Performance and Interpretation of Sonography in the Practice of Nephrology: Core Curriculum 2024.

Ultrasonography is increasingly being performed by clinicians at the point of care, and nephrologists are no exception. This Core Curriculum illustrates how ultrasonography can be incorporated into clinical decision making across the spectrum of kidney disease to optimize the care nephrologists provide to patients. Sonography is valuable in outpatient and inpatient settings for the diagnosis and management of acute and chronic kidney disease, evaluation of cystic disease, urinary obstruction, pain, hematuria, proteinuria, assessment of volume status, and in providing guidance for kidney biopsy. As kidney disease advances, ultrasound is useful in the placement and maintenance of temporary and permanent access for dialysis. After kidney transplantation, ultrasonography is critical for evaluation of allograft dysfunction and for biopsies. Sonography skills expedite patient care and enhance the practice of nephrology and are relatively easily acquired with training. It is our hope that this curriculum will encourage nephrologists to learn and apply this valuable skill.

Outcomes Among Patients Hospitalized With COVID-19 and Acute Kidney Injury.

RATIONALE & OBJECTIVE: Outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) and acute kidney injury (AKI) are not well understood. The goal of this study was to investigate the survival and kidney outcomes of these patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Patients (aged≥18 years) hospitalized with COVID-19 at 13 hospitals in metropolitan New York between March 1, 2020, and April 27, 2020, followed up until hospital discharge. EXPOSURE: AKI. OUTCOMES: Primary outcome: in-hospital death. SECONDARY OUTCOMES: requiring dialysis at discharge, recovery of kidney function. ANALYTICAL APPROACH: Univariable and multivariable time-to-event analysis and logistic regression. RESULTS: Among 9,657 patients admitted with COVID-19, the AKI incidence rate was 38.4/1,000 patient-days. Incidence rates of in-hospital death among patients without AKI, with AKI not requiring dialysis (AKI stages 1-3), and with AKI receiving dialysis (AKI 3D) were 10.8, 31.1, and 37.5/1,000 patient-days, respectively. Taking those without AKI as the reference group, we observed greater risks for in-hospital death for patients with AKI 1-3 and AKI 3D (HRs of 5.6 [95% CI, 5.0-6.3] and 11.3 [95% CI, 9.6-13.1], respectively). After adjusting for demographics, comorbid conditions, and illness severity, the risk for death remained higher among those with AKI 1-3 (adjusted HR, 3.4 [95% CI, 3.0-3.9]) and AKI 3D (adjusted HR, 6.4 [95% CI, 5.5-7.6]) compared with those without AKI. Among patients with AKI 1-3 who survived, 74.1% achieved kidney recovery by the time of discharge. Among those with AKI 3D who survived, 30.6% remained on dialysis at discharge, and prehospitalization chronic kidney disease was the only independent risk factor associated with needing dialysis at discharge (adjusted OR, 9.3 [95% CI, 2.3-37.8]). LIMITATIONS: Observational retrospective study, limited to the NY metropolitan area during the peak of the COVID-19 pandemic. CONCLUSIONS: AKI in hospitalized patients with COVID-19 was associated with significant risk for death.

Acute kidney injury in patients hospitalized with COVID-19.

The rate of acute kidney injury (AKI) associated with patients hospitalized with Covid-19, and associated outcomes are not well understood. This study describes the presentation, risk factors and outcomes of AKI in patients hospitalized with Covid-19. We reviewed the health records for all patients hospitalized with Covid-19 between March 1, and April 5, 2020, at 13 academic and community hospitals in metropolitan New York. Patients younger than 18 years of age, with end stage kidney disease or with a kidney transplant were excluded. AKI was defined according to KDIGO criteria. Of 5,449 patients admitted with Covid-19, AKI developed in 1,993 (36.6%). The peak stages of AKI were stage 1 in 46.5%, stage 2 in 22.4% and stage 3 in 31.1%. Of these, 14.3% required renal replacement therapy (RRT). AKI was primarily seen in Covid-19 patients with respiratory failure, with 89.7% of patients on mechanical ventilation developing AKI compared to 21.7% of non-ventilated patients. 276/285 (96.8%) of patients requiring RRT were on ventilators. Of patients who required ventilation and developed AKI, 52.2% had the onset of AKI within 24 hours of intubation. Risk factors for AKI included older age, diabetes mellitus, cardiovascular disease, black race, hypertension and need for ventilation and vasopressor medications. Among patients with AKI, 694 died (35%), 519 (26%) were discharged and 780 (39%) were still hospitalized. AKI occurs frequently among patients with Covid-19 disease. It occurs early and in temporal association with respiratory failure and is associated with a poor prognosis.

