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Role of Point-Of-Care Ultrasonography in the Evaluation and Management

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Role of Point-Of-Care Ultrasonography in the Evaluation and Management Role of Point-of-Care Ultrasonography in the Evaluation and Management of Kidney Disease Jorge Lamarche, MD; Alfredo Peguero Rivera, MD; Craig Courville, MD; Mohamed Taha, MD; Marina Antar-Shultz, DO; and Andres Reyes, MD Imaging at the nephrology point of care provides an important and continuously expanding tool to improve diagnostic accuracy in concert with history and physical examination. he evaluation of acute kidney injury protocols into the modified focused assess- Jorge Lamarche, Alfredo Peguero Rivera, Craig (AKI) often starts with the classic pre- ment with sonography for trauma (FAST) Courville, Mohamed Taha, Trenal, renal, and postrenal causalities, examination in conjunction with limited and Marina Antar-Shultz delineating a practical workable approach echocardiography and lung sonography (Fig- are Academic Nephrology in its differential diagnosis. Accordingly, the ure 1). The original FAST protocol was devel- Attending Physicians at the James A. Haley Veterans' history, physical examination, urinalysis, oped by the American Institute of Ultrasound Hospital and Assistant Pro- and kidney-bladder sonography are stan- in Medicine and the American College of fessors at the University of 3 dard resources in the initial approach to Emergency Physicians. South Florida Department of Nephrology and Hyper- renal disease assessment. Ultrasonography These protocols have allowed the evalu- tension, all in Tampa, Flor- has a well-established role as an important ation of extracellular volume, which is im- ida. At the time the article adjuvant for postrenal diagnosis of renal portant to measure for the diagnosis and was written Andres Reyes failure. Nevertheless, most of the causes of management of renal diseases. For example, was a Medical Fellow at the University of South Florida. AKI are prerenal and renal. the evaluation of lung water by POC ultra- Correspondence: Some etiologies of kidney injury are se- sonography for patients with ESRD is emerg- Jorge Lamarche quelae of systemic diseases in which sonog- ing as a promising tool. In a study of patients ([email protected]) raphy can be diagnostically analogous to the with ESRD undergoing hemodialysis, POC history and physical examination. Further- ultrasonography detected moderate-to-severe more, ultrasonography may be informative lung congestion in 45% of patients, most of in various clinical scenarios, for example, pa- whom (71%) were asymptomatic. Two years tients with chronic kidney disease (CKD) of follow-up of patients was associated with and end-stage renal disease (ESRD). In this 3 to 4 times greater risk of heart attack and narrative review, the contribution of point- death, respectively, compared with individ- of-care (POC) sonography to the evaluation uals without congestion on sonography.4-6 and management of AKI, CKD, and associ- Thus, ultrasound assessment of lung water ated diseases are explored beyond the tra- in patients with ESRD may prove to be an es- ditional sonogram uses for kidney biopsy, sential tool to assure an adequate ultrafiltra- central catheter placement, and/or screening tion and improve patient outcomes. of hydronephrosis. Two important elements made possible ACUTE KIDNEY INJURY the incorporation of POC sonography into Prerenal nephrology practice.1,2 First, the development The physical examination provides evaluation of handheld reliable and portable ultrasound of effective arterial circulatory flow (EACF) devices and, second, the derived capacity of and is clinically useful in the evaluation of POC sonography to obtain objective signs prerenal azotemia. The utility is more obvious of physiologic and/or pathophysiologic phe- in the extremes of EACF. However, in the case nomena. The latter clinical application is re- of blood volume losses of > 10% or the physi- alized through the incorporation of POC ologic equivalent, heart rate, blood pressure, mdedge.com/fedprac DECEMBER 2018 • FEDERAL PRACTITIONER • 27 Kidney Disease Management FIGURE 1 Acute Kidney Injury Assessment finding is that pulmonary hypertension may induce false-positive results.12,13 Hepatic vein dilation is another sign of HF and/or pulmonary hypertension. Furthermore, so- nographic images of the left ventricle either from the parasternal long axis or subxiphoid approach can identify supranormal left ven- tricular ejection fraction (LVEF) or hyper- dynamic heart as an important clue of the absolute or relative decrease of EACF.14 Con- versely, a decrease in EACF in patients with low LVEF can be assessed qualitatively at the bedside in patients with systolic HF. Support- ing evidence of prerenal azotemia as the re- sult of HF can be suggested by the presence of