Lung Ultrasound to Diagnose Pulmonary Congestion Among Patients on Hemodialysis: Comparison of Full Versus Abbreviated Scanning Protocols

      Rationale & Objective

      Pulmonary congestion contributes to morbidity and mortality in patients with kidney failure on hemodialysis, but physical assessment is an insensitive approach to its detection. Lung ultrasound is useful for assessing the presence and severity of pulmonary congestion, but the most widely validated 28-zone study is cumbersome. We sought to compare abbreviated 4-, 6-, and 8-zone studies to 28-zone studies.

      Study Design

      Diagnostic test study.

      Setting & Participants

      Convenience sample of 98 patients with kidney failure on hemodialysis presenting to an emergency department in the United States.

      Tests Compared

      4-, 6-, and 8-zone lung ultrasound studies versus a 28-zone lung ultrasound.


      Prediction of pulmonary congestion and 30-day mortality.


      All patients completed a 28-zone lung ultrasound. Correlation coefficients (nonparametric Spearman) between each of the studies were high (all values > 0.84). Bland-Altman analysis showed good agreement. Each of the short-form studies discriminated well with area under the receiver-operator characteristic curve > 0.83 for no-to-mild versus moderate-to-severe pulmonary congestion. During a median follow-up period of 778 days, 46 (47%) died. Patients with moderate-to-severe pulmonary congestion on lung ultrasound had a 30-day mortality rate similar to that observed among patients with no-to-mild pulmonary congestion (OR, 0.95 [95% CI, 0.70-1.29]).


      Single-center study conducted in an emergency care setting, convenience sample of patients, and lack of long-term follow-up data.


      Among hemodialysis patients presenting to an emergency department, 4-, 6-, or 8-zone lung ultrasounds were comparable to 28-zone studies for the assessment of pulmonary congestion. The mortality rates did not differ between those with no-to-mild and moderate-to-severe pulmonary congestion.

