Supplementary Material for: Venous Excess Doppler Ultrasound (VExUS): a Visual Guide to Decongestion in Cardiorenal syndrome

Promptly recognizing congestion, both clinical and hemodynamic is paramount in the
management of patients with heart failure. The pathophysiology of congestion involves a
complex interplay of absolute fluid gain, volume redistribution from venous capacitance beds
to the central venous circulation, inadequate excretion due to renal dysfunction, salt and water
retention, and endothelial dysfunction. While congestive nephropathy is gaining wider
recognition as a distinct variant of hemodynamic acute kidney injury (AKI), there are limited
bedside diagnostic tools for proper evaluation of these patients. In this manuscript, we describe
a case of AKI where POCUS helped us diagnose clinically silent congestion as well as monitor
the response to therapy. A patient with heart failure with mildly reduced ejection fraction was
initially administered intravenous fluids for rise in serum creatinine attributed to volume
depletion. However, POCUS demonstrated a completely different scenario with severe venous
congestion. Both sonographic stigmata of congestion and serum creatinine improved with
diuretic therapy. Furthermore, serial VExUS (Venous Excess Doppler Ultrasound) scans
facilitated the visualization of decongestion in real time.