Nephrologist-performed Point-of-Care Ultrasound in Acute Kidney Injury: beyond Hydronephrosis

Point-of-care ultrasonography spotlight: Could venous excess ultrasound serve as a shared language for internists and intensivists?

Point-of-care ultrasonography (POCUS), particularly venous excess ultrasound (VExUS) is emerging as a valuable bedside tool to gain real-time hemodynamic insights. This modality, derived from hepatic vein, portal vein, and intrarenal vessel Doppler patterns, offers a scoring system for dynamic venous congestion assessment. Such an assessment can be crucial in effective management of patients with heart failure exacerbation. It facilitates diagnosis, quantification of congestion, prognostication, and monitoring the efficacy of decongestive therapy. As such, it can effectively help to manage cardiorenal syndromes in various clinical settings. Extended or eVExUS explores additional veins, potentially broadening its applications. While VExUS demonstrates promising outcomes, challenges persist, particularly in cases involving renal and liver parenchymal disease, arrhythmias, and situations of pressure and volume overload overlap. Proficiency in utilizing spectral Doppler is pivotal for clinicians to effectively employ this tool. Hence, the integration of POCUS, especially advanced applications like VExUS, into routine clinical practice necessitates enhanced training across medical specialties.

Nephrologist-Led Simulation-Based Focused Cardiac Ultrasound Workshop for Medical Students: Insights and Implications

Background

Point-of-care ultrasonography (POCUS) is being increasingly recognized as an adjunct to physical examination. However, limited availability of trained faculty in specialties other than emergency medicine and lack of universal training standards remain key barriers to its widespread integration into undergraduate and graduate medical curricula. In this study, we sought to explore the effectiveness of a short simulation-based workshop for medical students teaching basic cardiac ultrasound led by a nephrologist.

Methods

Workshops were conducted for 2 different groups of 4th-year medical students with a total of 25 attendees. The workshop consisted of a 1-hour lecture followed by 15 minutes of cardiac anatomy simulation and a 2- to 2.5-hour hands-on session in the simulation laboratory. An anonymous precourse questionnaire comprising 10 questions assessing the interpretation of common grayscale ultrasound findings encountered in patients with undifferentiated hypotension was performed. After the workshop, a postcourse exam and survey were conducted, retesting the same concepts and seeking the students' feedback on the course.

Results

In total, 23 and 20 students answered the pre- and postcourse surveys, respectively. The mean total score on the pretest was 63.8% ± 13.6%, which significantly increased to 91.5% ± 10.5% on the posttest (P < .001). About 90% of the respondents strongly agreed that the cardiac anatomy simulation improved their understanding of the cardiac sonographic anatomy; 75% strongly agreed that the hands-on simulation enhanced their confidence in image acquisition and interpretation; and 70% said they would choose nephrology elective if POCUS training was integrated with it.

Conclusions

A nephrologist-led diagnostic POCUS workshop using simulation techniques is effective in improving the learners' knowledge, understanding of the sonographic cardiac anatomy, and confidence in image acquisition. Integration of POCUS training may increase medical student interest in nephrology elective rotations.

Transcending boundaries: Unleashing the potential of multi-organ point-of-care ultrasound in acute kidney injury

Acute kidney injury (AKI) is a clinical syndrome characterized by a rapid increase in serum creatinine levels or a decrease in urine output or both. In spite of thorough history-taking, physical examination, and laboratory analysis, there are limitations in the diagnostic process and clinical monitoring of AKI. Point-of-care ultrasonography (POCUS), a limited ultrasound study performed by clinicians at the bedside, has emerged as a valuable tool in different clinical settings. In this discussion, we explore the potential of POCUS performed by nephrologists to address specific questions encountered in the diagnosis and management of AKI patients. POCUS not only aids in excluding hydronephrosis but also provides real-time insights into hemodynamics, enabling formulation of individualized treatment plans. Further studies are required to assess the impact of multi-organ POCUS on pragmatic patient outcomes related to AKI, as well as its potential in risk stratification and identification of different levels of AKI severity and pathophysiological signatures.

New Miniaturized System for Ultrafiltration: Rationale and Design of a Single-Center, Crossover, Randomized, Open-Label, Pilot Study Protocol

INTRODUCTION

Fluid overload and congestion are common features in patients with heart failure and are associated with negative clinical outcomes. Therapies for these conditions are diuretic-centered but frequently fail to achieve patient-adequate hydration status, prompting the use of extracorporeal ultrafiltration. Artificial Diuresis 1 (AD1) is a miniaturized, portable, and wearable system designed to deliver isolated ultrafiltration with the finest degree of simplicity and practicality.

METHODS/DESIGN

Single-center, crossover, randomized, open-label pilot study to investigate the safety and the efficacy (concerning ultrafiltration accuracy) of extracorporeal ultrafiltration with the device AD1 in comparison to isolated ultrafiltration with a traditional machine (PrisMaX). Patients with chronic kidney disease stage 5D (on hemodialysis) or intensive care patients presenting acute kidney injury stage 3D (requiring hemodialysis) will carry out a single session of isolated ultrafiltration with each of the machines. The safety primary outcomes will be the occurrence of adverse events. The efficacy primary outcome will be the accuracy of ultrafiltration rate (delivered/prescribed) on each of the devices.

CONCLUSION

AD1 is a novel miniaturized device for extracorporeal ultrafiltration. This study will be the first-in-human use of AD1 in patients with fluid overload.

Point-of-care ultrasound in diagnosis and management of congestive nephropathy

Congestive nephropathy is kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics. As a part of cardiorenal syndrome, the diagnosis is usually made based on history and physical examination, with findings such as jugular venous distension, a third heart sound, and vital signs as supporting findings. More recently, however, these once though objective measures have come under scrutiny for their accuracy. At the same time, bedside ultrasound has increased in popularity and is routinely being used by clinicians to take some of the guess work out of making the diagnosis of volume overload and venous congestion. In this mini-review, we will discuss some of the traditional methods used to measure venous congestion, describe the role of point-of-care ultrasound and how it can ameliorate a clinician’s evaluation, and offer a description of venous excess ultrasound score, a relatively novel scoring technique used to objectively quantify congestion. While there is a paucity of published large scale clinical trials evaluating the potential benefit of ultrasonography in venous congestion compared to gold standard invasive measurements, more study is underway to solidify the role of this objective measure in daily clinical practice.