      Graphical abstract

      Index Words

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        • Zoccali C.
        • Torino C.
        • Tripepi R.
        • et al.
        Pulmonary congestion predicts cardiac events and mortality in ESRD.
        J Am Soc Nephrol. 2013; 24 (doi:10.1681/ASN.2012100990): 639-646
        • Torino C.
        • Gargani L.
        • Sicari R.
        • et al.
        The agreement between auscultation and lung ultrasound in hemodialysis patients: the LUST study.
        Clin J Am Soc Nephrol. 2016; 11 (2005–2001. doi:10.2215/CJN.03890416)
        • Maw A.M.
        • Hassanin A.
        • Ho P.M.
        • et al.
        Diagnostic accuracy of point-of-care lung ultrasonography and chest radiography in adults with symptoms suggestive of acute decompensated heart failure: a systematic review and meta-analysis.
        JAMA Netw Open. 2019; 2e190703
        • Mongodi S.
        • Santangelo E.
        • De Luca D.
        • et al.
        Quantitative lung ultrasound: time for a consensus?.
        Chest. 2020; 158: 469-470
        • Loutradis C.
        • Papadopoulos C.E.
        • Sachpekidis V.
        • et al.
        Lung ultrasound-guided dry weight assessment and echocardiographic measures in hypertensive hemodialysis patients: a randomized controlled study.
        Am J Kidney Dis. 2020; 75: 11-20
        • Loutradis C.
        • Sarafidis P.A.
        • Ekart R.
        • et al.
        The effect of dry-weight reduction guided by lung ultrasound on ambulatory blood pressure in hemodialysis patients: a randomized controlled trial.
        Kidney Int. 2019; 95: 1505-1513
        • Koratala A.
        • Ross D.W.
        Lung ultrasound in hemodialysis patients: is it practical to scan 28 zones?.
        Am J Kidney Dis. 2020; 75: 815
        • Arun Thomas ET, Mohandas M.K.
        • George J.
        Comparison between clinical judgment and integrated lung and inferior vena cava ultrasonography for dry weight estimation in hemodialysis patients.
        Hemodial Int. 2019; 23: 494-503
        • Platz E.
        • Lewis E.F.
        • Uno H.
        • et al.
        Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients.
        Eur Heart J. 2016; 37: 1244-1251
        • Platz E.
        • Campbell R.T.
        • Claggett B.
        • et al.
        Lung ultrasound in acute heart failure.
        JACC Hear Fail. 2019; 7: 849-858
        • Gargani L.
        • Sicari R.
        • Raciti M.
        • et al.
        Efficacy of a remote web-based lung ultrasound training for nephrologists and cardiologists: a LUST trial sub-project.
        Nephrol Dial Transplant. 2016; 31: 1982-1988
        • Baker K.
        • Mitchell G.
        • Stieler G.
        Limited lung ultrasound protocol in elderly patients with breathlessness; agreement between bedside interpretation and stored images as acquired by experienced and inexperienced sonologists.
        Australas J Ultrasound Med. 2013; 16: 86-92
        • Picano E.
        • Pellikka P.A.
        Ultrasound of extravascular lung water: a new standard for pulmonary congestion.
        Eur Heart J. 2016; 37: 2097-2104
        • Gargani L.
        • Volpicelli G.
        How I do it: lung ultrasound.
        Cardiovasc Ultrasound. 2014; 12: 25
        • Buessler A.
        • Chouihed T.
        • Duarte K.
        • et al.
        Accuracy of several lung ultrasound methods for the diagnosis of acute heart failure in the ED: a multicenter prospective study.
        Chest. 2020; 157: 99-110
        • Scali M.C.
        • Zagatina A.
        • Simova I.
        • et al.
        B-lines with lung ultrasound: the optimal scan technique at rest and during stress.
        Ultrasound Med Biol. 2017; 43: 2558-2566
        • Gluecker T.
        • Capasso P.
        • Schnyder P.
        • et al.
        Clinical and radiologic features of pulmonary edema.
        Radiographics. 1999; 19: 1507-1531
        • Lichtenstein D.
        • Goldstein I.
        • Mourgeon E.
        • Cluzel P.
        • Grenier P.
        • Rouby J.J.
        Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome.
        Anesthesiology. 2004; 100: 9-15
        • Lichtenstein D.A.
        • Mezière G.A.
        Relevance of lung ultrasound in the diagnosis of acute respiratory failure the BLUE protocol.
        Chest. 2008; 134: 117-125
        • Jambrik Z.
        • Monti S.
        • Coppola V.
        • et al.
        Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water.
        Am J Cardiol. 2004; 93: 1265-1270
        • Lung water by ultrasound guided treatment in hemodialysis patients (the Lust Study) identifier: NCT02310061. Updated May 7, 2021.
        Date accessed: December 1, 2020
        • Tierney D.M.
        • Huelster J.S.
        • Overgaard J.D.
        • et al.
        Comparative performance of pulmonary ultrasound, chest radiograph, and CT among patients with acute respiratory failure.
        Crit Care Med. 2020; : 151-157
        • Covic A.
        • Siriopol D.
        • Voroneanu L.
        Use of lung ultrasound for the assessment of volume status in CKD.
        Am J Kidney Dis. 2018; 71: 412-422
        • Noble V.E.
        • Murray A.F.
        • Capp R.
        • Sylvia-Reardon M.H.
        • Steele D.J.R.
        • Liteplo A.
        Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis: time course for resolution.
        Chest. 2009; 135: 1433-1439
        • Mallamaci F.
        • Benedetto F.A.
        • Tripepi R.
        • et al.
        Detection of pulmonary congestion by chest ultrasound in dialysis patients.
        JACC Cardiovasc Imaging. 2010; 3: 586-594
        • Siriopol D.
        • Onofriescu M.
        • Voroneanu L.
        • et al.
        Dry weight assessment by combined ultrasound and bioimpedance monitoring in low cardiovascular risk hemodialysis patients: a randomized controlled trial.
        Int Urol Nephrol. 2017; 49: 143-153
        • Reisinger N.
        • Koratala A.
        Lung ultrasound: a valuable tool for the assessment of dialysis patients with COVID-19.
        Clin Exp Nephrol. 2020; 24: 850-852