The Use of the Venous Excess Ultrasound Score as a Bedside Tool to Predict Incidence of Acute Kidney Injury in Patients with Septic Shock, a prospective observational study

The Use of the Venous Excess Ultrasound Score as a Bedside Tool to Predict Incidence of Acute Kidney Injury in Patients with Septic Shock, a prospective observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Use of the Venous Excess Ultrasound Score as a Bedside Tool to Predict Incidence of Acute Kidney Injury in Patients with Septic Shock, a prospective observational study Hanady Mohammed Elfeky, Hatem Amin AttaAllah, Yasser Ibrahim Fathy, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5433176/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Assessment of venous congestion in septic shock patients is important, but it is often lacking due to the absence of a noninvasive bedside tool. The Venous Excess Ultrasound Grading System (VExUS) is an ultrasound score that has been associated with acute kidney injury (AKI) in cardiac patients. The objectives of this study were to assess the grade of congestion using VExUS in septic shock patients and to evaluate the correlation between serial VExUS scores and AKI, as well as the associations between VExUS scores and fluid balance, fluid overload, intensive care unit (ICU) stay duration, mechanical ventilation duration, and in-hospital mortality. Methods This was a prospective observational cohort study. We included 40 adult septic shock patients admitted to the ICU at Menoufia University Hospitals, following approval by the Ethics Committee. Patients with pregnancy, heart failure, portal hypertension, inferior vena cava thrombosis, and liver cirrhosis were excluded. Daily VExUS examinations were performed on the included patients, who were then monitored for the onset of new AKI. On day 7, patients were categorized based on changes in their VExUS scores into improving, unchanged, and worsening groups. Patients who developed AKI were followed until either the resolution of the AKI or the initiation of dialysis. Results The study enrolled forty patients, and those with AKI had higher VExUS scores (VExUS 2 and 3) than those without AKI, with significant differences on Days 2, 3, 4, and 6 of admission. Regarding VExUS status after one week, 50% of patients who developed AKI had worsening VExUS scores, compared to 16.7% of those without AKI, which is statistically significant. Furthermore, among AKI patients, 50% who improved their AKI parameters also showed improved VExUS scores, whereas none with worsening AKI parameters did. However, this change was not statistically significant. VExUS scores ≥ 2 demonstrated good specificity (83.3%) with a low false-positive rate. However, sensitivity was low (25%). Patients with worsening VExUS scores required dialysis more often (41.7%) than those with stable VExUS scores (12.5%), had longer durations of mechanical ventilation, and experienced higher mortality compared to other patients. Conclusion The VExUS score may be a useful predictor of AKI in patients with septic shock. Clinical trial registration : The study was registered in the Pan African Clinical Trials Registry: PACTR202409715853957, date:2/9/2024. Venous Excess Ultrasound Score Acute Kidney Injury Septic Shock Bedside Ultrasound Point of Care Ultrasound Figures Figure 1 Figure 2 Introduction Septic shock, a life-threatening condition arising from a dysregulated host response to infection, poses a significant challenge in critical care settings. The complex interplay of inflammatory mediators, hemodynamic instability, and organ dysfunction contributes to its high mortality rates. 1 , 2 Acute kidney injury, a frequent complication of septic shock, further exacerbates the clinical picture and impacts patient outcomes. 3 Proper identification of individuals at risk for developing AKI is essential for prompt management and improved prognosis. 4 Fluid therapy is a critical component in septic shock management that needs adequate dose and duration to avoid both dehydration and fluid overload. In recent years, there has been an increasing interest in using bedside ultrasonography to evaluate fluid status in critically ill patients. Venous congestion may arise from compromised cardiac function, venous obstruction, and fluid overload. Increased venous pressure may result in renal venous congestion, reduced glomerular filtration rate (GFR), and worsening of AKI. 5 Accurate assessment of venous congestion is essential for early intervention and effective management of septic shock and associated AKI. Recent advances in ultrasound technology, such as the venous excess ultrasound score (VExUS), provide a non-invasive means to evaluate venous congestion and predict AKI. By assessing inferior vena cava (IVC) size, portal, hepatic, and renal venous flow patterns, these tools offer valuable insights into the patient’s hemodynamic status, aiding in the timely diagnosis and management of AKI in septic shock. 6 , 7 VExUS demonstrates a strong predictive capability for AKI in septic shock, necessitating further investigation. The study suggests that VEXUS sores could be a predictive tool for the early detection of acute renal impairment in septic shock patients. It evaluates the correlation between serial VExUS scores and AKI as well as the association between VExUS scores and fluid balance, fluid overload, ICU stay duration, mechanical ventilation duration, and in-hospital mortality rates. Methods Patients We performed a prospective, observational, single-center study in the ICU at Menoufia University Hospitals (Menoufia, EGYPT). This study was approved by the Institutional Review Board of Ethics Committee in Menoufia University, Faculty of Medicine with approval number 12/2022 ANES28. All patients received a written informed letter and gave consent to participate. The study was performed according to the ethical standards in the 1964 Declaration of Helsinki. We included all patients aged 18 to 80 years diagnosed with septic shock according to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria 1 and admitted to the ICU within 24 hours of sepsis diagnosis. Patients were excluded if they were pregnant, discharged from the ICU within 7 days, had undergone cardiopulmonary resuscitation (CPR), or had any of the following conditions: IVC thrombus, conditions affecting portal Doppler assessment (e.g., cirrhosis or portal thrombosis), chronic kidney disease (CKD) with an estimated GFR < 60 mL/min/1.73 m², dialysis, moderate to severe tricuspid regurgitation, or impaired systolic function. Data Collection For included patients, demographic and clinical data were recorded, including sex, age, weight, comorbidities, vital signs, laboratory results, and daily fluid balance. We evaluated APACHE II (Acute Physiology and Chronic Health Evaluation II) and SOFA (Sequential Organ Failure Assessment) scores at admission, and reassessed SOFA after 7 days. Peripheral signs of volume overload and clinical interventions, such as mechanical ventilation and renal replacement therapy (RRT) requirements, were also evaluated. All patients underwent serial ultrasound examinations for VExUS scoring within 24 hours of ICU admission and continued daily for 7 days. We monitored kidney function and urine output daily to identify AKI, adhering to the Kidney Disease Improving Global Outcomes (KDIGO) criteria for staging. 2 On day 7, Patients were categorized into improving, unchanged, or worsening groups based on changes in their VExUS scores from baseline, with follow-up continuing until AKI resolution or the initiation of dialysis. Steps of VExUS Assessment VExUS is a four-step protocol for evaluating IVC diameter, hepatic, portal, and intra-renal veins doppler flow patterns. 3 , 4 Preparation and Patient Positioning The patient was positioned supine, with the head of the bed lowered to 0º and the legs bent. The operator was positioned on the patient's right side. An abdominal probe from the SonoScape ultrasound system (China) was used, with the abdominal preset, color Doppler (CD), and pulsed wave Doppler (PWD) to successfully conduct the exam. IVC diameter measurement The probe was placed on the patient in the sub-xiphoid location in the sagittal plane, seeing the IVC entering the right atrium in brightness mode. The diameter of the IVC was commonly measured approximately 1–2 cm caudal to the confluence of the hepatic vein as shown in Fig. 1 a. If the IVC diameter is < 2 cm, the patient is considered to have no congestion, corresponding to a VExUS score of 0. If the IVC is ≥ 2 cm and does not collapse with respiration, it may indicate venous congestion. The VExUS score is then completed by acquiring all necessary views. Hepatic vein assessment : We evaluated the middle or right hepatic veins. Initially, we identified the hepatic veins using B-mode by positioning the probe in the right upper quadrant and fanning it anteriorly and posteriorly. The hepatic veins, which are thin walled, were seen communicating with the IVC. Subsequently, we assessed the vessels with CD and applied the PWD gate to the hepatic vein. The normal flow pattern in the hepatic veins features three waves: a small retrograde A wave, followed by anterograde S and D waves. The S wave is usually significantly larger in magnitude than the D wave (S:D ratio > 1), as illustrated in Fig. 1 b. In the context of venous congestion, a diminished amplitude of the S wave suggests a mild abnormality. An eventual reversal of the S wave signals a severe waveform abnormality. 5 Portal vein assessment The portal vein was identified using B-mode by placing the probe in the right upper quadrant and fanning it anteriorly and posteriorly. The portal vein was recognized by its thick, hyperechoic walls. Then, we evaluated the vessels with CD and positioned the PWD gate within the portal vein which had normally constant monophasic flow with minimal variation during respiration as shown in Fig. 1 c. As venous congestion increased, the flow became pulsatile. The pulsatility index (PI) of the portal vein is calculated using Doppler ultrasound by calculating the maximum velocity (Vmax) to the minimum velocity (Vmin) divided by mean velocity (Vmean) over the cardiac cycle. A PI of less than 30% was normal; between 30 and 49% denoted mild portal vein abnormality, and greater than 50% indicated severe portal vein abnormality. Intra renal veins assessment Renal veins were identified using B-mode imaging positioning the probe along the right posterior axillary line. The focus was on the interlobar or arcuate renal veins within the renal cortex. Following this, we used CD to further evaluate the vessels. Finally, we assessed the venous flow using a single PWD gate placed over the CD signal, revealing a negative tracing of the venous flow with normal uninterrupted monophasic flow as shown in Fig. 1 d. As venous congestion gets worse, this creates a biphasic waveform with clear diastolic and systolic phases, which indicates a mild abnormality. If only diastolic flow is present and systolic flow is absent, this signifies a severe waveform abnormality. The VExUS score grades VExUS score ranges from grades 0–3: In grade 0, a non-dilated IVC [< 2 cm] indicates that no congestion is present. In grade 1, a dilated IVC and any combination of normal or mildly abnormal flow patterns indicate mild congestion. In grade 2, a dilated IVC and one severely abnormal flow pattern indicate moderate congestion. In grade 3, a dilated IVC and two or more severely abnormal flow patterns indicate severe congestion. 