Role of point-of-care ultrasonography in kidney disease management: A single solution for multiple challenges

Abstract

In this editorial, we comment on the article by Diniz et al published in the recent issue of the World Journal of Nephrology. Point-of-care ultrasound (POCUS) is rapidly becoming a transformative tool in nephrology and medicine in general, which can be used in both inpatient and outpatient settings. With approximately 850 million people living with chronic kidney disease worldwide, POCUS offers nephrologists a real-time, non-invasive method to avoid diagnostic delays and accelerate complex treatment pathways. Its clinical applications include the assessment of hemodynamics, volume status, vascular access guidance, and dialysis-related complications. By improving clinical decision-making at the bedside and thereby reducing unnecessary testing and healthcare inefficiencies, POCUS can transform and implement nephrology practice. The inclusion of a certifiable, standardized POCUS curriculum in undergraduate medical education is a worthy and feasible goal. Early exposure to ultrasound-based diagnostic tools would greatly enhance nephrology education and equip future physicians with important skills that could transform clinical practice.

Key Words: Point-of-care ultrasound; Hemodialysis; Kidney function; Chronic kidney disease; Cardiology; Cardiac ultrasound; Echography; Vexus score; Medical education; Artificial intelligence in ultrasound

Core Tip: Point-of-care ultrasound (POCUS) is a revolutionary diagnostic tool in nephrology, providing a rapid, non-invasive bedside examination for a wide range of clinical scenarios-from assessing hemodynamics and fluid status to dialysis-related complications and guiding vascular access. Integrating POCUS into routine nephrology practice can improve diagnostic accuracy, reduce reliance on redundant imaging and streamline patient management. This editorial highlights the urgent need for standardized POCUS education and calls for its inclusion in student and residency curricula as a critical step in reshaping nephrology care.

This editorial refers to "Point-of-care ultrasonography in nephrology: Growing applications, misconceptions and future outlook" by Diniz et al, 2025; https://dx.doi.org/10.5527/wjn.v14.i2.105374.

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INTRODUCTION

A recent review by Martínez-Sánchez et al[1] pointed out the growing role of point-of-care ultrasound (POCUS) in the clinical diagnostic and therapeutic management of hyponatremia appropriately defining it as “a routine extension of the physical exam” a real-time, objective and reproducible tool for the bedside assay of intravascular volume alongside biochemical markers.

As a matter of fact, the growing volume of literature on POCUS reflects the rising awareness of the scientific community towards this tool, that is gaining an increasingly important role in daily clinical practice, unfolding its broad potential for real-time bedside assessment both in the emergent settings, such as the intensive care unit (ICU)[2,3] and internal medicine wards[4,5], with increasing use also in the paediatric ICU for different purposes[6,7].

Among the many medical specialties, nephrology particularly benefits from the versatility of POCUS. In the past, the few applications of POCUS in nephrology were limited to organ-specific assessments such as cortical thickness, Doppler vascularization, cystic disease assessment and biopsy. Rapid developments in medicine and technological advances have taken nephrology a long way from these beginnings and today POCUS represents a widely recognized and valuable tool for managing the complex needs of frail, acutely ill inpatients, and for treating unexpected complications during routine outpatient evaluations. Thanks to this broad applicability, POCUS can be used comprehensively across the continuum of care.

The paradigm shift from a merely descriptive instrument to a dynamic tool for functional assessment can be well recognized when critically overviewing the exponential rise of literature about POCUS in nephrology, moving from simple procedural guidance to a sophisticated multi-organ diagnostic framework.

Cornerstone publications from nephrology societies, such as the International Alliance for POCUS in Nephrology position statement[8], and the creation of a Nephrology Core Curriculum[9], highlight the necessity of standardized training in order to safely integrate POCUS into global nephrology curricula. This awareness has made the advance of POCUS a one-way process rapidly spreading also to other disciplines, as confirmed by the latest publication of consensus recommendations for POCUS curricula in internal medicine[4,5] and primary care medicine[10,11].

