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

Point-of-care ultrasound training in nephrology: a position statement by the International Alliance for POCUS in Nephrology

Point-of-care ultrasonography (POCUS) has rapidly evolved from a niche technology to an indispensable tool across medical specialties, including nephrology. This evolution is driven by advancements in technology and the visionary efforts of clinicians in emergency medicine and beyond. Recognizing its potential, medical schools are increasingly integrating POCUS into training curricula, emphasizing its role in enhancing diagnostic accuracy and patient care. Despite these advancements, barriers such as limited faculty expertise and 'lack of' standardized guidelines hinder widespread adoption and regulation. The International Alliance for POCUS in Nephrology (IAPN), through this position statement, aims to guide nephrologists in harnessing the diagnostic power of POCUS responsibly and effectively. By outlining core competencies, recommending training modalities and advocating for robust quality assurance measures, we envision a future where POCUS enhances nephrology practice globally, ensuring optimal patient outcomes through informed, evidence-based decision-making. International collaboration and education are essential to overcome current challenges and realize the full potential of POCUS in nephrology and beyond.

Point-of-Care Ultrasound: A Vital Tool for Anesthesiologists in the Perioperative and Critical Care Settings

Point-of-care ultrasound (POCUS) is an essential skill in various specialties like anesthesiology, critical care, and emergency medicine. Anesthesiologists utilize POCUS for quick diagnosis and procedural guidance in perioperative and critical care settings. Key applications include vascular ultrasound for challenging venous and arterial catheter placements, gastric ultrasound for aspiration risk assessment, airway ultrasound, diaphragm ultrasound, and lung ultrasound for respiratory assessment. Additional utilities of POCUS can include multi-organ POCUS evaluation for undifferentiated shock or cardiac arrest, ultrasound-guided central neuraxial and peripheral nerve blocks, focused cardiac ultrasound, and novel applications such as venous excess ultrasound. This review highlights these POCUS applications in perioperative and intensive care and summarizes the latest evidence of their accuracy and limitations.

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.

Portal vein pulsatility: An important sonographic tool assessment of systemic congestion for critical ill patients

In this editorial we comment on the article by Kuwahara et al, published in the recent issue of the World Journal of Cardiology. In this interesting paper, the authors showed a correlation between portal vein pulsatility ratio, examined by bedside ultrasonography, and prognosis of hospitalized patients with acute heart failure. Systemic congestion is being notoriously underdetected in the acutely ill population with conventional methods like clinical examination, biomarkers, central venous pressure estimation and X-rays. However, congestion should be a key therapeutic target due to its deleterious effects to end organ function and subsequently patient prognosis. Doppler flow assessment of the abdominal veins is gaining popularity worldwide, as a valuable tool in estimating comprehensively congestion and giving a further insight into hemodynamics and patient management.

Seeing through the myths: Practical aspects of diagnostic point-of-care ultrasound in nephrology

Point of care ultrasonography (POCUS) is emerging as an invaluable tool for guiding patient care at the bedside, providing real-time diagnostic information to clinicians. Today, POCUS is recognized as the fifth pillar of bedside clinical examination, alongside inspection, palpation, percussion, and auscultation. In spite of growing interest, the adoption of diagnostic POCUS in nephrology remains limited, and comprehensive training beyond kidney ultrasound is offered in only a few fellowship programs. Moreover, several misconceptions and barriers surround the integration of POCUS into day-to-day nephrology practice. These include myths about its scope, utility, impact on patient outcomes and legal implications. In this minireview, we address some of these issues to encourage wider and proper utilization of POCUS.

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.

Venous Excess Doppler Ultrasound: A Visual Guide to Decongestion in Cardiorenal Syndrome

Promptly recognizing congestion, both clinical and hemodynamic, is paramount in the management of patients with heart failure. The pathophysiology of congestion involves a complex interplay of absolute fluid gain, volume redistribution from venous capacitance beds to the central venous circulation, inadequate excretion due to renal dysfunction, salt and water retention, and endothelial dysfunction. While congestive nephropathy is gaining wider recognition as a distinct variant of hemodynamic acute kidney injury (AKI), there are limited bedside diagnostic tools for proper evaluation of these patients. In this manuscript, we describe a case of AKI where POCUS helped us diagnose clinically silent congestion as well as monitor the response to therapy. A patient with heart failure with mildly reduced ejection fraction was initially administered intravenous fluids for rise in serum creatinine attributed to volume depletion. However, POCUS demonstrated a completely different scenario with severe venous congestion. Both sonographic stigmata of congestion and serum creatinine improved with diuretic therapy. Furthermore, serial venous excess Doppler ultrasound scans facilitated the visualization of decongestion in real time.