5 Sample size calculation: The sample size was calculated based on an expected effect size of 40 patients, using G*Power with 80% power and a critical t-value of 1.6. Additionally, the sample size was estimated using the formula N = Z2pq/d2​, where Z represents the standardized value for a 95% confidence level (1.96), p is the estimated proportion of the target population with the characteristic (0.03), q is 1 minus p, and d is the margin of error set at 0.05. Using these parameters, the required sample size was determined to be 40 patients. Statistical Analysis Data were analyzed using SPSS version 26.0. Descriptive statistics are reported as frequency and percentages for qualitative variables, and as mean ± standard deviation (SD) or median and interquartile range (IQR) for quantitative variables. The Chi-squared test was used to assess relationships between qualitative variables. One-way ANOVA was applied to compare more than two samples with normally distributed data, while the Kruskal-Wallis test was used for non-normally distributed data. The normality of quantitative data was evaluated using the Shapiro-Wilk test. A P-value < 0.05 was considered statistically significant. Results The study involved patients aged 18–78 years, with a mean age of 52.9 years. On admission, there were no significant differences in APACHE II and SOFA scores among patients with different VExUS scores. However, patients with worsening VExUS scores had significantly higher SOFA scores seven days after admission. Those with worse VExUS scores also had significantly higher serum creatinine levels ( Table 1 ) . Table 1 Baseline characteristics of the study subjects. Variables All patients (N = 40) VExUS status (N = 40) P-value Improving (N = 12) Worsening (N = 12) No change (N = 16) Sociodemographic data Age Mean ± SD Min.–Max 52.9 ± 14.3 18–78 54.08 ± 19.05 18–72 56.9 ± 13.4 32–78 48.9 ± 10.28 32–67 0.151 Sex Male, n (%) Female, n (%) 23 (57.5%) 17 (42.5%) 9 (75%) 3 (25%) 7 (58.3%) 5 (41.7%) 7 (43.8%) 9 (56.3%) 0.253 Weight Mean ± SD Min.–Max. 82 ± 19 40–140 80.41 ± 22.7 40 − 120 88.33 ± 21.77 65 − 140 77.5 ± 13.5 60– 100 0.335 Comorbidities HTN Yes, n (%) 9 (22.5%) 4 (33.3%) 2 (16.7%) 3 (18.8%) 0.557 DM Yes, n (%) 15(37.5%) 5 (41.7%) 5 (37.5%) 5 (31.3%) 0.801 IHD Yes, n (%) 4 (10%) 2 (16.7%) 1 (8.3%) 1 (6.3%) 0.644 Malignancy Yes, n (%) 7 (17.5%) 1 (8.3%) 2 (16.7%) 4 (25%) 0.515 Clinical scores APACHEII Median (IQR) 12 (10–14) 14 (11–15) 11 (10–13) 10 (10–13) 0.213 SOFA, Median (IQR) Admission Day 7 9 (8–12) 4 (1–8) 9 (8–12) 1(1–4) 10 (8–12) 9 (5–13) 10 (8–11) 2 (1–7) 0.763 0.01* Vital data MAP (mmHg) Median (IQR) 49 (43–55) 53 (45–55) 48 (43–53) 49 (44–55) 0.689 Heart rate (bpm) Mean ± SD 114 ± 22 112 ± 25 112 ± 18 116 ± 23 0.867 Respiratory rate (bpm) Median (IQR) 28 (25–30) 27 (25–32) 28 (25–30) 27 (25–29) 0.812 SPO2 (%) Median (IQR 92 (89–95) 90 (85–95) 91 (88–95) 92 (90–99) 0.255 Laboratory finding Serum creatinine (mg/dL) Median (IQR) Admission Day 7 1 (0.9 − 1.3) 1.2 (1–2.5) 1.2 (1–1.3) 1.1 (1–2) 1.2 (1–1.3) 2.6 (1.2–3.5) 1(0.8–1.1) 1.1 (1–1.4) 0.074 0.039* Serum lactate (mmol/L) Median (IQR) Admission Day 7 4.8 (4–6) 2 (1–4.5) 5.3 (4.2–6.1) 2 (1–4.3) 4.2 (4–6) 3.3 (1.9–5) 4.9 (4.2–6) 1.9 (1–4.3) 0.484 0.362 BUN (mg/dL) Median (IQR) 40 (27–60) 40 (26–52) 45 (40–62) 31 (26–53) 0.201 Hb(g/dl) Median (IQR) 11.1 (9.4–12.9) 12.3 (9.2–13.8) 10.3 (9–11.8) 11.2 (9.7–11.5) 0.426 Na (mEq/L) Median (IQR) 137 (135–140) 140 (138–141) 135 (134–139) 136 (134–140) 0.098 K (mEq/L Median (IQR) 4.7 (3.9–5.2) 5 (3.7–5.2) 4.9 (4.4–5.2) 4.1 (3.8–4.9) 0.133 CL (mEq/L) Median (IQR) 118 (101–132) 115 (102–130) 129 (98–134) 116 (104–131) 0.965 VExUS: venous excess ultrasound score. HTN: hypertension. DM: diabetes millitus. IHD: ischemic heart disease. ABACHII: Acute Physiology and Chronic Health Evaluation II. SOFA: Sequential Organ Failure Assessment MAP: Mean arterial pressure. SPO2: Peripheral capillary oxygen saturation.. Hb: Hemoglobin. BUN: Blood Urea Nitrogen. Na: sodium. K: potassium. CL: chloride * Significant (p value < 0.05). VExUS score frequencies at different timelines and its association with AKI Patients with AKI exhibited higher VExUS scores (VExUS 2 and 3) than those without AKI, with significant differences on Days 2, 3, 4, and 6 of admission ( Table 2 ) . Regarding VExUS status after one week, 50% of patients who developed AKI had worsening VExUS scores, compared to 16.7% of those without AKI, which is statistically significant. Furthermore, among AKI patients, 50% who improved their AKI parameters also showed improved VExUS scores, whereas none with worsening AKI parameters did. However, this change was not statistically significant ( Fig. 2 ). Table 2 Frequency of VExUS scores and AKI development in all Study groups. Variable All patients (N = 40) All patients (N = 40) P-value AKI (N = 16) No AKI (N = 24) Day 1 VExUS 0, n (%) VExUS 1, n (%) VExUS 2, n (%) VExUS 3, n (%) 15 (37.5%) 17 (42.5%) 8 (20%) 0 (0) 4 (25%) 8 (50%) 4 (25%) 0 (0) 11 (45.8%) 9 (37.5%) 4 (16.7%) 0 (0) 0.491 Day 2 VExUS 0, n (%) VExUS 1, n (%) VExUS 2, n (%) VExUS 3, n (%) 1 (2.5%) 17 (42.5%) 16 (40%) 6 (15%) 0 (0) 3 (18.8%) 8 (50%) 5 (31.2%) 1 (4.2%) 14 (58.3%) 8 (33.3%) 1 (4.2%) 0.012* Day 3 VExUS 0, n (%) VExUS 1, n (%) VExUS 2, n (%) VExUS 3, n (%) 2 (5%) 18 (45%) 15 (37.5%) 5 (12.5%) 1 (6.3%) 4 (25%) 6 (37.5%) 5 (31.2%) 1 (4.2%) 14 (58.3%) 9 (37.5%) 0 (0) 0.013* Day 4 VExUS 0, n (%) VExUS 1, n (%) VExUS 2, n (%) VExUS 3, n (%) 9 (22.5%) 12 (30%) 15 (37.5%) 4 (10%) 1 (6.3%) 5 (31.2%) 6 (37.5%) 4 (25%) 8 (33.3%) 7 (29.2%) 9 (37.5%) 0 (0) 0.028* Day 5 VExUS 0, n (%) VExUS 1, n (%) VExUS 2, n (%) VExUS 3, n (%) 6 (15%) 20 (50%) 11 (27.5%) 3 (7.5%) 1 (6.3%) 7 (43.8%) 5 (31.2%) 3 (18.8%) 5 (20.8%) 13 (54.2%) 6 (25%) 0 (0) 0.101 Day 6 VExUS 0, n (%) VExUS 1, n (%) VExUS 2, n (%) VExUS 3, n (%) 8 (20%) 23 (57.5%) 6 (15%) 3 (7.5%) 3 (18.8%) 6 (37.5%) 5 (31.2%) 2 (12.5%) 5 (20.8%) 17 (70.8%) 1 (4.2%) 1 (4.2%) 0.046* Day 7 VExUS 0, n (%) VExUS 1, n (%) VExUS 2, n (%) VExUS 3, n (%) 16 (40%) 12 (30%) 7 (17.5%) 5 (12.5%) 4 (25%) 4 (25%) 4 (25%) 4 (25%) 12 (50%) 8 (33.3%) 3 (12.5%) 1 (4.2%) 0.113 Data are presented as numbers (N) (%). VExUS: venous excess ultrasound score. AKI: acute kidney injury. * Significant (p value < 0.05). Diagnostic performance of VExUS VExUS scores ≥ 2 on admission showed good specificity (83.3%) with few false positives, but sensitivity was low (25%) ( Table 3 ) . Table 3 Diagnostic performance of VExUS ≥ 2 on admission and AKI development. Diagnostic performance Value 95% CI Lower Limit Upper Limit Sensitivity 25% 7.3% 52.4% Specificity 83.3% 62.6% 95.3% Positive predictive value 50% 22.6% 77.4% Negative predictive value 62.5% 54.4% 70% Accuracy 60% 43.3% 75.1% VExUS: venous excess ultrasound score. AKI: Acute kidney injury. CI: Confidence interval. Association of the VExUS scores and secondary outcomes Twenty-five patients (62.5%) showed symptoms of volume overload, including pedal edema in 57.5%, pulmonary edema in 35%, pleural effusion in 32.5%, and ascites in 20%. Except for pleural effusions, all volume overload indicators were significantly greater in patients with worsening VExUS scores. The mean central venous pressures (CVP) differed significantly across the three VExUS score groups: on admission, 5 days later, and 7 days post-admission. A post-hoc analysis revealed that CVP on admission was considerably higher in patients with improved or worsening VExUS scores than in those with stable VExUS scores. Patients with worsening VExUS scores had significantly higher CVP levels five and seven days after admission compared to other groups (P = 0.034 and < 0.001, respectively). Additionally, the cumulative fluid balance was significantly lower in patients with improving VExUS scores (P = 0.005). Patients with worsening VExUS scores needed dialysis significantly more often (41.7%) compared to those with stable VExUS scores (12.5%), while none of the patients showing improvement in VExUS scores required dialysis. Patients with worsening VExUS scores had significantly longer periods of mechanical ventilation and higher mortality compared to others ( Table 4 ) . Table 4 The association of the VExUS scores status and signs of volume overload, central venous pressure, cumulative fluid balance, morbidities, and mortality in all patients (N = 40) Variable All patients (N = 40) VExUS status (N = 40) P value Improving (N = 12) Worsening (N = 12) No change (N = 16) Signs of volume overload, N (%) 25 (62.5%) 6 (50%) 12 (100%) 7 (43.7%) 0.008* Pulmonary edema, N (%) 14 (35%) 4 (33.3%) 8 (66.7%) 2 (12.5%) 0.016* Pleural effusion, N (%) 13 (32.5%) 3 (25%) 7 (58.3%) 3 (18.8%) 0.077 Pedal edema, N (%) 23 (57.5%) 5 (41.7%) 11 (91.7%) 7 (43.8%) 0.018* Ascites, N (%) 8 (20%) 0 (0) 7 (58.3%) 1 (6.3%) 0.001* CVP (cmH2O), Mean ± SD 1) Admission 2) Day 3 3) Day 5 4) Day 7 10.6 ± 5.8 13 ± 4.9 13.3 ± 4.5 12.3 ± 4.9 12.7 ± 5.4 12.8 ± 3.2 13.2 ± 2.4 10.3 ± 2 12.4 ± 3.9 14.8 ± 4.1 15.9 ± 3.7 16.9 ± 3.1 7.7 ± 6.4 1.9 ± 6.2 11.6 ± 5.4 10.4 ± 5.3 0.031 * 0.308 0.034 * < 0.001 * Fluid balance (mL), Median (IQR) 1950 (1200–2500) 1350 (-700–2000) 1800 (1450–2450) 2050 (1825–2750) 0.081 C. fluid balance (mL), Median (IQR) 4200 (1355–6575) 850 (-1950–3600) 6150 (4375–7980) 4550 (2350–6500) 0.005* Clinical outcomes Needed dialysis, N (%) 7 (17.5%) 0 (0) 5 (41.7%) 2 (12.5%) 0.031 ¥ * Needed MV, N (%) 20 (50%) 8 (66.7%) 8 (66.7%) 4 (25%) 0.036* Days on MV (days), Median (IQR) 1 (0–6) 2 (0–4) 7 (0–12) 0 (0–1) 0.019* ICU stay (days), Median (IQR) 10 (8–14) 10 (8–14) 10 (8–14) 10 (7–14) 0.91 Mortality (died), N (%) 9 (22.5%) 1 (8.3%) 7 (58.3%) 1 (6.3%) 0.004 ¥ * VExUS: venous excess ultrasound score. CVP: central venous pressure. SD: standard deviation. IQR: interquartile range. C. fluid balance: cumulative fluid balance. MV: mechanical ventilation. P values followed by ¥ used Monte Carlo Test correction for Chi-squared Test. *Statistically significant at P < 0.05. IVC: Inferior vena cava. VExUS: venous excess ultrasound score. AKI: Acute kidney injury. Discussion The study analyzed 40 adult patients with septic shock in the ICU, revealing that those who developed AKI had significantly higher VExUS scores (VExUS 2 and 3) on Days 2, 3, 4, and 6 of admission. The correlation between AKI incidence and higher VExUS highlights VExUS's potential in early AKI prediction. Several studies support the prognostic value of VExUS scores in predicting AKI. For instance, Rola et al. 10 demonstrated that higher VExUS scores correlate with increased AKI risk in heart failure patients. Similarly, Viana-Rojas et al. 11 assessed the association between VExUS score and AKI in patients with acute coronary syndrome (ACS) and found that patients with a VExUS score ≥ 1 significantly raised the risk of developing acute AKI (Odds ratio (OR) = 6.8, P = 0.001). Additionally, Beaubien-Souligny et al. 12 studied the predictability of AKI using VExUS in 145 patients who underwent cardiac surgery and showed that a VExUS score > 1 at admission offered a useful positive likelihood ratio (+ LR = 6.37) in predicting AKI in these patients, aligning with our findings. These studies collectively demonstrate that elevated VExUS scores correlate with higher AKI risk across various patient populations such as those with ACS, heart failure, and post cardiac surgery. However, only two studies, Prager et al. 13 and ours, focused on septic shock patients. Prager et al. 13 found that ICU Septic patients with venous congestion, as assessed by VExUS, had a higher risk of requiring renal replacement therapy (Hazard ratio (HR) = 3.35), though not statistically significant. Our findings reinforce VExUS's efficacy in evaluating venous congestion and its renal function impact. Contrarily, a study by Andrei et al. 14 which studied VExUS scores in 145 general ICU patients showed no significant association between admission VExUS > 1 and AKI development (OR = 0.499, P = 0.136) in ICU patients. This suggests that VExUS may not be a good indicator of volume status in general ICU patients and that general ICU patients may have low susceptibility to developing severe systemic congestion, unlike our population which included patients with septic shock that have higher incidence of venous congestion and AKI. Additionally, they followed up patients for only 72 hours after admission, restricting the interpretation to this time window. While VExUS scores are effective in predicting AKI, they also extend beyond the AKI prediction. The study also sheds light on the relationship between VExUS scores and the clinical course of AKI. The observation, while not statistically significant, suggests a potential role for VExUS in monitoring the response to therapy in AKI. This observation aligns with the findings of Bhardwaj et al. who studied 30 ICU patients with a provisional diagnosis of cardiorenal syndrome and found that AKI resolution correlated significantly with improved VExUS scores (P = 0.003). 