ACKD

Cardiac Ultrasound for the Nephrologist:

Know Thy Heart to Know Thy Kidneys
Pankaj Goyal, Joseph Minardi, and Ankit Sakhuja

Kidney disease patients have a high prevalence of cardiovascular morbidity and mortality. It can be challenging to adequately
assess their cardiovascular status based on physical examination alone. Cardiac ultrasound has proven to be a powerful tool to
accomplish this objective and is increasingly being adopted by noncardiologists to augment their skills and expedite clinical
decision-making. With the advent of inexpensive and portable ultrasound equipment, simplified protocols, and focused
training, it is becoming easier to master basic cardiac ultrasound techniques. After a short course of training in focused cardiac
ultrasound, nephrologists can quickly and reliably assess ventricular size and function, detect clinically relevant pericardial effu-
sion and volume status in their patients. Additional training in Doppler ultrasound can extend their capability to measure car-
diac output, right ventricular systolic pressure, and diastolic dysfunction. This information can be instrumental in effectively
managing patients in inpatient, office, and dialysis unit settings. The purpose of this review is to highlight the importance
and feasibility of incorporating cardiac ultrasound in nephrology practice, discuss the principles of basic and Doppler ultrasound
modalities and their clinical utility from a nephrologist’s perspective.
Q 2021 by the National Kidney Foundation, Inc. All rights reserved.
Key Words: Cardiac ultrasound, Echocardiography, Volume overload, Pericardial effusion, Doppler

“A 72-year-old woman with hypertension and end stage
kidney disease (ESKD) on intermittent hemodialysis pre-
sented with shortness of breath and fatigue. Physical exam
was significant for bibasilar crackles and laboratory
results showed serum potassium of 6.7 mEq/L. She under-
went hemodialysis on two consecutive days. During the
second session, her blood pressure dropped from 100/
53 mm Hg to 85/53 mm Hg, and her heart rate increased
from 89 to 130 beats/min. She was started on vasopressors
with a further drop in blood pressure to 64/39."1
T he clinical case above highlights the inherent connec-
tion between the heart and kidneys. Malfunctioning
of either deeply impacts the other.2 The prevalence of car-
diovascular diseases among patients with CKD is
extremely high.3 It is common for a nephrologist to
encounter challenging situations such as intradialytic hy-
potension, uncontrolled hypertension, volume overload,
difficulty in adjusting dry-weight, chest pain during
From the Division of Nephrology, Kidney C.A.R.E (Clinical Advancement,
Research, and Education) Program, University of Cincinnati, Cincinnati, OH
(P.G.); Division of Emergency and Clinical Ultrasound, Department of Emer-
gency Medicine, West Virginia University, Morgantown, WV (J.M.); and Divi-
sion of Cardiovascular Critical Care, Department of Cardiovascular and
Thoracic Surgery, Morgantown, WV (A.S.).
Financial Disclosure: Dr Minardi occasionally works as a consultant for GE
Healthcare and gets reimbursed for his time and travel. Dr Sakhuja and Dr Goyal
declare that they have no relevant financial interests.
Support: See Acknowledgments (page 216).
Address correspondence to Ankit Sakhuja, MBBS, FACP, FASN, Depart-
ment of Cardiovascular and Thoracic Surgery 1 Medical Center Drive, PO
Box 8500 West Virginia University, Morgantown, WV 26505. E-mail: ankit.
sakhuja@hsc.wvu.edu
Ó 2021 by the National Kidney Foundation, Inc. All rights reserved.
1548-5595/$36.00
https://doi.org/10.1053/j.ackd.2021.04.001
dialysis, and at times, life-threatening emergencies such
as cardiac tamponade and arrest.
Until recently, nephrologists have relied primarily on
physical examination to assess their patients’ cardiovascu-
lar and hemodynamic status. However, recent studies have
shown that lung crackles and peripheral edema very poorly
reflect interstitial lung edema and intravascular volume
status in patients.4,5 Cardiac auscultation, similarly, has
limited accuracy in diagnosing and grading most valvular
abnormalities.6 Ultrasound is the most portable form of car-
diac imaging. It is extremely safe, involves no ionizing radi-
ation, and can be used for serial examination in patients of
all age groups. Incorporating ultrasound as a part of the
physical examination can equip the nephrologists to
reliably and rapidly diagnose, triage, and treat various
cardiovascular conditions in their patients.
The utility of cardiac ultrasound in nephrology has thus
far been limited due to the complexity of diagnostic
protocols, high cost, lack of proper training/equipment,
and time needed to acquire multiple images for interpreta-
tion. With the widespread adoption of “Focused Cardiac
Ultrasound (FoCUS)” to answer clinically relevant ques-
tions by noncardiologists, there has been a surge in simpli-
fied protocols utilizing affordable and portable ultrasound
systems. Among a subset of nephrologists, however, there
is still a lack of enthusiasm and adequate training to
integrate cardiac ultrasound in their day-to-day practice.
The purpose of this review is to outline the principles of
FoCUS useful for the practicing nephrologist in inpatient,
office, and dialysis unit settings. We will also review the
principles of advanced echocardiographic techniques
that can be helpful in specific clinical scenarios.
FOCUSED CARDIAC ULTRASOUND FOR THE
NEPHROLOGIST
Mastering the fundamentals of FoCUS requires an under-
standing of cardiac anatomy, imaging windows, and
views. The training focuses on making the learners

