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Koratala A. Point-of-care ultrasonography in cirrhosis-related acute kidney injury: How I do it. World J Crit Care Med 2024; 13:93812. [DOI: 10.5492/wjccm.v13.i2.93812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/24/2024] [Accepted: 05/14/2024] [Indexed: 06/03/2024] Open
Abstract
Discerning the etiology of acute kidney injury (AKI) in cirrhotic patients remains a formidable challenge due to diverse and overlapping causes. The conventional approach of empiric albumin administration for suspected volume depletion may inadvertently lead to fluid overload. In the recent past, point-of-care ultrasonography (POCUS) has emerged as a valuable adjunct to clinical assessment, offering advantages in terms of diagnostic accuracy, rapidity, cost-effectiveness, and patient satisfaction. This review provides insights into the strategic use of POCUS in evaluating cirrhotic patients with AKI. The review distinguishes basic and advanced POCUS, emphasizing a 5-point basic POCUS protocol for efficient assessment. This protocol includes evaluations of the kidneys and urinary bladder for obstructive nephropathy, lung ultrasound for detecting extravascular lung water, inferior vena cava (IVC) ultrasound for estimating right atrial pressure, internal jugular vein ultrasound as an alternative to IVC assessment, and focused cardiac ultrasound for assessing left ventricular (LV) systolic function and identifying potential causes of a plethoric IVC. Advanced POCUS delves into additional Doppler parameters, including stroke volume and cardiac output, LV filling pressures and venous congestion assessment to diagnose or prevent iatrogenic fluid overload. POCUS, when employed judiciously, enhances the diagnostic precision in evaluating AKI in cirrhotic patients, guiding appropriate therapeutic interventions, and minimizing the risk of fluid-related complications.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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2
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Sethi SK, Mahan J, Hu J, Koratala A, Soni K, Singh Y, Abitbol C, DeFreitas M, Reisinger N, Argaiz ER, Yap HK, Badeli H, Kalra M, VanGeest J, Nair N, Raynor J, Alhasan KA, McCulloch M, Bunchman T, Sharma V, Raina R. Point-of-Care Ultrasound (POCUS) Training Curriculum for Pediatric Nephrology: PCRRT-ICONIC Group Recommendations. KIDNEY360 2024; 5:671-680. [PMID: 38477662 DOI: 10.34067/kid.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/06/2024] [Indexed: 03/14/2024]
Abstract
Key Points
Despite a high need and interest in point-of-care ultrasound (POCUS) in trainees and faculty of Pediatric Nephrology, the majority are not receiving POCUS training.There is a need to establish a structured pediatric nephrology POCUS program for clinicians and fellows.This study suggests a blueprint of POCUS curriculum which can serve as a foundation for POCUS education in pediatric nephrology centers worldwide.
Background
Point-of-care ultrasound (POCUS) is commonly used in adult specialties, pediatric emergency medicine, and neonatal and pediatric critical care. Specifically, in the field of pediatric nephrology, POCUS plays a valuable role in the critical inpatient and outpatient settings. However, the lack of guidelines and a standardized curriculum for POCUS in pediatric nephrology has led to substantial discrepancies in both clinical practice and training.
Methods
A multinational, multicenter survey regarding POCUS usefulness and training was sent to 225 pediatric nephrology residents, fellows, and physicians with expertise in pediatric nephrology. On the basis of the results, an ideal pediatric nephrology POCUS curriculum was formulated with a panel of experts from across the world. Eighteen experts were included, with each expert having >10 years of experience in using POCUS in adult and pediatric nephrology. A Delphi method was used to further solidify guidelines regarding the content, curriculum, and vital skills of using POCUS in pediatric nephrology.
Results
A total of 134 pediatric nephrology trainees, specialists, and faculty responded to the survey (59.6% completion rate). A total of 87.4% of respondents believe that formal POCUS training is either highly desirable or should be mandatory in pediatric nephrology fellowship programs. Identified barriers to receiving training included lack of an organized curriculum, lack of POCUS experts and pediatric intensivists, lack of ultrasound equipment, lack of financial support, and lack of dedicated time during training. An expert panel was convened, and a Delphi survey was conducted to formulate guidelines to overcome the barriers to pediatric nephrology POCUS and standardize the training process.