6 Rihl et al. 15 demonstrated that guiding diuretic use based on VExUS scores led to significantly more renal replacement therapy-free days over 28 days in patients with severe AKI and that patients with higher initial VExUS scores who reduced their scores within 48 hours benefited the most. Furthermore, Bitar et al. 16 assessed VExUS in 33 patients with sepsis and cardiorenal syndromes and found a link between AKI resolution and improvement in VExUS grades (P = 0.005). The diagnostic performance of VExUS ≥ 2 on admission for predicting AKI development showed high specificity (83.3%) but low sensitivity (25%), suggesting it is a strong AKI indicator when present, but its absence does not rule out AKI. A positive predictive value of 50% indicates that half of patients with a VExUS score ≥ 2 may develop AKI. A study by Natraj et al. 5 found that a VExUS score > 2 was associated with AKI following congenital heart surgeries and that a VExUS score > 2 had a specificity of 84%, which is like our study findings. This study found a strong link between worsening VExUS scores and signs of volume overload, such as pedal edema, pulmonary edema, and ascites, indicating VExUS's validity as a marker for fluid overload in septic shock. This ability to identify volume overload could help optimize fluid management and reduce AKI risk. However, this contrasts with Bhardwaj et al. 6 which found no significant correlation between VExUS scores and volume overload signs. Our research showed lower cumulative fluid balance in patients with improving VExUS scores, aligning with findings from Bhardwaj et al. 6 which showed a significant association between fluid balance and VExUS scores in patients with cardiorenal syndrome (P = 0.03) and Bitar et al. 16 showed a significant association between changes in VExUS grades and fluid balance (P = 0.006). This association between VExUS scores and fluid balance further supports its potential role in optimizing fluid management and preventing complications related to fluid overload. CVP, a traditional measure of fluid status, was significantly higher in patients with worsening VExUS scores on days 5 and 7 after admission, consistent with Menéndez-Suso et al. 17 which showed a significant association between VExUS scores and CVP elevation in critically ill children (P < 0.001). This suggests that VExUS might offer additional insights beyond CVP for assessing fluid status in septic shock. Furthermore, serum creatinine levels, a critical marker of renal function, were significantly elevated in patients exhibiting worsening VExUS scores by day 7 post-admission. This aligns with findings from Gravina et al. 18 which reported a strong correlation between VExUS score changes and improvements in renal function metrics. These findings collectively underscore the potential of VExUS as an effective tool for predicting AKI, enabling clinicians to adjust management strategies for patients at heightened risk. Worsening VExUS scores in the study were significantly associated with adverse clinical outcomes, including increased rates of dialysis and mechanical ventilation, longer ventilation durations, and higher mortality. This was consistent with Beaubien-Souligny et al. 12 showed a significantly increased mortality in patients with VExUS 2 (HR = 4.03, P < 0.001), and VExUS 3 (HR = 2.7, P = 0.03), compared to patients with VExUS scores 0 and 1. These findings highlight the clinical relevance of VExUS in predicting and potentially preventing complications in septic shock. The ability of VExUS to identify patients at risk of adverse outcomes may facilitate the implementation of targeted interventions to improve prognosis. Limitations First, the small sample size may limit the generalizability of the findings. Second, conducting the study at a single center could introduce selection bias. Additionally, the lack of ECG during VExUS score assessment makes it somewhat difficult to interpret the images and exclusion of many patients due to incomplete VExUS assessment. Excluding patients may be a source of bias. Our study may be limited by its observational, non-blind design, and we did not use a direct, quantitative indicator of congestion since it is not possible in current clinical practice. We need further research to validate the prognostic value of VExUS scores across different patient populations and settings. Standardized protocols for VExUS assessment and training programs for healthcare providers could also enhance the accuracy and consistency of measurements. Conclusion Our study highlights the significant association between VExUS scores and AKI development in septic shock patients. These findings underscore the role of venous congestion in AKI pathophysiology and position VExUS as a valuable tool for risk stratification and management in critically ill patients. This study was conducted and reported according to the STROBE guidelines for observational studies. 19 Abbreviations AKI Acute kidney injury VExUS The Venous Excess Ultrasound Grading System GFR Glomerular filtration rate ICU Intensive care unit IVC Inferior vena cava CPR Cardiopulmonary resuscitation CKD Chronic kidney disease APACHE II Acute Physiology and Chronic Health Evaluation II SOFA Sequential Organ Failure Assessment RRT Renal replacement therapy KDIGO Kidney Disease Improving Global Outcomes CD Color Doppler PWD Pulsed wave doppler Vmax Maximum velocity Vmin Minimum velocity V mean Mean velocity CVP Central venous pressures ACS Acute coronary syndrome HR Hazard Ratio Declarations Ethics approval and Consent to Participate This study was conducted from January 2023 to March 2024 in the intensive care unit (ICU) at Menoufia University Hospitals, after obtaining informed oral consent from the patient's legal surrogates and the approval of the Institutional Review Board (IRB) of Menoufia University, Menoufia, Egypt (Approval No. 12/2022 ANES28) on December 1, 2022. Data availability statement: Data is available upon reasonable request from the corresponding author. Source(s) of Support and Funding: the authors receive no specific funding for this work. Open access funding is provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB). Acknowledgements: Nil Conflict of Interest Statement: The authors declare no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Author contributions statement: Conception and study design: HME, GMF, YIF. Data collection: HME, GMF, ATH. Statistical analysis: HME, HAA, YIF. Interpretation of data: HME, HAA, YIF, GMF, ATH. Writing up the first draft of the paper: HME, GME. Critical revision of the manuscript: HME, HAA, YIF. Final approval of the manuscript: all authors. References Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock. Intensive Care Med. 2021;47(11):1181–1247. Machado FR, Cavalcanti AB, Bozza FA, et al. The epidemiology of sepsis in Brazilian intensive care units (the Sepsis Prevalence Assessment Database, SPREAD): an observational study. Lancet Infect Dis. 2017;17(11):1180–1189. White LE, Hassoun HT, Bihorac A, et al. Acute kidney injury is surprisingly common and a powerful predictor of mortality in surgical sepsis. J Trauma Acute Care Surg. 2013;75(3):432–8. Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med. 2015;41(8):1411–23. Natraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MT, Ranjit S. Venous congestion assessed by venous excess ultrasound (VExUS) and acute kidney injury in children with right ventricular dysfunction. Indian J Crit Care Med. 2024;28(5):447–452. Bhardwaj V, Vikneswaran G, Rola P, et al. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med. 2020;24(9):783–789. Pourmand A, Pyle M, Yamane D, Sumon K, Frasure SE. The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients. World J Emerg Med. 2019;10(4):232–238. Kellum JA, Lameire N, Aspelin P, et al. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2(1):1–138. Singh S, Koratala A. Utility of Doppler ultrasound derived hepatic and portal venous waveforms in the management of heart failure exacerbation. Clin Case Rep. 2020;8(8):1489–1493. Rola P, Miralles-Aguiar F, Argaiz E, et al. Clinical applications of the venous excess ultrasound (VExUS) score: conceptual review and case series. The Ultrasound Journal. 2021;13(1):32. Viana-Rojas JA, Argaiz E, Robles-Ledesma M, et al. Venous excess ultrasound score and acute kidney injury in patients with acute coronary syndrome. Eur Heart J Acute Cardiovasc Care. 2023;12(7):413–419. Beaubien-Souligny W, Rola P, Haycock K, et al. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. The Ultrasound Journal. 2020;12(1):16. Prager R, Arntfield R, Wong MYS, et al. Venous congestion in septic shock quantified with point-of-care ultrasound: a pilot prospective multicentre cohort study. Can J Anaesth. 2024;71(5):640–649. Andrei S, Bahr PA, Nguyen M, Bouhemad B, Guinot PG. Prevalence of systemic venous congestion assessed by Venous Excess Ultrasound Grading System (VExUS) and association with acute kidney injury in a general ICU cohort: a prospective multicentric study. Crit Care. 2023;27(1):224. Rihl MF, Pellegrini JAS, Boniatti MM. VExUS Score in the Management of Patients With Acute Kidney Injury in the Intensive Care Unit: AKIVEX Study. J Ultrasound Med. 2023;42(11):2547–2556. Bitar ZI, Maadarani OS, Elzoueiry MM, Abdelfatah M, Antony B, Elhabibi ME. Venous excess ultrasound score in patients with sepsis and cardiorenal syndrome. Critical Care & Shock. 2023;26(6) Menéndez-Suso JJ, Rodríguez-Álvarez D, Sánchez-Martín M. Feasibility and Utility of the Venous Excess Ultrasound Score to Detect and Grade Central Venous Pressure Elevation in Critically Ill Children. J Ultrasound Med. 2023;42(1):211–220. Gravina, Ilenia & Meo, Antonio & Verde, et al. #1988 VExUS score as a method to guide diuretic treatment in CKD patients with congestive nephropathy by right heart failure. Nephrology Dialysis Transplantation. 