Central to this shift is the validation of the venous excess ultrasound (VExUS) grading system[12] and its latest update (extended VExUS)[13], which provide a quantifiable metric for systemic congestion-a critical driver of cardiorenal syndrome and acute kidney injury (AKI) guiding decongestion in ways traditional physical exams cannot[14,15].

For clinicians to take full advantage of POCUS, a solid understanding of its capabilities and appropriate applications is essential. While POCUS is not a substitute for a full clinical evaluation (including history taking, physical examination and formal radiological imaging), it should be considered a powerful adjunct. Furthermore, POCUS can provide reliable and immediate answers to precise and well-specified clinical questions, improving diagnostic accuracy and efficiency at the bedside.

CURRENT CONTEXT AND NEW ROLE OF POCUS

In addition to caring for acutely ill patients who require bedside evaluation, nephrologists must also routinely and repeatedly examine patients with chronic kidney disease (CKD), both for routine clinical examination and for dialysis.

Therapy adjustment requires frequent multi-parametric assessments with a relevant number of laboratory and diagnostic tests, which ultimately lead to avoidable delays in timely and effective clinical decision-making.

A well consolidated example of streamlined diagnostic and interventional management benefitting from bedside ultrasound evaluation is found in the management of neoplastic and obstructive urinary disease, in most cases, entrusted to the urologist, and in some instances, entirely delegated.

Dialysis patients, in particular, often experience complications that disrupt dialysis sessions[16]. These interruptions not only cause unnecessary stress for patients and health care providers, but often require additional diagnostic evaluations, with increased costs and potential harm to frail patients[17]. These factors undermine an otherwise streamlined and fluid care process leading to an exponential increase in costs for healthcare systems.

Furthermore, diagnostic fragmentation (where assessments are delegated to different specialists based on individual organ systems) can sometimes lead to delayed diagnosis, which could be almost immediate with the right tools in the hands of the attending nephrologist, the guardian of the complex interrelationships between cardiovascular, hepatic, respiratory and renal homeostasis[18,19].

Timely and targeted bedside assessments guided by clinical reasoning can quickly convey the etiology of the disease underlying an altered hemodynamic status. Paradigmatic examples of this complex balance are illustrated by Diniz et al[20] who provide a comprehensive overview of the main POCUS applications in the assessment of systemic hemodynamic and volumetric status through lung ultrasound (LUS), focused cardiac ultrasound (FoCUS) and the VExUS.

The outdated misconception that specialists should only focus on their specific field of expertise is not only obsolete but potentially harmful in the era of evidence-based medicine-this is particularly true for nephrology. The integration of LUS into routine dialysis has been shown to be beneficial even in asymptomatic patients, enabling early detection of subclinical fluid overload, better long-term blood pressure control, and prevention of acute heart decompensation, as demonstrated by the LUST trial and related studies[21,22]. Moreover, the limitations of physical examination alone in assessing hemodynamic status have led to the adoption of ultrasound-based techniques such as VExUS. These have become essential tools in the dialysis setting, offering clear advantages in monitoring and guiding fluid decongestion therapy, particularly in patients with cardiorenal syndrome; in fact early detection and tailored therapeutical adjustment help reducing acute decompensation events and unnecessary hospitalizations[23,24].

In short POCUS has the potential to drive a virtuous circle in clinical practice by enabling faster and more accurate diagnoses, reducing the need for unnecessary repeated evaluations, and ultimately lowering healthcare costs. Figure 1 graphically summarizes a comprehensive and detailed overview of the varied applications of POCUS in nephrology. The importance and impact of integrating POCUS into the routine workflow may be better understood when looking at the alarming data reported in the International Consensus Statement by the American Society of Nephrology, the European Renal Association and the International Society of Nephrology released in 2024[25].

Figure 1 This figure illustrates the common clinical applications of point-of-care ultrasound assessment per organ or apparatus. LV: Left ventricle; RV: Right ventricle; IVC: Inferior vena cava; RI: Resistive index; VExUS: Venous excess ultrasound; AV: Arteriovenous.

