Lung Ultrasound to Diagnose Pulmonary Congestion Among Patients on Hemodialysis: Comparison of Full Versus Abbreviated Scanning Protocols.

RATIONALE & OBJECTIVE: Pulmonary congestion contributes to morbidity and mortality in patients with kidney failure on hemodialysis, but physical assessment is an insensitive approach to its detection. Lung ultrasound is useful for assessing the presence and severity of pulmonary congestion, but the most widely validated 28-zone study is cumbersome. We sought to compare abbreviated 4-, 6-, and 8-zone studies to 28-zone studies. STUDY DESIGN: Diagnostic test study. SETTING & PARTICIPANTS: Convenience sample of 98 patients with kidney failure on hemodialysis presenting to an emergency department in the United States. TESTS COMPARED: 4-, 6-, and 8-zone lung ultrasound studies versus a 28-zone lung ultrasound. OUTCOME: Prediction of pulmonary congestion and 30-day mortality. RESULTS: All patients completed a 28-zone lung ultrasound. Correlation coefficients (nonparametric Spearman) between each of the studies were high (all values > 0.84). Bland-Altman analysis showed good agreement. Each of the short-form studies discriminated well with area under the receiver-operator characteristic curve > 0.83 for no-to-mild versus moderate-to-severe pulmonary congestion. During a median follow-up period of 778 days, 46 (47%) died. Patients with moderate-to-severe pulmonary congestion on lung ultrasound had a 30-day mortality rate similar to that observed among patients with no-to-mild pulmonary congestion (OR, 0.95 [95% CI, 0.70-1.29]). LIMITATIONS: Single-center study conducted in an emergency care setting, convenience sample of patients, and lack of long-term follow-up data. CONCLUSIONS: Among hemodialysis patients presenting to an emergency department, 4-, 6-, or 8-zone lung ultrasounds were comparable to 28-zone studies for the assessment of pulmonary congestion. The mortality rates did not differ between those with no-to-mild and moderate-to-severe pulmonary congestion.

Integrative Volume Status Assessment.

Volume status assessment is a critical but challenging clinical skill and is especially important for the management of patients in the emergency department, intensive care unit, and dialysis unit where accurate intravascular assessment is necessary to guide appropriate fluid management. Assessment of volume status is subjective and can vary from provider to provider, posing clinical dilemmas. Traditional non-invasive methods of volume assessment include assessment of skin turgor, axillary sweat, peripheral edema, pulmonary crackles, orthostatic vital signs, and jugular venous distension. Invasive assessments of volume status include direct measurement of central venous pressure and pulmonary artery pressures. Each of these has their own limitations, challenges, and pitfalls and were often validated based on small cohorts with questionable comparators. In the past 30 years, the increased availability, progressive miniaturization, and falling price of ultrasound devices has made point of care ultrasound (POCUS) widely available. Emerging evidence base and increased uptake across multiple subspecialities has facilitated the adoption of this technology. POCUS is now widely available, relatively inexpensive, free of ionizing radiation, and can help providers make medical decisions with more precision. POCUS is not intended to replace the physical exam, but rather to complement clinical assessment, guiding providers to give thorough and accurate clinical care to their patients. We should be mindful of the nascent literature supporting the use of POCUS and other limitations as uptake increases among providers and be wary not to use POCUS to substitute clinical judgement, but integrate ultrasonographic findings carefully with history and clinical examination.

Persistent Interferon Production by Double Negative T Cells and Collapsing Focal Segmental Glomerulosclerosis.

Collapsing glomerulopathy has multiple associations, including viral infections, medications like bisphosphonates and interferon, autoimmune diseases, and genetic predisposition. We report a case of collapsing focal segmental glomerulosclerosis associated with persistently high levels of interferon gamma produced by T-cell receptor αß (+), CD4- CD8- (double negative) T lymphocytes that progressed despite treatment and improvement of other cytokine levels. Double negative T cells are elevated and activated in autoimmune lymphoproliferative syndrome (ALPS). Production of elevated interferon gamma levels from double negative T cells in ALPS despite treatment provides insight to the pathophysiology of collapsing glomerulopathy, guiding future research for collapsing glomerulopathy.

Contrast Media-Different Types of Contrast Media, Their History, Chemical Properties, and Relative Nephrotoxicity.

History of contrast dates back to the 1890s, with the invention of the radiograph. Nephrotoxicity has been a main limitation in ideal contrast media (CM). High-osmolar contrast media no longer are in clinical use due to overwhelming evidence supporting greater nephrotoxicity with these CM compared with current CM. Contrast-induced nephropathy (CIN) remains a common cause of in-hospital acute kidney injury. The choice contrast agent is determined mainly by cost and institution practice. This review focuses on the history, chemical properties, and experimental and clinical studies on the various groups of CM and their role in CIN.