Conclusions
After collaborating with prominent pediatric nephrologists, global POCUS experts proposed a comprehensive POCUS training curriculum tailored specifically for pediatric nephrology trainees, with an appeal for all pediatric nephrology education programs to integrate POCUS instruction into their curricula.
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Affiliation(s)
| | - John Mahan
- Pediatric Nephrology, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio
| | - Jieji Hu
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kritika Soni
- Pediatric Nephrology, Medanta, The Medicity, Gurgaon, India
| | - Yogen Singh
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California
| | - Carolyn Abitbol
- Division of Nephrology, Department of Pediatrics, University of Miami/Holtz Children's Hospital, Miami, Florida
| | - Marissa DeFreitas
- Division of Nephrology, Department of Pediatrics, University of Miami/Holtz Children's Hospital, Miami, Florida
| | - Nathaniel Reisinger
- Division of Renal Electrolyte and Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eduardo R Argaiz
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico
| | - Hui Kim Yap
- Children's Kidney Centre, Khoo Teck Puat - National University Children's Medical Institute, Singapore
| | - Hamidreza Badeli
- Pediatric Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Meenal Kalra
- Department of Paediatrics, Kasturba Medical College, Manipal, India
| | | | - Nikhil Nair
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - James Raynor
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Khalid A Alhasan
- Pediatric Nephrology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mignon McCulloch
- Department of Paediatric Nephrology and Transplantation, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Timothy Bunchman
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Vivek Sharma
- Department of Imaging and Radiology, Medanta, The Medicity, Gurgaon, India
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Schnure N, Elfadil MM, Chan W, Baston C, Shofer F, Panebianco N. Trends in Point of Care Ultrasound Familiarity Among Undergraduate Medical Clerkship Educators. POCUS JOURNAL 2024; 9:80-86. [PMID: 38681158 PMCID: PMC11044932 DOI: 10.24908/pocus.v9i1.16678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
OBJECTIVES Despite growing use of point of care ultrasound (POCUS), there remains a paucity of data about familiarity with POCUS among educators who dictate curricular content in undergraduate medical education. This paper aims to longitudinally characterize the level of comfort and frequency of POCUS use among faculty involved in undergraduate clerkship education. METHODS A web-based cross-sectional survey assessing comfort, frequency of use, and awareness of indications for POCUS among faculty involved in Internal Medicine, Family Medicine, and Surgery undergraduate clerkship education in a single urban academic medical center in 2016 and again in 2022. RESULTS A total of 45 responses from 2016 and 30 responses from 2022 are included. The percentage of faculty "not comfortable" with performing POCUS decreased from 78% to 46%, although the overall change in comfort was not statistically significant. Comfort interpreting POCUS images, frequency of POCUS use, and familiarity with the clinical applications of POCUS all improved. Faculty identified multiple barriers to more frequent POCUS use. CONCLUSIONS Over a six-year period at one urban, academic medical center, comfort with POCUS and frequency of use have increased slightly but remain low among core faculty responsible for clerkship education. There are still large gaps in knowledge and very few faculty regularly use POCUS, which can be attributed to multiple different barriers.
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Affiliation(s)
- Nilan Schnure
- Section of Hospital Medicine, University of PennsylvaniaPhiladelphia, PAUSA
| | | | - Wilma Chan
- Division of Emergency Ultrasound, Department of Emergency Medicine, University of PennsylvaniaPhiladelphia, PAUSA
| | - Cameron Baston
- Department of Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphia, PAUSA
| | - Frances Shofer
- Division of Emergency Ultrasound, Department of Emergency Medicine, University of PennsylvaniaPhiladelphia, PAUSA
| | - Nova Panebianco
- Division of Emergency Ultrasound, Department of Emergency Medicine, University of PennsylvaniaPhiladelphia, PAUSA
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Nikitiuk BE, Rydzewska-Rosołowska A, Kakareko K, Głowińska I, Hryszko T. On Whether Ca-125 Is the Answer for Diagnosing Overhydration, Particularly in End-Stage Kidney Disease Patients-A Systematic Review. Int J Mol Sci 2024; 25:2192. [PMID: 38396869 PMCID: PMC10889175 DOI: 10.3390/ijms25042192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Overhydration (OH) is a prevalent medical problem that occurs in patients with kidney failure, but a specific marker has still not been found. Patients requiring kidney replacement therapy suffer from a water imbalance, which is correlated with mortality rates in this population. Currently, clinicians employ techniques such as bioimpedance spectroscopy (BIS) and ultrasound (USG) markers of overhydration or markers of heart and kidney function, namely NT-pro-BNP, GFR, or creatinine levels. New serum markers, including but not limited to Ca-125, galectin-3 (Gal-3), adrenomedullin (AMD), and urocortin-2 (UCN-2), are presently under research and have displayed promising results. Ca-125, which is a protein mainly used in ovarian cancer diagnoses, holds great potential to become an OH marker. It is currently being investigated by cardiologists as it corresponds to the volume status in heart failure (HF) and ventricular hypertrophy, which are also associated with OH. The need to ascertain a more precise marker of overhydration is urgent mainly because physical examinations are exceptionally inaccurate. The signs and symptoms of overhydration, such as edema or a gradual increase in body mass, are not always present, notably in patients with chronic kidney disease. Metabolic disruptions and cachexia can give a false picture of the hydration status. This review paper summarizes the existing knowledge on the assessment of a patient's hydration status, focusing specifically on kidney diseases and the role of Ca-125.
