Assessment Of Volume Status Research Articles

In-hospital bioimpedance-derived total body water predicts short-term cardiovascular mortality and re-hospitalizations in acute decompensated heart failure patients.

Hospital re-admissions in heart failure (HF) patients are mostly caused by an acute exacerbation of their chronic congestion. Bioimpedance analysis (BIA) has emerged as a promising non-invasive method to assess the volume status in HF. However, its correlation with clinically assessed volume status and its prognostic value in the acute intra-hospital setting remains uncertain. In this single-center observational study, patients (n = 49) admitted to the cardiology ward for acute decompensated HF (ADHF) underwent a daily BIA-derived volume status assessment. Median hospital stay was 7 (4-10) days. Twenty patients (40%) reached the composite endpoint of cardiovascular mortality or re-hospitalization for HF over 6months. Patients at discharge displayed improved NYHA class, lower body weight, plasma and blood volume, as well as lower NT-proBNP levels compared to the admission. Compared to patients with total body water (TBW) less than or equal to that predicted by body weight, those with higher relative TBW levels had elevated NT-proBNP and E/e´ (both p < 0.05) at discharge. In the Cox multivariate regression analysis, the BIA-derived delta TBW between admission and discharge showed a 23% risk reduction for each unit increase (HR = 0.776; CI 0.67-0.89; p = 0.0006). In line with this finding, TBW at admission had the highest prediction importance of the combined endpoint for a subgroup of high-risk HF patients (n = 35) in a neural network analysis. In ADHF patients, BIA-derived TBW is associated with the increased risk of HF hospitalization or cardiovascular death over 6months. The role of BIA for prognostic stratification merits further investigation.

Bedside imaging

Sonography, in particular echocardiography, is essential in the assessment of volume status and hemodynamics in critically ill patients. Examination of the left ventricle, in addition to assessing ventricular function, provides valuable information, including the "kissing papillary muscle sign," which may indicate fluid responsiveness. Examination of the right ventricle is also important because it is sensitive to both volume and pressure overload. Assessment of diastolic function and measurement of inferior vena cava width and variability provide clues to left and right ventricular preload, respectively. Measurement of stroke volume and cardiac output allows further assessment of hemodynamics and also permits determination of stroke volume variability.

Mistaken Identity: Misidentification of Other Vascular Structures as the Inferior Vena Cava and How to Avoid It.

While point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) is broadly perceived as having value in intravascular volume status assessment, this has not been borne out in large-scale meta-analyses containing heterogenous populations of acutely ill patients. While the limitations of IVC POCUS could be largely due to the complexity of the relationship between IVC appearance and volume status, another confounder not widely appreciated is the ease with which the aorta or right hepatic vein (RHV) can be mistaken for the IVC. While misidentification of the aorta as the IVC has been recognized elsewhere, misidentification of the RHV for the IVC has not and, in our experience, occurs frequently, even in the hands of experienced sonographers. We demonstrate how these errors occur and provide guidance on how to systematically avoid them.

Volume Status among Hyponatremic admitted Patients

Introduction: The kidneys play a vital role in the management of hyponatremic patients with fluid disturbances. This task becomes more challenging in presence of comorbidities like chronic kidney disease or congestive heart failure. Accurate assessment of volume status and urinary sodium excretion is essential part for the correct management.. Both impaired renal function and compromised left ventricular function complicate the accurate evaluation of a patient's fluid status. Method: This cross-sectional prospective study was conducted over 262 adult patients with hyponatremia at The Indus Hospital, Karachi from 2017 to 2020. The patient's volume status at the time of enrollment was categorized as normovolemic, hypovolemic, or hypervolemic based on clinical examination. Spot urine sodium, chloride, potassium, urine and serum osmolality, serum urea, and Random blood sugar were all done. Results: There was a total of 262 patients in which 123 (46.9%) were male and 139 (53.1%) were female. The mean age was 54.1 ± 16.4 years. The overall comorbid burden was high 227(86.64%), in which hypertension and CKD contributed more. Out of 262 patients, half of them suffered from hypovolemia 131(50%). Spot urine sodium (&gt;20 meq) was found in 219(83.58/%) patients, in which predominant volume status was hypovolemia 104(47.5%). Moreover, among those who could not survive were 28 (10.7%), in which hypovolemia contributed more than other volume status 12(42.85%). Conclusion: Hypovolemia came out to be the predominant volume status among hyponatremic patients with high comorbid burden. Majority excreted more sodium in spot urine sample despite of hypovolemia in majority.

