Lung ultrasound to detect and monitor pulmonary congestion in patients with acute kidney injury in nephrology wards: a pilot study

  • Vincenzo Panuccio
  • Rocco Tripepi
  • Giovanna Parlongo
  • Angela Mafrica
  • Graziella Caridi
  • Francesco Catalano
  • Francesco Marino
  • Giovanni Tripepi
  • Francesca Mallamaci
  • Carmine ZoccaliEmail author
Original Article



Lung congestion and frank pulmonary edema are established complications of acute kidney injury (AKI) and early detection and monitoring of lung congestion may be useful for the clinical management of AKI patients.


We compared standardized clinical criteria (including lung crackles and peripheral edema grading) and simultaneous chest ultrasound (US) to detect lung congestion in a series of 39 inpatients with AKI.


At baseline, twelve patients (31%) were clinically euvolemic and twelve presented clear-cur cardiovascular congestion (31%) by clinical criteria. Fifteen patients (38%) were hypovolemic. The median number of US-B lines in patients with cardiovascular congestion was much higher (50, inter-quartile range 27–99) than in euvolemic (14, IQR 11–37) and hypovolemic patients (7, IQR 3–16, P < 0.001). Remarkably, a substantial proportion of asymptomatic euvolemic (66%) and hypovolemic (46%) patients had lung congestion of moderate to severe degree (> 15 US-B lines) by lung US. Crackles severity and the number of US-B lines over time were inter-related (Spearman’s ρ = 0.38, P < 0.01) but the agreement (Cohen k statistics) between the two metrics was unsatisfactory. Forty-eight percent of patients had lung congestion of moderate to severe degree by lung US and this estimate by far exceeded that by clinical criteria (32%).


This pilot study shows that chest US has potential for the detection of lung congestion at a pre-clinical stage in AKI. The results of this pilot study form the basis for a clinical trial testing the usefulness of this technique for guiding lung congestion treatment in patients with AKI.


AKI Lung congestion CKD Lung ultrasound 


Compliance ethical standards

Conflict of interest

The authors declare no conflict of interest.

Ethical statement

The protocol of this study was approved by the ethical committee of our hospital.


