VExUS ultrasonography in the assessment of systemic venous congestion: An essential tool for the modern nephrologist

Abstract

Introduction: Systemic venous congestion is a frequently underestimated but clinically relevant finding, especially in critically ill patients with heart failure, acute kidney injury (AKI), sepsis, or chronic kidney disease. Traditional tools to assess volume status and congestion often lack sensitivity and accuracy. The emergence of point-of-care ultrasound (POCUS), and specifically the VExUS protocol (Venous Excess Ultrasound Score), provides nephrologists with a dynamic and integrative method for evaluating hemodynamic congestion and its impact on target organs.

Objetive: This article offers a comprehensive review of the VExUS protocol, detailing the pathophysiological basis of systemic venous congestion, its clinical relevance, and the limitations of conventional tools such as inferior vena cava diameter assessment. It explains the methodology of the VExUS protocol, which combines ultrasound evaluation of the inferior vena cava, hepatic veins, portal vein, and intrarenal veins using Doppler.

Methodology: The grading system of VExUS is presented to stratify the severity of congestion and guide therapeutic decisions. The clinical applications of VExUS in various nephrology settings—including intensive care units, emergency departments, dialysis units, and outpatient clinics—are discussed, as well as its role in the management of cardiorenal syndrome and fluid therapy individualization.

Results: The reviewed evidence indicates that the VExUS protocol allows for the identification and grading of systemic venous congestion through the integrated assessment of the inferior vena cava, hepatic veins, portal vein, and intrarenal veins. Available studies demonstrate its usefulness for risk stratification of acute kidney injury and for guiding the assessment and individualized management of fluid overload across different clinical settings. However, the available evidence is concentrated primarily in critically ill and postoperative patients, and its application to other populations requires further validation.

Conclusions: VExUS represents a significant advancement in the evaluation of systemic venous congestion, allowing for earlier detection, risk stratification, and personalized management. Its implementation improves diagnostic accuracy and therapeutic precision, particularly in fluid overload and AKI scenarios. With appropriate training, nephrologists can effectively integrate this tool into daily practice, enhancing multidisciplinary collaboration and patient outcomes.