208 Adv Chronic Kidney Dis. 2021;28(3):208-217

 Cardiac Ultrasound for the Nephrologist 209

comfortable with image acquisition, interpretation, and is performed to answer a specific clinical question with a
integrating this information into clinical practice. These pretest probability in mind. The basic cardiac views ex-
objectives can be best achieved by interactive didactics plained previously can be used to quickly answer the
and hands-on training done simultaneously or within a commonly encountered clinical questions in nephrology,
reasonable timeframe of each other to maximize learning. most importantly qualitative assessment of LV function,
right ventricular (RV) size/function, and pericardial
The Technique of Cardiac Ultrasound effusion.
Understanding the basics of ultrasound physics is impor-
tant to acquire and interpret cardiac ultrasound images. Left Ventricular Systolic Function. LV systolic dysfunc-
A detailed discussion of various ultrasound systems and tion (LVSD) has important diagnostic and prognostic im-
transducers is available elsewhere in this issue. Here, we plications for nephrologists. CKD is an independent risk
will focus on the fundamentals of acquiring and interpret- factor for impaired LV systolic and diastolic function in
ing cardiac images using a “phased array” transducer. The children.10 Reduced cardiac peak performance and cardiac
“all-in-one” transducers employ a circuit that simulates a functional reserve have been described in adult patients
piezoelectric crystal allowing it to produce a broader range with asymptomatic CKD in absence of pre-existing cardiac
of frequencies. Multiple organ systems, including the disease or diabetes.11 LVSD as defined by ejection fraction
heart, can be imaged using this transducer. ,50% is seen in approximately 1 in 4 patients with
Most standard phased array transducers have a fre- ESKD.12 All-cause mortality increases 6-fold in ESKD
7
quency of 1-5 MHz with an imaging depth up to 35 cm. patients with LVSD.13 Thus, serial measurements of LV
It is primarily used for imaging heart and inferior vena systolic function in CKD and dialysis patients can provide
cava but may be used for lungs and abdominal structures valuable insight into their clinical course and impact
as well. It has a small footprint (20 3 15 mm) ideal to ma- management decision such as timely expert referral, vol-
neuver between ribs and a ume management, and opti-
high frame rate (.100/sec) CLINICAL SUMMARY
mizing pharmacotherapy.
to capture images of the mov- In the acute setting, deter-
ing heart. For these reasons, it mination of LV systolic func-
 Cardiovascular diseases are highly prevalent in CKD
is the preferred transducer tion is equally important,
patients and knowledge of focused cardiac ultrasound
for the cardiac ultrasound. enables nephrologists to reliably assess ventricular size especially in those with un-
According to the commonly and function, pericardial effusion, and volume overload. differentiated shock and
used cardiology convention, acute kidney injury (AKI).14
the screen orientation marker  Basic principles and applications of cardiac ultrasound can An acute worsening of LV
or “dot” indicating the lead- be learned effectively and used as a part of the physical
systolic function can explain
examination by noncardiologists after a short course of
ing edge of the ultrasound the worsening renal function
training.
array is located to the right in patients with cardio-renal
side of the monitor screen  Additional expertise in Doppler modalities may help syndrome. Among patients
(Fig 1). As per the “dot evaluate cardiac output, right ventricular systolic with ST-elevation myocardial
matches the dot” principle, pressure, left ventricular diastolic dysfunction, and infarction (STEMI)
the phased array orientation tamponade physiology.
undergoing coronary inter-
marker points toward the vention, LVSD is a strong
structures displayed on the and independent predictor
right side of the screen. The operators need to acquaint of AKI.15
themselves with various transducer movements; sliding, FoCUS is more reliable than the physical examination,
rocking, sweeping, fanning, and rotating to optimize image laboratory parameters, and chest x-ray for detecting
acquisition (Supplementary Fig 1).8 LVSD and acute decompensated heart failure.16 FoCUS re-
There are 3 commonly used imaging windows for cardiac lies on the qualitative assessment of LV function by the vi-
ultrasound (parasternal, apical, and subcostal). They can be sual method instead of quantitative measurements that
combined with the 4 imaging planes (long axis, short axis, can be time-consuming, need additional training and
4-chamber, and 2-chamber) to yield the various traditional may not be as accurate in these scenarios.17 Qualitative
views used in comprehensive echocardiography.9 We assessment of LV function is sufficient for FoCUS purposes
recommend that the cardiac structures be imaged in at least and skills needed for visual estimation of LV systolic func-
2 imaging planes. Parasternal and subcostal windows are tion can be acquired by noncardiologists with focused
typically easier to master than the apical window. For training. Studies have shown that after a limited experi-
FoCUS purposes, we recommend 5 most commonly used ence of 20 practice studies, internal medicine residents
views for nephrologists to achieve proficiency and answer were able to interpret reduced LV systolic function with
the majority of clinical questions (Fig 1, Table 1). both sensitivity and specificity above 90%.18
Qualitative assessment of LV systolic function can be per-
Clinical Utility of Basic Cardiac Ultrasound formed in all 4 views mentioned in Table 1; however, para-
Similar to other diagnostic tools in medicine, clinical sternal long-axis (PLAX) and parasternal short-axis
information gathered from FoCUS is most useful when it (PSAX) views are most useful for this purpose. In the

Adv Chronic Kidney Dis. 2021;28(3):208-217

210 Goyal et al
Figure 1. Basic focused cardiac ultrasound views with probe positioning and normal ultrasound images: (A) parasternal long
axis (PLAX); (B) parasternal short axis (PSAX); (C) apical 4-chamber (A4C); and (D) subcostal 4-chamber (S4C). Abbreviations:
AV, aortic valve; ICS, intercostal space; IVS, interventricular septum; LA, left atrium; LV, left ventricle; RA, right atrium; RV,
right ventricle.
PLAX view, LV systolic function can be visually estimated
by observing the distance between the anterior leaflet of
the mitral valve and interventricular septum at end-
diastole, also known as E-Point Septal Separation (EPSS,
Supplementary Fig 2). An EPSS cutoff of 7 mm has a
100% sensitivity and over 50% specificity to identify severe
LVSD.19 LVSD can also be estimated by the degree of LV
wall thickening (normal ~ 40%) and fractional shortening
of the LV cavity during systole. Based on visual estimation,
LV systolic function can be broadly divided into four
categories: hyperdynamic, normal, reduced, and severely
reduced (Supplementary Video 1).
It is important to assess LV systolic function by
different views, as both PLAX and apical 4-chamber
(A4C) views only show anteroseptal and inferolateral
walls of LV. PSAX is an excellent view to visualize all
four walls of LV for estimation of true global LV func-
tion, but it should be obtained at the mid-ventricular
papillary muscle level to avoid over or underestimation
of LV systolic function. It is possible to evaluate regional
wall motion abnormalities with PSAX, but it requires
additional expertise. Subcostal 4-chamber (S4C) view
in isolation is frequently the only view available in
emergent situations such as cardio-pulmonary resuscita-
tion and can yield important diagnostic information
such as underlying cardiac tamponade. Only septal
and lateral walls are visualized in this view. If S4C is
the only view available, consider including a subcostal
short axis view to assess global LV function. A subcostal
short-axis view can be obtained from the S4C view by
rotating the probe counterclockwise.
Right Ventricular Function. Right heart failure is caused
by right-sided pressure/volume overload or direct RV
injury from trauma or infarction. It can be an unrecognized
cause of cardio-renal syndrome.20 Pulmonary hyperten-
sion and right heart failure may result in decreased
eGFR by central venous congestion and decreasing cardiac
output as a result of leftward bowing of interventricular
septum (IVS).20 Right ventricular dysfunction has been
associated with the development of AKI in critically ill
patients, heart transplant recipients, patients with decom-
pensated heart failure and pulmonary hypertension.21-23
Cardiac ultrasound is a readily available tool to accu-
rately estimate RV size/function and IVS kinetics. It can
help evaluate acutely ill patients with undifferentiated res-
piratory failure and shock and guide treatment decisions
regarding inotropic support and fluid management.
Administering IV fluids in a patient with RV dilation
and bowing of IVS may compromise LV filling worsening
the shock state.24