The global prevalence of CKD is 850 million people, a figure that is likely underestimated due to a lack of early detection and it is destined to increase with ageing of population. Currently CKD is among the fastest-growing causes of mortality, contributing significantly to global mortality. It is currently recognized as the 7^th leading global risk factor for mortality and ranks as the second most common cause of death in Central America. Around 13.3 million cases of AKI are diagnosed each year, predominantly in low and lower-middle-income countries. By 2030, an estimated 5.4 million individuals will require kidney replacement therapy, with millions more lacking access to appropriate treatment. CKD plays a significant role in contributing to and exacerbating the burden of other major non-communicable diseases including ischemic heart disease, stroke and peripheral vascular disease, diabetes and cancer.

In economic terms, CKD imposes a substantial financial burden. In the United States alone, annual federal costs are more than 85.4 billion dollars, representing 23.5% of Medicare fee-for-service spending. In Europe, aggregated annual healthcare costs of CKD are estimated to be higher than those of cancer or diabetes mellitus, not counting the increase of costs for cardiovascular diseases exacerbated by CKD.

Furthermore, the average length of hospital stay in the United Kingdom is 35% longer for people with CKD compared to people without the condition. An example flowchart showing how the introduction of POCUS can accelerate the treatment of dialysis patients is shown in Figure 2.

Figure 2 This flowchart provides an example of the different pathways that an outpatient on dialysis can take in the event of acute cardiac decompensation during a dialysis session. The benefits from a proper use of point-of-care ultrasound are intuitive. FoCUS: Focused cardiac ultrasound.

