Background: Fluid overload leading to pulmonary congestion is an important issue in patients undergoing hemodialysis. This study aimed to determine if a simplified method of extravascular lung water assessment using ultrasound provided clinically relevant information. Methods: This prospective study recruited 47 patients from a single hemodialysis center. Pulmonary ultrasound was performed before and after 2 hemodialysis sessions in 28 regions on the thorax. The B-line score was defined as the percentage regions where B-lines were present. Results: When B-lines were detected before hemodialysis, a significant relationship was found between fluid removal and the change in B-line score. Patients with a B-line score of ≥21.4% (4th quartile) after the second hemodialysis session were more likely to be hospitalized for pulmonary edema or acute coronary syndrome. Conclusions: A simplified pulmonary assessment using ultrasound provides relevant information about pulmonary congestion in hemodialysis patients and identifies patients at risk of hospitalization for heart-related problems.

Keywords:
Point-of-care ultrasound, Fluid balance management, Hemodialysis, Pulmonary edema, Pulmonary ultrasound, B-line artifact, Fluid overload, End-stage renal disease
1.
Flythe JE, Kshirsagar AV, Falk RJ, Brunelli SM: Associations of posthemodialysis weights above and below target weight with all-cause and cardiovascular mortality. Clin J Am Soc Nephrol 2015; 10: 808–816.
2.
Shoji T, Tsubakihara Y, Fujii M, Imai E: Hemodialysis-associated hypotension as an independent risk factor for two-year mortality in hemodialysis patients. Kidney Int 2004; 66: 1212–1220.
3.
Palmer BF, Henrich WL: Recent advances in the prevention and management of intradialytic hypotension. J Am Soc Nephrol 2008; 19: 8–11.
4.
Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G, Copetti R, Bouhemad B, Reissig A, Agricola E, Rouby JJ, Arbelot C, Liteplo A, Sargsyan A, Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E, Petrovic T; International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS): International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38: 577–591.
5.
Piette E, Daoust R, Denault A: Basic concepts in the use of thoracic and lung ultrasound. Curr Opin Anaesthesiol 2013; 26: 20–30.
6.
Agricola E, Bove T, Oppizzi M, Marino G, Zangrillo A, Margonato A, Picano E: “Ultrasound comet-tail images”: a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest 2005; 127: 1690–1695.
7.
Picano E, Frassi F, Agricola E, Gligorova S, Gargani L, Mottola G: Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr 2006; 19: 356–363.
8.
Hasan AA, Makhlouf HA: B-lines: transthoracic chest ultrasound signs useful in assessment of interstitial lung diseases. Ann Thorac Med 2014; 9: 99–103.
9.
Sekiguchi H, Schenck LA, Horie R, Suzuki J, Lee EH, McMenomy BP, Chen TE, Lekah A, Mankad SV, Gajic O: Critical care ultrasonography differentiates ARDS, pulmonary edema, and other causes in the early course of acute hypoxemic respiratory failure. Chest 2015; 148: 912–918.
10.
Lichtenstein D, Meziere G: A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med 1998; 24: 1331–1334.
11.
Prosen G, Klemen P, Strnad M, Grmec S: Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care 2011; 15:R114.
12.
Meola M, Nalesso F, Petrucci I, Samoni S, Ronco C: Clinical scenarios in acute kidney injury: pre-renal acute kidney injury. Contrib Nephrol 2016; 188: 21–32.
13.
Jambrik Z, Gargani L, Adamicza A, Kaszaki J, Varga A, Forster T, Boros M, Picano E: B-lines quantify the lung water content: a lung ultrasound versus lung gravimetry study in acute lung injury. Ultrasound Med Biol 2010; 36: 2004–2010.
14.
Bedetti G, Gargani L, Corbisiero A, Frassi F, Poggianti E, Mottola G: Evaluation of ultrasound lung comets by hand-held echocardiography. Cardiovasc Ultrasound 2006; 4: 34.
15.
Mallamaci F, Benedetto FA, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C: Detection of pulmonary congestion by chest ultrasound in dialysis patients. JACC Cardiovasc Imaging 2010; 3: 586–594.
16.
Panuccio V, Enia G, Tripepi R, Torino C, Garozzo M, Battaglia GG, Marcantoni C, Infantone L, Giordano G, De Giorgi ML, Lupia M, Bruzzese V, Zoccali C: Chest ultrasound and hidden lung congestion in peritoneal dialysis patients. Nephrol Dial Transplant 2012; 27: 3601–3605.
17.
Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJ, Liteplo A: Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. Chest 2009; 135: 1433–1439.
18.
Donadio C, Bozzoli L, Colombini E, Pisanu G, Ricchiuti G, Picano E, Gargani L: Effective and timely evaluation of pulmonary congestion: qualitative comparison between lung ultrasound and thoracic bioelectrical impedance in maintenance hemodialysis patients. Medicine (Baltimore) 2015; 94:e473.
19.
Zoccali C, Torino C, Tripepi R, Tripepi G, D'Arrigo G, Postorino M, Gargani L, Sicari R, Picano E, Mallamaci F; Lung US in CKD Working Group: Pulmonary congestion predicts cardiac events and mortality in ESRD. J Am Soc Nephrol JASN 2013; 24: 639–646.
20.
Siriopol D, Hogas S, Voroneanu L, Onofriescu M, Apetrii M, Oleniuc M, Moscalu M, Sascau R, Covic A: Predicting mortality in haemodialysis patients: a comparison between lung ultrasonography, bioimpedance data and echocardiography parameters. Nephrol Dial Transplant 2013; 28: 2851–2859.
21.
Siriopol D, Voroneanu L, Hogas S, Apetrii M, Gramaticu A, Dumea R, Burlacu A, Sascau R, Kanbay M, Covic A: Bioimpedance analysis versus lung ultrasonography for optimal risk prediction in hemodialysis patients. Int J Cardiovasc Imaging 2016; 32: 263–270.
22.
Jambrik Z, Monti S, Coppola V, Agricola E, Mottola G, Miniati M, Picano E: Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water. Am J Cardiol 2004; 93: 1265–1270.
23.
Zoccali C: Lung ultrasound in the management of fluid volume in dialysis patients: potential usefulness. Semin Dial 2017; 30: 6–9.
24.
Vitturi N, Dugo M, Soattin M, Simoni F, Maresca L, Zagatti R, Maresca MC: Lung ultrasound during hemodialysis: the role in the assessment of volume status. Int Urol Nephrol 2014; 46: 169–174.
25.
Torino C, Gargani L, Sicari R, Letachowicz K, Ekart R, Fliser D, Covic A, Siamopoulos K, Stavroulopoulos A, Massy ZA, Fiaccadori E, Caiazza A, Bachelet T, Slotki I, Martinez-Castelao A, Coudert-Krier MJ, Rossignol P, Gueler F, Hannedouche T, Panichi V, Wiecek A, Pontoriero G, Sarafidis P, Klinger M, Hojs R, Seiler-Mussler S, Lizzi F, Siriopol D, Balafa O, Shavit L, Tripepi R, Mallamaci F, Tripepi G, Picano E, London GM, Zoccali C: The agreement between auscultation and lung ultrasound in hemodialysis patients: the LUST study. Clin J Am Soc Nephrol 2016; 11: 2005–2011.
© 2017 S. Karger AG, Basel
2017
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.