A unique case of nephrogenic systemic fibrosis from gadolinium exposure in a patient with normal eGFR.

A 57-year-old woman presented with swelling and thickening of the skin of the lower extremities. Three months prior to presentation, patient had MRI with gadolinium as part of an evaluation for suspected pancreatic malignancy. Creatinine levels at the time of gadolinium exposure were 0.9-1.2 mg/dL, with a corresponding estimated glomerular filtration rate of 64 mL/min/1.73m2 by modification of diet in renal disease equation. Twenty-four-hour urine creatinine clearance was performed as an outpatient following development of symptoms. This revealed a creatinine clearance of 23 mL/min, suggestive of advanced chronic kidney disease despite an estimated glomerular filtration rate of 64 mL/min/1.73m2 Skin biopsy was positive for sclerosing dermopathy. These findings, in addition to the temporal association with gadolinium exposure, led to the diagnosis of nephrogenic systemic fibrosis.

Breathlessness at High Altitude: First Episode of Bronchoconstriction in an Otherwise Healthy Sojourner.

Bhandari, Sanjeeb Sudarshan, Pranawa Koirala, Sadichhya Lohani, Pratibha Phuyal, and Buddha Basnyat. Breathlessness at high altitude: first episode of bronchoconstriction in an otherwise healthy sojourner. High Alt Med Biol.. 18:179-181, 2017-High-altitude illness is a collective term for less severe acute mountain sickness and more severe high-altitude pulmonary edema (HAPE) and high-altitude cerebral edema, which we can experience while traveling to high altitude. These get better when we get down to the lower altitudes. People with many comorbidities also have been traveling to high altitudes from the dawn of civilization. Obstructive airway diseases can be confused with HAPE at high altitude. Asthma is one of those obstructive pulmonary diseases, but it is shown to get better with travel to the altitudes higher than the residing altitude. We present a case of 55-year-old nonsmoker, athletic, female, a lowland resident who developed difficulty breathing for the first time at high altitude. She did not get better with the descent to lower altitude and timely intake of acetazolamide. Her pulmonary function test showed obstructive airway pattern, which got better with salbutamol/ipratropium nebulization and oxygen.

Apolipoprotein C-II Deposition Amyloidosis: A Potential Misdiagnosis as Light Chain Amyloidosis.

Hereditary amyloidoses are rare and pose a diagnostic challenge. We report a case of hereditary amyloidosis associated with apolipoprotein C-II deposition in a 61-year-old female presenting with renal failure and nephrotic syndrome misdiagnosed as light chain amyloidosis. Renal biopsy was consistent with amyloidosis on microscopy; however, immunofluorescence was inconclusive for the type of amyloid protein. Monoclonal gammopathy evaluation revealed kappa light chain. Bone marrow biopsy revealed minimal involvement with amyloidosis with kappa monotypic plasma cells on flow cytometry. She was started on chemotherapy for light chain amyloidosis. She was referred to the Mayo clinic where laser microdissection and liquid chromatography mass spectrometry detected high levels of apolipoprotein C-II, making a definitive diagnosis. Apolipoprotein C-II is a component of very low-density lipoprotein and aggregates in lipid-free conditions to form amyloid fibrils. The identification of apolipoprotein C-II as the cause of amyloidosis cannot be solely made with routine microscopy or immunofluorescence. Further evaluation of biopsy specimens with laser microdissection and mass spectrometry and DNA sequencing of exons should be done routinely in patients with amyloidoses for definitive diagnosis. Our case highlights the importance of determining the subtype of amyloidosis that is critical for avoiding unnecessary therapy such as chemotherapy.

A case of hypermucoviscous Klebsiella pneumoniae liver abscess syndrome in an Iraqi male.

A 53-year-old man presented with fevers, productive cough and decreased appetite. He emigrated from Iraq 4 years ago. Chest x-ray revealed a left lung consolidation. Respiratory cultures and two sets of blood cultures grew out pan-susceptible Klebsiella pneumoniae Liver ultrasound revealed a 6.4-cm complex lesion in the left hepatic lobe. A biopsy of the liver lesion produced bloody purulent aspirate; abscess cultures yielded a highly viscous pan-susceptible K. pneumoniae Klebsiella pneumoniae liver abscess syndrome is a newly described invasive syndrome due to a hypermucoviscous phenotype associated with serotypes K1 and K2 of Klebsiella. Although it is more commonly endemic to the Asian-Pacific region, it has been increasingly reported as an emerging global disease. We present the first case of this syndrome in a patient of middle-eastern descent. We also present pictorial evidence of the microbe's unique viscous, muculent texture grown on agar.