Effect of Venous Excess Ultrasonography on Dry Weight Assessment in Patients with ESRD Before Discharge

Introduction: Accurate dry weight (DW) in End-Stage Kidney Disease (ESKD) patients on hemodialysis (HD) is defined as the lowest tolerated post-dialysis weight achieved without signs or symptoms of hypovolemia or hypervolemia. Establishing an accurate DW in ESKD is a challenge. Despite clinical evaluation and traditional Point-of-Care Ultrasound (POCUS), up to 80% of patients may not achieve optimal DW. This adversely affects HD efficacy, cardiovascular burden, and survival. Venous Excess Ultrasound (VExUS), a POCUS modality, can identify hemodynamic congestion and monitor therapeutic response, overcoming limitations of conventional assessments. Many hospitalized ESKD patients present with elevated VExUS scores despite being at their DW. We aim to evaluate VExUS score normalization as a guide for DW adjustment. Case Description: A 54F with ESKD on HD, HTN and Antiphospholipid syndrome was admitted due to chills and dyspnea. On arrival, her SpO2 was 87% on room air(RA), BP 131/85 and HR 105, without signs of volume overload on exam. Initial Hgb was 6.7 g/dL, CT angiography confirmed pulmonary emboli(PE) throughout the right and left lower lobes without right ventricular strain. Her established outpatient DW was 67 kg; however, her standing pre-HD weight at our hospital was 64.3 kg (2.7 kg below DW). HD was initiated for clearance only. Ten minutes into the session, a VExUS assessment revealed mild venous congestion (Grade 1), IVC of 1.7cm with<50% inspiratory collapse, and bilateral B-lines on lung bases. Based on these VExUS findings ultrafiltration(UF) goal of 2 L was instituted. After 3h of HD and 1.7L of UF achieved, repeat VExUS demonstrated resolution of venous congestion (grade 0 in hepatic and portal veins), decreased IVC diameter with>50% collapse; reduction in B-lines. SpO2 improved to 92% on RA despite her PE. The standing post-HD weight was 62.6 kg, which was established as her new, VExUS-guided DW. Discussion: VExUS score is increasingly integrated into fluid status evaluation in Nephrology and Critical care. It offers the capacity to dynamically track fluid removal during HD. Traditional DW assessment based on clinical signs has limited specificity and poor predictive value. Incorporating VExUS into a comprehensive POCUS protocol offers a precise and objective method for estimating optimal DW, potentially overcoming the inherent inaccuracies of conventional approaches.