#203 POCUS for AKI & Dialysis | Real Cases That Changed Management

[SPEAKER_00]: I think it's something that is recognized by both internal medicine and forology is something that our trainees should be learning. [SPEAKER_00]: We just need to have the infrastructure to do it. [SPEAKER_00]: I think as our generation of doctors kind of rises up, I think that infrastructure will grow further, but I honestly I can't imagine practicing without it. [SPEAKER_02]: Welcome to CoreM.

[SPEAKER_02]: We have a special Nephmanus episode today and you just heard from Dr. Jeffrey Cot. [SPEAKER_00]: Hi, my name is Jeffrey Cot. [SPEAKER_00]: I'm a nephrologist and intensivist at Madder Hospital, which is part of the Northwest of Somalmong Island, and I'm also part of the Neffmanist Executive Committee. [SPEAKER_02]: And I'm also here with Dr. Noah Markwitz.

[SPEAKER_01]: Hi, I'm Dr. Noah Markwitz, a PGY3 internal medicine resident at Montefir, and soon to be in a phrology fellow at Mount Sinai. [SPEAKER_01]: I'm personally beginning my own pocus journey, and I'm thrilled to share some of the amazing teaching points we learned from Dr. Cot. [SPEAKER_02]: Yes, before we get started, what is Neff Madness and what are we doing here today?

[SPEAKER_01]: So, Neff Madness is mirrored after the March Madness College Basketball Tournament, and the goal is to award the topic that we think is going to be the face of Nefrology in 2026, the most influential or most exciting thing that's going to happen in the years to come. [SPEAKER_01]: So, a bracket is going to be made of different concepts in Nefrology, and these concepts will then go head to head with each other.

[SPEAKER_01]: The winner of each matchup is decided by a panel of experts. [SPEAKER_01]: I can say that I look forward to Neff Madness every year because there's so much content released from it, experts write blogs, like I feel like I go through a mini-nephrology fellowship every March. [SPEAKER_01]: And of course, there's the podcasts. [SPEAKER_02]: Yes, which is why we're here today.

[SPEAKER_02]: So today we're talking about what is going ahead to head in the northeast region, bracket, which is point of care ultrasound, pocus, and the [SPEAKER_01]: So we're going to be going through four cases. [SPEAKER_01]: The first two being pocus for AKI and the second two being pocus for end stage renal disease. [SPEAKER_01]: So as we go through these cases, think about what you want to vote for as the future of nephrology.

[SPEAKER_02]: All right, I think Jeff we're so excited to learn from you today and why you're so passionate about ultra-sounds and kind of some of the cases that have made you think, oh, I'm so glad I had these skills. [SPEAKER_02]: And for listeners, all these cases are de-identified.

[SPEAKER_01]: So our first case is a 71-year-old male with a past medical history of BPH with prior hydronephrosis, diffuse large B cell lymphoma, currently receiving archop, who's here with abnormal labs from his oncology appointment.

[SPEAKER_01]: He received his last chemotherapy as an outpatient three days ago, and was found to have a potassium of 6.7, a creatine of 4.5, which is a big jump because three days ago his creatine was 1.1. [SPEAKER_01]: They got more labs in the emergency room and showed the potassium was up to 7. [SPEAKER_01]: The LDH was over a thousand. [SPEAKER_01]: Foss was 6.7, Yurik acid was 12, and the calcium was 8.8. [SPEAKER_01]: The patient states he's been passing urine without any issues.

[SPEAKER_02]: Yeah, wow, that crat and jump is impressive, right? [SPEAKER_02]: He was somebody that lived like 1.15 and went up to 4.5. [SPEAKER_02]: And then in the ER, they got all these other labs, a potassium of 7 and LDH in like 1100s, a fossil of 6.7, the york acid of 12. [SPEAKER_02]: I mean, this is just a screaming tumor license syndrome, TLS in a person with diffuse large b-cell.

[SPEAKER_00]: Obviously, you know, when we're getting this calls in a probability fellow, you're first thought should be to go through your pre-intrinsic and post-renal causes, you know, always keep those in the back of your mind. [SPEAKER_00]: But in this case, TLS is certainly high in the differential, with TLS, the reason why that matters is because you may be a little quicker to pull the trigger on kidney replacement therapy.

[SPEAKER_00]: If you're unable to keep up with the intrinsic potassium generation, you're going to have to be a little quicker to pull the trigger on dialysis. [SPEAKER_00]: So when I was seeing this patient, I was really just looking for a reason not to dial it. [SPEAKER_01]: So when the patient tells you that they're passing urine without issues, are you kind of done with the post-renal bucket? [SPEAKER_00]: Yeah, it's a good question.