CHALLENGES, HURDLES AND SOLUTIONS

The development and distribution of POCUS was not without its challenges. One of the biggest problems raised by the scientific community was the lack of standardisation of both the technique and the training. While the benefits of POCUS have been proven, its integration into clinical practise requires slow progress, as a hasty and non-standardised introduction can cause potential harm[26,27]. The ability to assess specific sonographic parameters does not automatically translate into an accurate diagnosis without comprehensive clinical evaluation, including integration with laboratory findings and physical examination. For example, a pulsatile hepatic vein Doppler signal reflects elevated right atrial pressure and impaired right-sided filling rather than volume status per se, and can therefore arise both from true fluid overload and from intrinsic right ventricular dysfunction, including pulmonary hypertension, right heart failure or significant tricuspid regurgitation. Conversely, an A-line pattern on LUS should not be equated with hypovolemia: It merely indicates the absence of a sonographic interstitial syndrome and may be present in euvolemic states or even in patients with acute pulmonary embolism, where pulmonary aeration is typically preserved despite significant hemodynamic compromise. Accurate interpretation therefore requires integration with FoCUS and the overall clinical picture. In addition, similarly to every ultrasound examination, POCUS is limited by operator dependent variability which is difficult to standardize. Limitations include operator-dependent error rates of 15%-20% in untrained users[28-31]. Since its inception, another major hurdle has been the difficulty in practically implementing the skills required for safe and reliable use in clinical practice. Although many solutions have been proposed, issues such as institutional costs, individual scepticism, and technical problems in the qualitative standardization of practical application and theoretical training have prevented actual trials. To solve these problems, it is imperative that scientific societies take a leading role in defining objective criteria and standards across all disciplines. A first step forward was taken in 2024 with the release of the International Alliance for POCUS in Nephrology position paper[8]. This document delineates the core competencies required for high-quality and recognized POCUS training, with a clear distinction from advanced imaging skills that require additional specialized expertise. Criteria have been developed to assess a certifiable POCUS training in nephrology; current consensus suggests 25-50 supervised renal ultrasounds and 50 cardiac exams for basic competency[8]. It also speculates on possible ways to deliver the required training. While solutions for not-yet-specialized practitioners include variable and integrable strategies such as textbooks, lectures, and workshops, the integration of POCUS into academic training and residency courses is the real game changer. Some preliminary studies have examined the impact of integrating POCUS educational programs during both medical school and internal medicine residency, with encouraging results[32-34], with promise for impactful results coming from structured training programmes[35]. Concerns have been raised about ethical problems: The race towards POCUS implementation in training programs must not threaten the central position of the patient or impair its experience of care. Bedside POCUS education requires explicit patient consent, particularly for intimate exams like bladder volume assessment. Every year early-career clinicians take their first steps among older colleagues and patients; this generational shift is the best time to integrate POCUS into the educational programs for students and residents and to present POCUS as an extension of the physical examination or as a visual stethoscope. In this specific historical context rapid technological evolution is forcing its role in everyday tasks and novel concepts gained position in POCUS training programs. Worldwide availability of ultrasound has been achieved long ago, but modern devices carry notable advantages, like cutting edge software implementation, increased portability (handheld ultrasound devices) and competitivity in terms of costs[8]. Additional advantage may be seen from the integration of artificial intelligence (AI) into handheld devices, addressing the operator-dependency barrier; a review of literature by Kim et al[36] scoped the use of AI automated biometry achieving diagnostic accuracy comparable to expert sonographers in resource-limited settings. The potential of AI implementation to POCUS represent the iceberg hiding beneath the surface with a rapidly growing amount of studies with applications in the emergency setting and in the organ focused assessment[37,38]. Experimental applications are several and range from automated volume assessment and precise residual urine measurement from biplanar images, as shown by Alpert et al[39] to automated hemodynamic parameters calculation both in cardiac (left ventricular stroke volume and ejection fraction) and vena cava measurement[40]. Further advancement is coming with software AI integration, that is expected to radically impact our life in an irreversible way in the nearest future both in adult and pediatric population[41,42]. While promising, these technologies require validation in multicenter trials before widespread adoption. Validation of AI-automated measurements may reduce in the next future subjectivity in image interpretation mitigating operator variability. Potential educational advantages may come from the use of simulators that, through the use of advanced mannequins and augmented reality, can help trainees to develop confidence with the ultrasound examination[8,43]. This use cases find a precious application especially in the educational setting aiming to minimizing the operator dependent variability that represents to date the main limitation of POCUS. A surprisingly relevant role in education is played also by tele-education: A randomized trial by Suzuki et al[44] demonstrated superior results from tele-education compared to self-directed learning. Additional input comes from social media that has proven to be a strong divulgative tool with the novel format of “knowledge pills” straight in the hand[8]. Table 1 summarizes the most recent evidence supporting POCUS with correlation to the main clinical implications in the nephrology field.

Table 1 Summarizes the most recent and founding literature supporting point-of-care ultrasound divided by topic field with correlation to the main clinical implications.

