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Role of Point-of-Care Ultrasonography in the Evaluation and Management of Kidney Disease

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.
Federal Practitioner. 2018 December;35(12):27-33
December 6, 2018|Federal Practitioner
Jorge Lamarche, MD;Alfredo Peguero Rivera, MD;Craig Courville, MD;Mohamed Taha, MD;Marina Antar-Shultz, DO;Andres Reyes, MD
Author and Disclosure Information

Jorge Lamarche, Alfredo Peguero Rivera, Craig Courville, Mohamed Taha, and Marina Antar-Shultz are Academic Nephrology Attending Physicians at the James A. Haley Veterans' Hospital and Assistant Professors at the University of South Florida Department of Nephrology and Hypertension, all in Tampa, Florida. At the time the article was written Andres Reyes was a Medical Fellow at the University of South Florida.
Correspondence: Jorge Lamarche (jorge.lamarche@va.gov)

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

Cardiac Arrest in ESRD

Patients with ESRD may have sudden cardiac arrest as a result of several etiologies. During the advance cardiac life support algorithm, there is a brief period of evaluation of the electrical rhythm in which echocardiography can be helpful with the diagnosis immediately after the 2 initial minutes of cardiopulmonary resuscitation. An enlarged right ventricular cavity (> 2/3 of the left ventricle) is a sonographic sign of a pulmonary embolism.

Bedside sonography has the potential to alter the current guidelines of advance cardiac life support management. For example, if the bedside echo shows a significant pericardial effusion, a pericardiocentesis could be performed faster as it would be diagnosed faster. In addition, at times the heart may appear to be beating rapidly but there is a small amount of fluid (blood) within the cardiac chambers. This may be from an extreme case of dehydration for which rapid administration of IV fluids may help manage. Therefore, a quick bedside point of care echocardiography may reveal a cardiac anomaly that may be able to be restored in a efficient manner. 

Pulseless electrical activity is the most common rhythm found in ESRD. The presence of hypercontractile myocardium in the absence of a pulse would suggest the need for fluids or blood instead of the usual epinephrine and cardiopulmonary resuscitation (Figure 5).

Related: General Applications of Ultrasound in Rheumatology Practice

Conclusion

Ultrasonography at the POC provides an important and continuously expanding tool to improve nephrological diagnostic accuracy in concert with history and physical examination. Extracellular fluid evaluation is paramount in all kidney disease conditions. Recent clinical studies in lung ultrasonography suggest that the learning curve for the medical provider is quicker than with other organs. Because POC sonography in association with limited bedside echocardiography may reveal discriminatory signs of pneumonia and differentiate between cardiogenic vs noncardiogenic pulmonary edema, such imaging may be important cost-effective strategies in the management of dyspnea and in the categorization/etiology of AKI. Therefore, incorporation of POC sonography into clinical practice will require that medical schools, residency programs, and nephrology fellowship programs design teaching strategies within their respective curricula. Research studies with outcomes regarding diagnosis, morbidity, and mortality are necessary in these areas.

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