[SPEAKER_00]: I think the answer is no, I've seen enough patients tell me that they're urinating, okay, and then mind up having full blotters or hydrant or frosts on ultrasound, or sometimes they're just endorsing incontinence, but just not really kind of acknowledging it that way. [SPEAKER_00]: So, yes, it may make my suspicion a little bit lower, but it doesn't entirely roll it out for me. [SPEAKER_01]: So let's kind of enter focus into this.

[SPEAKER_01]: In my mind, there's, you can ask the nurses to blatter scan. [SPEAKER_01]: You can get a formal, renal blatter ultrasound, and then you can do your own focus. [SPEAKER_01]: So what's the difference between the three and how they each helpful? [SPEAKER_00]: Yeah, so a post-wide residual or just a bladder scan is, you know, going to be fairly easy and probably would be enough to roll it out.

[SPEAKER_00]: The one issue I will say with that is, you know, in this case, you're asking a nurse to do that. [SPEAKER_00]: But in this case, this is a fairly busy ER. [SPEAKER_00]: I, you know, could have asked the nurse. [SPEAKER_00]: She had many other patients. [SPEAKER_00]: It might have actually taken a little bit of time to actually get done. [SPEAKER_00]: and then they have to actually be able to report it to you. [SPEAKER_00]: You know, you may not be at the bedside anymore.

[SPEAKER_00]: So, you know, post-warrius Israel Blotterscan is completely fine. [SPEAKER_00]: It just has a future, I'll back to my mind. [SPEAKER_00]: Real Blottersound will obviously be our gold standard. [SPEAKER_00]: The issue with that, depending on the hospital, is one that can take a little bit of time to get to. [SPEAKER_00]: They're also a little bit on the more costly side potentially at some kind of studies say that it can be between $200,000 per scan.

[SPEAKER_00]: So that leaves the voltage sound. [SPEAKER_00]: If you have an ultrasound available and obviously have the confidence and skills and ability to actually perform your own kind of bring a letter ultrasound, it's something that you can do relatively easily. [SPEAKER_00]: One, it's fairly sensitive and specific. [SPEAKER_00]: It could pair to our gold standard, our renal blood roll chandor CT scan, and two, the time that it takes to actually get done, can be hours today's faster.

[SPEAKER_00]: So, you know, for me, if we're in this situation, I'm reaching for point of control to sound, because I think it's going to be the quickest thing, and it's going to get me my answer, fastest. [SPEAKER_02]: Yeah, and then God, you're a thorough, because what did you find? [SPEAKER_02]: Doing pocus. [SPEAKER_00]: Yes, so I demonstrated bilateral hydrogen refrosis in a pretty large bladder, so at that point, asked the nurse to place fully, which she thankfully did quickly.

[SPEAKER_00]: I'm just kind of watching his laps throughout the night. [SPEAKER_00]: They'd come down and we were kind of able to avoid dialas in him. [SPEAKER_00]: In this case, it certainly looked like we were looking more and obstructive from the frappathy as opposed to some kind of intrinsic cause of TLS. [SPEAKER_02]: Awesome. [SPEAKER_02]: That's amazing. [SPEAKER_02]: What a great story. [SPEAKER_02]: Okay, so here we have the power of pocus, right?

[SPEAKER_02]: He was able to find Hydrodephosis and diagnosed postrenal obstruction due to BPH. [SPEAKER_02]: And he helped avoid dials in this patient who was on chemotherapy in at first glance. [SPEAKER_02]: His labs were screaming TLS, right?

[SPEAKER_02]: And this was also just a good humbling teaching point about labs in severe A.K.I. [SPEAKER_02]: can look a little bit like TLS hypercolemia, hyperphosotemia, hypererosemia, [SPEAKER_02]: and he was able to do all this with just pocus at the bedside and he didn't need to get a formal renal ultrasound. [SPEAKER_01]: Trant, different hospitals say different things. [SPEAKER_01]: Do you guys also call that the Arbus? [SPEAKER_02]: What? [SPEAKER_02]: No, what is an Arbus.

