The aim of this case is to visually showcase severe right-sided congestion. As mentioned earlier, eVExUS, or ‘extended VExUS‘, involves examining more veins than the traditional trio of hepatic, portal, and intrarenal (in cases where they are inaccessible or unreliable). Although in this instance the severity of congestion is obvious and eVExUS is not necessary for management, the objective is to depict various waveforms for educational purposes. Apical 4-chamber view reveals leftward bulging of the interventricular septum throughout the cardiac cycle, indicating elevated right atrial pressure ..read more

Venous congestion often stems from fluid overload. However, it’s important to recognize that POCUS does not directly measure blood volume but instead assesses blood flows and pressure gradients. Whether to remove fluid or do something else depends on the clinical context. The following images were obtained from a hospitalized patient with decompensated Group I pulmonary hypertension and acute kidney injury right after right heart catheterization (RHC). Key RHC measurements included a central venous pressure of 15 mmHg, mean pulmonary artery pressure of 37 mmHg, pulmonary vascular resistance of ..read more

Currently, there is growing interest in femoral vein Doppler, mainly due to its perceived ease of image acquisition. Elevated femoral vein pulsatility indicates venous congestion with reasonable specificity. However, this parameter’s low sensitivity may make it unreliable for ruling out congestion (the vein is far from the heart). One study showed that femoral vein Doppler has good accuracy in detecting venous congestion and demonstrates moderate agreement with VExUS grading (Kappa value of 0.62, P < 0.001). Nevertheless, the weak correlation with CVP in this study underscores the caution r ..read more

Encountering venous valves is not uncommon, and they can potentially be confused with pathology such as dissection by uninformed clinicians. In nephrology practice, internal jugular vein (IJV) valves are often observed when assessing right atrial pressure or placing a dialysis catheter. In fact, IJV valves are present in more than 90% of the population. These valves, located deep in the neck, are better visualized with a linear transducer with a smaller footprint (or a hockey stick probe) and in patients with a dilated IJV. Below are a couple of examples and an illustration demonstrating the p ..read more

In a previous discussion, we delved into the TIE fighter sign in the context of pelvic ascites, where the automated bladder scanner misinterpreted ascites as a full urinary bladder. Here is another example of the TIE fighter sign, but with a different underlying pathology – this time, it’s due to a large ovarian cyst. It’s essential to recognize that these ‘named signs’ merely reflect our pareidolias or imaginative perceptions and should not be exclusively linked to specific pathologies. Always approach the interpretation of findings within the appropriate clinical context. For instance, the ..read more

VExUS is an emerging field, and consequently, its practical application in day-to-day clinical practice is not widely acknowledged. Presented below are selected cases we have published (as of November 2023), each conveying a unique teaching point. Links to the full articles are provided; click on the word ‘case’. Case 1: This is a classic example showcasing how diuretic therapy led to the simultaneous improvement of all three waveforms (hepatic, portal, and intrarenal) alongside improvement in serum creatinine and sodium levels. It also underscores the general observation that improvement in t ..read more

If you’re a nephrologist in the United States seeking hands-on POCUS training, there are two upcoming courses to consider. The 17th POCUS workshop in Austin, organized by Dr. Nilam Soni and his team in January 2024, is designed primarily for internists but is very relevant for nephrologists as well. It’s the same Dr. Soni, editor of the most popular POCUS textbook. If a substantial number of nephrologists register, there will be an opportunity to focus on specific sonographic applications in a breakout session. Click here for more details and to register. A day-long POCUS precourse tailored fo ..read more

I shared this image on Twitter (X), asking to identify the anechoic area marked with an arrow. On the left side, there’s an M-mode image showing the long axis view of the dilated inferior vena cava (IVC), measuring 2.7 cm in diameter. On the right, you can see a transverse scan in the epigastric region displaying a few anechoic structures. Out of 312 respondents, 63% thought it was a transverse view of the plethoric IVC, but it’s not. It’s actually the gall bladder. The purpose of this poll is to urge people to consider normal anatomy first before jumping to pathology. Upon closer inspection ..read more

Earlier, we discussed the utility of POCUS in evaluating hemodynamic acute kidney injury in cirrhosis. The following images were obtained from a patient with alcoholic liver cirrhosis, who had been receiving empiric intravenous albumin at 1g/kg/day for four consecutive days due to acute kidney injury. Unfortunately, many healthcare providers fail to recognize the common occurrence of iatrogenic fluid overload and the diagnostic inadequacies of conventional physical examination. In this case, the continued administration of albumin was justified by pointing out the ‘absence of supplemental oxyg ..read more

Physical examination in acute kidney injury commences with kidney POCUS and concludes with a thorough evaluation of the hemodynamic circuit. It is important to note that kidney ultrasound should always include a bladder assessment. Below are images of the urinary bladder obtained from a patient with acute kidney injury. There was no hematuria or dysuria but the patient had a history of benign prostatic hyperplasia. These images depict a relatively irregular growth emerging from the bladder wall, sharing similar tissue characteristics. This finding raises suspicion of a bladder neoplasm, promp ..read more