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Affiliation(s)
| | - Alicja Rydzewska-Rosołowska
- 2nd Department of Nephrology, Hypertension, and Internal Medicine with Dialysis Unit, Medical University of Bialystok, 15-276 Bialystok, Poland; (B.E.N.); (K.K.); (I.G.); (T.H.)
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Romero-González G, Argaiz ER, Koratala A, González DA, Vives M, Juega J, Soler-Majoral J, Graterol F, Perezpayá I, Rodriguez-Chitiva N, Lorenzo-Ferris I, Narvaez C, Manrique J, Morales E, Rivera-Gorrín M, Ibeas J, Bover J, Sánchez E, de Sequera P. Towards standardization of POCUS training in Nephrology: the time is NOW. Nefrologia 2024; 44:5-9. [PMID: 38429147 DOI: 10.1016/j.nefroe.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 03/03/2024] Open
Affiliation(s)
- Gregorio Romero-González
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain; International Renal Research Institute of Vicenza, Vicenza, Italy.
| | - Eduardo R Argaiz
- Servicio de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México; Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Spain
| | - Abhilash Koratala
- División de Nefrología, Medical College of Wisconsin, Milwaukee, USA
| | - Duilio Ariel González
- Miembro del Grupo de la Red Española de Ecografía en Cuidado Crítico. Servicio de Anestesiología y Reanimación, Clínica Universidad de Navarra, Pamplona, Spain
| | - Marc Vives
- Copresidente del Grupo de la Red Española de Ecografía en Cuidado Crítico, Servicio de Anestesiología y Reanimación, Clínica Universidad de Navarra, Profesor Asociado, Facultad de Medicina, Universidad de Navarra, Pamplona, Spain
| | - Javier Juega
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Jordi Soler-Majoral
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Fredzzia Graterol
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Inés Perezpayá
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Néstor Rodriguez-Chitiva
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | | | - Carlos Narvaez
- Servicio de Nefrología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Joaquín Manrique
- Servicio de Nefrología, Hospital Universitario de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Enrique Morales
- Servicio de Nefrología, Hospital 12 de Octubre, Madrid, Spain
| | - Maite Rivera-Gorrín
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal. IRyCis. UAH, Madrid, Spain; Coordinadora del Grupo de Nefrología Diagnóstica e Intervencionista de la Sociedad Española de Nefrología, Spain
| | - José Ibeas
- Servicio de Nefrología, Parc Taulí Hospital Universitari, Institut d´investigació i innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Jordi Bover
- Servicio de Nefrología, Hospital Germans Trias i Pujol, Grupo REMAR-IGTP, Instituto de Investigación Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Emilio Sánchez
- Servicio de Nefrología, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | - Patricia de Sequera
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, Spain
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6
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Koratala A, Reisinger N. Point-of-Care Ultrasound Training in Nephrology: A Leap Forward, Not Merely a Check Mark. Kidney Med 2024; 6:100752. [PMID: 38188457 PMCID: PMC10770553 DOI: 10.1016/j.xkme.2023.100752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024] Open
Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathaniel Reisinger
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania
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Ehinmisan AO, Rosen R. Chest Pain and Hypotension in a Dialysis Patient. KIDNEY360 2024; 5:168-169. [PMID: 38271197 PMCID: PMC10917112 DOI: 10.34067/kid.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Affiliation(s)
| | - Raphael Rosen
- Division of Nephrology, Department of Medicine, Stamford Health Medical Group, Stamford, Connecticut
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8
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Overgaard J, Thilagar BP, Bhuiyan MN. A Clinician's Guide to the Implementation of Point-of-Care Ultrasound (POCUS) in the Outpatient Practice. J Prim Care Community Health 2024; 15:21501319241255576. [PMID: 38773821 PMCID: PMC11113028 DOI: 10.1177/21501319241255576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/24/2024] Open
Abstract
Point-of-care ultrasound (POCUS) is a valuable clinical tool used at the patient bedside to rapidly assess a wide variety of symptoms and problems which would otherwise take hours or even days. Though it has become the standard of care in Emergency Medicine and is becoming so in hospital internal medicine, less uptake has been appreciated in the outpatient setting despite reported interest from clinicians practicing there. A number of common barriers have been cited to explain this gap in use, which usually include access to equipment, mentorship, and time. In this review we present a proposed framework for clinicians who have an interest in implementing POCUS in their outpatient practice which we hope can mitigate some of these barriers and provide a more streamlined pathway to their desired goals.
