The use of venous Doppler to predict adverse kidney events in a general ICU cohort

Rory Spiegel, William Teeter, Scott Sullivan, Keegan Tupchong, Nabeel Mohammed, Mark Sutherland, Evan Leibner, Philippe Rola, Samuel M Galvagno Jr, Sarah B Murthi, Rory Spiegel, William Teeter, Scott Sullivan, Keegan Tupchong, Nabeel Mohammed, Mark Sutherland, Evan Leibner, Philippe Rola, Samuel M Galvagno Jr, Sarah B Murthi

Abstract

Background: Changes in Doppler flow patterns of hepatic veins (HV), portal vein (PV) and intra-renal veins (RV) reflect right atrial pressure and venous congestion; the feasibility of obtaining these assessments and the clinical relevance of the findings is unknown in a general ICU population. This study compares the morphology of HV, PV and RV waveform abnormalities in prediction of major adverse kidney events at 30 days (MAKE30) in critically ill patients.

Study design and methods: We conducted a prospective observational study enrolling adult patients within 24 h of admission to the ICU. Patients underwent an ultrasound evaluation of the HV, PV and RV. We compared the rate of MAKE-30 events in patients with and without venous flow abnormalities in the hepatic, portal and intra-renal veins. The HV was considered abnormal if S to D wave reversal was present. The PV was considered abnormal if the portal pulsatility index (PPI) was greater than 30%. We also examined PPI as a continuous variable to assess whether small changes in portal vein flow was a clinically important marker of venous congestion.

Results: From January 2019 to June 2019, we enrolled 114 patients. HV abnormalities demonstrate an odds ratio of 4.0 (95% CI 1.4-11.2). PV as a dichotomous outcome is associated with an increased odds ratio of MAKE-30 but fails to reach statistical significance (OR 2.3 95% CI 0.87-5.96), but when examined as a continuous variable it demonstrates an odds ratio of 1.03 (95% CI 1.00-1.06). RV Doppler flow abnormalities are not associated with an increase in the rate of MAKE-30 INTERPRETATION: Obtaining hepatic, portal and renal venous Doppler assessments in critically ill ICU patients are feasible. Abnormalities in hepatic and portal venous Doppler are associated with an increase in MAKE-30. Further research is needed to determine if venous Doppler assessments can be useful measures in assessing right-sided venous congestion in critically ill patients.

Keywords: Ultrasound; Venous congestion; Venous return.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Ultrasound surface and B-mode anatomy and normal venous Doppler waveforms
Fig. 2
Fig. 2
Normal and abnormal venous Doppler waveforms

References

    1. O'Connor ME, Prowle JR. Fluid overload. Crit Care Clin. 2015;31(4):803–821. doi: 10.1016/j.ccc.2015.06.013.
    1. Malbrain M, Van Regenmortel N, Saugel B, et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care. 2018;8(1):66. doi: 10.1186/s13613-018-0402-x.
    1. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486–552. doi: 10.1097/CCM.0000000000002255.
    1. Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol. 2009;53(7):589–596. doi: 10.1016/j.jacc.2008.05.068.
    1. Wiedemann HP, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564–2575. doi: 10.1056/NEJMoa062200.
    1. 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. Ultrasound J. 2020;12(1):16. doi: 10.1186/s13089-020-00163-w.
    1. Beaubien-Souligny W, Eljaiek R, Fortier A, et al. The association between pulsatile portal flow and acute kidney injury after cardiac surgery: a retrospective cohort study. J Cardiothorac Vasc Anesth. 2018;32(4):1780–1787. doi: 10.1053/j.jvca.2017.11.030.
    1. Eljaiek R, Cavayas YA, Rodrigue E, et al. High postoperative portal venous flow pulsatility indicates right ventricular dysfunction and predicts complications in cardiac surgery patients. Br J Anaesth. 2019;122(2):206–214. doi: 10.1016/j.bja.2018.09.028.
    1. Beaubien-Souligny W, Benkreira A, Robillard P, et al. Alterations in portal vein flow and intrarenal venous flow are associated with acute kidney injury after cardiac surgery: a prospective observational cohort study. J Am Heart Assoc. 2018;7(19):e009961. doi: 10.1161/JAHA.118.009961.
    1. Iida N, Seo Y, Sai S, et al. Clinical implications of intrarenal hemodynamic evaluation by Doppler ultrasonography in heart failure. JACC Heart Fail. 2016;4(8):674–682. doi: 10.1016/j.jchf.2016.03.016.
    1. Glaser JJ, Cardarelli C, Galvagno S, Scalea TM, Murthi SB. Bridging the gap: Hybrid cardiac echo in the critically ill. J Trauma Acute Care Surg. 2016;81:S157–S161. doi: 10.1097/TA.0000000000001020.
    1. Semler MW, Rice TW, Shaw AD, et al. Identification of major adverse kidney events within the electronic health record. J Med Syst. 2016;40(7):167. doi: 10.1007/s10916-016-0528-z.
    1. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44(3):837–845. doi: 10.2307/2531595.
    1. Hockin RR. A biometrics invited paper the analysis and selection of variables in linear regression. Biometrics. 1976;32(1):1–49. doi: 10.2307/2529336.
    1. Zhang Z. Variable selection with stepwise and best subset approaches. Ann Transl Med. 2016;4(7):136. doi: 10.21037/atm.2016.03.35.
    1. Palevsky PM, Molitoris BA, Okusa MD, et al. Design of clinical trials in acute kidney injury: report from an NIDDK workshop on trial methodology. Clin J Am Soc Nephrol. 2012;7(5):844–850. doi: 10.2215/CJN.12791211.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren