Point-of-care ultrasound in diagnosis and management of congestive nephropathy

Abstract

Congestive nephropathy is kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics. As a part of cardiorenal syndrome, the diagnosis is usually made based on history and physical examination, with findings such as jugular venous distension, a third heart sound, and vital signs as supporting findings. More recently, however, these once though objective measures have come under scrutiny for their accuracy. At the same time, bedside ultrasound has increased in popularity and is routinely being used by clinicians to take some of the guess work out of making the diagnosis of volume overload and venous congestion. In this mini-review, we will discuss some of the traditional methods used to measure venous congestion, describe the role of point-of-care ultrasound and how it can ameliorate a clinician’s evaluation, and offer a description of venous excess ultrasound score, a relatively novel scoring technique used to objectively quantify congestion. While there is a paucity of published large scale clinical trials evaluating the potential benefit of ultrasonography in venous congestion compared to gold standard invasive measurements, more study is underway to solidify the role of this objective measure in daily clinical practice.

Venous Excess Doppler Ultrasound: A Visual Guide to Decongestion in Cardiorenal Syndrome

“…In addition, renal dysfunction can exacerbate the existing fluid overload, resulting in a vicious cycle. As such, it is imperative that objective assessment of fluid status is crucial for appropriate management of patients with fluid disorders [ 8 ]. Nevertheless, paucity of accurate bedside diagnostic tools to detect hemodynamic congestion has left the cardiorenal physicians with some precision guesswork to do in day-to-day practice.…”

Portal vein pulsatility: An important sonographic tool assessment of systemic congestion for critical ill patients

“…The term extended venous excess ultrasound score (E-VExUS) or extended VExUS has been proposed to include Doppler interrogation of additional veins such as internal jugular, splenic, and femoral veins[ 28 ], or even sonographic estimation of the intestinal wall[ 29 ].…”

“…VExUS may quantify congestion but may not indicate the reason of congestion, nor differentiate between pressure or volume overload. This is why the physician should interpret Doppler findings in the clinical context and combine clinical assessment with information from laboratory tests, echocardiography or even right heart catheterization[ 25 , 28 ] in more challenging cases.…”

Seeing through the myths: Practical aspects of diagnostic point-of-care ultrasound in nephrology

“…In addition, POCUS reduces fragmentation of care by allowing multiple evaluations performed during the same study. For example, a nephrologist evaluating a patient with suspected congestive nephropathy can assess cardiac function, right atrial pressure, presence or absence of venous congestion, pleural effusion, and ascites in a few minutes at bedside[ 5 , 6 ]. In contrast, without POCUS, obtaining answers to the same questions would require ordering a multitude of studies, including an echocardiogram, a chest radiograph, an abdominal sonogram, and a duplex study of the right upper quadrant and kidney.…”

“…Therefore, it is conceivable that the assessment of volume status using POCUS is vital in nephrology practice. As outlined in prior publications, incorporating multi-organ POCUS, which includes focused cardiac ultrasound, lung ultrasound, and Doppler assessment of systemic veins, greatly assists in evaluating cases of hemodynamic AKI[ 5 , 19 , 20 ]. This is especially valuable in addressing common diagnostic challenges such as hepatorenal dysfunction[ 21 ].…”