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Zoccali C, Mark PB, Sarafidis P, Agarwal R, Adamczak M, Bueno de Oliveira R, Massy ZA, Kotanko P, Ferro CJ, Wanner C, Burnier M, Vanholder R, Mallamaci F, Wiecek A. Diagnosis of cardiovascular disease in patients with chronic kidney disease. Nat Rev Nephrol 2023; 19:733-746. [PMID: 37612381 DOI: 10.1038/s41581-023-00747-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/25/2023]
Abstract
Patients with chronic kidney disease (CKD) are at high risk of cardiovascular disease (CVD) and cardiovascular death. Identifying and monitoring cardiovascular complications and hypertension is important for managing patients with CKD or kidney failure and transplant recipients. Biomarkers of myocardial ischaemia, such as troponins and electrocardiography (ECG), have limited utility for diagnosing cardiac ischaemia in patients with advanced CKD. Dobutamine stress echocardiography, myocardial perfusion scintigraphy and dipyridamole stress testing can be used to detect coronary disease in these patients. Left ventricular hypertrophy and left ventricular dysfunction can be detected and monitored using various techniques with differing complexity and cost, including ECG, echocardiography, nuclear magnetic resonance, CT and myocardial scintigraphy. Atrial fibrillation and other major arrhythmias are common in all stages of CKD, and ambulatory heart rhythm monitoring enables precise time profiling of these disorders. Screening for cerebrovascular disease is only indicated in asymptomatic patients with autosomal dominant polycystic kidney disease. Standardized blood pressure is recommended for hypertension diagnosis and treatment monitoring and can be complemented by ambulatory blood pressure monitoring. Judicious use of these diagnostic techniques may assist clinicians in detecting the whole range of cardiovascular alterations in patients with CKD and enable timely treatment of CVD in this high-risk population.
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Affiliation(s)
- Carmine Zoccali
- Renal Research Institute, New York, NY, USA.
- Institute of Biology and Molecular Genetics (BIOGEM), Ariano Irpino, Italy.
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET) c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy.
| | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Indiana University School of Medicine, Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Katowice, Poland
| | - Rodrigo Bueno de Oliveira
- Department of Internal Medicine (Nephrology), School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Ziad A Massy
- Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, Billancourt, France
- INSERM U-1018, Centre de recherche en épidémiologie et santé des populations (CESP), Equipe 5, Paris-Saclay University (PSU), Paris, France
- University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), FCRIN INI-CRCT, Villejuif, France
| | - Peter Kotanko
- Renal Research Institute, LLC Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Paediatrics, University Hospital, Ghent, Belgium
| | - Francesca Mallamaci
- Nephrology and Transplantation Unit, Grande Ospedale Metropolitano Reggio Cal and CNR-IFC, Reggio Calabria, Italy
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
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Velarde-Ruiz Velasco JA, Tapia Calderón DK, Llop Herrera E, Castro Narro G, García Jiménez ES, Cerda Reyes E, Higuera de la Tijera F, Cano Contreras AD, Moreno Alcántar R, Chávez Ramírez RM, Calleja Panero JL. Beyond conventional physical examination in hepatology: POCUS. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:381-391. [PMID: 37833134 DOI: 10.1016/j.rgmxen.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/26/2023] [Indexed: 10/15/2023]
Abstract
Point-of-care ultrasound (POCUS) refers to the use of ultrasound imaging through pocket-sized sonographic devices at the patient's bedside, to make a diagnosis or direct a procedure and immediately answer a clinical question. Its goal is to broaden the physical examination, not to replace conventional ultrasound studies. POCUS has evolved as a complement to physical examination and has been adopted by different medical specialties, including hepatology. A narrative synthesis of the evidence on the applications of POCUS in hepatology was carried out, describing its usefulness in the diagnosis of cirrhosis of the liver, metabolic dysfunction-associated steatotic liver disease (MASLD), decompensated cirrhosis, and portal hypertension. The review also encompasses more recent applications in the hemodynamic evaluation of the critically ill patient with cirrhosis of the liver, patients with other liver diseases, as well as in the ultrasound guidance of procedures. POCUS could make up part of the daily clinical practice of gastroenterologists and hepatologists, simplifying the initial evaluation of patients and optimizing clinical management. Its accessibility, ease of use, and low adverse event profile make POCUS a useful tool for the properly trained physician in the adequate clinical setting. The aim of this review was to describe the available evidence on the usefulness of POCUS in the daily clinical practice of gastroenterologists and hepatologists.
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Affiliation(s)
- J A Velarde-Ruiz Velasco
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico; Departamento de Clínicas Médicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - D K Tapia Calderón
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, IDIPHISA, Ciberhd, Majadahonda, Madrid, Spain.
| | - E Llop Herrera
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, IDIPHISA, Ciberhd, Majadahonda, Madrid, Spain
| | - G Castro Narro
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E S García Jiménez
- Servicio de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - E Cerda Reyes
- Servicio de Gineco-Obstetricia, Hospital Central Militar, Mexico City, Mexico
| | - F Higuera de la Tijera
- Servicio de Gastroenterología, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - A D Cano Contreras
- Instituto de Investigaciones Médico-Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - R Moreno Alcántar
- Unidad Médica de Alta Especialidad Hospital de Especialidades CMN SXXI, Mexico City, Mexico
| | - R M Chávez Ramírez
- Unidad de Cuidados Intensivos, Hospital de Ginecoobstetricia, UMAE CMNO IMSS, Guadalajara, Jalisco, Mexico
| | - J L Calleja Panero
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, IDIPHISA, Ciberhd, Majadahonda, Madrid, Spain
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Cook DL, Patel S, Nee R, Little DJ, Cohen SD, Yuan CM. Point-of-Care Ultrasound Use in Nephrology: A Survey of Nephrology Program Directors, Fellows, and Fellowship Graduates. Kidney Med 2023; 5:100601. [PMID: 36941846 PMCID: PMC10024220 DOI: 10.1016/j.xkme.2023.100601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Rationale & Objective Adoption of point-of-care ultrasound (POCUS) into nephrology practice has been relatively slow. We surveyed US nephrology program directors, their fellows, and graduates from a single training program regarding current/planned POCUS training, clinical use, and barriers to training and use. Study Design Anonymous, online survey. Setting & Participants All US nephrology program directors (n=151), their fellows (academic year 2021-2022), and 89/90 graduates (1980-2021) of the Walter Reed Nephrology Program. Analytical Approach Descriptive. Results 46% (69/151) of program directors and 33% (118/361) of their fellows responded. Response rate was 62% (55/89) for Walter Reed graduates. 51% of program directors offered POCUS training, most commonly bedside training in non-POCUS oriented rotations (71%), didactic lectures (68%), and simulation (43%). 46% of fellows reported receiving POCUS training, but of these, many reported not being sufficiently trained/not confident in kidney (56%), bladder (50%), and inferior vena cava assessment (46%). Common barriers to training reported by program directors were not enough trained faculty (78%), themselves not being sufficiently trained (55%), and equipment expense (51%). 64% of program directors and 55% of fellows reported <10% of faculty were able to perform POCUS. 64% of fellows reported having too little POCUS training. 72% of program directors and 77% of graduates felt POCUS should be incorporated into the fellowship curriculum. 59% of fellows and 61% of graduates desired hands-on POCUS training rather than didactic lectures or simulation. Limitations Loss of respondents as program directors and fellows progressed through the survey. Conclusions Nephrology program directors, fellows, and graduates surveyed want POCUS training incorporated into the fellowship curriculum. No group felt sufficiently trained to confidently perform POCUS, and the major barrier to training was lack of sufficiently trained faculty. This highlights the need to "train the trainers" before POCUS can be fully integrated into fellowship training and regularly used in nephrology practice.
