Editorial

Blood Purif Received: January 7, 2022

Accepted: February 14, 2022
DOI: 10.1159/000522652 Published online: March 18, 2022

Multi-Organ Point-Of-Care Ultrasound

in Acute Kidney Injury
Abhilash Koratala a Claudio Ronco b, c Amir Kazory d
     

aDivision
of Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA; bDepartment of
Nephrology, International Renal Research Institute of Vicenza (IRRIV), San Bortolo Hospital, Vicenza, Italy;
cDepartment of Medicine, University of Padova, Padova, Italy; dDivision of Nephrology, Hypertension and

Renal Transplantation, University of Florida, Gainesville, FL, USA

Keywords outcomes, the potential of this technique to stratify the risk

Point-of-care ultrasound · Physical examination · and to identify patients with different levels of severity of AKI
Nephrology · Acute kidney injury · VExUS · Hepatorenal and different pathophysiological signatures.
© 2022 S. Karger AG, Basel

Abstract
Acute kidney injury (AKI) is a clinical syndrome caused by a
multitude of hemodynamic, toxic, and structural insults to
the kidney, and portends worse patient outcomes. Despite
careful history taking, physical examination, and analysis of
laboratory data, a void is evident in the diagnostic process
and clinical monitoring of AKI. Point-of-care ultrasonogra-
phy (POCUS) is a limited ultrasound study performed by the
clinician at bedside as an adjunct to physical examination.
Growing body of evidence points to POCUS as a powerful
tool in a variety of clinical settings. Herein, we discuss how
nephrologist-performed POCUS has the potential to provide
answers to focused questions that we encounter in diagno-
sis and management of patients with AKI. From excluding
hydronephrosis to providing real-time insights into hemo-
dynamics, incorporation of POCUS helps integrate all the
pieces of patient data and formulate individualized treat-
ment plans. Future studies are needed to evaluate the im-
pact of multi-organ POCUS on AKI-related pragmatic patient
Point-of-care ultrasonography (POCUS) is a limited
bedside ultrasound (US) examination performed by the
clinician to answer focused clinical questions and guide
patient management. Once confined to procedural guid-
ance, the utility of diagnostic POCUS is being increas-
ingly recognized in the field of nephrology as an adjunct
to physical examination [1, 2]. In fact, some institutions
have formally integrated POCUS training into their ne-
phrology fellowship curricula [3]. While the role of PO-
CUS has been discussed in a variety of clinical settings, its
role in acute kidney injury (AKI) remains less well ex-
plored.
AKI is frequently encountered in hospitalized patients
and is a clinical manifestation of several pathophysiolog-
ic processes that acutely affect the renal function [4]. It is
associated with high mortality rates ranging from 16 to
50% depending on the severity, etiology, comorbidity
burden, as well as socioeconomic factors [5, 6], which un-

Karger@karger.com © 2022 S. Karger AG, Basel Correspondence to:

www.karger.com/bpu Abhilash Koratala, akoratala @ mcw.edu

Lungs
Pulmonary edema
Pleural effusion
Pneumonia
Venous Doppler
HEPATIC V.
Hepatic vein
PORTAL V.
Portal vein
Renal parenchymal vein
ELEVATED RIGHT
HEART PRESSURE
Urinary bladder
Outlet obstruction uncluding
blocked Foley catheter
Fig. 1. Common sonographic parameters and findings assessed using POCUS in AKI. Red and blue arrows indi-
cate blood blow; yellow arrows indicate backward transmission of cardiac pressures. Illustration made using Bio-
render®. IVC, inferior vena cava; IJV, internal jugular vein; US, ultrasound.
derscores the importance of timely diagnosis and appro-
priate treatment. The etiology of AKI can be broadly di-
vided into hemodynamic causes (i.e., impaired renal per-
fusion), obstruction of the urinary tract, and intrinsic
renal diseases including glomerulonephritis and tubu-
lointerstitial pathology. This classification is rather sim-
plistic; in clinical practice, multiple pathologies can coex-
ist, and syndrome-based nomenclature might be more
suitable such as cardiorenal, hepatorenal, hepatocardio-
renal, and sepsis-associated AKI depending on the con-
text [7, 8]. In patients presenting with AKI, urinary tract
obstruction must be excluded as a readily treatable etiol-
ogy. As such, a renal sonogram is often obtained as a part
of initial diagnostic work up to rule out hydronephrosis.
POCUS allows this binary yes-or-no question to be an-
swered within minutes. Moreover, having first-hand
knowledge of the patient’s history and clinical course is
an added advantage for the clinician compared to a radi-
ologist. In one study, general internist-performed PO-
CUS had a sensitivity of 90% and specificity of 96% for
detection of hydronephrosis [9]. Similarly, bladder-relat-
ed causes of obstruction such as blocked Foley catheter,
stone, mass, and prostatomegaly can be identified at the
bedside by nephrologist using ultrasonography [10].
2 Blood Purif
DOI: 10.1159/000522652
Color version available online
ELEVATED LEFT
HEART PRESSURE
Heart
Left and right ventricular systolic function
Stroke volume
Pericardial effusion
Left ventricular filling pressures
Right ventricular sydtolic pressure
Right atrial pressure by IVC/IJV US
Kidney
Size and echogenicity
Hydronephrosis
Peri-nephric collections
Resistive index
The utility of POCUS in discerning the cause of intrin-
sic AKI is limited. Parameters such as cortical echogenici-
ty, kidney size, and arterial resistive index (RI) are useful
when interpreted in the right clinical context but are non-
specific [11]. For example, enlarged kidneys with pre-
served parenchymal thickness and altered cortical echo-
genicity may prompt the nephrologist to pursue work up
for infiltrative diseases such as amyloidosis and malig-
nancy although these findings are not diagnostic per se
[10, 12]. On the other hand, in instances where baseline
serum creatinine is not available, the likelihood of treat-
able disease can be deemed low if the kidney size is small
and cortical echogenicity is increased [13].
In our opinion, hemodynamic AKI is where nephrol-
ogist-performed POCUS could prove the most helpful.
This type of AKI encompasses various insults that result
in renal hypoperfusion (e.g., hypovolemia, systemic vaso-
dilatation, and increased intra-abdominal pressure) and
renal venous congestion. It must be noted that renal per-
fusion is determined by the difference between forward
flow/mean arterial pressure and venous outflow/right
atrial pressure (RAP). However, clinical assessment had
traditionally revolved around the adequacy of forward
flow, ignoring the deleterious effect of venous conges-
Koratala/Ronco/Kazory
 Color version available online
HEPATIC PORTAL INTRA-RENAL

100% pulsatile with flow reversal

Na 127 mmol/L Creatinine 2.6 mg/dL AP: Severe congestion, start IV diuretic

100% pulsatile with flow reversal

Na 132 mmol/L Creatinine 2 mg/dL AP: Severe congestion, continun IV diuretic

Continuous (Normal)

Na 135 mmol/L Creatinine 1.7 mg/dL AP: Improving congestion, transition to oral diuretic

Continuous (Normal)

Na 137 mmol/L Creatinine 1.5 mg/dL (baseline) AP: Improving congestion, discharge with follow up

Fig. 2. Doppler venous waveforms demonstrating improvement
(from top to bottom) in a patient with AKI and hyponatremia. In
physiologic state, hepatic vein Doppler resembles central venous
trace, and S-wave is larger than the D-wave. As the RAP increases,
S-wave reduces in amplitude and finally reverses leaving only D-
wave below the baseline. Portal vein is normally continuous (<30%
pulsatile) and the pulsatility increases with increasing RAP eventu-
ally with late-systolic flow reversal (below-the-baseline flow). Pul-
satile portal vein might indicate gut congestion, which potentially
influences diuretic absorption. Renal parenchymal vein is normal-
ly continuous (similar to portal but below-the-baseline) and with
increasing RAP, becomes pulsatile with distinct S- and D-waves,
with S-reversal ultimately like that of hepatic vein. Generally, im-
provement in portal vein precedes that of hepatic and renal veins
as seen above. Renal interstitial edema may delay the recovery of
venous waveform. Na, serum sodium; AP, assessment and plan;
S-wave, systolic wave; D-wave, diastolic wave.