Renal Ultrasound, Dialysis Catheter Placement, and Kidney Biopsy Experience of US Nephrology Fellows.

Procedures are a key component to the practice of nephrology. The Accreditation Council for Graduate Medical Education (ACGME) requires nephrology fellows to acquire skills and demonstrate competency in the performance of several procedures during fellowship training, including temporary hemodialysis catheter placement, biopsy of native and transplanted kidneys, and various dialytic therapies. It is also required that fellows acquire competency in the interpretation of renal imaging, including renal ultrasound, during their training. To gain a more recent perspective of nephrology fellows' experiences regarding renal ultrasonography, dialysis catheter placement, and kidney biopsies, we carried out a national survey of nephrology fellows in May 2014. A majority of the programs did not offer formal clinical training in renal ultrasonography. In addition, a significant percentage of fellows in adult nephrology may not be acquiring the required procedural skills and competency during fellowship training. In this perspective, we explore some of the reasons for this occurrence and propose some measures that the nephrology training community can take to enhance procedural skills and competency of fellows.

Role of Point of Care Ultrasonography in Patients with COVID-19 Associated Acute Kidney Injury.

The severe acute respiratory virus covariate-2 (SARS CoV-2) that causes Corona Virus Disease 2019 (COVID-19) has affected more than 194 million people worldwide and has attributed to or caused more than 4 million deaths. Acute kidney injury (AKI) is a common complication of COVID-19. Point of care ultrasonography (POCUS) can be a useful tool for the nephrologist. POCUS can be used to elucidate the cause of kidney disease and then also help to manage volume status. Here, we review pearls and pitfalls of using POCUS to manage COVID-19 associated AKI with special attention to kidney, lung, and cardiac ultrasound.

Point-of-care ultrasonography in nephrology comes of age.

The physical exam is changing. Many have argued that the physical exam of the 21st century should include point-of-care ultrasound (POCUS). POCUS is being taught in medical schools and has been endorsed by the major professional societies of internal medicine. In this review we describe the trend toward using POCUS in medicine and describe where the practicing nephrologist fits in. We discuss what a nephrologist's POCUS exam should entail and we give special attention to what nephrologists can gain from learning POCUS. We suggest a 'nephro-centric' approach that includes not only ultrasound of the kidney and bladder, but of the heart, lungs and vascular access. We conclude by reviewing some of the sparse data available to guide training initiatives and give suggested next steps for advancing POCUS in nephrology.

Recovery of Severe Acute Kidney Injury in a Patient with COVID-19: Role of Lung Ultrasonography.

Acute kidney injury (AKI) is recognized as a complication of COVID-19 among hospitalized patients. Lung ultrasonography (LUS) can be a useful tool in the management of COVID-19 pneumonia when interpreted correctly. However, the role of LUS in management of severe AKI in the setting of COVID-19 remains to be defined. We report a 61-year-old male who was hospitalized with acute respiratory failure from COVID-19 pneumonia. In addition to requiring invasive mechanical ventilation, our patient developed AKI and severe hyperkalemia requiring urgent dialytic therapy during his hospital stay. Our patient remained dialysis dependent despite subsequent recovery of lung function. Three days following discontinuation of mechanical ventilation, our patient developed a hypotensive episode during his maintenance hemodialysis treatment. A point of care LUS performed soon after the intradialytic hypotensive episode found no extravascular lung water. Hemodialysis was discontinued and the patient was initiated on intravenous fluids for one week. AKI subsequently resolved. We consider LUS an important tool in identifying COVID-19 patients that would benefit from intravenous fluids following recovery of lung function.

Point-of-Care Ultrasound Training during Nephrology Fellowship: A National Survey of Fellows and Program Directors.