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Affiliation(s)
- David L. Cook
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Samir Patel
- Washington DC VA Medical Center, Washington, District of Columbia
| | - Robert Nee
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Dustin J. Little
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Scott D. Cohen
- Washington DC VA Medical Center, Washington, District of Columbia
| | - Christina M. Yuan
- Walter Reed National Military Medical Center, Bethesda, Maryland
- Address for Correspondence: Christina M. Yuan, MD, Nephrology SVC, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889.
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12
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Bhasin-Chhabra B, Koratala A. Point of care ultrasonography in onco-nephrology: A stride toward better physical examination. World J Nephrol 2023; 12:29-39. [PMID: 37035508 PMCID: PMC10075017 DOI: 10.5527/wjn.v12.i2.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/27/2023] [Accepted: 03/09/2023] [Indexed: 03/21/2023] Open
Abstract
Onco-Nephrology is an emerging subspecialty of Nephrology that focuses on a broad spectrum of renal disorders that can arise in patients with cancer. It encompasses acute kidney injury (AKI), complex fluid, electrolyte, and acid-base disorders, as well as chronic kidney disease caused or exacerbated by cancer and/or its treatment. In many such scenarios including AKI and hyponatremia, objective evaluation of hemodynamics is vital for appropriate management. Point of care ultrasonography (POCUS) is a limited ultrasound exam performed at the bedside and interpreted by the treating physician intended to answer focused clinical questions and guide therapy. Compared to conventional physical examination, POCUS offers substantially higher diagnostic accuracy for various structural and hemodynamic derangements. In this narrative review, we provide an overview of the utility of POCUS enhanced physical examination for the Onconephrologist supported by the current evidence and our experience-based opinion.
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Affiliation(s)
- Bhavna Bhasin-Chhabra
- Division of Nephrology and Hypertension, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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13
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Koratala A, Taleb Abdellah A, Reisinger N. Nephrologist-performed point-of-care venous excess Doppler ultrasound (VExUS) in the management of acute kidney injury. J Ultrasound 2023; 26:301-306. [PMID: 36617380 PMCID: PMC10063755 DOI: 10.1007/s40477-022-00760-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/28/2022] [Indexed: 01/09/2023] Open
Abstract
Acute kidney injury (AKI) is frequently associated with alterations in fluid balance making accurate assessment of hemodynamics a vital component of patient management. Unfortunately, conventional parameters such as history, physical examination, vital signs, weight, natriuretic peptides have limitations in this regard. Point of care ultrasonography (POCUS) is a clinician-performed limited ultrasound study intended to answer focused clinical questions at the bedside. In the past several years, it has evolved as an extension of physical examination in various medical specialties. Herein, we describe a case of AKI where nephrologist-performed multi-organ POCUS aided in accurate diagnosis of fluid overload state. In addition, we describe how venous Doppler (VExUS) evaluation can be used to monitor the efficacy of decongestive therapy in real-time. Nephrologists should adopt a multi-parametric approach integrating all the pieces of hemodynamic puzzle when evaluating patients with AKI and fluid/electrolyte disorders.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Room A7633, Milwaukee, WI, 53226, USA.
| | - Ahmed Taleb Abdellah
- Division of Nephrology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Room A7633, Milwaukee, WI, 53226, USA
| | - Nathaniel Reisinger
- Division of Renal Electrolyte and Hypertension, University of Pennsylvania Hospital, Philadelphia, USA
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14
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Koratala A, Reisinger N. Point of Care Ultrasound in Cirrhosis-Associated Acute Kidney Injury: Beyond Inferior Vena Cava. KIDNEY360 2022; 3:1965-1968. [PMID: 36514396 PMCID: PMC9717633 DOI: 10.34067/kid.0005522022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 12/05/2022]
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15
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Reisinger NC, Koratala A. Incorporating Training in POCUS in Nephrology Fellowship Curriculum. Clin J Am Soc Nephrol 2022; 17:1442-1445. [PMID: 36130825 PMCID: PMC9528260 DOI: 10.2215/cjn.09580822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin
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16
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Abstract
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.
