In the NEWS: Point of Care ultrasound of the Lungs and the Nephrologists

Point of care US is increasingly being used in many medical specialties. Nephrology is catching along swiftly as well.  A recent review by our team led by Ross et al discuss the role of Lung US in the ESRD population.  After a systematic review,  we concluded that lung US can be used to determine volume status in chronic ESRD patients by using the B-line score model( see figure above from paper) as discussed in the paper.

As nephrologists, we should be using this in practice and help diagnose and prognosticate high risk patients and perhaps prevent re-admissions.

The role of lung ultrasonography in nephrology practice requires further research regarding its clinical applications. We stated in our paper the following amazing ways it can be used in clinical practice..

i.            What is the role of lung ultrasonography in the management of AKI in the intensive care unit? Could it be used as an endpoint for continuous renal replacement therapy?

ii.            Given the association of mortality with the presence of B-lines in the chronic dialysis population, what is the role of lung ultrasonography in the management of the patient on chronic HD? Could B-lines be used to guide need for increased ultrafiltration and would this change long-term outcome?

iii.            Could lung ultrasonography be used to guide diuretic therapy in patients with chronic cardiorenal syndrome?

iv.            As B-lines detect subclinical volume expansion, could lung ultrasonography be useful in differentiating hypervolemic from euvolemic hyponatremia?

Where can one learn to get point of care US training?

The Emory US course is the mecca of US training: check out the details here

http://medicine.emory.edu/renal-medicine/education/ultrasonography-nephrologists.html

NKF Spring Clinical Meetings 2017 had a course run by us as a pre-course specifically on point of care US. Similar course will be prepared for 2018

https://www.kidney.org/spring-clinical/program/physician-highlights

KidneyCon 2018 will also be having a hands on workshop for Point of care US training

http://kidneycon.org/workshop/

NKF Spring Meetings: Pre course on Point of Care Ultrasound for the Nephrologist

We shall be providing with NKF(Spring Clinical Meetings 2017) the first ever Renal
course on point of care Ultrasound pre course: this is the practical training of using a portable ultrasound in volume assessment, renal and bladder sonogram for daily use on "rounds".  See below for details but the link on NKF website for Spring meetings has more details

https://www.kidney.org/spring-clinical/program/physician-highlights

NKF Spring Clinical Meetings: Point of Care Ultrasound for the Nephrologist

From

04/18/2017     7:30 AM

To

04/18/2017     12:30 PM

Walt Disney World Swan and Dolphin, Orlando, FL

Description

The renal consultant needs knowledge of lung ultrasound to determine volume status, renal and bladder ultrasound to evaluate for obstruction and knowledge of vascular access guidance to assist in placement of catheters. This course will focus on the above elements in point of care ultrasonography. 

• Image acquisition will be practiced on human models using high-quality ultrasound machines and supervised by experienced faculty. Training sessions give you practical, hands-on training with a 1:3 teacher-to-learner ratio, so you benefit from personal instruction.
• Image interpretation during group sessions under the supervision of experienced faculty members offers relevant practice. Numerous ultrasound images demonstrating normal and pathologic findings will give you a comprehensive learning opportunity. As you improve your skills, you will be further challenged with unknowns and case-based image sets.
• Knowledge base will be enhanced with lectures that focus on important aspects of point of care ultrasonography applicable to the renal consultant. Discussions will have immediate application within your practice.

Learning Objectives:

Upon completion of this course, participants will be able to:

• Discuss how to perform lung ultrasonography and ultrasonography of the renal system.

• Identify appropriate uses of ultrasonography in renal practice.
• Demonstrate appropriate image acquisition techniques required for renal ultrasonography.
• Interpret image-based clinical cases to help identify abnormalities.

Faculty:

Paul Mayo, MD

Mangala Narasimhan, MD,

Daniel Ross, MD

Kenar Jhaveri, MD

Topics:

Breakfast and Introductions

Lung Ultrasound for the Assessment of Volume Status

Hands on Lung Ultrasound
Image Interpretation Lung Ultrasound

Break

Vascular Access/ IVC Size

Hands on Vascular Access/IVC

Image Interpretation Vascular Access/IVC

Renal Bladder Ultrasound

Hands on Renal Ultrasound

Image Interpretation

Wrap-up and Evaluation

  

4.25 credits/contact hours

REQUIRED: Separate registration fee of $60 for NKF Members, $75 for Non-Members, $40 for Fellows/Residents. Includes light breakfast, and CME credits. Participation is limited, so register early.  

In the NEWS: Lung Ultrasound and volume assessment in ESRD

Your new device- the lung ultrasound has made its way in Europe. A recent trail in CJASN discusses the value of using lung ultrasound in assessing volume status of a patient.  Lung water can be used in a way in clinical practice as it is being used in critical care and cardiology to assess volume in ESRD patients.  Few prior studies that have looked at the role of ESRD and lung ultrasound in clinical practice and training of fellows/faculty  are here:

http://imaging.onlinejacc.org/article.aspx?articleid=1109604&issueno=6

http://ndt.oxfordjournals.org/content/28/11/2851.abstract?

ijkey=eebd33fc20a5ebdf81673c8b84bc28486ace19ee&keytype2=tf_ipsecsha

https://www.ncbi.nlm.nih.gov/pubmed/26880463

This new study in CJASN looked at >1000 patients pre and post HD via lung ultrasound simultaneous to standardized lung exams ( crackles ) and peripheral edema.  What the investigators found was that the lung congestion by crackles, edema or a combination was inferior to ultrasound B lines in various analysis.  Using the knowledge of B lines might guide us in better managing volume status in our ESRD patients. 