2024;39.10.1093/ndt/gfae069.1125. von Elm E, Altman DG, Egger M, et al. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5433176","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":385034918,"identity":"d968b893-225d-4600-9e85-b444810b54d4","order_by":0,"name":"Hanady Mohammed Elfeky","email":"data:image/png;base64,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","orcid":"","institution":"Menoufia University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hanady","middleName":"Mohammed","lastName":"Elfeky","suffix":""},{"id":385034919,"identity":"5bc134fc-92bd-4bff-93d4-a10dee56cd6c","order_by":1,"name":"Hatem Amin AttaAllah","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hatem","middleName":"Amin","lastName":"AttaAllah","suffix":""},{"id":385034920,"identity":"9d8df4d8-707f-4066-93c5-9f44fbe34722","order_by":2,"name":"Yasser Ibrahim Fathy","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yasser","middleName":"Ibrahim","lastName":"Fathy","suffix":""},{"id":385034921,"identity":"ef7dd662-a121-4e46-9f78-9441df7acedd","order_by":3,"name":"Gehad Mahmoud Fawzi","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gehad","middleName":"Mahmoud","lastName":"Fawzi","suffix":""},{"id":385034922,"identity":"5f8722eb-56a4-49fd-be07-cf36727984d7","order_by":4,"name":"Ahmed Taha Helwa","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Taha","lastName":"Helwa","suffix":""}],"badges":[],"createdAt":"2024-11-11 15:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5433176/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5433176/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71612116,"identity":"8b08a39b-7441-4ace-b9c1-e1f508676b40","added_by":"auto","created_at":"2024-12-17 06:57:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":313255,"visible":true,"origin":"","legend":"\u003cp\u003eSteps for the venous excess ultrasound score: \u003cstrong\u003ePanel a:\u003c/strong\u003e Measurement of the IVC diameter. \u003cstrong\u003ePanel b\u003c/strong\u003e: The hepatic veins with normal triphasic waveform. \u003cstrong\u003ePanel c\u003c/strong\u003e: Portal vein normal waveform pattern. \u003cstrong\u003ePanel d\u003c/strong\u003e: Interlobar veins, revealing a normal flow with a negative tracing.\u003c/p\u003e\n\u003cp\u003eIVC: Inferior vena cava.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5433176/v1/d2145627f90b09bc8157784a.jpg"},{"id":71612115,"identity":"effd2386-17b6-4f9b-b8bb-ef495445b267","added_by":"auto","created_at":"2024-12-17 06:57:26","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":220275,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of VExUS scores in \u003cstrong\u003ea)\u003c/strong\u003e all study group (N= 40) and in \u003cstrong\u003eb)\u003c/strong\u003e patients who developed AKI (N = 16).\u003c/p\u003e\n\u003cp\u003eVExUS: venous excess ultrasound score. AKI: Acute kidney injury.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5433176/v1/e14deb3f3c37111f54b40753.jpg"},{"id":72508672,"identity":"1f4e1d11-337b-4ae4-9452-462917190b4f","added_by":"auto","created_at":"2024-12-28 08:01:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1450348,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5433176/v1/1a5bc0ed-05ed-4041-844c-793a7402e13e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Use of the Venous Excess Ultrasound Score as a Bedside Tool to Predict Incidence of Acute Kidney Injury in Patients with Septic Shock, a prospective observational study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSeptic shock, a life-threatening condition arising from a dysregulated host response to infection, poses a significant challenge in critical care settings. The complex interplay of inflammatory mediators, hemodynamic instability, and organ dysfunction contributes to its high mortality rates.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Acute kidney injury, a frequent complication of septic shock, further exacerbates the clinical picture and impacts patient outcomes.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eProper identification of individuals at risk for developing AKI is essential for prompt management and improved prognosis.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Fluid therapy is a critical component in septic shock management that needs adequate dose and duration to avoid both dehydration and fluid overload. In recent years, there has been an increasing interest in using bedside ultrasonography to evaluate fluid status in critically ill patients. Venous congestion may arise from compromised cardiac function, venous obstruction, and fluid overload. Increased venous pressure may result in renal venous congestion, reduced glomerular filtration rate (GFR), and worsening of AKI.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Accurate assessment of venous congestion is essential for early intervention and effective management of septic shock and associated AKI. Recent advances in ultrasound technology, such as the venous excess ultrasound score (VExUS), provide a non-invasive means to evaluate venous congestion and predict AKI. By assessing inferior vena cava (IVC) size, portal, hepatic, and renal venous flow patterns, these tools offer valuable insights into the patient\u0026rsquo;s hemodynamic status, aiding in the timely diagnosis and management of AKI in septic shock.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eVExUS demonstrates a strong predictive capability for AKI in septic shock, necessitating further investigation. The study suggests that VEXUS sores could be a predictive tool for the early detection of acute renal impairment in septic shock patients. It evaluates the correlation between serial VExUS scores and AKI as well as the association between VExUS scores and fluid balance, fluid overload, ICU stay duration, mechanical ventilation duration, and in-hospital mortality rates.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eWe performed a prospective, observational, single-center study in the ICU at Menoufia University Hospitals (Menoufia, EGYPT). This study was approved by the Institutional Review Board of Ethics Committee in Menoufia University, Faculty of Medicine with approval number 12/2022 ANES28. All patients received a written informed letter and gave consent to participate. The study was performed according to the ethical standards in the 1964 Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eWe included all patients aged 18 to 80 years diagnosed with septic shock according to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e and admitted to the ICU within 24 hours of sepsis diagnosis. Patients were excluded if they were pregnant, discharged from the ICU within 7 days, had undergone cardiopulmonary resuscitation (CPR), or had any of the following conditions: IVC thrombus, conditions affecting portal Doppler assessment (e.g., cirrhosis or portal thrombosis), chronic kidney disease (CKD) with an estimated GFR\u0026thinsp;\u0026lt;\u0026thinsp;60 mL/min/1.73 m\u0026sup2;, dialysis, moderate to severe tricuspid regurgitation, or impaired systolic function.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eFor included patients, demographic and clinical data were recorded, including sex, age, weight, comorbidities, vital signs, laboratory results, and daily fluid balance. We evaluated APACHE II (Acute Physiology and Chronic Health Evaluation II) and SOFA (Sequential Organ Failure Assessment) scores at admission, and reassessed SOFA after 7 days. Peripheral signs of volume overload and clinical interventions, such as mechanical ventilation and renal replacement therapy (RRT) requirements, were also evaluated.\u003c/p\u003e \u003cp\u003eAll patients underwent serial ultrasound examinations for VExUS scoring within 24 hours of ICU admission and continued daily for 7 days. We monitored kidney function and urine output daily to identify AKI, adhering to the Kidney Disease Improving Global Outcomes (KDIGO) criteria for staging. \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e On day 7, Patients were categorized into improving, unchanged, or worsening groups based on changes in their VExUS scores from baseline, with follow-up continuing until AKI resolution or the initiation of dialysis.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSteps of VExUS Assessment\u003c/h2\u003e \u003cp\u003eVExUS is a four-step protocol for evaluating IVC diameter, hepatic, portal, and intra-renal veins doppler flow patterns.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePreparation and Patient Positioning\u003c/strong\u003e \u003cp\u003eThe patient was positioned supine, with the head of the bed lowered to 0\u0026ordm; and the legs bent. The operator was positioned on the patient's right side. An abdominal probe from the SonoScape ultrasound system (China) was used, with the abdominal preset, color Doppler (CD), and pulsed wave Doppler (PWD) to successfully conduct the exam.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIVC diameter measurement\u003c/strong\u003e \u003cp\u003eThe probe was placed on the patient in the sub-xiphoid location in the sagittal plane, seeing the IVC entering the right atrium in brightness mode. The diameter of the IVC was commonly measured approximately 1\u0026ndash;2 cm caudal to the confluence of the hepatic vein as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea. If the IVC diameter is \u0026lt;\u0026thinsp;2 cm, the patient is considered to have no congestion, corresponding to a VExUS score of 0. If the IVC is \u0026ge;\u0026thinsp;2 cm and does not collapse with respiration, it may indicate venous congestion. The VExUS score is then completed by acquiring all necessary views.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eHepatic vein assessment\u003c/b\u003e: We evaluated the middle or right hepatic veins. Initially, we identified the hepatic veins using B-mode by positioning the probe in the right upper quadrant and fanning it anteriorly and posteriorly. The hepatic veins, which are thin walled, were seen communicating with the IVC. Subsequently, we assessed the vessels with CD and applied the PWD gate to the hepatic vein. The normal flow pattern in the hepatic veins features three waves: a small retrograde A wave, followed by anterograde S and D waves. The S wave is usually significantly larger in magnitude than the D wave (S:D ratio\u0026thinsp;\u0026gt;\u0026thinsp;1), as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb. In the context of venous congestion, a diminished amplitude of the S wave suggests a mild abnormality. An eventual reversal of the S wave signals a severe waveform abnormality.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePortal vein assessment\u003c/strong\u003e \u003cp\u003eThe portal vein was identified using B-mode by placing the probe in the right upper quadrant and fanning it anteriorly and posteriorly. The portal vein was recognized by its thick, hyperechoic walls. Then, we evaluated the vessels with CD and positioned the PWD gate within the portal vein which had normally constant monophasic flow with minimal variation during respiration as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec. As venous congestion increased, the flow became pulsatile. The pulsatility index (PI) of the portal vein is calculated using Doppler ultrasound by calculating the maximum velocity (Vmax) to the minimum velocity (Vmin) divided by mean velocity (Vmean) over the cardiac cycle. A PI of less than 30% was normal; between 30 and 49% denoted mild portal vein abnormality, and greater than 50% indicated severe portal vein abnormality.