Thoracic Fluid Content as an Indicator of High Intravenous Diuretic Requirements in Hospitalized Patients with Decompensated Heart Failure.

Background: The main cause of hospitalization in patients with heart failure is hypervolemia. Therefore, the primary treatment strategy involves diuretic therapy using intravenous loop diuretics to achieve decongestion and euvolemia. Some patients with acutely decompensated heart failure (ADHF) do not respond well to diuretic treatment, which may be due to diuretic resistance (DR). Such cases require high doses of diuretic medications and combination therapy with diuretics of different mechanisms of action. Although certain predisposing factors for diuretic resistance have been identified (such as hypotension, type 2 diabetes, impaired renal function, and hyponatremia), further research is needed to identify other pathophysiological markers of DR. Objective: This study aims to identify admission markers that can predict a high requirement for intravenous diuretics in hospitalized patients with decompensated heart failure. Methods: This study included 102 adult patients hospitalized for ADHF. At admission, patients underwent clinical assessment, laboratory parameter evaluation (including the N-terminal prohormone of brain natriuretic peptide [NT-proBNP] levels), and hemodynamic assessment using impedance cardiography (ICG). Hemodynamic profiles were based on the use of parameters such as heart rate (HR), blood pressure (BP), and thoracic fluid content (TFC) as markers of volume status. The analysis included 97 patients with documented doses of intravenous diuretic use. Patients were stratified into two groups based on median diuretic consumption (equivalent to 540 mg of intravenous furosemide): the high-loop diuretic utilization (LDU) group (n = 49) and the low-LDU group (n = 48). Results: Compared to low-LDU patients, high-LDU patients had greater thoracic fluid content at admission, both quantitatively (37.4 ± 8.1 vs. 34.1 ± 6.9 kOhm-1; p = 0.024) and qualitatively (TFC ≥ 35 kOhm-1: 59.2% vs. 33.3%; p = 0.011). Anemia was more common in the high-LDU group (67.4% vs. 43.8%; p = 0.019), as was elevated NT-proBNP (≥median of 3952 pg/mL: 60.4% vs. 37.5%; p = 0.024). High LDU was associated with a significantly longer hospitalization duration (12.9 ± 6.4 vs. 7.0 ± 2.6 days; p < 0.001). Logistic regression analysis identified anemia, elevated NT-proBNP, and high TFC as predictors of high LDU (HR: 2.65, 2.54, and 2.90, respectively). In a multifactorial model, only high TFC remained an independent predictor (HR: 2.60, 95% CI 1.04-6.49; p = 0.038). Conclusions: TFC was the sole independent admission marker of a high requirement for intravenous diuretics in patients hospitalized for decompensated heart failure. An objective assessment of volume status by impedance cardiography may support intensive personalized decongestion therapy.

Fluid management in the septic peri-operative patient.

This review provides insight into recent clinical studies involving septic peri-operative patients and highlights gaps in understanding fluid management. The aim is to enhance the understanding of safe fluid resuscitation to optimize peri-operative outcomes and reduce complications. Recent research shows adverse surgical and clinical outcomes with both under- and over-hydration of peri-operative patients. The kinetic of intravenous fluids varies significantly during surgery, general anaesthesia, and sepsis with damage to endothelial glycocalyx (EG), which increases vascular permeability and interstitial oedema. Among clinical anaesthesia, neuraxial anaesthesia and sevoflurane have less effect on EG. Hypervolemia and the speed and volume of fluid infusion are also linked to EG shedding. Despite improvement in the antisepsis strategies, peri-operative sepsis is not uncommon. Fluid resuscitation is the cornerstone of sepsis management. However, overzealous fluid resuscitation is associated with increased mortality in patients with sepsis and septic shock. Personalized fluid resuscitation based on a careful assessment of intravascular volume status, dynamic haemodynamic variables and fluid tolerance appears to be a safe approach. Balanced solutions (BS) are preferred over 0.9% saline in patients with sepsis and septic shock due to a potential reduction in mortality, when exclusive BS are used and/or large volume of fluids are required for fluid resuscitation. Peri-operative goal-directed fluid therapy (GDFT) using dynamic haemodynamic variables remains an area of interest in reducing postoperative complications and can be considered for sepsis management (Supplementary Digital Content). Optimization of peri-operative fluid management is crucial for improving surgical outcomes and reducing postoperative complications in patients with sepsis. Individualized and GDFT using BS is the preferred approach for fluid resuscitation in septic peri-operative patients. Future research should evaluate the interaction between clinical anaesthesia and EG, its implications on fluid resuscitation, and the impact of GDFT in septic peri-operative patients.