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17
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Romero-González G, Manrique J, Slon-Roblero MF, Husain-Syed F, De la Espriella R, Ferrari F, Bover J, Ortiz A, Ronco C. PoCUS in nephrology: a new tool to improve our diagnostic skills. Clin Kidney J 2022; 16:218-229. [PMID: 36755847 PMCID: PMC9900589 DOI: 10.1093/ckj/sfac203] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Indexed: 11/14/2022] Open
Abstract
Point-of-Care Ultrasonography (PoCUS) aims to include a fifth pillar (insonation) in the classical physical examination in order to obtain images to answer specific questions by the clinician at the patient's bedside, allowing rapid identification of structural or functional abnormalities, enabling more accurate volume assessment and supporting diagnosis, as well as guiding procedures. In recent years, PoCUS has started becoming a valuable tool in day-to-day clinical practice, adopted by healthcare professionals from various medical specialties, never replacing physical examination but improving patient and medical care and experience. Renal patients represent a wide range of diseases, which lends PoCUS a special role as a valuable tool in different scenarios, not only for volume-related information but also for the assessment of a wide range of acute and chronic conditions, enhancing the sensitivity of conventional physical examination in nephrology. PoCUS in the hands of a nephrologist is a precision medicine tool.
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Affiliation(s)
| | - Joaquin Manrique
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain,Nephrology Department, University Hospital of Navarra, Pamplona, Spain
| | - María F Slon-Roblero
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain,Nephrology Department, University Hospital of Navarra, Pamplona, Spain
| | - Faeq Husain-Syed
- Department of Medicine, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, USA,Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse, Giessen, Germany
| | | | | | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias I Pujol, Badalona, Spain,REMAR-IGTP Group, Research Institute Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IISFundacion Jimenez Diaz UAM, Madrid, Spain
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Vicenza, Italy,Professor of Medicine - University of Padova, Padova, Italy,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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Abstract
The role of venous congestion in abnormal kidney function is being increasingly recognized. It is well known that unresolved congestion is associated with adverse kidney and overall outcomes in patients with heart failure. Similarly, any condition that leads to elevated central venous pressure, such as pulmonary hypertension, can result in impaired kidney perfusion by increasing its afterload. Point-of-care ultrasonography (POCUS) enables the clinician to objectively assess hemodynamics at the bedside and, thereby, guide patient management. Lung POCUS has received widespread attention in the recent past because of the relative ease of the technique, but it reflects only left heart pressures and not venous congestion. Although inferior vena cava POCUS is used to estimate right atrial pressure, its isolated use cannot demonstrate organ congestion. Moreover, it is associated with several technical and conceptual limitations. Recently, venous excess Doppler ultrasound has emerged as a tool to assess venous congestion at the organ level in real time. Severe flow abnormalities in hepatic, portal, and kidney parenchymal veins have shown to predict the risk of congestive kidney injury. In addition, it helps to objectively monitor the efficacy of decongestive therapy. In this review, we provide a brief overview of various components of venous excess Doppler ultrasound and share our perspective on incorporating this novel tool in nephrology practice.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI
- Address for Correspondence: Abhilash Koratala, MD, Division of Nephrology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, 7 floor HUB, Room A 7633, Wauwatosa, WI 53226.
| | - Nathaniel Reisinger
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
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19
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Koratala A, Ronco C, Kazory A. Multi-Organ Point-Of-Care Ultrasound in Acute Kidney Injury. Blood Purif 2022; 51:967-971. [DOI: 10.1159/000522652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/14/2022] [Indexed: 12/28/2022]
Abstract
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.
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20
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Taleb Abdellah A, Koratala A. Nephrologist-performed Point-of-Care Ultrasound in Acute Kidney Injury: beyond Hydronephrosis. Kidney Int Rep 2022; 7:1428-1432. [PMID: 35685325 PMCID: PMC9171614 DOI: 10.1016/j.ekir.2022.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/16/2022] [Accepted: 02/21/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Correspondence: Abhilash Koratala, Division of Nephrology, Medical College of Wisconsin, 8701 West Watertown Plank Road, Room A 7633, Wauwatosa, Wisconsin 53226, USA.
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