateral B-lines, a plethoric IVC, and VExUS Grade 3 supported aggressive initial decongestion. • Response to treatment: After 48 hours, respiratory distress and pulmonary edema have substantially improved and VExUS has decreased from Grade 3 to Grade 2. • New problem: Continued diuresis has resulted in hypokalemia (K⁺ 3.1 mmol/L), hypochloremia (Cl⁻ 92 mmol/L), and metabolic alkalosis (pH 7.48, HCO₃⁻ 35 mmol/L), together with diminishing diuretic response. • VExUS should not be treated as an isolated therapeutic target: Not every patient will achieve, or should be forced to achieve, VExUS Grade 0. Chronic pulmonary hypertension, RV dysfunction, significant tricuspid regurgitation, CKD, increased intrathoracic pressure, and raised intra-abdominal pressure can result in persistently abnormal venous Doppler findings. • Tricuspid regurgitation is particularly important: Significant TR can transmit systolic pressure backward into the hepatic veins, producing persistent systolic blunting or reversal. An abnormal hepatic venous waveform may therefore persist despite adequate clinical decongestion. Further fluid removal solely to normalize VExUS could worsen electrolyte depletion, metabolic alkalosis, renal perfusion, and kidney function without providing additional clinical benefit. The immediate priority is to correct potassium and chloride depletion, address the metabolic alkalosis, reassess volume status, and determine whether the residual congestion is actually producing ongoing organ dysfunction. 💎NephroCC Pearl 💥 VExUS guides decongestion—it is not a standalone treatment target. 💥 Do not chase Grade 0. TR, RV dysfunction and pulmonary hypertension may cause persistent Doppler abnormalities. 💥 Serial trends matter more than a single grade. Interpret VExUS alongside clinical and pulmonary improvement. 💥 Know when to stop: electrolyte depletion, alkalosis and declining diuretic response should prompt reassessment. Take-home: Treat the congestion, not the VExUS number.
Wrong Answer: ❌ E. Add a potassium-sparing diuretic and continue aggressive diuresis — Incorrect: The priority is to reassess volume status and correct electrolyte/acid–base disturbances, not intensify diuresis.