Nephrology rapid response team in the intensive care unit

Acute kidney injury (AKI) is a frequent complication in patients admitted to the intensive care unit (ICU), and it is known as an independent factor for adverse outcomes like increased length of hospital stay, the development of chronic kidney disease (CKD), and increased mortality with the associated high cost to healthcare systems. The use of AKI biomarkers and new tools such as point-of-care ultrasonography (POCUS) to perform a hemodynamic and volume status assessment has made it more feasible to detect or predict kidney damage in a very accurate way, thereby avoiding the progression of AKI. The design and implementation of a nephrology rapid response team (NRRT) should be considered to improve patient outcomes and healthcare costs. In this paper, we provide an overview of the implementation of an NRRT.

Integration of Diagnostic Lung Ultrasound Into Clinical Practice by Hospitalists in an Academic Medical Center: A Retrospective Chart Review.

Background Point-of-care lung ultrasound (LUS) is a guideline-recommended imaging modality that has been shown to be more accurate than chest radiography for multiple causes of dyspnea. This study was conducted to understand the impact of LUS on real-world clinical decision-making among hospitalists. Methods A retrospective chart review was conducted of patients who received a LUS while hospitalized at a quaternary care academic medical center between July 2020 and June 2022. Data was extracted from the electronic health record (EHR) into a standardized REDCap form. Cases were defined as patients who had received a LUS that (1) had images archived and accessible to viewing through the EHR and (2) had an imaging report documented in the EHR. Results Of the 820 LUSs reviewed, 297 (36.2%) were performed to evaluate for appropriateness of thoracentesis, 205 (25%) for diagnosing or monitoring of pneumonia related to COVID-19, 169 (20.6%) for volume status assessment, 136 (16.6%) for worsening respiratory status, 114 (13.9%) for monitoring pleural effusions, 64 (7.8%) for diagnosing or monitoring of pneumonia not related to COVID-19, and 12 (1.5%) for monitoring of diuresis. Documentation was sufficient to determine clinical decision-making in 730 (89%) of LUSs reviewed, 739 (90.1%) were considered to be diagnostically useful, and 327 (39.9%) changed management. Conclusions These findings suggest LUS was diagnostically useful and routinely changed management in hospitalist practice. Further, documentation in the EHR was sufficient to allow for the evaluation of real-world clinical decision-making using LUS, which is an important gap in both the education and health services research literature.

Association between wait time of central venous pressure and 28-day mortality in critically patients with acute pancreatitis: A restrospective cohort study.

Hemodynamic management is crucial in patients with acute pancreatitis. Central venous pressure (CVP) is widely used to assess volume status. Our aim was to determine the optimal time window for obtaining CVP measurements to prevent adverse outcomes in patients. This study utilized data from the Medical Information Mart for Intensive Care (MIMIC) IV database. The primary outcome under investigation was the 28-day mortality, while secondary outcomes included 90-day mortality and 1-year mortality. To categorize the study population, a CVP waiting time of 12 hours was employed as the grouping criterion, followed by the utilization of Cox regression analysis to compare the outcomes between the 2 groups. Our study included a total of 233 patients, among whom 154 cases (66.1%) underwent CVP measurements within 12 hours after admission to the Intensive Care Unit (ICU). Univariate and multivariate Cox regression analyses revealed a significantly increased risk of 28-day mortality in patients from the delayed CVP monitoring group compared to those who underwent early CVP measurements (HR = 2.87; 95% CI: 1.35-6.13; P = .006). Additionally, consistent results were observed for the risks of 90-day mortality (HR = 1.91; 95% CI: 1.09-3.35; P = .023) and 1-year mortality (HR = 1.84; 95% CI: 1.09-3.10; P = .023). In the ICU, an extended waiting time for CVP measurements in patients with acute pancreatitis was associated with an increased risk of 28-day mortality.