[SPEAKER_01]: renal bladder ultrasound are bus. [SPEAKER_02]: I picture like a bus going up someone's renal's but it's not it's like going to the ureters and bladder. [SPEAKER_02]: Anyways, I mean we have different things. [SPEAKER_02]: We say rocky so you know it's rocky. [SPEAKER_02]: Yeah I know when I first heard this I was like shake my head but once you get into it you just keep saying it. [SPEAKER_01]: To not make too much of a ruckus, I think we should move on here.

[SPEAKER_01]: So, now's a good time to talk about when do we actually need to get that renal bladder ultrasound or arbus? [SPEAKER_01]: So the Journal of Hospital Medicine has a great things we do for no reason on the arbus. [SPEAKER_01]: So we're going to attach it to our notes, but they describe a validated risk assessment tool with things such as history of hydronephrosis, history of recurrent UTIs, and absence of heart failure.

[SPEAKER_02]: Okay, that's really great because I feel like we constantly write hashtag aka and like reflexely ordered that renal ultrasound or R bus as you cool kids say and yeah, so most you want to like are we over ordering this thing. [SPEAKER_01]: So the score helps you risk stratify. [SPEAKER_01]: They recommend always starting with a post void residual and only in high risk patients who the AKI isn't resolving. [SPEAKER_01]: Should you get that formal renal bladder ultrasound?

[SPEAKER_01]: Due to this patient's prior history of Hydroinephrosis, he would have met criteria for the renal bladder ultrasound. [SPEAKER_01]: But what's cool about pocus is you don't even need to wait for the nurse to do the post void residual. [SPEAKER_01]: You can do it yourself while the nurses are busy with their tasks.

[SPEAKER_02]: Yeah, and I guess that begs the question, we know if we're going to order this renal platter ultrasound is like the big thing, just to, hey, I want to rule out hydronofrosis, or is there any other information we can gather from it? [SPEAKER_00]: I think if you've got somebody with that elevated creatine, you've never been in your hospital for, you're not sure if this is a cuter chronic echogenicity cortex thickness, that could point towards the chronicity.

[SPEAKER_02]: Yeah, and just like close at loop about chronicity, what will a cortical thickness size and the echogenicity tell you that would say, oh, this has been more chronic, and you disease versus an acute process.

[SPEAKER_00]: Yeah, so if you were having more echogenic kidney, so meaning like, you know, if we're going to look at an image, if the brightness of the kidney is similar to that of the liver, that's going to tell you that there's probably a little quinnicity chronic kidney disease, kidney size as well, which I forgot to mention, you know, if you've got a smaller kidney, but something that theoretically as well could point towards some kind of chronic kidney disease, and then cortical thickness, a few have a thinner cortex, something that's probably just a little more scarred, fibrodic, that also can point towards chronic kidney disease.

[SPEAKER_02]: and how chronic to someone's kidney disease have to be for us to be able to catch it on pocus or renal ultrasound. [SPEAKER_00]: The answer is you can have a normal creatinine and have those findings, or I should say it was like in quote unquote normal creatinine and have those findings, so it's not a, I guess we'll say 100%, like you can have increased microgenicity with a baseline creatinine.

[SPEAKER_00]: It just may mean somebody's probably got CKD, it just hasn't shown up in the labs yet. [SPEAKER_02]: This is just a little bit of a far hasn't taken a hit. [SPEAKER_00]: Their cranny has to be kind of like to get about the person who's got, you know, diabetic kin disease, they've got that out of your own area and, you know, cranny's just still normal for them. [SPEAKER_00]: They haven't had that GFR decline for that they will have at some point. [SPEAKER_02]: Oh, interesting.

[SPEAKER_02]: Yeah. [SPEAKER_02]: So maybe those changes can be seen even before that GFR declines. [SPEAKER_02]: Okay. [SPEAKER_01]: Would any of this show up on Pocus or that's really more for a formal ultrasound? [SPEAKER_00]: If it answers yes, I think honestly, the ultrasound machines that we have are really really good at this point that are the portable ones. [SPEAKER_02]: All right, let us summarize this case then.

[SPEAKER_01]: So we had a patient who we were concerned about TLS, which is important because it might push us to do dialysis earlier. [SPEAKER_01]: But just by using Pocus, we were able to see the hydronephrosis and realize it was more of a post-reel picture, place a fully avoid unnecessary dialysis and avoid misdiagnosing TLS. [SPEAKER_02]: Yes. [SPEAKER_02]: And then to summarize that different types of scans, you can use to look for post renal disease.