Assessing RV size and function using FoCUS primarily
depends on comparing its size, shape, and wall thickness
with LV and evaluating IVS kinetics in all possible views.
In a normal heart, RV walls are thinner than LV, and the
RV chamber size is approximately two-thirds of LV. In
the PSAX view, RV is crescent-shaped (Fig 1B), while it is
triangular in the A4C view (Fig 1C). These characteristics
are altered in the presence of acute or chronic RV dysfunc-
tion, dilatation, and hypertrophy.
Only the right ventricular outflow tract is visible in PLAX
view limiting its utility in assessing RV function; however,
severe dilatation and hypokinesis of RV may be diagnosed
with the help of this view (Fig 2A, Supplementary
Video 2). PSAX view allows direct comparison of RV
size and shape with LV. Flattening of IVS and enlarged
RV in this view results in a “D” shaped LV cavity
(Fig 2B, Supplementary Video 2), suggesting RV pressure
(flattening during systole) or volume overload (flattening
during diastole).25
Adv Chronic Kidney Dis. 2021;28(3):208-217
Adv Chronic Kidney Dis. 2021;28(3):208-217
Table 1. Imaging Views for Focused Cardiac Ultrasound
Marker “Dot” How to Optimize
Imaging Views Patient Position Probe Position Orientation Image Quality? Ideal View Structures Seen Uses
Parasternal long Supine or left Left sternal border, Pointing toward Left lateral AV and MV AV, MV, LV, LVOT, LV size and
axis (PLAX) lateral decubitus 3rd or 4th ICS patient’s right decubitus visible and RVOT, function; AV/
(range 2-5 ICS) shoulder (10 o’clock position; end slightly right to pericardium, MV function;
position) inspiration or the center of ascending and left atrial size;
end-expiration image descending circumferential
images; slight aorta pericardial
rotation may effusion
open LV cavity
Parasternal short Supine or left Left sternal border, Pointing toward Center PLAX view Both papillary LV, papillary Global LV
axis (PSAX) at lateral decubitus 3rd or 4th ICS patient’s left at MV, rotate muscles muscles, function;
mid-ventricular (range 2-5 ICS) shoulder (2 o’clock clockwise 90 ; should be interventricular RWMA; shape/
level position) five different visible and septum, RV, function of
imaging planes symmetric; pericardium interventricular
can be obtained circular LV septum in

Cardiac Ultrasound for the Nephrologist

by tilting the cavity setting of RV
probe from base dilatation
of the
heart to apex;
mid-ventricular
or papillary
muscle
level is most
useful for FoCUS
purposes
Apical 4-chamber Supine or left LV apex (usually Pointing toward Locate apex by All 4 chambers LV, RV, LA, RA, AV, RV systolic
(A4C) lateral decubitus located in the 5th patient’s left side (2 palpation or (LV, RV, LA, RA) MV function and
ICS close to mid- o’clock position) slide transducer should be size in relation
clavicular line) toward apex visible with to LV; global LV
from a PSAX interventricular systolic
view septum in the function; MV/
followed by center TV evaluation;
tilting the beam pericardial
toward right effusion
shoulder; use
rocking to align
interventricular
septum in the
center of image;
use rotation to
visualize LV/RV
cavities in
appropriate
longitudinal
sections
(Continued )

211
 Table 1. Imaging Views for Focused Cardiac Ultrasound (Continued )

212
Marker “Dot” How to Optimize
Imaging Views Patient Position Probe Position Orientation Image Quality? Ideal View Structures Seen Uses
Subcostal 4- Supine Under xiphoid Pointing toward Probe needs to be All 4 chambers LV, RV, LA, RA, AV, RV size and
chamber (S4C) process, patient’s left side (3 flattened and should be MV, and function;
ultrasound beam o’clock position) pressed firmly; visible along pericardium global LV
is directed upward bend patient’s the long axis of function;
behind the knees; breath- heart pericardial
sternum hold at deep effusion and
inspiration; tamponade;
sliding useful view in
transducer acutely ill
slightly to the patients, may
right side to use obtain images
liver as the without
acoustic window interrupting
may help in case CPR; preferred
of bowel gas view in COPD
and
mechanically
ventilated
patients due to
downward

Goyal et al
displacement
of diaphragm
Subcostal IVC Supine Under xiphoid Pointing toward Use liver as the Uniform IVC, hepatic vein, Guide fluid
(Supplementary process patient’s head (12 acoustic diameter; right atrium management;
Fig 4) o’clock position) window; IVC can draining into estimate RA
be distinguished right atrium pressure;
from aorta by its tamponade
thin walls, physiology
collapsibility,
and
Adv Chronic Kidney Dis. 2021;28(3):208-217

communication
with hepatic vein
and right atrium

Abbreviations: AV, aortic valve; COPD, chronic obstructive pulmonary disease; CPR, cardio-pulmonary resuscitation; ICS, intercostal space; IVC, inferior vena cava; LA, left atrium;
LV, left ventricle; LVOT, left ventricle outflow tract; MV, mitral valve; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract; RWMA, regional wall motion ab-
normalities.
 Cardiac Ultrasound for the Nephrologist 213

Figure 2. Right ventricular dilation suggesting increased right heart pressures: (A) parasternal long-axis view with RV . LV
and IVS bowing; (B) parasternal short-axis view with “D-shaped” LV cavity; (C) apical 4-chamber view with cardiac apex domi-
nated by RV suggesting severe RV dilation. Abbreviations: IVS, interventricular septum; LV, left ventricle; RV, right ventricle.

A4C is the most informative view to diagnose global RV
dysfunction. It allows a side-by-side comparison of both
ventricles. It also allows visualization of IVS motion and
bowing. Similar to LV, qualitative estimation of RV dilation
and systolic function is preferred by visual method for
FoCUS purposes. Recognizing the “true” view vs atypical
or foreshortened view when assessing RV size and func-
tion is important. RV size is categorized as normal (,2/3
of LV size), moderately dilated (.2/3 of LV), or severely
dilated (RV . LV, apex dominated by RV, Fig 2A–C,
Video 2) based on visual assessment. As the RV dilates,
its shape changes from crescentic to circular in PSAX
view, and triangular to ovoid in A4C view. RV primarily
contracts longitudinally and its systolic function can be
estimated to be normal, reduced, or severely reduced by
observing the motion of tricuspid annulus also called
tricuspid annular plane systolic excursion or TAPSE
(Supplementary Fig 3) for quantitative estimation (normal
range 22-24 mm, RV systolic dysfunction ,16 mm).26
Advanced users can utilize A4C view for measuring
TAPSE, Doppler flow evaluation of tricuspid valve, and
estimation of pulmonary pressure.
In the S4C view, triangular RV is seen in the near-field
view. Like A4C, it is a good view for a side-by-side com-
parison of ventricles size and shape, especially when the
A4C view is difficult to obtain. S4C is the preferred view
for measuring RV wall thickness due to its location being
perpendicular to the ultrasound beam. In acute RV failure,
wall thickness is generally ,0.5 cm. When RV failure
becomes chronic, the walls become hypertrophied with a
thickness .1 cm.
Pericardial Effusion. Pericardial effusion is defined as an
accumulation of fluid greater than the normal 50 mL of the
physiological amount in the pericardial space.27 The etiol-
ogy for pericardial effusions is diverse and includes malig-
nancy, trauma, infection, inflammatory, and auto-immune
conditions.27 The prevalence of asymptomatic pericardial
effusion in ESKD patients has been reported to be as
high as 62% and it can be a result of additional factors
such as accumulation of uremic solutes and inadequate
dialysis.28 Based on these factors, pericarditis or pericar-
dial effusion in advanced CKD patients has been broadly
categorized into uremic and dialysis-associated
pericarditis.29 Uremic pericarditis has been described to
occur because of the accumulation of toxic metabolites
before or within 8 weeks of starting kidney replacement
therapy.30 Whereas dialysis-associated pericarditis is

Figure 3. Circumferential pericardial effusion: (A) parasternal long-axis view showing effusion in near and far-field, co-exist-
ing pleural effusion can be differentiated from pericardial effusion from its relative location with DTA (not visible, the approx-
imate location is shown), and pericardium; (B) parasternal short-axis view with circumferential pericardial effusion and
pleural effusion; (C) subcostal 4-chamber view with large pericardial effusion and the diastolic collapse of RV free wall sug-
gestive of tamponade physiology. Abbreviations: DTA, descending thoracic aorta; LV, left ventricle; RV, right ventricle.

Adv Chronic Kidney Dis. 2021;28(3):208-217

214 Goyal et al
thought to be due to fluid overload and metabolic abnor-
malities resulting from inadequate long-term kidney
replacement therapy.30 Pericardial effusion has been
noticed more frequently in ESKD patients starting
emergent hemodialysis.31
Pericardial or cardiac tamponade is a deadly complica-
tion of pericardial effusion with an estimated incidence
of 3.1% in non-ESKD patients with pericarditis and 10-
20% in patients with uremic or dialysis-associated pericar-
ditis.32,33 It can be difficult to diagnose tamponade by
history and physical examination in kidney disease pa-
tients as they have a gradual accumulation of pericardial
fluid. They usually present with vague complaints, appear
weak, and may not have the classical findings of Beck’s
triad (hypotension, jugular venous distension and muffled
heart sounds) as seen in trauma patients with the rapid
accumulation of fluid.32,34
FoCUS allows rapid, reliable, and noninvasive diagnosis
of pericardial effusion and tamponade by noncardiologists
with .95% accuracy when compared with conventional
echocardiography.35,36 Identification of pericardial effu-
sion at the bedside can be very helpful for nephrologists.
It expedites management by initiating or intensifying dial-
ysis and allowing timely referral for drainage of a large
effusion. A diagnosis of cardiac tamponade and emergent
ultrasound-guided pericardiocentesis may be lifesaving.
Pericardial effusion can be identified as an anechoic
(black) space between the hyperechoic (bright white)
visceral and parietal layers of the pericardium. In a supine
patient, free-flowing pericardial fluid initially accumulates
posteriorly in the dependent portion of the pericardial sac
and then becomes more circumferential as the volume of
effusion increases.37 Posteriorly located small pericardial
effusions can be seen in the far-field of PLAX view as an
anechoic space traversing anterior to the descending
thoracic aorta. The location of fluid in relation to the aorta
is important to distinguish pericardial effusion from a left
pleural effusion which is seen deeper or posterior to the
descending thoracic aorta (Fig 3A).
In the S4C view, the anechoic space of pericardial
effusion is initially seen in the near field, and then circum-
ferentially as more fluid accumulates (Fig 3C). It is impor-
tant to distinguish a pericardial effusion from an epicardial
fat pad, which will appear more isoechoic and will not
change with the patient’s position like a free-flowing peri-
cardial effusion. Similarly, complicated effusions with
purulent material, blood, thrombus, fibrin, and cellular
debris may not appear anechoic and could be misinter-
preted as epicardial fat or myocardium. Peritoneal fluid
(ascites) is present adjacent to the diaphragm and can be
misinterpreted as a pericardial effusion in the S4C view;
however, ascites will not be circumferential or visible in
other views.
The size of the pericardial effusion can be estimated by
measuring the maximum dimension of anechoic space
during diastole. Small effusions are typically ,1 cm, mod-
erate 1-2 cm and large effusions are .2 cm.37 Large effu-
sions typically require drainage; however, the
hemodynamic significance of a pericardial effusion also
depends on its rate of accumulation, and fluid characteris-
tics (serous vs hemorrhagic). A rapidly accumulating or lo-
culated small to moderate effusion in penetrating cardiac
injuries may result in higher pericardial pressure than
RA and RV leading to tamponade and hemodynamic
compromise.7,34
Cardiac tamponade should be suspected in any hemody-
namically unstable patient with circumferential pericardial
effusion. In cases of pulseless electrical activity arrest, the
incidence of pericardial effusion has been noted to be as
high as 67%.38 Important echocardiographic signs of tam-
ponade are RA and RV collapse during their respective dia-
stolic phases when the chamber pressure is lowest, IVC
dilatation .2 cm with ,50% respiratory variation, or a
large pericardial effusion with swinging heart (Video
3).37 IVC plethora has excellent sensitivity (97%) and nega-
tive predictive value for ruling out cardiac tamponade.37
Clinical and echocardiographic evidence of tamponade
is a true medical emergency. Intravenous fluids and vaso-
active agents can be used as temporizing interventions in
hypotensive patients; however, emergent pericardiocente-
sis is of paramount importance for definitive management.
A surgical evaluation may be warranted for purulent
effusions and traumatic hemopericardium.