Current use, training, and barriers in point-of-care ultrasound in nephrology: A national survey of VA medical centers.

Point-of-care ultrasound (POCUS) can improve diagnostic accuracy, reduce procedural complications and enhance physician-patient interactions in nephrology. Currently, there is limited knowledge about how practicing nephrologists are using POCUS. This study aimed to characterize current POCUS use, training needs, and barriers to use among nephrology groups. A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of staff and nephrology specialty chiefs. Chiefs of staff (n=130) and nephrology chiefs (n=79) completed surveys on facility- and service-level POCUS use (response rates of 100% and 77%, respectively). Current diagnostic or procedural POCUS use was reported by 41% of nephrology groups, and the most common POCUS applications were central line insertion (28%) and assessment of urinary retention (23%), hydronephrosis (18%), volume status (15%), and bladder (14%). Lack of training was the most common barrier (72%), and most nephrology groups (65%) desired POCUS training. Limited access to ultrasound equipment and POCUS training were barriers reported by 54% and 18% of groups, respectively. A minority of nephrology groups currently use common POCUS applications including evaluation of urinary retention, hydronephrosis, and volume status. The most common barriers to POCUS use in nephrology were lack of trained providers and ultrasound equipment. Investment in POCUS training and infrastructure is needed to expand and standardize POCUS use in nephrology.

IVC collapsibility indices in assessment of volume overload in neonatal cardiac patients

BackgroundFluid overload is associated with increased morbidity and mortality in critically ill patients. An accurate assessment of fluid status in neonatal cardiac pediatric patients is required for assessment of fluid overload. Estimation of fluid status using different Doppler parameters may be helpful in determination of fluid status.PurposeTo evaluate difference in fluid status in neonates with and without congenital heart diseases. To detect sensitivity of Doppler Ultrasound in early determination of fluid status. To compare between different parameters (IVC diameter, IVCCI, and IVC/AO ratio) between cardiac and healthy neonates.MethodsTransabdominal Doppler parameters of 25 full-term newborns with congenital heart diseases and congestive heart failure were compared to 25 post-natal age and sex-matched normal healthy neonates serving as controls. Aortic as well as inspiratory and expiratory inferior vena cava diameters were measured. Subsequently, inferior vena cava collapsibility index (IVCCI) and inferior vena cava-to-aortic ratio (IVC/AO) were calculated.ResultsFluid overload detected by increased IVC diameter (decreased IVCCI and increased IVC/AO ratio) was observed in the cardiac compared to the control group. There was positive correlation between the fluid volume and the IVC diameter and IVC/AO ratio and negative correlation with the IVC collapsibility indices.ConclusionsFluid overload with increased IVC diameter and lack of IVC collapsibility were observed in neonates with congenital heart diseases and congestive heart failure compared with those hemodynamically stable controls. We recommend the use of IVC diameter, IVCCI, and IVC/AO ratio as rapid, easy and sensitive parameters in assessing volume status.

VPExam in Heart Failure Innovating Virtual Cardiac Care

Telehealth and Virtual care are growing fields of importance, but the loss of comprehensive physical exam creates barriers to managing complex patients especially those with heart failure. Disruptive digital tools such as VPExam virtual care combine augmented reality instruction of visuals with bluetooth stethoscopes and ECGs to improve accuracy by assessing volume status, cardiopulmonary auscultation, arrythmia detection, and providing structured data including remote patient monitoring (RPM) data, vitals, medication reconciliation, and labs. VPExam intervention has significantly improved outcomes for high-risk and underserved populations with heart failure discharged to Skilled Nursing Facilities and Home Care. VPExam QI revealed workflows for both routine and urgent cardiology consultation following heart failure hospitalizations resulted in moderate significance modification in clinical management in 84% of encounters, while being associated with a 40% relative risk reduction in 30-day hospital readmission rate and a 56% relative risk reduction in 30-day mortality rate. The review summarizes both challenges to cardiac transitions of care and the evolution of cardiac virtual care with actionable physical exam data to optimize readmissions and mortality that is especially relevant to the underserved populations of skilled nursing facilities and home bound patients served by home care agencies.