[SPEAKER_02]: On one hand, yes, you can tell the nurses, can you help me get a post void residual? [SPEAKER_02]: That's good and can help roll out kind of post renal obstruction. [SPEAKER_02]: And then on the other spectrum, you can order a formal renal bladder ultrasound and kind of wait for that to come back. [SPEAKER_02]: But there's this wonderful checklist where we can kind of wrist ratify patients. [SPEAKER_02]: So we don't have to order it for every single ATI.

[SPEAKER_02]: And then the last option is we can do our own pocus. [SPEAKER_01]: And the last teaching point I just want to say out loud, just because the patient says they can pass urine, don't be so quick to rule out post-renal.

[SPEAKER_02]: All right, let's move on to case two. [SPEAKER_02]: We have a 65 year old female. [SPEAKER_02]: She has a past medical history of half-path who is being admitted for a heart-feeler exacerbation. [SPEAKER_02]: She also has a history of diabetic kidney disease, her baseline creatine lives in like the 2.2 to 0.5. [SPEAKER_02]: Her creatine on admission is three, and then day three of admission after diarrhea is a bumps up to 3.5, okay?

[SPEAKER_02]: So on one hand, [SPEAKER_02]: On day three, some good news is her O2 requirements are down from four leaders as a candidate of room hair and she's negative 2.5 leaders from admission, all right, and so I think here a lot of people might have him and how I'd be like, okay, she doesn't look that volume overload maybe we can just charge her she doesn't have any extra requirements are there in the inpatient needs.

[SPEAKER_02]: On the other hand, someone might say, oh, man, our kidney is still not back to normal. [SPEAKER_02]: Is it just CKD progression? [SPEAKER_02]: Should we stop and think about other causes? [SPEAKER_02]: Should we die re-smorg? [SPEAKER_02]: And there's a lot of places to pause here. [SPEAKER_00]: when you stop is really always a difficult question to answer. [SPEAKER_00]: You know, based on this exam, this stem, you know, this patient seems like they've gotten a lot better.

[SPEAKER_00]: She's two and a half years negative. [SPEAKER_00]: She's not an option anymore. [SPEAKER_00]: She's looking like she's you will limit. [SPEAKER_00]: We'll say, but I think, you know, this is a situation where these am can lie. [SPEAKER_00]: I think, you know, we've all seen the data that maybe in our exams, unfortunately, hardest grade is determining volumes status so we would hope they'd be.

[SPEAKER_00]: And so this is a case where really we're saying, okay, our creatines elevated. [SPEAKER_00]: Sometimes, in elevation and creating, if you're diaries, somebody is not a bad thing. [SPEAKER_00]: It might just mean you're trying them out. [SPEAKER_00]: The creating is, in theory, we'll say getting more concentrated, and the creating is rising without really injury. [SPEAKER_00]: It's just rising because we're drying them out.

[SPEAKER_00]: But it's kind of always hard to determine again, are they still wet? [SPEAKER_00]: And they've still got, you know, a ki from cardiovascular renal syndrome, or we just actually drying them out. [SPEAKER_00]: And that's, I think we're a point of control, something kind of common to help us out, and they're not in a way.

[SPEAKER_01]: So everyone's familiar with Pocus for the IVC, but I think the newest contribution from ultrasound is Vexus, where you're not only looking at the IVC, but also the hepatic vein, portal vein, and intra-renal veins to look for any patterns of congestion. [SPEAKER_00]: Vx is after all is Venus excess ultrasound. [SPEAKER_00]: So we're looking for essentially ascessive fluid in our Venus system that ultimately correlates with acute kidney injury.

[SPEAKER_00]: We put pulsate Doppler over that little red and blue spec and then that kind of allows you to see a real arterial waveform, not your main renal artery, but type your intralobularities and also your Venus waveform as well. [SPEAKER_00]: So you can, again, look for changes and patterns that will indicate whether somebody has congestion or not. [SPEAKER_01]: And then there's a scoring system based off the pattern. [SPEAKER_01]: Can you try to explain the scoring system?

[SPEAKER_01]: Because that's where I get confused. [SPEAKER_00]: Yeah, of course. [SPEAKER_00]: So the scoring system is really going to be there. [SPEAKER_00]: And I encourage you to obviously look at the actual images online. [SPEAKER_00]: Because I think it's probably the easiest way to kind of get this. [SPEAKER_00]: But the scoring system is essentially going to be based on the how abnormal the waveforms are. [SPEAKER_00]: So you have to have a large IPC.

