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Reviews in Cardiovascular Medicine  2019, Vol. 20 Issue (4): 263-266     DOI: 10.31083/j.rcm.2019.04.564
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Alterations in Doppler-derived renal venous stasis index during decompensation of right heart failure and fluid overload in a patient with pulmonary hypertension
Faeq Husain-Syed1, 2, 3, *(), Horst-Walter Birk1, Khodr Tello3, 4, Manuel J. Richter3, 4, Claudio Ronco2, Peter A. McCullough5, Tanja Schörmann1, Fiorenza Ferrari6, Gökhan Yücel7, Babak Yazdani8, Hans-Dieter Walmrath3, 4, Werner Seeger1, 3, 4, 9, Henning Gall3, 4, H. Ardeschir Ghofrani3, 4, 10
1 Department of Internal Medicine II, Division of Nephrology, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392 Giessen, Germany
2 Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Via Rodolfi, 37-36100 Vicenza, Italy
3 Department of Internal Medicine II, Division of Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, 35392, Giessen, Germany
4 Universities of Giessen and Marburg Lung Center (UGMLC) [member of the German Center for Lung Research (DZL)], Klinikstrasse 33, 35392, Giessen, Germany
5 Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, 621 N Hall Street, Dallas, Texas 75226, USA
6 Intensive Care Unit, I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19-27100 Pavia, Italy
7 First Department of Medicine, Faculty of Medicine, University Medical Center Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
8 Fifth Department of Medicine, Faculty of Medicine, University Medical Center Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
9 Max Planck Institute for Heart and Lung Research, Parkstrasse 1, 61231 Bad Nauheim, Germany
10 Department of Pulmonology, Kerckhoff-Klinik, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
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Renal congestion is becoming recognized as a potential contributor to cardiorenal syndromes. Adequate control of congestion with simultaneous preservation of renal function has been proposed as a central goal of the management of heart failure. We report our care of a 48-year-old woman suffering from right heart failure and massive fluid overload due to severe pulmonary hypertension secondary to a combination of left-heart disease and status after recurrent pulmonary embolisms. Alterations in Doppler-derived intrarenal venous flow patterns and a novel renal venous stasis index were used to evaluate improvement in renal venous congestion during decompensation. Due to refractory congestion despite optimal medical treatment and continuous veno-venous hemodialysis, a peritoneal dialysis catheter was placed to relieve the massive ascites. The paracentesis of ascites led to a significant loss of weight, normalization of hydration status with subsequent termination of continuous veno-venous hemodialysis, and a significant improvement in clinical and echocardiographic parameters. Renal Doppler ultrasonography showed continuous improvement in intrarenal venous flow patterns and the renal venous stasis index indicative of effective decongestion up to a normal intrarenal venous flow pattern and renal venous stasis index. Furthermore, residual renal function increased during follow-up. This case demonstrates the feasibility of renal Doppler ultrasonography as a simple, non-invasive, and integrative measure of renal congestion. The renal venous stasis index and intrarenal venous flow patterns may be useful to evaluate the treatment response and to guide therapy in patients with right heart failure.

Key words:  Cardiorenal syndromes      pulmonary hypertension      renal Doppler ultrasonography      venous congestion     
Submitted:  15 September 2019      Accepted:  28 November 2019      Published:  30 December 2019     
*Corresponding Author(s):  Faeq Husain-Syed     E-mail:

Cite this article: 

Faeq Husain-Syed, Horst-Walter Birk, Khodr Tello, Manuel J. Richter, Claudio Ronco, Peter A. McCullough, Tanja Schörmann, Fiorenza Ferrari, Gökhan Yücel, Babak Yazdani, Hans-Dieter Walmrath, Werner Seeger, Henning Gall, H. Ardeschir Ghofrani. Alterations in Doppler-derived renal venous stasis index during decompensation of right heart failure and fluid overload in a patient with pulmonary hypertension. Reviews in Cardiovascular Medicine, 2019, 20(4): 263-266.

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Figure 1.  Time-course of body weight, invasive hemodynamics, right ventricular systolic function (TAPSE), neurohormonal activation (BNP), and residual renal function (eGFR using Chronic Kidney Disease Epidemiology Collaboration (Levey et al., 2009)) during hospital stay. A marked reduction in weight and BNP level, and an increase in TAPSE over time was seen after continuous relief from ascites, followed by progressive improvement in residual renal function. Dark-blue and pink bars denote CRRT and paracentesis of ascites/peritoneal ultrafiltration sessions, respectively. BNP, b-type natriuretic peptide; CRRT, continuous renal replacement therapy; eGFR, estimated glomerular filtration rate; ICU, intensive care unit; i.v., intravenous; mPAP, mean pulmonary artery pressure; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RAP, right atrial pressure; IRVF, intrarenal venous flow; RVSI, renal venous stasis index; TAPSE, tricuspid annular plane systolic excursion.

Table 1.  At a glance commentary
• The renal venous stasis index (RVSI) is a new and integrative Doppler measure of renal venous congestion.
• RVSI indicates the proportion of the cardiac cycle during which there is no renal venous outlet flow and is calculated as (cardiac cycle time-venous flow time)/cardiac cycle time.
• The present case vignette presents the potential usefulness of RVSI as a dynamic marker of alterations in renal venous congestion secondary to right heart failure.
• RVSI may provide additional prognostic information in daily clinical practice to better characterize patients with cardiorenal syndromes.
• Longitudinal studies are needed to assess the utility of renal Doppler ultrasonography-estimated renal congestion to guide decongestive or heart failure therapy.
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