Current use, training, and barriers in point-of-care ultrasound in nephrology: A national survey of VA medical centers.

BACKGROUND: Point-of-care ultrasound (POCUS) can improve diagnostic accuracy, reduce procedural complications and enhance physician-patient interactions in nephrology. Currently, there is limited knowledge about how practicing nephrologists are using POCUS. OBJECTIVE: This study aimed to characterize current POCUS use, training needs, and barriers to use among nephrology groups. MATERIALS AND METHODS: A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of staff and nephrology specialty chiefs. RESULTS: Chiefs of staff (n = 130) and nephrology chiefs (n = 79) completed surveys on facility- and service-level POCUS use (response rates of 100% and 77%, respectively). Current diagnostic or procedural POCUS use was reported by 41% of nephrology groups, and the most common POCUS applications were central line insertion (28%) and assessment of urinary retention (23%), hydronephrosis (18%), volume status (15%), and bladder (14%). Lack of training was the most common barrier (72%), and most nephrology groups (65%) desired POCUS training. Limited access to ultrasound equipment and POCUS training were barriers reported by 54% and 18% of groups, respectively. CONCLUSION: A minority of nephrology groups currently use common POCUS applications including evaluation of urinary retention, hydronephrosis, and volume status. The most common barriers to POCUS use in nephrology were lack of trained providers and ultrasound equipment. Investment in POCUS training and infrastructure is needed to expand and standardize POCUS use in nephrology.

Current opinion in quantitative lung ultrasound for the nephrologist.

PURPOSE OF REVIEW: Volume overload mediates worse cardiovascular outcomes in patients with end-stage kidney disease (ESKD) on hemodialysis (HD), leading to increased acute care utilization. Understanding the presence of pulmonary congestion, which is often clinically silent, could be instrumental in predicting acute care needs and mitigating risks through appropriate therapy. This review provides an overview of the existing literature on lung ultrasound in ESKD patients. RECENT FINDINGS: Quantitative lung ultrasound predicts adverse cardiovascular outcomes in ESKD patients on HD. The largest randomized controlled trial of a lung ultrasound-guided ultrafiltration strategy demonstrated control of pulmonary congestion without an increased risk of intradialytic hypotension, arrhythmia, or access thrombosis. Despite this, the study was negative in the incidence of the primary composite endpoint of all-cause death, nonfatal myocardial infarction, and decompensated heart failure. A post hoc analysis showed promise with reductions in recurrent acute care utilization and cardiovascular events. Recent research has focused on simplification of the 28-zone lung ultrasound, and abbreviated protocols have been shown to retain prognostic ability. SUMMARY: Lung ultrasound is a valuable tool for nephrologists to diagnose and manage pulmonary congestion. However, its optimal integration with other hemodynamic parameters to formulate effective management strategies remains elusive. Future studies should address these gaps and find solutions to the training inadequacies in clinician-performed ultrasound.

Lung Ultrasonographic Signs in Pulmonary Disease - A Video Review.

Lung ultrasound (US) is a well-established imaging tool in the inpatient and critical care setting. It has proven its worth in the rapid bedside diagnosis of a variety of conditions pertaining to the lungs and the thorax. Lung US was initially introduced as a bedside imaging tool to evaluate the size and characteristics of pleural effusion. Over the years, the field of lung ultrasonography has rapidly expanded introducing nuances in image interpretation. Numerous primary and secondary signs have been described in the literature to identify both normal and abnormal findings. The primary signs can help narrow the list of differential diagnoses, whereas the addition of secondary signs help create an imaging pattern facilitating the confirmation of diagnosis or recognition of the underlying disease process. These wide variety of signs and patterns can present a challenge to the learning of lung ultrasonography, particularly to a novice user. We sought to compile a comprehensive list of these findings to serve as a useful resource to aid effortless adoption of lung ultrasonography in clinical practice. In this review, we narrate the evolution of lung US, describe common protocols applied in performance of the lung US, and illustrate a comprehensive list of common lung US signs and patterns along with their differential diagnosis and clinical utility.

Point-of-care ultrasound in pediatric nephrology.

Point-of-care ultrasound (POCUS) has evolved in recent years in clinical practice, helping in early bedside diagnosis of important etiologies. Many medical schools and training programs are integrating POCUS into their curriculum. Especially with the technological advances of newer handheld ultrasound devices, POCUS has now become a component adjunct to clinical examination, in the clinic and bedside in critical care units. The diagnostic utility of POCUS lies both in early identification of critical kidney disease, and also extra-renal pathologies from a focused cardiac ultrasound, lung ultrasound, and integrated fluid assessment. There is a need to incorporate POCUS in training in pediatric nephrology and establish competency standard criteria. This review shall cover how POCUS helps in enhancing patient care in pediatric kidney disorders and critical children, and the recent advances.

Point of Care Ultrasound Training in Nephrology: Twitter Poll as a Modern Tool for Development of an Effective Curriculum.