[SPEAKER_00]: You have to have an IPC that's greater than two centimeters to kind of a non-variable to start. [SPEAKER_00]: And then, depending on what you're looking for is at least one of those vessels that you're interrogating, those beings that you're interrogating, has to have severe congestion. [SPEAKER_00]: And if more than one has severe congestion, that's your Vexus, like two and three.

[SPEAKER_00]: And a Vexus score greater than two is what's really correlates in the literature with an acutic in the injury. [SPEAKER_02]: Going back to this patient who had some CKD at baseline, creating up to 2.2 to 2.5, day three of admission, negative 2.5 liters off oxygen so some wins, but her creatinine still hanging at 3.5. [SPEAKER_02]: Somebody could say, like, oh, maybe her CKD's progressed. [SPEAKER_02]: Should we die a little more?

[SPEAKER_02]: Should we stop and think about other causes? [SPEAKER_02]: Curious how you applied vaccines and what the outcome was? [SPEAKER_00]: Yeah, so I mean, I think the big thing is drier is always better for people. [SPEAKER_00]: So on her ultrasound, I had her Vexasquora as to it was the entire renal congestion was severe. [SPEAKER_00]: She also did have portal Venus kind of pulsatility. [SPEAKER_00]: So at that point, we want to starting her on a laser strip.

[SPEAKER_00]: Plus a Thia's eye diuretic metlesone and really started to kind of aggressively diaries her. [SPEAKER_02]: And then this is what really stood out for me with this case. [SPEAKER_02]: At the end of this patient's hospitalization, she ended up being net negative 29 liters. [SPEAKER_02]: And this is just bizarre because I could totally see someone on around being like, oh, she's negative 2.5 liter. [SPEAKER_02]: She's off oxygen great.

[SPEAKER_02]: And yes, her discharge creatine came down to 3.0. [SPEAKER_02]: So as a reminder, I get it peaked at 3.5, day 3 of admission, but it didn't necessarily go back down to the pre admission 2.2, 2.5 where she lived. [SPEAKER_00]: And an uncreatening didn't get worse. [SPEAKER_00]: We're always so worried about how we overdireasing is our creative mercening, but in this case, we really had, we had it somebody who, if we had stopped, it probably would have been harmful for them.

[SPEAKER_00]: So we want to be using a non-invasive test to essentially guide our management and really kind of again, try her out. [SPEAKER_02]: Yeah, it's so humbling these cases, like, oh, someone can be hiding 29 layers of fluid. [SPEAKER_02]: And you're like, okay, should I stop after my 2.5? [SPEAKER_02]: They're off oxygen. [SPEAKER_02]: I'm good, right? [SPEAKER_02]: They look dry, but you don't know until you kind of look at some of those veins a little bit closer.

[SPEAKER_01]: The take-home points for case two are obvious. [SPEAKER_01]: The patient was hiding 29 liters from us. [SPEAKER_01]: And it was only with vexists that we were able to identify it. [SPEAKER_01]: Before we do this third case, we have to take a transition point here because this whole NF madness bracket has been Pocus for AKI versus Pocus for CKD. [SPEAKER_01]: And I'm pretty sold on Pocus for AKI.

[SPEAKER_01]: I don't really see how Pocus for CKD is going to top it because those were two good cases. [SPEAKER_00]: We'll see. [SPEAKER_00]: I mean, I think we've got a couple more good cases coming up. [SPEAKER_02]: Alright, next we have a 57-year-old female. [SPEAKER_02]: She has end-stradial disease on hemodialysis. [SPEAKER_02]: She's anurec and she also has a history of COPD and this chronic cough.

[SPEAKER_02]: She's at the dialysis unit for her usual dialysis session and she's that she's been short of breath for the past few weeks and it's really worth some of the last few days. [SPEAKER_02]: And it's not like she's missed any dialysis sessions in between.

[SPEAKER_02]: Her estimated dry weight actually had with recently lowered a USB 59 kilograms is now 57, and I think she's been tolerating that just fine without any hypotension during dials, sessions, her blood pressure is 125 or 83, she's on room air, but she does have these end-expertory releases. [SPEAKER_01]: I can see this being another hard case because we have a patient coming in with known COPD. [SPEAKER_01]: We're hearing weasers on our physical exam.

[SPEAKER_01]: So I'm very excited to hear how you some pocus to figure out is this for COPD. [SPEAKER_01]: She actually just more volume overloaded than normal. [SPEAKER_00]: Yeah, and this is a, you know, dry weight is a really hard thing to kind of handle into else's patient. [SPEAKER_00]: So, you know, the liggies that this could be COPD, it could be volume overload. [SPEAKER_00]: She's got maybe some signs of both dry weight has been challenging.

