Automated lung ultrasound image assessment using artificial intelligence to identify fluid overload in dialysis patients.

BACKGROUND: Fluid assessment is challenging, and fluid overload poses a significant problem among dialysis patients, with pulmonary oedema being the most serious consequence. Our study aims to develop a simple objective fluid assessment strategy using lung ultrasound (LUS) and artificial intelligence (AI) to assess the fluid status of dialysis patients. METHODS: This was a single-centre study of 76 hemodialysis and peritoneal dialysis patients carried out between July 2020 to May 2022. The fluid status of dialysis patients was assessed via a simplified 8-point LUS method using a portable handheld ultrasound device (HHUSD), clinical examination and bioimpedance analysis (BIA). The primary outcome was the performance of 8-point LUS using a portable HHUSD in diagnosing fluid overload compared to physical examination and BIA. The secondary outcome was to develop and validate a novel AI software program to quantify B-line count and assess the fluid status of dialysis patients. RESULTS: Our study showed a moderate correlation between LUS B-line count and fluid overload assessed by clinical examination (r = 0.475, p < 0.001) and BIA (r = 0.356. p < 0.001). The use of AI to detect B-lines on LUS in our study for dialysis patients was shown to have good agreement with LUS B lines observed by physicians; (r = 0.825, p < 0.001) for the training dataset and (r = 0.844, p < 0.001) for the validation dataset. CONCLUSION: Our study confirms that 8-point LUS using HHUSD, with AI-based detection of B lines, can provide clinically useful information on the assessment of hydration status and diagnosis of fluid overload for dialysis patients in a user-friendly and time-efficient way.

Handheld ultrasound-guided cannulation of difficult hemodialysis arteriovenous access: A randomized controlled trial.

INTRODUCTION: Cannulation of complex arteriovenous fistula (AVF) or graft (AVG) frequently poses challenges to renal nursing practice. Ultrasound (US) guidance on visualizing central and peripheral venous access has been widely adopted in nephrology, reducing vascular intervention complications. Renal nurses could acquire this point-of-care technique to increase the successful cannulation rate while facilitating confidence build-up during practice. We aim to evaluate the use of handheld US on difficult AVF/AVG cannulation in a hospital-based dialysis unit. METHODS: We conducted a single-center randomized controlled trial from January 2021 to January 2022. Ten renal nurses were trained by an interventional nephrologist before patient recruitment and had completed a pre- and posttraining questionnaire on their confidence level. Fifty hemodialysis patients with complex AVF were randomized to US-guided or conventional cannulation. The total time spent on cannulation and patients' pain scores were also collected. FINDINGS: Renal nurses increased their confidence level after training (pretraining score 26.6 ± 6.9 vs. posttraining score 36.4 ± 3.0; p = 0.014). There was a higher success rate (only one cannulation attempt required) for US-guided (96%) versus conventional (72.0%) cannulation (p = 0.049). US-guided cannulation had a lower pain score than the conventional method (1.48 ± 0.73 vs. 2.13 ± 0.95, p = 0.012). The pre-cannulation assessment time and time spent on cannulation were comparable between the two groups. DISCUSSION: Our study showed that US-guided cannulation increased renal nurses' confidence level in difficult cannulation and improved success rate. Larger scale studies are required to further assess the applications of handheld US in AVF cannulation, particularly in different clinical settings (e.g., chronic dialysis centers).

A real-world study on SGLT2 inhibitors and diabetic kidney disease progression.

Background: Randomized controlled trials have demonstrated the benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2is) in people with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). However, real-world data on CKD progression and the development of end-stage kidney disease (ESKD) remains scarce. Our aim was to study renal outcomes of people with diabetic kidney disease (DKD) using SGLT2is in a highly prevalent DKD population. Methods: Between 2016 and 2019 we recruited T2DM patients in the renal and diabetic clinics in a regional hospital in Singapore. Patients prescribed SGLT2is were compared with those on standard anti-diabetic and renoprotective treatment. The outcome measures were CKD progression [a ≥25% decrease from baseline and worsening of estimated glomerular filtration rate (eGFR) categories according to the Kidney Disease: Improving Global Outcomes guidelines] and ESKD (eGFR <15 mL/min/1.73 m2). Results: We analysed a total of 4446 subjects; 1598 were on SGLT2is. There was a significant reduction in CKD progression {hazard ratio [HR] 0.60 [95% confidence interval (CI) 0.49-0.74]} with SGLT2is. The HR for eGFR ≥45 mL/min/1.73 m2 and 15-44 mL/min/1.73 m2 was 0.60 (95% CI 0.47-0.76) and 0.43 (95% CI 0.23-0.66), respectively. There was also a reduction in risk for developing ESKD for the entire cohort [HR 0.33 (95% CI 0.17-0.65)] and eGFR 15-44 mL/min/1.73 m2 [HR 0.24 (95% CI 0.09-0.66)]. Compared with canagliflozin and dapagliflozin, empagliflozin showed a sustained risk reduction of renal outcomes across CKD stages 1-4. Conclusions: This real-world study demonstrates the benefits of SGLT2is on CKD progression and ESKD. The effect is more pronounced in moderate to advanced CKD patients.