Perelman School of Medicine, Hospital of the University of Pennsylvania, Division of Renal, Electrolyte and Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin.
Kidney360. 2021 Nov 11;3(1):176-184. doi: 10.34067/KID.0003972021. eCollection 2022 Jan 27.
Volume overload, and its attendant increase in acute care utilization and cardiovascular morbidity and mortality, represents a critical challenge for the practicing nephrologist. This is particularly true among patients with ESKD on HD, where predialysis volume overload and intradialytic and postdialytic hypovolemia account for almost a third of all cost for the Medicare dialysis benefit. Quantitative lung ultrasound is a tool for assessing the extent of extravascular lung water that outperforms physical exam and plain chest radiography. B-lines are vertical hyperechoic artifacts present in patients with increased extravascular lung water. B-lines have been shown to decrease dynamically during the hemodialysis treatment in proportion to ultrafiltration volume. Among patients with chronic heart failure, titration of diuretics on the basis of the extent of pulmonary congestion noted on lung ultrasonography has been shown to decrease recurrent acute care utilization. Early data from randomized controlled trials of lung ultrasound-guided ultrafiltration therapy among patients with ESKD on HD have shown promise for potential reduction in recurrent episodes of decompensated heart failure and cardiovascular events. Ultimately, lung ultrasound may predict those who are ultrafiltration tolerant and could be used to decrease acute care utilization and, thus, cost in this population.
容量超负荷及其导致的急性医疗利用率增加和心血管发病率和死亡率增加，是临床肾脏病医生面临的一个重大挑战。对于接受血液透析治疗的终末期肾病患者来说尤其如此，因为透析前容量超负荷以及透析期间和透析后低血容量占医疗保险透析福利总成本的近三分之一。定量肺部超声是一种评估血管外肺水程度的工具，其表现优于体格检查和普通胸部 X 线摄影。B 线是存在于血管外肺水增加患者中的垂直高回声伪影。已经证明，B 线在血液透析治疗过程中会随着超滤量的增加而动态减少。在慢性心力衰竭患者中，根据肺部超声检查发现的肺部淤血程度来滴定利尿剂，已被证明可以减少急性医疗利用率的复发。在接受血液透析治疗的终末期肾病患者中进行的肺部超声引导超滤治疗的随机对照试验的早期数据显示，该疗法可能有希望减少失代偿性心力衰竭和心血管事件的复发。最终，肺部超声可能预测那些能够耐受超滤的患者，并可用于降低该人群的急性医疗利用率，从而降低成本。