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIntra renal veins assessment\u003c/strong\u003e \u003cp\u003eRenal veins were identified using B-mode imaging positioning the probe along the right posterior axillary line. The focus was on the interlobar or arcuate renal veins within the renal cortex. Following this, we used CD to further evaluate the vessels. Finally, we assessed the venous flow using a single PWD gate placed over the CD signal, revealing a negative tracing of the venous flow with normal uninterrupted monophasic flow as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed. As venous congestion gets worse, this creates a biphasic waveform with clear diastolic and systolic phases, which indicates a mild abnormality. If only diastolic flow is present and systolic flow is absent, this signifies a severe waveform abnormality.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eThe VExUS score grades\u003c/h2\u003e \u003cp\u003eVExUS score ranges from grades 0\u0026ndash;3: In grade 0, a non-dilated IVC [\u0026lt;\u0026thinsp;2 cm] indicates that no congestion is present. In grade 1, a dilated IVC and any combination of normal or mildly abnormal flow patterns indicate mild congestion. In grade 2, a dilated IVC and one severely abnormal flow pattern indicate moderate congestion. In grade 3, a dilated IVC and two or more severely abnormal flow patterns indicate severe congestion.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eSample size calculation:\u003c/h2\u003e \u003cp\u003eThe sample size was calculated based on an expected effect size of 40 patients, using G*Power with 80% power and a critical t-value of 1.6. Additionally, the sample size was estimated using the formula N\u0026thinsp;=\u0026thinsp;Z2pq/d2​, where Z represents the standardized value for a 95% confidence level (1.96), p is the estimated proportion of the target population with the characteristic (0.03), q is 1 minus p, and d is the margin of error set at 0.05. Using these parameters, the required sample size was determined to be 40 patients.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS version 26.0. Descriptive statistics are reported as frequency and percentages for qualitative variables, and as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median and interquartile range (IQR) for quantitative variables. The Chi-squared test was used to assess relationships between qualitative variables. One-way ANOVA was applied to compare more than two samples with normally distributed data, while the Kruskal-Wallis test was used for non-normally distributed data. The normality of quantitative data was evaluated using the Shapiro-Wilk test. A P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study involved patients aged 18\u0026ndash;78 years, with a mean age of 52.9 years. On admission, there were no significant differences in APACHE II and SOFA scores among patients with different VExUS scores. However, patients with worsening VExUS scores had significantly higher SOFA scores seven days after admission. Those with worse VExUS scores also had significantly higher serum creatinine levels \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study subjects.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eVExUS status (N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImproving\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWorsening\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSociodemographic data\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003cp\u003eMin.\u0026ndash;Max\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e \u003cp\u003e18\u0026ndash;78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54.08\u0026thinsp;\u0026plusmn;\u0026thinsp;19.05\u003c/p\u003e \u003cp\u003e18\u0026ndash;72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e \u003cp\u003e32\u0026ndash;78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.28\u003c/p\u003e \u003cp\u003e32\u0026ndash;67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.151\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003cp\u003eFemale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (57.5%)\u003c/p\u003e \u003cp\u003e17 (42.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (75%)\u003c/p\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (58.3%)\u003c/p\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (43.8%)\u003c/p\u003e \u003cp\u003e9 (56.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003cp\u003eMin.\u0026ndash;Max.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82\u0026thinsp;\u0026plusmn;\u0026thinsp;19\u003c/p\u003e \u003cp\u003e40\u0026ndash;140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80.41\u0026thinsp;\u0026plusmn;\u0026thinsp;22.7\u003c/p\u003e \u003cp\u003e40 \u0026minus;\u0026thinsp;120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.33\u0026thinsp;\u0026plusmn;\u0026thinsp;21.77\u003c/p\u003e \u003cp\u003e65 \u0026minus;\u0026thinsp;140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77.5\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e \u003cp\u003e60\u0026ndash; 100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (22.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.557\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (31.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.801\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.644\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAPACHEII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (10\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (11\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (10\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (10\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.213\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSOFA, Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdmission\u003c/p\u003e \u003cp\u003eDay 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (8\u0026ndash;12)\u003c/p\u003e \u003cp\u003e4 (1\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (8\u0026ndash;12)\u003c/p\u003e \u003cp\u003e1(1\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (8\u0026ndash;12)\u003c/p\u003e \u003cp\u003e9 (5\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (8\u0026ndash;11)\u003c/p\u003e \u003cp\u003e2 (1\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.763\u003c/p\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVital data\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (43\u0026ndash;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (45\u0026ndash;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48 (43\u0026ndash;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49 (44\u0026ndash;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart rate (bpm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114\u0026thinsp;\u0026plusmn;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112\u0026thinsp;\u0026plusmn;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e112\u0026thinsp;\u0026plusmn;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e116\u0026thinsp;\u0026plusmn;\u0026thinsp;23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespiratory rate (bpm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (25\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (25\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (25\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27 (25\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.812\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPO2 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92 (89\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90 (85\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91 (88\u0026ndash;95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92 (90\u0026ndash;99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaboratory finding\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum creatinine\u003c/p\u003e \u003cp\u003e(mg/dL)\u003c/p\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdmission\u003c/p\u003e \u003cp\u003eDay 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.9 \u0026minus;\u0026thinsp;1.3)\u003c/p\u003e \u003cp\u003e1.2 (1\u0026ndash;2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.2 (1\u0026ndash;1.3)\u003c/p\u003e \u003cp\u003e1.1 (1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.2 (1\u0026ndash;1.3)\u003c/p\u003e \u003cp\u003e2.6 (1.2\u0026ndash;3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1(0.8\u0026ndash;1.1)\u003c/p\u003e \u003cp\u003e1.1 (1\u0026ndash;1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003cp\u003e0.039*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum lactate (mmol/L)\u003c/p\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdmission\u003c/p\u003e \u003cp\u003eDay 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8 (4\u0026ndash;6)\u003c/p\u003e \u003cp\u003e2 (1\u0026ndash;4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.3 (4.2\u0026ndash;6.1)\u003c/p\u003e \u003cp\u003e2 (1\u0026ndash;4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.2 (4\u0026ndash;6)\u003c/p\u003e \u003cp\u003e3.3 (1.9\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.9 (4.2\u0026ndash;6)\u003c/p\u003e \u003cp\u003e1.9 (1\u0026ndash;4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.484\u003c/p\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBUN\u003c/p\u003e \u003cp\u003e(mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (27\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (26\u0026ndash;52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45 (40\u0026ndash;62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31 (26\u0026ndash;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.201\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb(g/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.1 (9.4\u0026ndash;12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.3 (9.2\u0026ndash;13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.3 (9\u0026ndash;11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.2 (9.7\u0026ndash;11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.426\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNa\u003c/p\u003e \u003cp\u003e(mEq/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137 (135\u0026ndash;140)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e140 (138\u0026ndash;141)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e135 (134\u0026ndash;139)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e136 (134\u0026ndash;140)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eK\u003c/p\u003e \u003cp\u003e(mEq/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.7 (3.9\u0026ndash;5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (3.7\u0026ndash;5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.9 (4.4\u0026ndash;5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.1 (3.8\u0026ndash;4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCL\u003c/p\u003e \u003cp\u003e(mEq/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118 (101\u0026ndash;132)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115 (102\u0026ndash;130)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e129 (98\u0026ndash;134)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e116 (104\u0026ndash;131)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.965\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eVExUS: venous excess ultrasound score. HTN: hypertension. DM: diabetes millitus. IHD: ischemic heart disease. ABACHII: Acute Physiology and Chronic Health Evaluation II. SOFA: Sequential Organ Failure Assessment MAP: Mean arterial pressure. SPO2: Peripheral capillary oxygen saturation.. Hb: Hemoglobin. BUN: Blood Urea Nitrogen. Na: sodium. K: potassium. CL: chloride * Significant (p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eVExUS score frequencies at different timelines and its association with AKI\u003c/h2\u003e \u003cp\u003ePatients with AKI exhibited higher VExUS scores (VExUS 2 and 3) than those without AKI, with significant differences on Days 2, 3, 4, and 6 of admission \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Regarding VExUS status after one week, 50% of patients who developed AKI had worsening VExUS scores, compared to 16.7% of those without AKI, which is statistically significant. Furthermore, among AKI patients, 50% who improved their AKI parameters also showed improved VExUS scores, whereas none with worsening AKI parameters did. However, this change was not statistically significant \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of VExUS scores and AKI development in all Study groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAll patients (N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAKI\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo AKI\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVExUS 0, n (%)\u003c/p\u003e \u003cp\u003eVExUS 1, n (%)\u003c/p\u003e \u003cp\u003eVExUS 2, n (%)\u003c/p\u003e \u003cp\u003eVExUS 3, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (37.5%)\u003c/p\u003e \u003cp\u003e17 (42.5%)\u003c/p\u003e \u003cp\u003e8 (20%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003cp\u003e8 (50%)\u003c/p\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (45.8%)\u003c/p\u003e \u003cp\u003e9 (37.5%)\u003c/p\u003e \u003cp\u003e4 (16.7%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVExUS 0, n (%)\u003c/p\u003e \u003cp\u003eVExUS 1, n (%)\u003c/p\u003e \u003cp\u003eVExUS 2, n (%)\u003c/p\u003e \u003cp\u003eVExUS 3, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.5%)\u003c/p\u003e \u003cp\u003e17 (42.5%)\u003c/p\u003e \u003cp\u003e16 (40%)\u003c/p\u003e \u003cp\u003e6 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e3 (18.8%)\u003c/p\u003e \u003cp\u003e8 (50%)\u003c/p\u003e \u003cp\u003e5 (31.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (4.2%)\u003c/p\u003e \u003cp\u003e14 (58.3%)\u003c/p\u003e \u003cp\u003e8 (33.3%)\u003c/p\u003e \u003cp\u003e1 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.012*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVExUS 0, n (%)\u003c/p\u003e \u003cp\u003eVExUS 1, n (%)\u003c/p\u003e \u003cp\u003eVExUS 2, n (%)\u003c/p\u003e \u003cp\u003eVExUS 3, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5%)\u003c/p\u003e \u003cp\u003e18 (45%)\u003c/p\u003e \u003cp\u003e15 (37.5%)\u003c/p\u003e \u003cp\u003e5 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003cp\u003e6 (37.5%)\u003c/p\u003e \u003cp\u003e5 (31.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (4.2%)\u003c/p\u003e \u003cp\u003e14 (58.3%)\u003c/p\u003e \u003cp\u003e9 (37.5%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.013*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVExUS 0, n (%)\u003c/p\u003e \u003cp\u003eVExUS 1, n (%)\u003c/p\u003e \u003cp\u003eVExUS 2, n (%)\u003c/p\u003e \u003cp\u003eVExUS 3, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (22.5%)\u003c/p\u003e \u003cp\u003e12 (30%)\u003c/p\u003e \u003cp\u003e15 (37.5%)\u003c/p\u003e \u003cp\u003e4 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003cp\u003e5 (31.2%)\u003c/p\u003e \u003cp\u003e6 (37.5%)\u003c/p\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (33.3%)\u003c/p\u003e \u003cp\u003e7 (29.2%)\u003c/p\u003e \u003cp\u003e9 (37.5%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.028*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVExUS 0, n (%)\u003c/p\u003e \u003cp\u003eVExUS 1, n (%)\u003c/p\u003e \u003cp\u003eVExUS 2, n (%)\u003c/p\u003e \u003cp\u003eVExUS 3, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (15%)\u003c/p\u003e \u003cp\u003e20 (50%)\u003c/p\u003e \u003cp\u003e11 (27.5%)\u003c/p\u003e \u003cp\u003e3 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003cp\u003e7 (43.8%)\u003c/p\u003e \u003cp\u003e5 (31.2%)\u003c/p\u003e \u003cp\u003e3 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (20.8%)\u003c/p\u003e \u003cp\u003e13 (54.2%)\u003c/p\u003e \u003cp\u003e6 (25%)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVExUS 0, n (%)\u003c/p\u003e \u003cp\u003eVExUS 1, n (%)\u003c/p\u003e \u003cp\u003eVExUS 2, n (%)\u003c/p\u003e \u003cp\u003eVExUS 3, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (20%)\u003c/p\u003e \u003cp\u003e23 (57.5%)\u003c/p\u003e \u003cp\u003e6 (15%)\u003c/p\u003e \u003cp\u003e3 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (18.8%)\u003c/p\u003e \u003cp\u003e6 (37.5%)\u003c/p\u003e \u003cp\u003e5 (31.2%)\u003c/p\u003e \u003cp\u003e2 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (20.8%)\u003c/p\u003e \u003cp\u003e17 (70.8%)\u003c/p\u003e \u003cp\u003e1 (4.2%)\u003c/p\u003e \u003cp\u003e1 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.046*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVExUS 0, n (%)\u003c/p\u003e \u003cp\u003eVExUS 1, n (%)\u003c/p\u003e \u003cp\u003eVExUS 2, n (%)\u003c/p\u003e \u003cp\u003eVExUS 3, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (40%)\u003c/p\u003e \u003cp\u003e12 (30%)\u003c/p\u003e \u003cp\u003e7 (17.5%)\u003c/p\u003e \u003cp\u003e5 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (50%)\u003c/p\u003e \u003cp\u003e8 (33.3%)\u003c/p\u003e \u003cp\u003e3 (12.5%)\u003c/p\u003e \u003cp\u003e1 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eData are presented as numbers (N) (%). VExUS: venous excess ultrasound score. AKI: acute kidney injury. * Significant (p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDiagnostic performance of VExUS\u003c/h2\u003e \u003cp\u003eVExUS scores\u0026thinsp;\u0026ge;\u0026thinsp;2 on admission showed good specificity (83.3%) with few false positives, but sensitivity was low (25%) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic performance of VExUS\u0026thinsp;\u0026ge;\u0026thinsp;2 on admission and AKI development.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDiagnostic performance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower Limit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUpper Limit\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive predictive value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative predictive value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccuracy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eVExUS: venous excess ultrasound score. AKI: Acute kidney injury. CI: Confidence interval.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAssociation of the VExUS scores and secondary outcomes\u003c/h2\u003e \u003cp\u003eTwenty-five patients (62.5%) showed symptoms of volume overload, including pedal edema in 57.5%, pulmonary edema in 35%, pleural effusion in 32.5%, and ascites in 20%. Except for pleural effusions, all volume overload indicators were significantly greater in patients with worsening VExUS scores. The mean central venous pressures (CVP) differed significantly across the three VExUS score groups: on admission, 5 days later, and 7 days post-admission. A post-hoc analysis revealed that CVP on admission was considerably higher in patients with improved or worsening VExUS scores than in those with stable VExUS scores. Patients with worsening VExUS scores had significantly higher CVP levels five and seven days after admission compared to other groups (P\u0026thinsp;=\u0026thinsp;0.034 and \u0026lt;\u0026thinsp;0.001, respectively). Additionally, the cumulative fluid balance was significantly lower in patients with improving VExUS scores (P\u0026thinsp;=\u0026thinsp;0.005). Patients with worsening VExUS scores needed dialysis significantly more often (41.7%) compared to those with stable VExUS scores (12.5%), while none of the patients showing improvement in VExUS scores required dialysis. Patients with worsening VExUS scores had significantly longer periods of mechanical ventilation and higher mortality compared to others \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe association of the VExUS scores status and signs of volume overload, central venous pressure, cumulative fluid balance, morbidities, and mortality in all patients (N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eVExUS status (N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImproving\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWorsening\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSigns of volume overload, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (62.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (43.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.008*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary edema, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.016*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (32.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePedal edema, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (57.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (91.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (43.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.018*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscites, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCVP (cmH2O), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003cp\u003e1) Admission\u003c/p\u003e \u003cp\u003e2) Day 3\u003c/p\u003e \u003cp\u003e3) Day 5\u003c/p\u003e \u003cp\u003e4) Day 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e \u003cp\u003e13\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003cp\u003e13.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003cp\u003e12.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003cp\u003e12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003cp\u003e13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003cp\u003e10.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003cp\u003e15.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003cp\u003e16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003cp\u003e11.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003cp\u003e10.