BACKGROUND AND OBJECTIVES: Point-of-care ultrasound (POCUS)-performed by a clinician during a patient encounter and used in patient assessment and care planning-has many potential applications in nephrology. Yet, US nephrologists have been slow to adopt POCUS, which may affect the training of nephrology fellows. This study sought to identify the current state of POCUS training and implementation in nephrology fellowships. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Concise survey instruments measuring attitudes toward POCUS, its current use, fellow competence, and POCUS curricula were disseminated to (1) 912 US nephrology fellows taking the 2021 Nephrology In-Training Examination and (2) 229 nephrology training program directors and associate program directors. Fisher exact, chi-squared, and Wilcoxon rank sum tests were used to compare the frequencies of responses and the average responses between fellows and training program directors/associate program directors when possible. RESULTS: Fellow and training program directors/associate program directors response rates were 69% and 37%, respectively. Only 38% of fellows (240 respondents) reported receiving POCUS education during their fellowship, and just 33% of those who did receive POCUS training reported feeling competent to use POCUS independently. Similarly, just 23% of training program directors/associate program directors indicated that they had a POCUS curriculum in place, although 74% of training program directors and associate program directors indicated that a program was in development or that there was interest in creating a POCUS curriculum. Most fellow and faculty respondents rated commonly covered POCUS topics-including dialysis access imaging and kidney biopsy-as "important" or "very important," with the greatest interest in diagnostic kidney ultrasound. Guided scanning with an instructor was the highest-rated teaching strategy. The most frequently reported barrier to POCUS program development was the lack of available instructors. CONCLUSIONS: Despite high trainee and faculty interest in POCUS, the majority of current nephrology fellows are not receiving POCUS training. Hands-on training guided by an instructor is highly valued, yet availability of adequately trained instructors remains a barrier to program development. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_09_21_CJN01850222.mp3.

Hypoglycemia in Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease: A Prospective Observational Study.

Background: Glycemic management in patients with type 2 diabetes mellitus (T2DM) and CKD can become complicated. One factor that may affect treatment is hypoglycemia. Hypoglycemia risk may be increased by several biologic processes in CKD. The objective of this study was to determine the frequency, severity, and risk factors for hypoglycemia in patients with T2DM and CKD. Methods: The design was a prospective observational study. A continuous glucose monitor (CGM) was worn by 80 patients for up to 14 days; glucose was measured every 15 minutes. Patients with T2DM and eGFR <45 ml/min were enrolled. Patients on dialysis were excluded. The primary outcome was to assess the frequency of hypoglycemic episodes during the study period. Hypoglycemic episodes were defined as a reduced glucose concentration (<70 mg/dl) lasting ≥15 minutes. Secondary outcomes included assessment of severity of hypoglycemia and risk factors for its development. Results: A total of 80 patients wore the CGM for a mean of 12.7±2.9 days. Hypoglycemic events occurred in 61 of 80 patients (76%) with glucose <70 mg/dl, and 49 of 80 (61%) with glucose <60 mg/dl. Prolonged hypoglycemic events (CGM glucose <54 mg/dl for ≥120 consecutive minutes) occurred in 31 patients (39%) with 118 total events. Most hypoglycemic episodes occurred overnight, from 1:00 am to 9:00 am. By multivariate analysis, lower hemoglobin A1c and treatment with insulin were two modifiable risk factors for hypoglycemic events. Conclusions: Patients with T2DM and CKD have frequent periods of hypoglycemia that can be severe and prolonged. Hemoglobin A1c does not portray the full scope of hypoglycemia risk. This study illustrates the need for careful monitoring of glucose levels in patients with T2DM and CKD.

Potentially Avoidable Readmissions in United States Hemodialysis Patients.

INTRODUCTION: Patients with end-stage kidney disease have a high risk of 30-day readmission to hospital. These readmissions are financially costly to health care systems and are associated with poor health-related quality of life. The objective of this study was to describe and analyze the frequency, causes, and predictors of 30-day potentially avoidable readmission to hospital in patients on hemodialysis. METHODS: We conducted a retrospective cohort study using the US Renal Data System data from January 1, 2008, to December 31, 2008. A total of 107,940 prevalent United States hemodialysis patients with 248,680 index hospital discharges were assessed for the main outcome of 30-day potentially avoidable readmission, as identified by a computerized algorithm. RESULTS: Of 83,209 30-day readmissions, 59,045 (70.1%) resulted in a 30-day potentially avoidable readmission. The geographic distribution of 30-day potentially avoidable readmission in the United States varied by state. Characteristics associated with 30-day potentially avoidable readmission included the following: younger age, shorter time on hemodialysis, at least 3 or more hospitalizations in preceding 12 months, black race, unemployed status, treatment at a for-profit facility, longer length of index hospital stay, and index hospitalizations that involved a surgical procedure. The 5-, 15-, and 30-day potentially avoidable readmission cumulative incidences were 6.0%, 15.1%, and 25.8%, respectively. CONCLUSION: Patients with end-stage kidney disease on maintenance hemodialysis are at high risk for 30-day readmission to hospital, with nearly three-quarters (70.1%) of all 30-day readmissions being potentially avoidable. Research is warranted to develop cost-effective and transferrable interventions that improve care transitions from hospital to outpatient hemodialysis facility and reduce readmission risk for this vulnerable population.