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients.

Management and prevention of acute decompensated heart failure remain highly prevalent and challenging medical conditions. Incorporation of Point-of-Care Ultrasound (POCUS) as an adjunctive tool for assessing volume status and treatment response has shown significant promise. POCUS can be used for imaging internal anatomic structures serially and capturing these images for comparison and measurement over time. This protocol describes a scalable and standardized methodology for the serial assessment of the inferior vena cava (IVC). The methodology includes serial image collection, measurement, and presentation in the electronic medical record. A workflow for POCUS-acquired images of the IVC was created to capture the images and measure the diameter in a discrete data field for direct comparison over time and in response to clinical management. The protocol also includes the assessment of the presence or absence of pleural effusion as discrete data in the standardized workflow. By integrating POCUS into heart failure management, clinicians can improve patient outcomes through more precise and timely adjustments in treatment.

Inferior vena cava-aortic ratio measurement as a promising modality in assessing intravascular volume in children with sepsis.

Hemodynamic monitoring is crucial for the comprehensive management of children with sepsis, particularly those involving the kidneys. Sepsis-associated acute kidney injury (S-AKI) is closely linked to poor outcomes. Recently, ultrasonography modalities have been widely accepted as a non-invasive, rapid, and reliable tool for assessing volume status. We conducted research to determine intravascular volume based on ultrasound examination in S-AKI patients. A prospective cohort study was conducted between December 2023 and March 2024 in the Pediatric Intensive Care Unit (PICU) at Hasan Sadikin General Hospital. We divided the patients into two groups: those with sepsis without AKI and those with S-AKI. The intravascular volume was measured by the IVC/Ao (inferior vena cava/abdominal aorta) ratio using two-dimensional ultrasonography and USCOM before and 24h after fluid treatment. The results were analyzed using SPSS 25, with a significance level of p < 0.05. A total of 36 pediatric patients (aged 1month-18years) with sepsis were included. The IVC/Ao ratio before and after the fluid intervention demonstrated significant differences between the two groups (p < 0.001). USCOM Cardiac Index (CI) before and after the intervention also showed significant differences between the two groups (p < 0.001). Patients with S-AKI exhibited a poor hemodynamic response in the IVC/Ao ratio two-dimensional ultrasonography and USCOM examination. IVC/Ao ratio measurement is as accurate as USCOM and can be used as a simple and cost-effective alternative for hemodynamic monitoring.

Evaluation of the Role of Inferior Vena Cava/Aortic Index Sonography in Assessment of Intravascular Volume Status in Resuscitation of Major Blunt Trauma Patients in Emergency Department

Evaluation of the Role of Inferior Vena Cava/Aortic Index Sonography in Assessment of Intravascular Volume Status in Resuscitation of Major Blunt Trauma Patients in Emergency Department

Effect of rigorous fluid management using monitoring of ECW ratio by bioelectrical impedance analysis in critically ill postoperative patients: A prospective, single-blind, randomized controlled study