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.031\u003cem\u003e*\u003c/em\u003e\u003c/p\u003e \u003cp\u003e0.308\u003c/p\u003e \u003cp\u003e0.034\u003cem\u003e*\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003cem\u003e*\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFluid balance (mL), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1950\u003c/p\u003e \u003cp\u003e(1200\u0026ndash;2500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1350\u003c/p\u003e \u003cp\u003e(-700\u0026ndash;2000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1800\u003c/p\u003e \u003cp\u003e(1450\u0026ndash;2450)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2050\u003c/p\u003e \u003cp\u003e(1825\u0026ndash;2750)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC. fluid balance (mL), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4200\u003c/p\u003e \u003cp\u003e(1355\u0026ndash;6575)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e850\u003c/p\u003e \u003cp\u003e(-1950\u0026ndash;3600)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6150\u003c/p\u003e \u003cp\u003e(4375\u0026ndash;7980)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4550\u003c/p\u003e \u003cp\u003e(2350\u0026ndash;6500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.005*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeeded dialysis, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.031\u003cem\u003e\u0026yen;\u003c/em\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeeded MV, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.036*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDays on MV (days), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (0\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.019*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU stay (days), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (8\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (8\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (8\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (7\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality (died), N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (22.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.004\u003cem\u003e\u0026yen;\u003c/em\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eVExUS: venous excess ultrasound score. CVP: central venous pressure. SD: standard deviation. IQR: interquartile range. C. fluid balance: cumulative fluid balance. MV: mechanical ventilation. P values followed by \u0026yen; used Monte Carlo Test correction for Chi-squared Test. *Statistically significant at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eIVC: Inferior vena cava.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eVExUS: venous excess ultrasound score. AKI: Acute kidney injury.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eThe study analyzed 40 adult patients with septic shock in the ICU, revealing that those who developed AKI had significantly higher VExUS scores (VExUS 2 and 3) on Days 2, 3, 4, and 6 of admission. The correlation between AKI incidence and higher VExUS highlights VExUS's potential in early AKI prediction. Several studies support the prognostic value of VExUS scores in predicting AKI. For instance, Rola et al.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e demonstrated that higher VExUS scores correlate with increased AKI risk in heart failure patients. Similarly, Viana-Rojas et al.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e assessed the association between VExUS score and AKI in patients with acute coronary syndrome (ACS) and found that patients with a VExUS score\u0026thinsp;\u0026ge;\u0026thinsp;1 significantly raised the risk of developing acute AKI (Odds ratio (OR)\u0026thinsp;=\u0026thinsp;6.8, P\u0026thinsp;=\u0026thinsp;0.001). Additionally, Beaubien-Souligny et al.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e studied the predictability of AKI using VExUS in 145 patients who underwent cardiac surgery and showed that a VExUS score\u0026thinsp;\u0026gt;\u0026thinsp;1 at admission offered a useful positive likelihood ratio (+\u0026thinsp;LR\u0026thinsp;=\u0026thinsp;6.37) in predicting AKI in these patients, aligning with our findings. These studies collectively demonstrate that elevated VExUS scores correlate with higher AKI risk across various patient populations such as those with ACS, heart failure, and post cardiac surgery. However, only two studies, Prager et al.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and ours, focused on septic shock patients. Prager et al.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e found that ICU Septic patients with venous congestion, as assessed by VExUS, had a higher risk of requiring renal replacement therapy (Hazard ratio (HR)\u0026thinsp;=\u0026thinsp;3.35), though not statistically significant.\u003c/p\u003e \u003cp\u003eOur findings reinforce VExUS's efficacy in evaluating venous congestion and its renal function impact. Contrarily, a study by Andrei et al.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e which studied VExUS scores in 145 general ICU patients showed no significant association between admission VExUS\u0026thinsp;\u0026gt;\u0026thinsp;1 and AKI development (OR\u0026thinsp;=\u0026thinsp;0.499, P\u0026thinsp;=\u0026thinsp;0.136) in ICU patients. This suggests that VExUS may not be a good indicator of volume status in general ICU patients and that general ICU patients may have low susceptibility to developing severe systemic congestion, unlike our population which included patients with septic shock that have higher incidence of venous congestion and AKI. Additionally, they followed up patients for only 72 hours after admission, restricting the interpretation to this time window. While VExUS scores are effective in predicting AKI, they also extend beyond the AKI prediction. The study also sheds light on the relationship between VExUS scores and the clinical course of AKI. The observation, while not statistically significant, suggests a potential role for VExUS in monitoring the response to therapy in AKI. This observation aligns with the findings of Bhardwaj et al. who studied 30 ICU patients with a provisional diagnosis of cardiorenal syndrome and found that AKI resolution correlated significantly with improved VExUS scores (P\u0026thinsp;=\u0026thinsp;0.003).\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRihl et al.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e demonstrated that guiding diuretic use based on VExUS scores led to significantly more renal replacement therapy-free days over 28 days in patients with severe AKI and that patients with higher initial VExUS scores who reduced their scores within 48 hours benefited the most. Furthermore, Bitar et al.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e assessed VExUS in 33 patients with sepsis and cardiorenal syndromes and found a link between AKI resolution and improvement in VExUS grades (P\u0026thinsp;=\u0026thinsp;0.005). The diagnostic performance of VExUS\u0026thinsp;\u0026ge;\u0026thinsp;2 on admission for predicting AKI development showed high specificity (83.3%) but low sensitivity (25%), suggesting it is a strong AKI indicator when present, but its absence does not rule out AKI. A positive predictive value of 50% indicates that half of patients with a VExUS score\u0026thinsp;\u0026ge;\u0026thinsp;2 may develop AKI.\u003c/p\u003e \u003cp\u003eA study by Natraj et al. \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e found that a VExUS score\u0026thinsp;\u0026gt;\u0026thinsp;2 was associated with AKI following congenital heart surgeries and that a VExUS score\u0026thinsp;\u0026gt;\u0026thinsp;2 had a specificity of 84%, which is like our study findings.\u003c/p\u003e \u003cp\u003eThis study found a strong link between worsening VExUS scores and signs of volume overload, such as pedal edema, pulmonary edema, and ascites, indicating VExUS's validity as a marker for fluid overload in septic shock. This ability to identify volume overload could help optimize fluid management and reduce AKI risk.\u003c/p\u003e \u003cp\u003eHowever, this contrasts with Bhardwaj et al.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e which found no significant correlation between VExUS scores and volume overload signs.\u003c/p\u003e \u003cp\u003eOur research showed lower cumulative fluid balance in patients with improving VExUS scores, aligning with findings from Bhardwaj et al.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e which showed a significant association between fluid balance and VExUS scores in patients with cardiorenal syndrome (P\u0026thinsp;=\u0026thinsp;0.03) and Bitar et al.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e showed a significant association between changes in VExUS grades and fluid balance (P\u0026thinsp;=\u0026thinsp;0.006). This association between VExUS scores and fluid balance further supports its potential role in optimizing fluid management and preventing complications related to fluid overload. CVP, a traditional measure of fluid status, was significantly higher in patients with worsening VExUS scores on days 5 and 7 after admission, consistent with Men\u0026eacute;ndez-Suso et al.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e which showed a significant association between VExUS scores and CVP elevation in critically ill children (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This suggests that VExUS might offer additional insights beyond CVP for assessing fluid status in septic shock. Furthermore, serum creatinine levels, a critical marker of renal function, were significantly elevated in patients exhibiting worsening VExUS scores by day 7 post-admission.\u003c/p\u003e \u003cp\u003eThis aligns with findings from Gravina et al.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e which reported a strong correlation between VExUS score changes and improvements in renal function metrics. These findings collectively underscore the potential of VExUS as an effective tool for predicting AKI, enabling clinicians to adjust management strategies for patients at heightened risk. Worsening VExUS scores in the study were significantly associated with adverse clinical outcomes, including increased rates of dialysis and mechanical ventilation, longer ventilation durations, and higher mortality. This was consistent with Beaubien-Souligny et al.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e showed a significantly increased mortality in patients with VExUS 2 (HR\u0026thinsp;=\u0026thinsp;4.03, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and VExUS 3 (HR\u0026thinsp;=\u0026thinsp;2.7, P\u0026thinsp;=\u0026thinsp;0.03), compared to patients with VExUS scores 0 and 1. These findings highlight the clinical relevance of VExUS in predicting and potentially preventing complications in septic shock. The ability of VExUS to identify patients at risk of adverse outcomes may facilitate the implementation of targeted interventions to improve prognosis.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLimitations\u003c/strong\u003e \u003cp\u003eFirst, the small sample size may limit the generalizability of the findings. Second, conducting the study at a single center could introduce selection bias. Additionally, the lack of ECG during VExUS score assessment makes it somewhat difficult to interpret the images and exclusion of many patients due to incomplete VExUS assessment. Excluding patients may be a source of bias. Our study may be limited by its observational, non-blind design, and we did not use a direct, quantitative indicator of congestion since it is not possible in current clinical practice. We need further research to validate the prognostic value of VExUS scores across different patient populations and settings. Standardized protocols for VExUS assessment and training programs for healthcare providers could also enhance the accuracy and consistency of measurements.\u003c/p\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study highlights the significant association between VExUS scores and AKI development in septic shock patients. These findings underscore the role of venous congestion in AKI pathophysiology and position VExUS as a valuable tool for risk stratification and management in critically ill patients.