  1. 1.
    Mehta RL, Cerdá J, Burdmann EA et al (2015) International Society of Nephrology’s 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology. Lancet 385:2616–2643. CrossRefPubMedGoogle Scholar
  2. 2.
    Ostermann M, Chang RWS (2007) Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 35:1837–1843. CrossRefPubMedGoogle Scholar
  3. 3.
    Uchino S, Bellomo R, Goldsmith D et al (2006) An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Crit Care Med 34:1913–1917. CrossRefPubMedGoogle Scholar
  4. 4.
    Fagugli RM, Patera F, Battistoni S, Tripepi G (2016) Outcome in noncritically ill patients with acute kidney injury requiring dialysis: effects of differing medical staffs and organizations. Med (United States) 95(30):e4277. CrossRefGoogle Scholar
  5. 5.
    Payen D, de Pont AC, Sakr Y et al (2008) A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 12:R74. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    RENAL Replacement Therapy Study Investigators, Bellomo R, Cass A et al (2012) An observational study fluid balance and patient outcomes in the randomized evaluation of normal vs. augmented level of replacement therapy trial*. Crit Care Med 40:1753–1760. CrossRefGoogle Scholar
  7. 7.
    Faubel S (2008) Pulmonary complications after acute kidney injury. Adv Chronic Kidney Dis 15:284–296. CrossRefPubMedGoogle Scholar
  8. 8.
    Picano E, Pellikka PA (2016) Ultrasound of extravascular lung water: a new standard for pulmonary congestion. Eur Heart J 37:2097–2104. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Enghard P, Rademacher S, Nee J et al (2015) Simplified lung ultrasound protocol shows excellent prediction of extravascular lung water in ventilated intensive care patients. Crit Care 19:36. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Mallamaci F, Benedetto FA, Tripepi R et al (2010) Detection of pulmonary congestion by chest ultrasound in dialysis patients. JACC Cardiovasc Imaging 3:586–594. CrossRefPubMedGoogle Scholar
  11. 11.
    Zoccali C, Torino C, Tripepi R et al (2013) Pulmonary congestion predicts cardiac events and mortality in ESRD. J Am Soc Nephrol 24:639–646. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kellum JA, Lameire N, Aspelin P et al (2012) Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2:1–138. CrossRefGoogle Scholar
  13. 13.
    Levey AS, Coresh J, Greene T et al (2006) Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med 145:247–254CrossRefGoogle Scholar
  14. 14.
    Kataoka H, Matsuno O (2008) Age-related pulmonary crackles (rales) in asymptomatic cardiovascular patients. Ann Fam Med 6:239–245. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Torino C, Gargani L, Sicari R et al (2016) The agreement between auscultation and lung ultrasound in hemodialysis patients: the LUST study. Clin J Am Soc Nephrol 11:2005–2011. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Eastridge BJ, Salinas J, McManus JG et al (2007) Hypotension begins at 110 mmHg: redefining??? Hypotension??? with data. J Trauma Inj Infect Crit Care 63:291–299. CrossRefGoogle Scholar
  17. 17.
    Hogan MA, Estridge S, Zygmont D (2007) Prentice-hall nursing reviews & rationales: medical-surgical nursing, 2nd edn. Prentice Hall, Upper Saddle RiverGoogle Scholar
  18. 18.
    Jacobs AK, Kushner FG, Ettinger SM et al (2013) ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 127:268–310. CrossRefPubMedGoogle Scholar
  19. 19.
    Volpicelli G, Elbarbary M, Blaivas M et al (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38:577–591. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Agricola E, Bove T, Oppizzi M et al (2005) “Ultrasound comet-tail images”: a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest 127:1690–1695. CrossRefPubMedGoogle Scholar
  21. 21.
    Picano E, Gargani L (2012) Ultrasound lung comets: the shape of lung water. Eur J Heart Fail 14:1194–1196. CrossRefPubMedGoogle Scholar
  22. 22.
    Frassi F, Gargani L, Tesorio P et al (2007) Prognostic value of extravascular lung water assessed with ultrasound lung comets by chest sonography in patients with dyspnea and/or chest pain. J Card Fail 13:830–835. CrossRefPubMedGoogle Scholar
  23. 23.
    Dellinger RP, Levy MM, Rhodes A et al (2013) Surviving sepsis campaign. Crit Care Med 41:580–637. CrossRefPubMedGoogle Scholar
  24. 24.
    Cohen J (1960) A coefficient of agreement for nominal scales. Educ Psychol Meas 20:37–46. CrossRefGoogle Scholar
  25. 25.
    Wang HE, Muntner P, Chertow GM, Warnock DG (2012) Acute kidney injury and mortality in hospitalized patients. Am J Nephrol 35:349–355. CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Hoste EAJ, Bagshaw SM, Bellomo R et al (2015) Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med 41:1411–1423. CrossRefPubMedGoogle Scholar
  27. 27.
    Selby NM, Crowley L, Fluck RJ et al (2012) Use of electronic results reporting to diagnose and monitor AKI in hospitalized patients. Clin J Am Soc Nephrol 7:533–540. CrossRefPubMedGoogle Scholar
  28. 28.
    Chertow GM, Burdick E, Honour M et al (2005) Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol 16:3365–3370. CrossRefPubMedGoogle Scholar
  29. 29.
    Paladino JD, Hotchkiss JR, Rabb H, 965 R (2009) Acute kidney injury and lung dysfunction: a paradigm for remote organ effects of kidney disease? Microvasc Res 77:8–12. CrossRefPubMedGoogle Scholar
  30. 30.
    Doi K, Rabb H (2016) Impact of acute kidney injury on distant organ function: recent findings and potential therapeutic targets. Kidney Int 89:555–564. CrossRefPubMedGoogle Scholar
  31. 31.
    Vieira JM, Castro I, Curvello-Neto A et al (2007) Effect of acute kidney injury on weaning from mechanical ventilation in critically ill patients. Crit Care Med 35:184–191. CrossRefPubMedGoogle Scholar
  32. 32.
    Maw AM, Hassanin A, Ho PM et al (2019) Diagnostic accuracy of point-of-care lung ultrasonography and chest radiography in adults with symptoms suggestive of acute decompensated heart failure. JAMA Netw Open 2:e190703. CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Mojoli F, Bouhemad B, Mongodi S, Lichtenstein D (2019) Lung ultrasound for critically ill patients. Am J Respir Crit Care Med 199:701–714. CrossRefPubMedGoogle Scholar

Copyright information

© Italian Society of Nephrology 2019

Authors and Affiliations

  • Vincenzo Panuccio
    • 1
  • Rocco Tripepi
    • 2
  • Giovanna Parlongo
    • 1
  • Angela Mafrica
    • 2
  • Graziella Caridi
    • 1
  • Francesco Catalano
    • 1
  • Francesco Marino
    • 1
  • Giovanni Tripepi
    • 1
  • Francesca Mallamaci
    • 1
    • 2
  • Carmine Zoccali
    • 2
    Email author
  1. 1.Nephrology, Dialysis and Transplantation UnitOspedali RiunitiReggio CalabriaItaly
  2. 2.CNR-IFC, Clinical Epidemiology and Pathophysiology of Renal Diseases and HypertensionNefrologia-Ospedali RiunitiReggio CalabriaItaly

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