tion/iatrogenic fluid overload on the kidney. Accumulat-
ing data, however, suggests that fluid overload portends
worse outcomes [14]. Adding to the problem, the diag-
nostic accuracy of conventional physical examination
findings is often limited for detecting clinically significant
aberrations in fluid status [1]. Multi-organ POCUS aids
in the objective volume status assessment by facilitating
comprehensive evaluation of the hemodynamic circuit at
the bedside. This involves Pump, Pipes, and Leaks ap-
proach where pump represents focused cardiac US (Fo-
CUS), pipes represent inferior vena cava (IVC) US and
Doppler evaluation of the systemic veins, and the leaks
indicate assessment of extravascular lung water and asci-
tes [15]. In other words, one can assess the forward arte-
rial inflow, venous outflow, as well as tissue congestion,
and instantaneously integrate this data with overall clini-
cal picture to formulate an individualized management
plan for the patient. For instance, in a patient suspected
to have hepatorenal syndrome, there is no reason to ad-
minister intravenous albumin if the lung US demon-
strates congestion, RAP is elevated, or FoCUS reveals
high cardiac output indicating a vasodilatory state rather
than volume depletion [16]. FoCUS also allows detection
of abnormalities such as cardiac chamber enlargement,
gross valvular dysfunction, and pericardial effusion
prompting appropriate intervention and/or specialist
consultation. Further, POCUS may provide clues to
raised intra-abdominal pressure by revealing large asci-
tes, bowel obstruction or gaseous distension, small IVC
discordant with internal jugular vein, and diminished he-
patic vein flow. Figure 1 illustrates the common sono-
graphic findings and parameters used in the evaluation of
AKI.
In addition, serial POCUS examinations can aid in as-
sessing the efficacy and adequacy of therapy. For exam-
ple, in a patient with hypovolemic AKI and/or hypona-
tremia, bedside stroke volume assessment can be used to
monitor improvement in hemodynamics along with lab-

POCUS in AKI Blood Purif 3

DOI: 10.1159/000522652
oratory data [17]. In a recent case series, Argaiz et al. [18]
showed that portal vein pulsatility improves in parallel
with serum creatinine with decongestive therapy in pa-
tients with acute heart failure outperforming isolated IVC
US. In fact, severe flow alterations on hepatic, portal, and
renal parenchymal venous Doppler (VExUS) together
with a dilated IVC have shown to predict congestive kid-
ney injury better than IVC alone [19]. Figure 2 illustrates
a case of AKI and hyponatremia where serial monitoring
of venous waveforms as a part of daily clinical examina-
tion showed consistent improvement with diuretic ther-
apy. This patient neither had pedal edema nor obvious
jugular venous distention; thought to be hypovolemic
prior to POCUS, and he was found with elevated RAP and
severe venous congestion (top panel). Of note, the patient
had heart failure with reduced ejection fraction and the
IVC was chronically dilated, which renders isolated use
of this parameter inadequate for follow-up.
Conceptually, measuring intrarenal arterial RI is an at-
tractive means to assess renal perfusion, which has been
studied in multiple clinical scenarios including heart fail-
ure, septic shock, and hepatorenal syndrome demonstrat-
ing some usefulness [20–23]. It is calculated by the for-
mula (peak systolic velocity – end diastolic velocity)/peak
systolic velocity in a given cardiac cycle. However, RI is
influenced by several variables including pulse pressure,
heart rate, arteriosclerosis, vasoconstriction, venous con-
gestion, underlying chronic kidney disease, valvular dis-
eases such as aortic stenosis as well as drugs limiting its
utility in the point-of-care settings [24]. Moreover, in our
experience, the inter- and intra-operator variability in re-
porting RI is high precluding reliable monitoring of re-
sponse to therapeutic intervention. On the other hand, we
find intrarenal venous Doppler more reliable and techni-
cally easier due to its qualitative nature i.e., waveform
analysis without the need for precise measurements. Ve-
nous congestion could very well be the explanation for
elevated RI in patients with volume overload as it increas-
es the resistance to flow. Interestingly enough, RAP has
shown to be a strong independent determinant of RI in
patients with shock [25]. Finally, even when a patient has
acute tubular necrosis diagnosed by urine sediment anal-
ysis, it would be prudent to identify and address superim-
posed volume disorders; such ongoing insults impede re-
nal recovery and might lead to relapses, portending worse
outcome [26].
In summary, multi-organ POCUS is a valuable addi-
tion to nephrologists’ toolkit, which enhances the diag-
nostic accuracy and guides therapy when properly inte-
grated with clinical and laboratory parameters. Future
research is needed to evaluate whether adoption of such
an integrative approach, as opposed to individual sono-
graphic parameters, would portend salutary impact on
the outcomes. We also need to explore whether this ap-
proach can successfully risk stratify the patients with var-
ious levels of severity of AKI in distinct clinical settings.
Conflict of Interest Statement
In the last 3 years, Dr. Claudio Ronco has been consulting or
part of advisory boards for ASAHI, Astute, Baxter, Biomerieux, B.
Braun, Cytosorbents, ESTOR, FMC, GE, Jafron, Medtronic, and
Toray. Dr. Amir Kazory has been consulting or part of advisory
boards for Elsevier, Inc. and NuWellis, Inc. Dr. Abhilash Koratala
has no conflicts of interest.
Funding Sources
No funding was received for this study.
Author Contributions
A.Ko. drafted the initial version of the manuscript, performed
point-of-care US studies. C.R. and A.Kz. reviewed and revised the
manuscript for critical intellectual content.

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