\u003c/p\u003e \u003cp\u003eThis study was conducted and reported according to the STROBE guidelines for observational studies.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAKI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcute kidney injury\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVExUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Venous Excess Ultrasound Grading System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGFR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGlomerular filtration rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive care unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInferior vena cava\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiopulmonary resuscitation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCKD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChronic kidney disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAPACHE II\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcute Physiology and Chronic Health Evaluation II\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSOFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSequential Organ Failure Assessment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRRT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRenal replacement therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKDIGO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKidney Disease Improving Global Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eColor Doppler\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePWD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePulsed wave doppler\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVmax\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaximum velocity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVmin\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinimum velocity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eV mean\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMean velocity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral venous pressures\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcute coronary syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHazard Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted from January 2023 to March 2024 in the intensive care unit (ICU) at Menoufia University Hospitals, after obtaining informed oral consent from the patient\u0026apos;s legal surrogates and the approval of the Institutional Review Board (IRB) of Menoufia University, Menoufia, Egypt (Approval No. 12/2022 ANES28) on December 1, 2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eData is available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource(s) of Support and Funding:\u0026nbsp;\u003c/strong\u003ethe authors receive no specific funding for this work. Open access funding is provided by The Science, Technology \u0026amp; Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Nil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and study design: HME, GMF, YIF. Data collection: HME, GMF, ATH. Statistical analysis: HME, HAA, YIF. Interpretation of data: HME, HAA, YIF, GMF, ATH. Writing up the first draft of the paper: HME, GME. Critical revision of the manuscript: HME, HAA, YIF. Final approval of the manuscript: all authors.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEvans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock. Intensive Care Med. 2021;47(11):1181\u0026ndash;1247.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMachado FR, Cavalcanti AB, Bozza FA, et al. The epidemiology of sepsis in Brazilian intensive care units (the Sepsis Prevalence Assessment Database, SPREAD): an observational study. Lancet Infect Dis. 2017;17(11):1180\u0026ndash;1189.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite LE, Hassoun HT, Bihorac A, et al. Acute kidney injury is surprisingly common and a powerful predictor of mortality in surgical sepsis. J Trauma Acute Care Surg. 2013;75(3):432\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med. 2015;41(8):1411\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNatraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MT, Ranjit S. Venous congestion assessed by venous excess ultrasound (VExUS) and acute kidney injury in children with right ventricular dysfunction. Indian J Crit Care Med. 2024;28(5):447\u0026ndash;452.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhardwaj V, Vikneswaran G, Rola P, et al. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med. 2020;24(9):783\u0026ndash;789.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePourmand A, Pyle M, Yamane D, Sumon K, Frasure SE. The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients. World J Emerg Med. 2019;10(4):232\u0026ndash;238.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKellum JA, Lameire N, Aspelin P, et al. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2(1):1\u0026ndash;138.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh S, Koratala A. Utility of Doppler ultrasound derived hepatic and portal venous waveforms in the management of heart failure exacerbation. Clin Case Rep. 2020;8(8):1489\u0026ndash;1493.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRola P, Miralles-Aguiar F, Argaiz E, et al. Clinical applications of the venous excess ultrasound (VExUS) score: conceptual review and case series. The Ultrasound Journal. 2021;13(1):32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViana-Rojas JA, Argaiz E, Robles-Ledesma M, et al. Venous excess ultrasound score and acute kidney injury in patients with acute coronary syndrome. Eur Heart J Acute Cardiovasc Care. 2023;12(7):413\u0026ndash;419.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeaubien-Souligny W, Rola P, Haycock K, et al. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. The Ultrasound Journal. 2020;12(1):16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrager R, Arntfield R, Wong MYS, et al. Venous congestion in septic shock quantified with point-of-care ultrasound: a pilot prospective multicentre cohort study. Can J Anaesth. 2024;71(5):640\u0026ndash;649.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndrei S, Bahr PA, Nguyen M, Bouhemad B, Guinot PG. Prevalence of systemic venous congestion assessed by Venous Excess Ultrasound Grading System (VExUS) and association with acute kidney injury in a general ICU cohort: a prospective multicentric study. Crit Care. 2023;27(1):224.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRihl MF, Pellegrini JAS, Boniatti MM. VExUS Score in the Management of Patients With Acute Kidney Injury in the Intensive Care Unit: AKIVEX Study. J Ultrasound Med. 2023;42(11):2547\u0026ndash;2556.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBitar ZI, Maadarani OS, Elzoueiry MM, Abdelfatah M, Antony B, Elhabibi ME. Venous excess ultrasound score in patients with sepsis and cardiorenal syndrome. Critical Care \u0026amp; Shock. 2023;26(6)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMen\u0026eacute;ndez-Suso JJ, Rodr\u0026iacute;guez-\u0026Aacute;lvarez D, S\u0026aacute;nchez-Mart\u0026iacute;n M. Feasibility and Utility of the Venous Excess Ultrasound Score to Detect and Grade Central Venous Pressure Elevation in Critically Ill Children. J Ultrasound Med. 2023;42(1):211\u0026ndash;220.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGravina, Ilenia \u0026amp; Meo, Antonio \u0026amp; Verde, et al. #1988 VExUS score as a method to guide diuretic treatment in CKD patients with congestive nephropathy by right heart failure. Nephrology Dialysis Transplantation. 2024;39.10.1093/ndt/gfae069.1125.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, et al. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Venous Excess Ultrasound Score, Acute Kidney Injury, Septic Shock, Bedside Ultrasound, Point of Care Ultrasound","lastPublishedDoi":"10.21203/rs.3.rs-5433176/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5433176/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAssessment of venous congestion in septic shock patients is important, but it is often lacking due to the absence of a noninvasive bedside tool. The Venous Excess Ultrasound Grading System (VExUS) is an ultrasound score that has been associated with acute kidney injury (AKI) in cardiac patients. The objectives of this study were to assess the grade of congestion using VExUS in septic shock patients and to evaluate the correlation between serial VExUS scores and AKI, as well as the associations between VExUS scores and fluid balance, fluid overload, intensive care unit (ICU) stay duration, mechanical ventilation duration, and in-hospital mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a prospective observational cohort study. We included 40 adult septic shock patients admitted to the ICU at Menoufia University Hospitals, following approval by the Ethics Committee. Patients with pregnancy, heart failure, portal hypertension, inferior vena cava thrombosis, and liver cirrhosis were excluded. Daily VExUS examinations were performed on the included patients, who were then monitored for the onset of new AKI. On day 7, patients were categorized based on changes in their VExUS scores into improving, unchanged, and worsening groups. Patients who developed AKI were followed until either the resolution of the AKI or the initiation of dialysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study enrolled forty patients, and those with AKI had higher VExUS scores (VExUS 2 and 3) than those without AKI, with significant differences on Days 2, 3, 4, and 6 of admission. Regarding VExUS status after one week, 50% of patients who developed AKI had worsening VExUS scores, compared to 16.7% of those without AKI, which is statistically significant. Furthermore, among AKI patients, 50% who improved their AKI parameters also showed improved VExUS scores, whereas none with worsening AKI parameters did. However, this change was not statistically significant. VExUS scores ≥ 2 demonstrated good specificity (83.3%) with a low false-positive rate. However, sensitivity was low (25%). Patients with worsening VExUS scores required dialysis more often (41.7%) than those with stable VExUS scores (12.5%), had longer durations of mechanical ventilation, and experienced higher mortality compared to other patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe VExUS score may be a useful predictor of AKI in patients with septic shock.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration\u003c/strong\u003e: The study was registered in the Pan African Clinical Trials Registry: PACTR202409715853957, date:2/9/2024.\u003c/p\u003e","manuscriptTitle":"The Use of the Venous Excess Ultrasound Score as a Bedside Tool to Predict Incidence of Acute Kidney Injury in Patients with Septic Shock, a prospective observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-17 06:57:22","doi":"10.21203/rs.3.rs-5433176/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2157a704-54ad-487d-8cab-b8853c571c44","owner":[],"postedDate":"December 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-28T07:53:32+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-17 06:57:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5433176","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5433176","identity":"rs-5433176","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}