<b><i>Background:</i></b> Lingering congestion portends poor outcomes in patients with heart failure (HF) and is a key target in their management. Studies have shown that physical exam has low yield in this setting and conventional methods for more precise assessment and monitoring of volume status (e.g., body weight, natriuretic peptides, and chest radiography) have significant inherent shortcomings. <b><i>Summary:</i></b> Point of care ultrasonography (POCUS) is a noninvasive versatile bedside diagnostic tool that enhances the sensitivity of conventional physical examination to gauge congestion in these patients. It also aids in monitoring the efficacy of decongestive therapy and bears prognostic significance. In this narrative review, we discuss the role of focused sonographic assessment of the heart, venous system, and extravascular lung water/ascites (i.e., the pump, pipes, and the leaks) in objective assessment of fluid volume status. <b><i>Key Messages:</i></b> Since each of the discussed components of POCUS has its limitations, a combinational ultrasound evaluation guided by the main clinical features would be the key to reliable assessment and effective management of congestion in patients with HF.

The application of bedside ultrasonography in routine clinical practice has dramatically evolved over the last few decades and will likely continue to grow as technological advances lead to enhanced portability and affordability of the equipment. Despite mounting interest, most nephrology fellowship training programs do not offer formal training in renal ultrasonography and there is inertia among practicing nephrologists to adopt this skill as a practice-changing advancement. Lack of familiarity with the topic is considered a key reason for this inertia. Understanding of basic ultrasound physics, instrumentation, principles of optimal image acquisition and interpretation is critical for enhanced efficiency and patient safety while using this tool. Herein, we provide a brief overview of the basic principles of diagnostic renal ultrasonography as well as introduction to common sonographic pathologies encountered in day-to-day nephrology practice with illustrative images.

As the coronavirus disease 2019 continues to spread across the globe, the knowledge of its epidemiology, clinical features, and management is rapidly evolving. Nevertheless, the data on optimal fluid management strategies for those who develop critical illness remain sparse. Adding to the challenge, the fluid volume status of these patients has been found to be dynamic. Some present with several days of malaise, gastrointestinal symptoms, and consequent hypovolemia requiring aggressive fluid resuscitation, while a subset develop acute respiratory distress syndrome with renal dysfunction and lingering congestion necessitating restrictive fluid management. Accurate objective assessment of volume status allows physicians to tailor the fluid management goals throughout this wide spectrum of critical illness. Conventional point-of-care ultrasonography (POCUS) enables the reliable assessment of fluid status and reducing the staff exposure. However, due to specific characteristics of COVID-19 (e.g., rapidly expanding lung lesions), a single imaging method such as lung POCUS will have significant limitations. Herein, we suggest a Tri-POCUS approach that represents concurrent bedside assessment of the lungs, heart, and the venous system. This combinational approach is likely to overcome the limitations of the individual methods and provide a more precise evaluation of the volume status in critically ill patients with COVID-19.

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Congestion represents the primary reason for hospitalization of patients with heart failure and is associated with adverse outcomes. Fluid overload has been shown to be inadequately addressed in a significant subset of these patients in part due to lack of robust, reliable, and readily available biomarkers for objective assessment and monitoring of therapy. Natriuretic peptides have long been used in this setting, often in conjunction with other assessment tools such as imaging studies. Patients presenting with concomitant cardiac and renal dysfunction represent a unique population with regard to congestion in that the interactions between the heart and the kidney can affect the utility and performance of biomarkers of fluid overload. Herein, we provide an overview of the currently available evidence on the utility of natriuretic peptides in these patients and discuss the clinical conundrum associated with their use in the setting of renal dysfunction. We highlight the potential divergence in the role of natriuretic peptides for assessment of volume status in a subset of patients with renal dysfunction who receive renal replacement therapy and call for future research to elucidate the utility of the biomarkers in this setting.

Background: Peritoneal dialysis (PD) has emerged as a mechanistically relevant therapeutic option for patients with heart failure (HF), volume overload, and varying degrees of renal dysfunction (i.e., chronic cardiorenal syndrome). Congestion has been identified as a potent ominous prognostic factor in this patient population, outperforming a number of established risk factors. As such, excess fluid removal is recognized as a relevant therapeutic target in this setting. Methods: Accumulating evidence points to the importance of sodium removal as part of any decongestive strategy because extraction of sodium-free water has little or no impact on the outcomes of these patients. Hence, optimization of sodium removal by PD should be the primary focus in the setting of HF and cardiorenal syndrome, especially if PD is started when the patient still has adequate residual renal function for clearance of waste products. Results: Herein, we provide an overview of approaches that can tailor PD treatment to the patients’ characteristics and clinical needs (e.g., choice of PD modality) to fully exploit its decongestive properties. Other methods that could prove helpful in the future will also be briefly discussed. Conclusion: While these strategies could help with efficient sodium extraction and volume optimization, future studies are needed to evaluate their impact on the outcomes of this specific patient population.

The management of complex fluid and electrolyte disorders is central to the practice of nephrologists. The sensitivity of physical examination alone to determine fluid status is limited, precluding accurate clinical decision making. Point-of-Care Ultrasonography (POCUS) is emerging as a valuable non-invasive bedside diagnostic tool for objective evaluation of physiological and hemodynamic parameters related to fluid status, tolerance, and responsiveness. Rapid bedside sonographic evaluation can obtain qualitative data on cardiac function as well as quantitative data on pulmonary congestion. Advanced POCUS, including goal-directed Doppler echocardiography provides additional quantitative information including flow velocities and pressures across the cardiac structures. Recently, abnormal Doppler flow patterns in abdominal organs secondary to increased right atrial pressure have been linked to congestive organ damage adding another component to the hemodynamic assessment. Integrating POCUS findings with clinical and laboratory data can further elucidate a patient's hemodynamic status. This drives decisions regarding crystalloid administration or, conversely, diuresis or ultrafiltration and allows tailored therapy for individual patients. In this article, we provide an overview of the focused assessment of cardiovascular function, pulmonary and venous congestion using POCUS and review relevant literature.