Background & AimsPrecise assessment of postoperative volume status is important to administrate optimal fluid management. Bioelectrical impedance analysis (BIA) which measures the body composition using electric character. Extracellular water (ECW) ratio by BIA represented as the ratio of ECW to total body water (TBW) and is known to reflect the hydration status. Based on this, we aimed to determine whether aggressive fluid control using ECW ratio could improve clinical outcomes through a single blind, randomized controlled trial. MethodsFrom November 2021 to December 2022, intensive care unit (ICU) patients admitted after surgery were randomly assigned to an intervention group or a control group whether postoperative fluid management was controlled via BIA. Among patients in the intervention group, dehydrated patients received a bolus infusion with crystalloid fluid whereas diuretics were administrated to overhydrated patients until the value of ECW ratio fell within its normal setting range (0.390–0.406). Contrarily, BIA was performed once a day for the control group. Patients in the control group received traditional fluid treatment regardless of BIA results. Primary outcome was in-hospital mortality in two groups. The secondary outcomes were postoperative morbidities, 28-day mortality. Results77 patients of the intervention group and 90 patients of the control group were finally analyzed. The in-hospital mortality (0 in intervention, 4.4% in control, p = 0.125) and 28-day mortality (1.3% in intervention, 14.4% in control, p = 0.002) showed lower incidence in the intervention group than in the control group. In multivariate analysis, the overhydrated status whose ECW ratio exceeding 0.406 [odds ratio (OR): 2.731, 95% confidence interval (CI): 1.001-7.663, p = 0.049] and high capillary leak index (CLI) value at ICU admission (OR: 1.024, 95% CI: 1.008-1.039, p = 0.002) were risk factors of postoperative morbidities. Regarding the 28-day mortality, high CLI value (OR: 1.025, 95% CI: 1.002-1.050, p = 0.037) and traditional strategy without BIA monitoring (OR: 9.903, 95% CI: 1.095-89.566, p = 0.041) were the significant predisposing factors. ConclusionOur results revealed the rigorous fluid treatment with volume control based on ECW ratio by BIA failed to achieve significant improvement in in-hospital mortality, but it could reduce 28-day mortality of ICU patients. Monitoring of ECW ratio may help establish optimal fluid treatment strategies for postoperative ICU patients who are susceptible to fluid imbalances with fluid overload. Trial registrationClinicalTrials.gov, NCT06097923, retrospectively registered on October 16, 2023, https://clinicaltrials.gov/study/NCT06097923?term=NCT06097923&rank=1

Role of point-of-care ultrasound (POCUS) in clinical hepatology.

Hospitalized patients with cirrhosis frequently require critical care management for sepsis, HE, respiratory failure, acute variceal bleeding, acute kidney injury (AKI), shock, and optimization for liver transplantation, while outpatients have unique care considerations. Point-of-care ultrasonography (POCUS) enhances bedside examination of the hepatobiliary system and relevant extrahepatic sites. POCUS includes cardiac US and is used to assess volume status and hemodynamic parameters like cardiac output, systemic vascular resistance, cardiac contractility, and pulmonary artery pressure, which aid in the early and accurate diagnosis of heart failure, cirrhotic cardiomyopathy, porto-pulmonary hypertension, hepatopulmonary syndrome, arrhythmia, and pulmonary embolism. This also helps in fluid management and vasopressor use in the resuscitation of patients with cirrhosis. Lung ultrasound (LUS) can help in differentiating pneumonia, effusion, and edema. Further, US guides interventions such as line placement, drainage of abdominal collections/abscesses, relief of tension pneumothorax, drainage of pleural and pericardial effusions, and biliary drainage in cholangitis. Additionally, its role is essential to assess liver masses foci of sepsis, for appropriate sites for paracentesis, and to assess for vascular disorders such as portal vein or hepatic vein thrombosis. Renal US can identify renal and postrenal causes of AKI and aid in diagnosis of prerenal AKI through volume assessment. In this review, we address the principles and methods of POCUS in hospitalized patients and in outpatients with cirrhosis and discuss the application of this diverse modality in clinical hepatology.

Portal Vein Doppler Is a Sensitive Marker for Evaluating Venous Congestion in End-Stage Kidney Disease