[SPEAKER_00]: One, if you lower it too much, people get hypotensive, they get cramped, it's a little difficulty. [SPEAKER_02]: Okay, so before we get too much into this case, let's just get into what is an estimated dry weight, this EDW that we might see in their following notes, and how is it actually used? [SPEAKER_00]: So, estimate driveway really is the baseline for the individual.

[SPEAKER_00]: So, you know, it's something that can be a little, we'll say, challenging to figure out initially, especially when somebody's starting dialysis, usually they're probably on the more overloaded side to begin with when they're starting dialysis. [SPEAKER_00]: So, it's something that will take a little bit of, you know, time and... [SPEAKER_00]: We'll say a little bit of trial and error as to actually figuring out But that's gonna be the baseline for that person.

[SPEAKER_00]: So like let's say, you know one day somebody comes in it They're driveway 55 kilos and they come in at 57 Well, they're gonna get two leaders off during that doubt session. [SPEAKER_00]: Let's say they come in the next day and they're now [SPEAKER_00]: 57.5, we'll now getting it to 1.5. [SPEAKER_00]: So it's kind of that standard of reference where the person will be diagnosed too.

[SPEAKER_00]: So when you're lowering driveway, you don't want to just go from like 57 to 53 right away. [SPEAKER_00]: It's something at least you would probably do a little bit of step-by-step action, make sure that the tolerating is still. [SPEAKER_00]: And then if they're doing okay, then you can kind of push it a little bit more. [SPEAKER_02]: OK, so how could poke is help us think through as a COPD exacerbation or volume overload?

[SPEAKER_00]: The only thing that's really been studied in the application dials that's setting is actually lung ultrasound. [SPEAKER_00]: And having B-lines on lung ultrasound is actually risk factor of mortality in dials. [SPEAKER_00]: Patients, again, unsurprising, having too much volume on somebody is not a good thing.

[SPEAKER_00]: So, you know, the probably biggest study and probably the most robust study of anything I've talked about today was actually the lust trial which came out several years ago. [SPEAKER_00]: It was a multi-centrum randomized trial that kind of used a lung ultrasound guided protocol versus standard of care.

[SPEAKER_01]: To try and simplify this study as much as possible, relief of lung congestion was achieved in 78% of patients in the intervention arm that used lung focus compared with 56% of patients in the standard of care arm. [SPEAKER_01]: But this did not translate into fewer mace or reduced mortality. [SPEAKER_00]: I think Monwell Chance probably got the most robust data in the outpatient house setting and that's probably what I wound up doing in this patient.

[SPEAKER_02]: Yeah, so curious about this patient, what did you see when you did focus? [SPEAKER_00]: So we saw a greater than 3B lines, which are statistically significant, we'll say for some kind of an intropranctimal fluid, and really all on fields, also saw an IVC that was greater than two centimeters and non-variable. [SPEAKER_00]: So then we further tried lower and lower weight a couple times and did ultimately kind of get that out of simple under control.

[SPEAKER_01]: To get some resolution on this case, it wasn't until they decreased her dry weight to 53 kilograms that not just her shortness of breath, but also this chronic cough fully reversed. [SPEAKER_02]: So what did they happen in her case? [SPEAKER_02]: She was like, Anne Eurek, did someone just like misgestimate 159 kilograms to her dry weight and then she just like lived with this chronic cough and she had COPD. [SPEAKER_02]: Like if we were to do a mini M&M on this, right?

[SPEAKER_02]: And like so the 59 was thought to be fine, but if we reassessed her chronic cough, maybe it wasn't from COPD and if we moved the dry weight to what's more after and get fluid off that how Turk cough symptoms get better. [SPEAKER_00]: People's dryweights can be stable for years, but the issue is that dialysis patient nutrition can be a little off. [SPEAKER_00]: So like in theory, if somebody's having less nutrition, there must mass make it a little worse.

[SPEAKER_00]: And that muscle mass is essentially and if they're wasting the same, it's gonna be fluid, it's gonna be water. [SPEAKER_00]: So even though maybe, yes, she was at her stable dryway, yes, this cough was kind of getting worse. [SPEAKER_00]: It didn't look like it's volume. [SPEAKER_00]: It could be a component of maybe her nutrition had been more poor. [SPEAKER_00]: And you know, that weight was not muscle mass anymore. [SPEAKER_00]: Now it's just water.