Left Ventricular Assist Devices and the Kidney.

Left ventricular assist devices (LVADs) are common and implantation carries risk of AKI. LVADs are used as a bridge to heart transplantation or as destination therapy. Patients with refractory heart failure that develop chronic cardiorenal syndrome and CKD often improve after LVAD placement. Nevertheless, reversibility of CKD is hard to predict. After LVAD placement, significant GFR increases may be followed by a late return to near baseline GFR levels, and in some patients, a decline in GFR. In this review, we discuss changes in GFR after LVAD placement, the incidence of AKI and associated mortality after LVAD placement, the management of AKI requiring RRT, and lastly, we review salient features about cardiorenal syndrome learned from the LVAD experience. In light of the growing number of patients using LVADs as a destination therapy, it is important to understand the effect of these devices on the kidney. Additional research and long-term data are required to better understand the relationship between the LVAD and the kidney.

Lung ultrasonography in end-stage renal disease: moving from evidence to practice-a narrative review.

Traditionally, point of care ultrasonography in nephrology has been used for renal biopsies and dialysis line placement. However, there is an emerging literature supporting the value of point of care lung ultrasonography in the assessment of volume status for dialysis patients. We conducted a review and identified 12 studies that examined the utility of lung ultrasonography in assessing volume status in patients with end-stage renal disease. We conclude that lung ultrasonography can be used to determine volume status in chronic dialysis patients by identifying lung congestion using the B-line score. Incorporating this technique into practice may have significant diagnostic and prognostic value for this high-risk population, as it provides the nephrologist with a useful bedside technique to assess extravascular lung water. Developing competence in lung ultrasonography is straightforward. The nephrology community should consider adding this useful tool into fellowship training, paralleling its broader use in other internal medicine specialties.

Adverse Renal Effects of Novel Molecular Oncologic Targeted Therapies: A Narrative Review.

Novel targeted anti-cancer therapies have resulted in improvement in patient survival compared to standard chemotherapy. Renal toxicities of targeted agents are increasingly being recognized. The incidence, severity, and pattern of renal toxicities may vary according to the respective target of the drug. Here we review the adverse renal effects associated with a selection of currently approved targeted cancer therapies, directed to EGFR, HER2, BRAF, MEK, ALK, PD1/PDL1, CTLA-4, and novel agents targeted to VEGF/R and TKIs. In summary, electrolyte disorders, renal impairment and hypertension are the most commonly reported events. Of the novel targeted agents, ipilumumab and cetuximab have the most nephrotoxic events reported. The early diagnosis and prompt recognition of these renal adverse events are essential for the general nephrologist taking care of these patients.

Effect of mycorrhizal fungi on the phytoextraction of weathered p,p-DDE by Cucurbita pepo.

Field experiments were conducted to assess the impact of inoculation with mycorrhizal fungi on the accumulation of weathered p,p'-DDE from soil by three cultivars of zucchini (Cucurbita pepo spp. pepo cv Costata Romanesco, Goldrush, Raven). Three commercially available mycorrhizal products (BioVam, Myco-Vam, INVAM) were inoculated into the root system of the zucchini seedlings at planting. In agreement with our previous findings, plants not inoculated with fungi accumulated large but variable amounts of contaminant, with root bioconcentration factors (BCFs, ratio of p,p'-DDE, on a dry weight basis, in the root to that in the soil) ranging from 10 to 48 and stem BCFs ranging from 5.5 to 11. The total amount of contaminant phytoextracted during the 62 day growing season ranged from 0.72-2.9%. The effect of fungal inoculation on the release of weathered p,p'-DDE from soil and on the subsequent uptake of the parent compound by zucchini appeared to vary at the cultivar level. For Goldrush, fungal inoculation generally decreased tissue BCFs but because of slightly larger biomass, did not significantly impact the percent contaminant phytoextracted. Alternatively, for Costata, BioVam and Myco-Vam generally enhanced p,p'-DDE accumulation from soil, and increased the amount of contaminant phytoextracted by up to 34%. For Raven, BioVam reduced contaminant uptake whereas Myco-Vam and INVAM increased contaminant phytoextraction by 53 and 60%, respectively. The data show that fungal inoculation may significantly increase the remedial potential of C. pepo ssp. pepo. The apparent cultivar specific response to mycorrhizal inoculation is unexpected and the subject of ongoing investigation.