Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore, Singapore.
Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
Hemodial Int. 2020 Oct;24(4):516-527. doi: 10.1111/hdi.12871. Epub 2020 Aug 18.
Volume assessment in end-stage kidney disease patients on hemodialysis (HD) remains inadequate by existing methods: clinical examination, bioimpedance spectroscopy, measurement of inferior vena cava diameter by ultrasound (IVCD), and plasma B-type natriuretic peptide (NT-pro BNP). This study aims to compare the performance of lung ultrasound against existing methods for volume assessment in a HD cohort.
Two nephrologists independently performed 28-point lung ultrasound immediately before and after midweek HD in 50 patients. Lung congestion was classified into mild, moderate, and severe categories based on lung ultrasound findings. Clinical examination for crepitations and oedema, change in hydration status (∆HS) measured by bioimpedance spectroscopy, NT-pro BNP, IVCD during inspiration (IVCDimin), expiration (IVCDimax), and inferior vena cava collapsibility index were also assessed before and after midweek HD.
In all, 61% of patients with normohydration status by bioimpedance spectroscopy had moderate or severe lung congestion on lung ultrasound. There were significant correlations between predialysis lung ultrasound, and NT-pro BNP (r = 0.432, P = 0.004), ∆HS (r = 0.447, P < 0.001), and IVCD parameters (P < 0.05). Some correlations weakened postdialysis (∆HS [r = 0.322, P = 0.01] and IVCDimax [r = 0.307, P = 0.03]), whereas NT-pro BNP and ∆HS paradoxically increased in 28% and 30% of the cohort, respectively. On receiver operator curve analysis, most methods of volume assessment had limited discriminatory power to detect mild lung congestion.
Lung ultrasound demonstrates some comparability with existing volume assessment methods in Asian dialysis patients. However, it appears more effective at detecting subclinical pulmonary congestion, and tracking fluid changes real-time compared to bioimpedance spectroscopy and NT-pro BNP.
目前，临床检查、生物电阻抗光谱法、超声测量下腔静脉直径（IVCD）和血浆 B 型利钠肽（NT-proBNP）等方法均不能充分评估血液透析（HD）终末期肾病患者的容量。本研究旨在比较肺部超声在 HD 患者容量评估中的表现与现有方法的差异。
两位肾病学家分别在 50 名患者中，在每周中 HD 前后，对其进行了 28 点肺部超声检查。根据肺部超声检查结果，将肺充血分为轻度、中度和重度。还评估了每周中 HD 前后的临床检查中肺部湿啰音和水肿、生物电阻抗光谱法测量的水合状态变化（∆HS）、NT-proBNP、吸气时 IVCD（IVCDimin）、呼气时 IVCD（IVCDimax）和下腔静脉塌陷指数。
在所有患者中，61%的生物电阻抗光谱法结果正常的患者在肺部超声检查中存在中度或重度肺充血。在预透析时，肺部超声与 NT-proBNP（r = 0.432，P = 0.004）、∆HS（r = 0.447，P<0.001）和 IVCD 参数之间存在显著相关性（P<0.05）。在透析后，一些相关性减弱（∆HS [r = 0.322，P = 0.01] 和 IVCDimax [r = 0.307，P = 0.03]），而 NT-proBNP 和 ∆HS 分别在 28%和 30%的患者中反而增加。在受试者工作特征曲线分析中，大多数容量评估方法的区分能力有限，无法检测到轻度肺充血。
在亚洲透析患者中，肺部超声与现有的容量评估方法具有一定的可比性。然而，与生物电阻抗光谱法和 NT-proBNP 相比，它似乎在检测亚临床性肺充血和实时跟踪液体变化方面更有效。
