P0214THE IMPORTANCE OF POINT-OF-CARE ULTRASOUND FOR NEPHROLOGIST IN EMERGENCY ROOM: A MONOCENTRIC STUDY
Authors: Albrizio Paolo , Costa Silvano , Foschi Annalisa , Milani Ivo Angelo Antonio , Rindi Stefano , Zucchi Manuela , Milanesi Fabio 
Published: June 2020

Abstract

Background and Aims
ultrasound is progressively expanding beyond Radiology Units getting a key role for the main part of medical and surgical specializations. Nephrology proves how a good mastery in ultrasound is critical for studying many aspects of renal disease such as acute kidney injury (AKI), chronic kidney disease (CKD), secondary causes of hypertension, kidney transplant, hemodialysis vascular accesses, hyperparathyroidism and so on. A place where is important for the Nephrologist to use ultrasound for getting a diagnostic help is hospital emergency room. Here, while having to face frequently with not optimal conditions for outdated ultrasound machines and patients without adequate preparation or compliance, the collection of few critical information with point-of-care ultrasound can make the difference in the diagnostic and therapeutic process.

Method
unprovided of an hospital ward our Unit activity is focused on dialysis, and nephrological examinations for patients hospitalized or not. We evaluated all the advices required to our Unit from the emergency room of our hospital between August 1st, 2016 and July 31th 2019. Then we selected those when Nephrologist decided to evaluate the patient also by point-of-care ultrasound. We collected data about age, sex, diagnostic questions, ultrasound findings, diagnosis and subsequent therapeutic processes.

Results
as shown in figure, among 393 advices, Nephrologists decided to use point-of-care ultrasound in 70 of them (18%, 47 males, 23 females, medium age 75,4±14 years).
More frequent diagnostic questions were related to alterations of biochemical renal function markers (77%) divided between AKI with (30%) or without (47%) a known history of CKD. Less frequent diagnostic questions were focused on clinical anomalies such as oligo-anuria (16%) and lower extremity edema and dyspnea (7%).
During point-of care ultrasound, more common findings were signs of CKD (41%) and urinary retention (48% divided in bladder retention -22%-, monolateral -4%- or bilateral hydronephrosis -22%-). Less frequent findings were normal kidneys (9%), unknown adult polycystic kidney disease (ADPKD) (1%) and suspect kidney myeloma (1%).
Guided by ultrasound, Nephrologist’s more frequent diagnosis were: AKI secondary to obstruction by various causes (46%: prostatic hypertrophy, kidney stones, dislodgment of bladder catheter or nephrostomy, solitary kidneys, intrinsic o extrinsic obstruction for subsequently diagnosed gynecological or urological cancers) and dehydration (36%). Less common diagnosis were congestive heart failure (11%) and uremia (7%).
Among all patients, only 17% were discharged: 8.3% entrusted to their general practitioner after intravenous hydration, 50% addressed to a nephrological follow-up, frequently after intravenous hydration, and 41.6% addressed to urological follow-up frequently after urinary catheter placement. The main part of patients (73%) were conservative treated by Nephrologist and hospitalized in various units: Internal Medicine (72,5%), Urology (21,5%, frequently after urinary catheter placement), Cardiology (4% with or without start of intravenous diuretic therapy) and Gynecology (2%). Finally, a significant part of patients (10%) required urgent hemodialysis treatment before being hospitalized.

Conclusion
in evaluated population, more frequent diagnosis formulated during nephrological advices in emergency room by our Unit were CKD and AKI due to obstructive causes. Besides these, point-of-care ultrasound allowed to promptly detect less frequent but not less important conditions such as unknown ADPKD, solitary kidneys or kidney myeloma. These data clarify how point-of-care ultrasound provides an important support for Nephrologist in clinical evaluation of emergency room patients, allowing to direct the subsequent investigations reducing useless examination and focusing the therapeutic process.