pleural effusions and bilateral comet/rock- ets tails or B lines in lung sonography.15 The easily recognizable hypoechoic ascitic Abbreviations: AGN, acute glomerulonephritis; AIN, acute interstitial nephritis; AKI, acute fluid in the presence of small, hyperechoic kidney injury; ATN, acute tubular necrosis; GU, genitourinary; IVC, inferior vena cava. gross changes in the echocardiographic tex- ture of liver may indicate a hepatorenal com- skin turgor, urinary output, and capillary re- ponent as the cause of prerenal failure. A fill may be within normal limits. Obvious small increase of > 20% in the diameter of the changes in these parameters during the phys- portal vein with deep inspiration indicates ical examination are considered relatively late portal hypertension, with a sensitivity of 80% manifestations.7-10 Therefore, prerenal fail- and a specificity of 100%.15,16 Other clini- ure is frequently diagnosed retrospectively cal scenarios leading to AKI in association after correction of the EACF through use of with systemic hypotension may be identi- crystalloids, blood products, vasopressors, fied quickly with the aid of POC sonography. inotropic agents, discontinuation of antihy- These scenarios include cardiac tampon- pertensive agents, or treatment of its prere- ade, tension pneumothorax, right ventricu- nal causes. Certain sonographic maneuvers, lar dysfunction (as a surrogate of pulmonary performed at the bedside during acute renal embolism), or an acute coronary event.16,17 injury, may be useful in many patients to eval- Alternatively, identifying the presence of se- uate a multitude of prerenal causes of AKI. vere left ventricular hypertrophy through Sonographic inferior vena cava (IVC) lu- POC ultrasonography in a patient with AKI minal diameter and inspiratory collapsibility and normal or low normal blood pressures together serve as a surrogate marker of pre- may alert clinicians to the diagnosis of nor- load venous return and right side heart func- motensive renal failure in individuals with tion. Such imaging results have been shown previously unrecognized severe hyperten- to be more accurate than jugular venous dis- sion. In this clinical context, keeping mean tension on physical examination but only arterial pressures higher than usual with va- modestly helpful as a surrogate for central sopressors may improve renal function while venous pressure (CVP), with more accuracy decreasing dialysis utilization.18-21 in the lower values of the CVP.11 However, Likewise, in clinical scenarios of shock this procedure can be repeated often after with AKI, POC ultrasonography has proven volume resuscitation to achieve a 1.5- to to be an indispensable tool. For example, 2.5-cm diameter dimension of the IVC and rapid exploration of the biliary tree dem- < 25% inspiratory collapsibility as a goal. onstrating anterior gallbladder wall thick- An IVC with a diameter > 2.5 cm in the ening, a stone or sludge, common bile duct context of a suspected prerenal AKI is more dilation, or perigallbladder inflammation likely the consequence of heart failure (HF) suggests acute cholecystitis and/or cholan- rather than hypovolemia. The caveat to this gitis as the cause. The presence of dyspnea 28 • FEDERAL PRACTITIONER • DECEMBER 2018 mdedge.com/fedprac Kidney Disease Management in association with hypoten- FIGURE 2 Sonograms of the Inferior Vena Cava Entering the Right sion and unilateral signs of a Atrium During (A) Inspiration and (B) Expiration (arrows) higher proportion of comet A B tails and/or a lung consoli- dation suggests pneumonia. Rapid differentiation be- tween acute respiratory dis- tress syndrome (ARDS) and pulmonary edema from HF is possible with ultrasonogra- phy. When pleural line abnor- malities are seen, ARDS is a common cause. POC ultrasonography will be key in management of ARDS, as ultrasound results will help avoid the use of ex- cessive diuretics, which can result in renal hypoperfusion and AKI.22 In trauma patients, the ultrasound examination will identify free ting and are an independent risk factor for fluid (bleeding) as the source of the prerenal poor survival in arterial hypertension and failure, along with its cause (aortic dissection, H F. 25-30 hepatic hemorrhage, splenic hemorrhage, ec- Other POC sonographic evaluations of topic pregnancy, etc).23 Sonographic free air intrinsic AKI have been helpful in the fol- observed in the abdomen can provide the lowing clinical scenarios. The presence of an clue of a perforated viscus.24 The sonographic ultrasonographic sign of sinusitis in the con- image of an inflamed pancreas can suggest text of nephritic sediment and a rapid decline pancreatitis as the cause of the systemic hypo- of renal function suggest antineutrophil cy- tension. Ultimately, intravascular losses in the toplasmic antibody (ANCA)-related vascu- hypoechoic edematous bowel wall
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