VExUS-Guided decongestion improves renal function in acute heart failure: a randomized controlled Trial

Background Optimal diuretic management in acute heart failure (AHF) requires balancing effective decongestion with the risk of worsening renal function. Persistent venous congestion is increasingly recognized as a major contributor to cardiorenal dysfunction. The Venous Excess Ultrasound Score (VExUS) provides a multiparametric assessment of systemic venous congestion; however, randomized evidence supporting VExUS-guided therapy is limited. Purpose We therefore evaluated whether VExUS-guided diuretic management preserves renal function compared with standard clinical assessment in patients hospitalized with AHF. Methods In this prospective, single-center, open-label randomized controlled trial, 38 patients admitted with AHF (NT-proBNP ≥300 pg/mL) were randomized 1:1 to VExUS-guided therapy or standard care. On day 3 of hospitalization, the intervention group underwent point-of-care ultrasound assessment, including measurement of the inferior vena cava diameter and Doppler evaluation of hepatic, portal, and intrarenal veins (VExUS grades 0–3). Diuretic therapy was adjusted according to VExUS grade: reduced for grades 0–1, maintained for grade 2, and intensified (including sequential nephron blockade) for grade 3. The primary endpoint was the change in eGFR between days 3 and 5. Secondary endpoints included the incidence of cardiorenal syndrome, length of stay, and 30-day HF readmission. Results VExUS-guided therapy resulted in significant improvement in renal function compared with standard care (+5.0±9.2 vs −0.5±7.1 mL/min/1.73m²; mean difference 5.6 mL/min/1.73m², 95% CI 0.16–10.94; p=0.044). Hospital stay was shorter in the VExUS group (median 7 vs 9 days; p=0.035). No patients in the intervention arm developed cardiorenal syndrome compared with 21.1% in controls (p=0.105). Thirty-day readmission rates were numerically lower (5.6% vs 11.8%, p=0.603). Conclusion VExUS-guided decongestion improved short-term renal function and reduced length of stay in AHF. These findings support the use of multiparametric venous congestion assessment to individualize diuretic therapy and potentially mitigate cardiorenal dysfunction.