#2999 Renal venous congestion as a predictor of poor prognosis in patients with acute decompensated heart failure
Authors: Andriamanohery Robinson Tsimine , Kontareva Natalia , Efremovtseva Marina , Aslanova Rena , Khruleva Yulia , Khutsishvili Nutsiko , Kobalava Zhanna 
Published: May 2024

Abstract

Background and Aims
Systemic venous congestion in acute decompensated heart failure (ADHF) is associated with a risk of end-organ damage and high in-hospital mortality. We aimed to assess the prevalence and severity of renal venous congestion using venous excess ultrasound (VExUS) protocol in intensive care unit (ICU) patients with ADHF, and to evaluate the association between type of intra-renal venous blood flow, incidence of acute kidney injury (AKI), and in-hospital death.

Method
A prospective single-center study included 99 patients who were admitted to the ICU with ADHF (mean age 71.1 ± 12.54 years, 56 (56.6%) males). Inclusion criteria: age ≥18 years, ADHF II–IV, signed informed consent. Exclusion criteria: acute coronary syndrome, severe concomitant diseases, refusal to participate in the study. Upon admission, routine clinical, laboratory and instrumental examinations, lung ultrasound using the BLUE protocol, and assessment of venous congestion using the pulse-wave dopplerography were performed. The presence of continuous blood flow was regarded as the absence of renal venous congestion, while intermittent (biphasic and monophasic blood flow) indicated venous congestion. The diagnosis of ADHF and AKI was established based on generally accepted criteria in accordance with modern international recommendations. All patients received optimal drug therapy. The end point was defined as death from cardiovascular causes during hospitalization. Statistical analysis was performed using SPSS Statistics, version 26.0.

Results
Upon admission, continuous renal venous blood flow was detected in 17 (17.2%) patients, intermittent in 82 (82.8%): biphasic in 47 (47.5%) and monophasic in 35 (35.3%). The patient groups were comparable in gender, age, frequency of coronary heart disease, diabetes mellitus, anemia. Atrial fibrillation was more common in case of monophasic (p &lt; 0.006), and arterial hypertension in patients with continuous venous blood flow (p &lt; 0.001). Patients with renal venous congestion, compared with patients without signs of congestion, had more severe heart failure: swollen neck veins: 5 (29.4%) vs 21 (45%) vs 28 (60%), p &lt; 0.001; hepatomegaly 12 (72.6%) vs 40 (85.1%) vs 31 (88.6%), p &lt; 0.001; edema 8 (47.3%) vs 40 (85.1%) vs 24 (68.6%), p &lt; 0.001; NYHA functional class IV 8 (47.1%) vs 32 (68.1%) vs 26 (74.6%), p &lt; 0.001; more B-lines on lung ultrasound, M+SD 28.82 ± 8.91 vs 34.38 ± 9.64 vs 35.37 ± 8.72, p &lt; 0.001, higher NTproBNP levels, pg/l, Ме(IQR) 2100 (1800;4560) vs 3418 (2300;8434) vs 4100 (2500;9282), p &lt; 0.001, and albuminuria levels mg/g, Ме(IQR) 85 (29;145) vs 127 (49;248) vs 139 (64;245), p &lt; 0.001. The incidence of AKI (4 (23.5%) vs 23 (49%) vs 31 (88.6%), p &lt; 0.001), and in-hospital death (0 (0) vs 11 (23.4%) vs 12 (34.3%), p &lt; 0.003) was also higher in the group of patients with monophasic renal blood flow.
The presence of renal venous congestion on admission was associated with an increased risk of death due to heart failure during hospitalization with RR 1.32 (95% CI: 1.16-2.64), p &lt; 0.001, and RR 1.64 (95% CI: 1.48-2.83), p &lt; 0.001 in patients with biphasic and monophasic renal venous blood flow respectively, and with development of AKI RR 3.29 (95% CI: 1.50-7.24), p &lt; 0.003 in patients with monophasic renal venous blood flow.

Conclusion
In ICU patients with ADHF, the presence of renal venous congestion, assessed on admission with Doppler ultrasound of the intrarenal veins using the VEXUS protocol, is associated with a high risk of developing AKI and in-hospital death.