Valvular Pathologies. Patients on long-term hemodialy-
sis are more likely to develop hemodynamically relevant
aortic and mitral valve disorders due to alterations in cal-
cium metabolism.39 Acute conditions for which screening
can be helpful for nephrologists include unexplained pul-
monary edema and heart failure resulting from the new
onset or worsening valvular dysfunction. A detailed eval-
uation of valvular pathologies is beyond the scope of
FoCUS; however, basic two-dimensional (2D) ultrasound
with color-flow Doppler can help screen for severe mitral
or aortic regurgitation that can significantly impact
management and warrants referral for comprehensive
echocardiography.
Basic 2D FoCUS may detect major valvular abnormal-
ities including calcification, large vegetations, flail leaflets,
thickening, and tethering, but these findings should be
used with caution and only in the appropriate clinical
context. Color-flow Doppler is the cornerstone of detecting
valvular regurgitation in FoCUS; however, it requires a
good understanding of its key concepts and consideration
to avoid misinterpretation.
BEYOND THE BASICS: ADVANCED CARDIAC
ULTRASOUND FOR THE NEPHROLOGIST
Competency in FoCUS can be attained by understanding
the basic principles of 2D echocardiography after a short
course of training.40 However, mastering advanced car-
diac ultrasound (ACUS) techniques can be more chal-
lenging and time consuming. It necessitates image
acquisition skills of a trained echocardiographer as well
as image interpretation and clinical application knowl-
edge similar to a cardiologist.41 While FoCUS is increas-
ingly being recognized as a mandatory skill among
several disciplines, ACUS remains an optional area of
expertise for noncardiologists. Depending on their interest
Adv Chronic Kidney Dis. 2021;28(3):208-217
 Cardiac Ultrasound for the Nephrologist
Figure 4. The Doppler principle in cardiac ultrasound. Doppler shift is maximum in (A) and (E) when blood flow is parallel to
the direction of the ultrasound beam, and minimum in (C) when they are perpendicular to each other.
and scope of practice, many nephrologists may find it
useful to become proficient in ACUS.
We have briefly outlined the basic principles of ACUS,
their limitations, and clinical utility for a practicing
nephrologist. A more detailed review is out of the scope
of this article. For interested learners, a comprehensive
review can be found in the standard echocardiography
texts.17,42,43
The Doppler Principle
In ACUS, Doppler is considered the language of blood
flow. As per the Doppler principle, the frequency of a re-
turning wave changes when the object reflecting the
wave (blood or myocardium) and the source of the wave
(transducer) are moving in relation to each other. A posi-
tive Doppler shift or increased frequency of the returning
ultrasound wave is observed when the blood flow is
toward the transducer, and a negative Doppler shift or
decreased frequency of the returning ultrasound wave is
seen when it is moving away. Depending on the type of
Doppler (spectral or color), positive Doppler shift is seen
as an upward deflection or red color, while negative
Doppler shift as downward deflection or blue color
(Fig 4). A popular mnemonic to remember this principle
is BART (Blue Away; Red Toward).44
As shown in Fig 4, in addition to informing about the
direction of blood flow the Doppler shift can also provide
information about its velocity. As is apparent in the figure,
Adv Chronic Kidney Dis. 2021;28(3):208-217
215
the Doppler shift depends on the cosine of the “Angle of
Insonation”—the angle between the direction of the ultra-
sound beam and blood flow. As you recall, the cosine of
90 is 0, whereas the cosine of 0 is 1. Therefore, the
Doppler shift has a negative correlation with the cosine
of the angle of insonation. This is a critical concept as a
high angle of insonation can lead to large underestima-
tions of the Doppler shifts and associated blood flow
velocities.
Types of Doppler
There are two basic types of Doppler ultrasounds—contin-
uous wave and pulsed wave. As the name suggests, the
continuous wave Doppler is continuously sending and
receiving the ultrasound waves, whereas the pulsed
wave Doppler alternates between transmission and receipt
of these waves. This basic difference between these modal-
ities provides opportunities for use in different clinical
contexts. The continuous wave Doppler measures all ve-
locities across the path of the ultrasound wave. It can mea-
sure very high velocities generated by turbulent flows
across the diseased valves. In contrast, the pulsed wave