In the editorial with it in CJASN, Dr. Rich Sherman writes “I believe that lung US will prove to be of value in improving the care of patients on dialysis . From a practical standpoint, I hope that this technique can provide us with at least one simple benefit. If a routine lung US on the previous Friday before dialysis might make these events less likely, then sign me up!”

I concur with Dr Sherman! I think Nephrologists should get familiar with the science and technology and embrace this change to help their patients. Dialysis units ( large and small) should consider carrying US machines to help guide volume exam and make clinical decisions. It will decrease hospitalizations, less radiation exposure( X rays) and hopefully less ER visits.

http://www.nephronpower.com/2016/02/in-news-training-in-lung-ultrasound-for.html

http://www.nephronpower.com/2016/01/perspective-how-ultrasound-machine-has.html

Image courtesy: coreem.net

In the NEWS: Training in Lung Ultrasound for nephrologists

Recent studies and posts in nephronpower have shown the importance of lung ultrasound in clinical care in nephrology. A recent letter in Kidney International by our fellow and faculty highlight this important skill as part of training for both fellows and faculty.

While renal sonography might be more sophisticated imaging technique requiring more training, lung sonograms should become part of your physical examination.  It should help one assess volume status better.

Take a look at this letter in KI.  

Image source: www.ultrasoundpodcast.com

In the News: Lung Ultrasounds in nephrotic syndromes: how it can help the kidney doctor

In a recent original investigation by Marino et al in this month’s issue of Kidney International the authors show that lung ultrasound has clinical utility beyond the outpatient dialysis unit.  Prior work by this Italian group has shown that the quantitation of B lines on lung ultrasound correlates with extravascular lung water and mortality in patient’s with ESRD on HD.  In the present study the authors quantified B lines in 42 non-dyspneic patients with active nephrotic syndrome and compared their findings to healthy controls and to ESKD patients.  For each of the three groups lung ultrasound was performed 5 minutes after lying supine, 60 minutes after lying supine, and then after standing.  They found that the number of B lines among patients with active nephrotic syndrome was similar to the number of B lines in chronic dialysis patients.  Furthermore they found that B lines in patients with nephrotic syndrome accumulated while lying supine for 60 minutes and diminished after standing up.  Further analysis demonstrated a strong indirect relationship between serum albumin and number of B lines in the nephrotic syndrome cohort.  In other words, a lower albumin was predictive of greater extravascular lung water.  Finally, the authors evaluated a subset of 11 patients that experienced disease remission.  Each of these patients had significantly fewer B lines compared to ultrasound results during active disease.  Quantitation of B lines by lung ultrasound can be learned in a single 3 to 4 hour training session and the procedure takes about four to six minutes to perform.  As ultrasound machines become smaller, cheaper, and more available, lung ultrasound will likely become a critical component in the assessment of volume status by nephrologists.

Post byDaniel Ross, MD
Hofstra Northwell School of Medicine

Perspective: How an Ultrasound machine has changed my practice?

My new instrument in the last 2 years has been the ultrasound probe.  It adds tremendous value to my physical exam. Residents in our program have traditionally been learning ultrasound skills as part of examining the patient: especially in the ICU.  Lungs look wet, kidneys look ok, bladder is full and IVC is plump.. We have now gotten information that can really make the care of the patient really swift. Official ultrasounds are still obtained but a quick and important organ examination can save lives and critical time..

Besides, I now feel that as nephrologists, this might be an important skill that we need to develop and gain acceptance too.  A patient calls and says he cannot urinate and he is having pain and he has known CKD. You see him but you are concerned about potential distal obstruction:- A quick bladder sonogram in the office can reveal the obstruction or distended bladder with urine and rather than an ER visit, you can promptly send this patient to the Urologist for foley insertion and home.

A dialysis patient tends not usually gain weight ( maybe 1kg between treatments) , comes in slightly short of breath. A lung ultrasound done by you reveal B lines and in multiple views suggesting fluid overload.  This allows you to take off 2kg today and patient feels better.  Alternatively, you would have done that anyway but also perhaps exposed the patient to an X-ray that might have not been necessary. 

My practice has changed with this revelation. Training our faculty and fellows in this important skill- sonogram of the bladder and kidney and lung US and IVC for volume status is important. In the era of declining interest in nephrology, perhaps this skill might shed some excitement in the field of nephrology.   Lung US compares favorably to CT scan for detection for pulmonary edema and might be better than CXR.

The Emory course on sonogram might be the excellent course. What I envision is more of a short burst of courses that can really help us use this in clinical practice like we use our stethoscope, and not focus on using it for billing/coding etc. purposes.  Let’s save lives by making a difference in our patients in a fast paced manner , avoid ER visits and giving them a more comprehensive care in the Nephrology clinic.

Here are some interesting references !

http://www.criticalecho.com/content/tutorial-9-lung-ultrasound

http://www.ncbi.nlm.nih.gov/pubmed/25030008

http://www.ncbi.nlm.nih.gov/pubmed/23884727

http://www.ncbi.nlm.nih.gov/pubmed/16716814