[SPEAKER_01]: That's really humbling to hear how just new threshold alone can lead to a lowering of a dry weight. [SPEAKER_01]: How often are you thinking about reassessing your like outpatient dials that's patient's dry weights? [SPEAKER_00]: It's probably something that should be done more frequently. [SPEAKER_00]: You're me with them at least monthly face-to-face. [SPEAKER_00]: And you see them like several times a month, at least weekly, I should say.

[SPEAKER_00]: But you know, it's really going to be based on kind of discussion with them symptoms and how what they can tolerate. [SPEAKER_01]: And then I think we should talk about kind of the opposite situation here. [SPEAKER_01]: We see patients come to the hospital all the time for intra-dioletic hypertension. [SPEAKER_01]: So is there any way pocus can help us out in those patients or to kind of risk stratify those patients?

[SPEAKER_00]: The answer is, there are some ultrasound findings that do correlate with that. [SPEAKER_00]: I mean, IVC is one of them, you know, a small, collapsible IVC is one of them, but it's really something that is not been fully played on the data to be honest.

[SPEAKER_00]: There's a lot of different ultra-carbon parameters that you can look at, which we kind of talked about a little bit, some cardiac, some, you know, a non-cardiac, but so far, IVC holds chance to be like the main one at this point. [SPEAKER_00]: But I think that's probably something, you know, those chance still being within the phrology relatively in its impency. [SPEAKER_00]: I think that's probably something we'll see better data at some point.

[SPEAKER_01]: I would say for me the biggest thing I'm taking away is even now is a medicine resident when I have dials as patients in the hospital I should kind of be assessing how they've been these past couple months and if I think their dry weight has changed That's something they should tell their nephrologist totally fair [SPEAKER_02]: So to recap this case, pocus doesn't have to stop in the hospital.

[SPEAKER_02]: We were in the Dallas Center, patient was short of breath, and with pocus, we were able to help realize the patient actually had more fluid to pull off, and we were able to lower their driveway. [SPEAKER_02]: And yes, it seems like we can all look out for more studies validating lung pocus and vaxis in the outpatient dials of settings. [SPEAKER_01]: Let's move on to our final case.

[SPEAKER_01]: We have a 63-year-old male with a past medical history of CKD-5 who presents to the emergency room at 7 p.m. with the B-UN of 140, potassium of 6.7, and obvious urenic symptoms.

[SPEAKER_01]: You tell the patient that he needs to start dialysis and he looks at you and asks if his fistula is ready to be used. [SPEAKER_01]: He said he had an outpatient fistula placed a few weeks ago. [SPEAKER_01]: So, can we use this fistula or does he need a temporary line placed? [SPEAKER_00]: Can we skip a line that's invasive? [SPEAKER_00]: That's a hiring infection risk. [SPEAKER_00]: And we can just use this fichola. [SPEAKER_00]: So let's just say, this is late in the afternoon.

[SPEAKER_00]: You're not going to get your vascular ultrasound. [SPEAKER_00]: Your AB fichola will shout to tell you whether it's right or not. [SPEAKER_00]: Again, what are your options? [SPEAKER_00]: To grab a probe and kind of do it yourself. [SPEAKER_00]: AV officials can take a little while to mature, like 6 to 12 weeks, and we're not far off from that, but we're technically little early, and they still have some inseaning and failure rates.

[SPEAKER_00]: So there are some rules, which we'll say, I don't really want to go to kind of in-depth on, but essentially the characteristics that may tell us about their AV officials more likely to be mature than not. [SPEAKER_00]: So the classic dogma is the rule of sixes, which is kind of a flow, which is really good made to determine based on your Edopler. [SPEAKER_00]: the vein diameter is greater than 6 millimeters and the vein depth is less than 6 millimeters.

[SPEAKER_00]: There's one study really on this and I think this is a really fascinating study because I think this is something that hopefully will allow for more research on this topic because you know, avoiding temporary dialysis lines I think is a really good thing for a patient. [SPEAKER_00]: But it's a study that essentially actually hadn't a phrology fellows perform a point of [SPEAKER_00]: and they were comparing that to kind of a retrospective standard of care.

[SPEAKER_00]: And what they actually found was that if the AOE official had certain characteristics, they were actually able to successfully calculate it earlier. [SPEAKER_00]: It was about 35 days versus kind of 63 in the standard of care group, which led to fewer infections and shorter central-binous catheter duration, and did not have any adverse outcomes in the official.