Doppler measures the blood velocity at a very specific
location between the pulsed wave Doppler gates on the ul-
trasound screen. It, however, is unable to measure high
velocities due to the phenomenon of “aliasing”.45 It is
therefore used to measure velocities at specific locations,
for example, at LV outflow tract to measure stroke volume.
216 Goyal et al
Color-flow and tissue Doppler are two special variants of
pulsed-wave Doppler that are frequently used in ACUS.
Clinical Utility of Advanced Cardiac Ultrasound
The utility of ACUS in nephrology practice lies in the fact
that it is readily available, cost-effective, and findings are
interpreted by clinicians who are well aware of patients’
clinical course. Real-time image acquisition and interpreta-
tion can be performed serially for patients on kidney
replacement therapy in inpatient and outpatient settings.
ACUS has several practical applications pertinent to a
nephrologist such as measurement of cardiac output, vol-
ume responsiveness, right ventricular systolic pressure, LV
diastolic dysfunction, tamponade physiology, hemodialy-
sis induced regional wall motion abnormalities,46,47 and
measuring transvalvular flow for assessing dynamic ab-
normalities during ultrafiltration.48 In addition to ACUS,
an understanding of Doppler principles has wider applica-
tions in nephrology including vessel identification for dial-
ysis catheter placement, arteriovenous fistula assessment,
diagnosing systemic venous congestion, and measuring
renal and splenic artery resistive indices during hemody-
namic assessment.44
A study that explored the feasibility of basic and
advanced cardiac ultrasound by trainees in the emergency
room found that advanced cardiac ultrasound adds less
than 7 minutes to the total time when performed by junior
residents.49 This was down to 4 minutes when performed
by fellows. Therefore, with appropriate training and prac-
tice, these additional views can be performed in specific
situations without significant burden. A detailed overview
of these applications is out of the scope of this review.
LIMITATIONS OF CARDIAC ULTRASOUND
Cardiac ultrasound findings can be non-specific and are
most useful when used to answer a specific clinical
question in a specific clinical scenario. Lack of hands-on
practice and interpretation of poor quality, off-axis images
may lead to incorrect conclusions negatively impacting
clinical decision-making. Nephrologists work in several
settings including hospital, office, and dialysis unit and
may not have readily available ultrasound equipment at
all locations. Not all hand-held devices may have optimal
image quality due to smaller screen size, lack of resolution,
and features to adjust image quality. Finally, the specific
training and maintenance of skill standards for FoCUS
and ACUS still need to be determined. They should be
utilized in conjunction with the physical examination
and the right clinical context. Any doubtful or significant
clinical findings should be confirmed with a referral for
comprehensive echocardiography.
CONCLUSION
FoCUS is increasingly being recognized as an essential
diagnostic tool across several clinical disciplines, including
nephrology. Our introductory case describes a not so un-
common scenario in a nephrologist’s practice who cares
for patients with advanced cardiac comorbidities. Coming
back to our case, a FoCUS examination was performed
revealing a large pericardial effusion, plethoric IVC, and
diastolic collapse of RV free wall suggestive of tamponade
physiology. The diagnosis was further supported by
ACUS showing .25% mitral inflow variation. An urgent
pericardial drain was placed at the bedside with drainage
of over 600 mL of pericardial fluid with immediate
improvement in her blood pressures. Aggressive ultrafil-
tration in the setting of an underlying large pericardial
effusion likely precipitated cardiac tamponade in this
case.1 It was further worsened after the initiation of vaso-
pressors due to the reduced time available for ventricular
filling. This simple case emphasizes the importance of add-
ing FoCUS and ACUS to nephrologists’armamentarium in
the fight against kidney diseases.
ACKNOWLEDGMENTS
Research reported in this publication was supported by the
National Institute of General Medical Sciences of the National In-
stitutes of Health under Award Number 5U54GM104942-04. The
content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes
of Health.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found at
https://doi.org/10.1053/j.ackd.2021.04.001.
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