Introduction: Determining ultrafiltration volume in patients undergoing intermittent hemodialysis (IHD) is an essential component in the assessment and management of volume status. Venous excess ultrasound (VExUS) is a novel tool used to quantify the severity of venous congestion at the bedside. Given the high prevalence of pulmonary hypertension in patients with end-stage kidney disease (ESKD), venous Doppler could represent a useful tool to monitor decongestion in these patients. Methods: This is a prospective observational study conducted in ESKD patients who were admitted to the hospital requiring IHD and ultrafiltration. Inferior vena cava maximum diameter (IVCd), portal vein Doppler (PVD), and hepatic vein Doppler (HVD) were performed in all patients before and after a single IHD session. Results: Forty-one patients were included. The prevalence of venous congestion was 88% based on IVCd and 63% based on portal vein pulsatility fraction (PVPF). Both mean IVCd and PVPF displayed a significant improvement after ultrafiltration. The percent decrease in PVPF was significantly larger than the percent decrease in IVCd. HVD alterations did not significantly improve after ultrafiltration. Conclusions: Our study revealed a high prevalence of venous congestion in hospitalized ESKD patients undergoing hemodialysis. After a single IHD session, there was a significant improvement in both IVCd and PVPF. HVD showed no significant improvement with one IHD session. PVPF changes were more sensitive than IVCd changes during volume removal. This study suggests that, due to its rapid response to volume removal, PVD, among the various components of the VExUS grading system, could be more effective in monitoring real-time decongestion in patients undergoing IHD.

Use of lung ultrasound to assess volume status and its association with physical examination in patients with chronic kidney disease.

Defining the optimal hydration status in patients with chronic kidney disease (CKD) is challenging, and the quest for an objective accurate method continues. Lung ultrasound (LUS) is a well-validated technique to estimate volume status. Previous studies examining the relationship between LUS and physical examination demonstrated conflicting results. We aimed to evaluate the correlation between LUS results and physical examination for assessing volume status in patients with CKD, and to compare different LUS protocols. A prospective, single-center trial correlating physical examination findings to LUS results in different CKD groups, including non-dialysis and dialysis patients. Hemodialysis patients were tested twice, before and after dialysis, to compare results with ultrafiltration volume. Different LUS protocols were performed and compared, including 16-, 12-, and 8-zone measurements. We recruited 175 participants. A strong positive correlation was demonstrated between 16- and 12-zone protocols [r=.91 (P<.001)] and between 12- and 8-zone protocols (r=.951, P<.001). Correlation was significant in various CKD groups. While blood pressure did not correlate with LUS score, there was a significant correlation between LUS and other components of the physical examination including lung crackles (OR=1.15 (95%CI 1.096-1.22), P<.01), pleural effusion (OR=1.15 (95%CI 1.09-2.13), P<.01) and peripheral edema (r=.24, P<.001). Ultrafiltration volume did not correlate significantly with change in LUS scores pre- and post-dialysis (r=.169, P=.065). Most components of physical examination findings correlated with extravascular lung water assessment on LUS in CKD patients. The use of a simplified pragmatic LUS protocol may facilitate LUS use in clinical practice.

Assessment of volume status of pediatric hemodialysis patients.

Accurate volume status assessment and dry weight achievement are the most challenging goals for a nephrologist. We aimed to evaluate the role of ultrasonographic parameters including lung ultrasound and inferior vena cava (IVC) measurements as practical methods of volume status assessment in children on hemodialysis by comparing them with established techniques, such as clinical evaluation and bioimpedance spectroscopy. A prospective cross-sectional study compared pre- and post-dialysis volume status using bioimpedance spectroscopy (BIS) parameters and clinical data with ultrasonographic lung B-lines and IVC parameters in children on regular hemodialysis. A total 60 children (mean age 9.4 ± 2.8years) were enrolled. Twenty patients (33.3%) were clinically overloaded to varying degrees (17 patients had mild to moderate signs of fluid overload and 3 patients had moderate to severe signs of fluid overload). All other patients (66.7%) were clinically euvolemic. Sonographic parameters were significantly lower post-dialysis than pre-dialysis, including lung B-line count and IVC diameter. IVC collapsibility index mean was significantly higher post-dialysis than pre-dialysis. There was a significant correlation between the lung B-line count, IVC parameters, and BIS-measured overhydration both before and after hemodialysis. Nine patients had ≥ 8 B-lines post-dialysis, only three of them were hypertensive. Clinical criteria alone are not specific for determining accurate fluid status in pediatric hemodialysis patients. Lung B-line score, IVC parameters, and BIS may be complementary to each other and to clinical data. Lung B-lines outperform IVC measurements and BIS in subclinical volume overload detection in pediatric hemodialysis patients.