#VExUS #POCUS case 🧵
1/ An #ESRD patient on #hemodialysis and known HF with reduced EF (37%) underwent right upper quadrant #ultrasound for abnormal LFTs. The report said, 'normal liver morphology and hemodynamics'
Nephrologist reviewed the images 👇 #Nephpearls
Everything

2/ ☝️images show a dilated inferior vena cava with an approximate anteroposterior diameter of 3 cm, systolic reversal in the hepatic vein flow, and a pulsatile portal vein with some flow reversal.
Even without intrarenal waveform, it's #VExUS grade 3 (also, IRVD is not

3/ Of note there was no pedal edema or shortness of breath.
A 👔formal #echocardiogram was ordered - reduction of LVEF from a baseline of 37 to ~30%, new right ventricular enlargement with interventricular septal flattening (D-sign) and severe functional tricuspid regurgitation

4/ Over the subsequent three days, we performed daily ultrafiltration, resulting in removal of 8 liters of fluid (net negative 4.5 liters on day 3).
At the end of 2nd session, we performed a follow up #VExUS showing significant improvement in congestion. Portal vein was

5/ Follow up #POCUS after the 3rd session demonstrated further improvement in IVC size (<2 cm) and collapsibility.
Remarkably, the shape of the IVC shifted from circular to oval during the decongestion of the patient, a clinically useful qualitative parameter.
Hepatic vein