INTRODUCTION: Point of care ultrasonography (POCUS) is being increasingly recognized as an adjunct to physical examination in the field of nephrology. However, paucity of trained faculty and standardized curricula remain key barriers to widespread adoption of this skill as well as development of reliable quality assessment programs at the institutional level. Herein, we sought to explore the utility of Twitter polls to gain insights into knowledge deficits of the learners for making curricular improvements while simultaneously disseminating POCUS pearls and pitfalls. METHODS: A series of 57 single-question polls were tweeted over a 12-month period, each containing an ultrasound image or a video asking for correct interpretation. These were sent out from the Twitter handle of NephroPOCUS.com (@NephroP), an online POCUS education tool. The answer and a brief explanation were shared in a subsequent tweet at the end of the voting period. Information on the percentage of correct answers, Tweet impressions, and engagements was collected and analyzed by the pre-determined difficulty level (I-III) and the organ/learning objective being tested. RESULTS: The number of responses per poll was 228 ± 94.6 (mean ± SD), and the percentage of correct responses was 57.9 ± 17.5 (mean ± SD). 16 (of 57) polls received less than 50% correct responses, of which 8 belonged to level III difficulty. The learning objectives that received the least number of correct responses in the kidney, cardiac, lung, vascular, and other categories were identification of end-stage kidney (16.2% correct answers), right pleural effusion on the parasternal short axis view of the heart (29%), right pleural effusion from the subxiphoid window (39%), grading of systemic venous congestion (27.3%), and identification of ascites on the right lateral chest window (15%), respectively. The overall engagement rate was 6.96%, which was above the median for health and higher education-related tweets on Twitter. Targeted didactic material was developed based on these results, published on various open-access nephrology education platforms. CONCLUSIONS: Twitter polls aid in identifying the knowledge gaps among POCUS learners. Information obtained from the polls can be used to improve POCUS-related curricula and develop targeted educational material to facilitate remote learning.

Multi-Organ Point-Of-Care Ultrasound in Acute Kidney Injury.

Acute kidney injury (AKI) is a clinical syndrome caused by a multitude of hemodynamic, toxic, and structural insults to the kidney, and portends worse patient outcomes. Despite careful history taking, physical examination, and analysis of laboratory data, a void is evident in the diagnostic process and clinical monitoring of AKI. Point-of-care ultrasonography (POCUS) is a limited ultrasound study performed by the clinician at bedside as an adjunct to physical examination. Growing body of evidence points to POCUS as a powerful tool in a variety of clinical settings. Herein, we discuss how nephrologist-performed POCUS has the potential to provide answers to focused questions that we encounter in diagnosis and management of patients with AKI. From excluding hydronephrosis to providing real-time insights into hemodynamics, incorporation of POCUS helps integrate all the pieces of patient data and formulate individualized treatment plans. Future studies are needed to evaluate the impact of multi-organ POCUS on AKI-related pragmatic patient outcomes, the potential of this technique to stratify the risk and to identify patients with different levels of severity of AKI and different pathophysiological signatures.

Point-of-Care Ultrasonography for Objective Volume Management in End-Stage Renal Disease.

Focused ultrasonography or point-of-care ultrasonography (POCUS) is increasingly considered as an essential bedside diagnostic tool. In patients with end-stage renal disease (ESRD) treated with hemodialysis, it can be used as an adjunct to physical examination to objectively assess the volume status and guide the rate and amount of ultrafiltration. Herein, we describe the case of an ESRD patient presenting with hypertensive urgency where POCUS disclosed the presence of hypervolemia despite unremarkable physical examination. The sonographic findings of the inferior vena cava, heart, and lungs guided fluid extraction during hemodialysis therapy, and the actual ultrafiltration volume was significantly higher than what was anticipated based on clinical findings. This case highlights the importance of using -POCUS as a tool for objective and precise assessment of volume status in patients with ESRD.

Extracorporeal Ultrafiltration for Acute Heart Failure: Lost Battle or Lasting Opportunity?

The negative prognostic impact of congestion and worsening renal function in patients with decompensated heart failure (HF) has been widely recognized. As diuretics are thought to provide suboptimal results and are associated with a number of adverse effects, a number of diuretic-sparing therapeutic strategies have been explored. Extracorporeal ultrafiltration (UF) represents an intriguing option that presumably lacks many of the untoward effects of diuretic-based regimens while portending several advantages. However, conflicting data have recently emerged in relation to some of its previously proposed beneficial effects possibly due to counterbalance of the underexplored mechanisms. Herein, the existing literature on the role of UF therapy for management of acute decompensated HF is briefly reviewed with special emphasis on its impact on surrogates of efficacy and safety such as excess fluid removal and renal function. A number of topics relevant to cardiorenal syndrome such as congestion and sodium removal are also discussed.

Chronic Kidney Disease in Pregnancy.

With the increasing prevalence of chronic kidney disease (CKD) worldwide, the number of pregnant women with various degrees of renal dysfunction is expected to increase. There is a bidirectional relation between CKD and pregnancy in which renal dysfunction negatively affects pregnancy outcomes, and the pregnancy can have a deleterious impact on various aspects of kidney disease. It has been shown that even mild renal dysfunction can increase considerably the risk of adverse maternal and fetal outcomes. Moreover, data suggest that a history of recovery from acute kidney injury is associated with adverse pregnancy outcomes. In addition to kidney dysfunction, maternal hypertension and proteinuria predispose women to negative outcomes and are important factors to consider in preconception counseling and the process of risk stratification. In this review, we provide an overview of the physiologic renal changes during pregnancy as well as available data regarding CKD and pregnancy outcomes. We also highlight the important management strategies in women with certain selected renal conditions that are seen commonly during the childbearing years. We call for future research on underexplored areas such as the concept of renal functional reserve to develop a potential clinical tool for prognostication and risk stratification of women at higher risk for complications during pregnancy.