[SPEAKER_00]: So I think that the kind of study that I think is really fascinating, and hopefully we'll again spawn more to kind of say how safe this is or not. [SPEAKER_01]: I think that's really cool because I really feel for this patient because you see so many patients in the ED who are unable to have their official place and for the patient who did everything right, they got their official place to go to the emergency room and still need the catheter sounds awful.

[SPEAKER_01]: So I think this is super exciting to be able to at 7 p.m. without needing a formal ultrasound, vascular surgery, be able to put the probe there and and figure out what needs to be done. [SPEAKER_00]: So we want to actually, you know, cannulating the fission on the patient is equal to start dialysis without obscene eating a temporary line. [SPEAKER_02]: Awesome. [SPEAKER_02]: That was another fantastic case. [SPEAKER_02]: So I guess we can pause here.

[SPEAKER_02]: I'm so curious to ask the room, or you would more of a fan for pocus for AGI, or pocus for end stage renal disease, who you had to kind of like choose between your two children. [SPEAKER_00]: I think it's probably intrinsic into the, at least the ICU Nefrology part of me, so I think I probably will say, A.K.I, just because you know, on it's more of my area of interest, we'll say, but again, both great teams, but I'd love to hear your guys' taste.

[SPEAKER_02]: I mean, you know, usually for me, I'd say I'm a sucker for those things that make us rethink the things that are lingering in the one liner. [SPEAKER_02]: So like, uh, that case number three where we got to rethink the chronic cough and actually make her symptoms go, right? [SPEAKER_02]: Hmm, that made me so happy. [SPEAKER_02]: But it is hard to overlook the benefit that we get from all these aches that are coming in and helping people get more dry because we have pocus in vaxis.

[SPEAKER_02]: So I, surprisingly, think I'll give it to the pocus for achy eye crew. [SPEAKER_01]: I can't believe I'm going to be different than everyone else, but we've all heard about Cardio Reno syndrome, Pocus for AKI. [SPEAKER_01]: I didn't even know it was possible to do Pocus as an outpatient, and I think the thought of doing Pocus at your outpatient dials to center and really improving these outcomes for dials as patients is awesome.

[SPEAKER_01]: And also the thought of saving that emergency room patient to have a line placed at 7 p.m. [SPEAKER_01]: I think it's really cool, so I'm going to vote for Pocus for ESRD. [SPEAKER_02]: And we will see where the votes come in and where we land in terms of March-Manus Jepian. [SPEAKER_01]: So, Triatt, this episode has really gotten me excited about Pocas. [SPEAKER_01]: I think, for my generation of doctors specifically, that gets to grow up with it.

[SPEAKER_01]: I mean, I'd just laugh thinking about how the Stethoscope has been a symbol of doctors for so long. [SPEAKER_01]: And I wonder if just in 20 years, that all the graphics are going to be replaced with a doctor walking around with a Pocas machine and not wearing a Stethoscope. [SPEAKER_02]: I know it's so wild to think, but it could vary, but it'll be in the future. [SPEAKER_01]: And fall disclosure, try it ever since we sat down to record this.

[SPEAKER_01]: I've been looking at every bladder and kidney I can with the ultrasound, and I found some hydronofrosis myself and some niste at post-renal diagnoses. [SPEAKER_02]: That's awesome. [SPEAKER_02]: That's a huge win. [SPEAKER_02]: No, I've been very inspired myself to get better at it. [SPEAKER_02]: And I'm like, who does to you that you've been doing it with all your A.K.I. [SPEAKER_02]: patients?

[SPEAKER_02]: Just like one more shout out to Dr. Jeffrey Coyne for all these cases together, we'll link everything about Neff Madness and her show notes. [SPEAKER_02]: If you have a chance, go ahead and vote, we'll link all that. [SPEAKER_02]: And thank you again, no up for helping kind of leave the ship here. [SPEAKER_01]: Thank you so much for having me. [SPEAKER_02]: Awesome. [SPEAKER_02]: Take care. [SPEAKER_01]: to recap this pig. [SPEAKER_02]: Okay. [SPEAKER_02]: That's so awful.

[SPEAKER_02]: So you've got my estimated dry weights. [SPEAKER_02]: Oh my gosh. [SPEAKER_02]: What is this? [SPEAKER_02]: I think some would pee for pocus. [SPEAKER_02]: That's the truth. [SPEAKER_02]: That's the worst word I can do. [SPEAKER_02]: Bless. [SPEAKER_02]: Okay. [SPEAKER_02]: Let's do this again.