Topic area	Ref.	Year	Key findings/implications
Critical care guidelines	Díaz-Gómez et al[2]	2025	Updated evidence-based recommendations for CCUS in cardiac arrest, septic shock, acute dyspnea/respiratory failure, volume resuscitation, and cardiogenic shock; focus on patient-important outcomes
Emergency medicine review	Mani et al[3]	2026	Identified 5 main themes: Ultrasound-guided regional anesthesia, POCUS in resuscitation, diagnostic POCUS, AI/technology integration, and governance/administration; strengthens utility across multiple clinical scenarios
Internal medicine curriculum (Delphi 1)	Chockalingam et al[4]	2025	Consensus on 53 POCUS skills (lung 25%, abdominal 23%, procedural 23%, cardiac 17%, MSK 9%, vascular 4%), 14 teaching methods, and 5 evaluation strategies for IM residency programs
Internal medicine curriculum (Delphi 2)	LoPresti et al[5]	2025	First US consensus for core IM residency curriculum: 12 diagnostic and 6 procedural indications, 15 diagnostic applications, 52 specific skill components (e.g., dyspnea, shock, chest pain, thoracentesis)
Pediatric emergency medicine	Lee et al[7]	2024	Enhances diagnostic accuracy in pediatric shock/cardiac arrest; improves procedural safety for nerve blocks, I, IV access; integral to clinical pathways for intussusception and testicular torsion
Nephrology training position statement	Koratala et al[8]	2024	IAPN position statement shifting POCUS from “optional” to a “core competency.” Establishes training modalities, and quality assurance measures for nephrology POCUS; emphasizes international collaboration and standardization
Nephrology core curriculum	Niyyar et al[9]	2024	AJKD Core Curriculum for nephrology POCUS: Acute/chronic kidney disease, cystic disease, urinary obstruction, volume status, kidney biopsy guidance, dialysis access placement/maintenance, transplant evaluation
Primary care training (EFSUMB)	Andersen et al[10]	2025	EFSUMB training recommendations and generic core curriculum for primary care physicians; corresponds to EFSUMB competence level 1; developed through Delphi process
Primary care curriculum (European Delphi)	Andersen et al[11]	2026	European consensus on 40 diagnostic POCUS examinations within 13 anatomical areas for primary care frontline physicians; 95 panelists from 28 countries; 85% showed substantial/moderate agreement
VExUS Score/hemodynamic assessment	Koratala et al[13]	2026	Evaluation of extended VExUS incorporating internal jugular and splenic veins.
VExUS score/hemodynamic assessment	Leyba et al[14]	2026	VExUS detects dynamic changes in volume status before/after hemodialysis; hepatic and portal vein scores improved significantly after fluid removal
VExUS Score/hemodynamic assessment	Borroni et al[15]	2026	Comprehensive review on VExUS valuable prognostic tool in cardiac ICU/HF; predictive performance less consistent in heterogeneous populations; limited evidence for guiding management strategies
Dialysis and access	Chocarro-Haro et al[16]	2025	Systematic review highlighting importance of person-centred management of haemodialysis. Recommends systematic assessment of vascular access and continuous training for nurses and patients
Fluid management	Josa-Laorden et al[23]	2025	Randomized trial comparing POCUS-guided vs standard diuretic titration in heart failure/AKI. Demonstrated reduced hospital readmission and improved renal functional recovery through individualized decongestion.
Nephrology-oriented POCUS education	Sakai et al[35]	2025	Japanese teaching hospital study: POCUS implementation for AKI increased significantly post-training; VExUS use for congestion assessment rose from 0% (2022) to 66.7% (2023); regular lectures and supervising physician training essential
AI integration	Kim et al[36]	2025	Review of 33 papers, reports that AI POCUS AI POCUS is most used in acute care and for targeted cardiac exams; it improves accessibility, simplifies use and expedites care; main uses are biometry, detection of abnormality and probe guidance
AI integration	East et al[37]	2025	AI reduces operator dependency, improves image quality; emerging innovations include autonomous scanning, real-time predictive analytics, tele-ultrasound, and patient-performed imaging
AI integration	Puticiu et al[38]	2026	AI-POCUS aided detection of blunt trauma injury, supporting eFAST standardization and triaging, with automated measurements and pattern recognition. AI–POCUS plays an emerging role in education and training standardization. Long term impact assessment requires prospective studies

AJKD: American Journal of Kidney Disease; AKI: Acute kidney injury; CCUS: Critical care ultrasonography; HF: Heart failure; IAPN: International Alliance for point-of-care ultrasound in Nephrology; ICU: Intensive care unit; VExUS: Venous excess ultrasound; POCUS: Point-of-care ultrasound; AI: Artificial intelligence; MSK: Musculoskeletal; IM: Internal medicine; eFAST: Extended Focal Assessment with Sonography in Trauma; EFSUMB: European Federation of Societies for Ultrasound in Medicine and Biology.

Finally a unique application scenario comes from the use of supervised remote application of POCUS outside healthcare structures, the so called “tele-pocus”, both employed for educational aims, geographically expanding the reach of certified professionals outside institutions and for actual diagnostic use by untrained medical population and sometimes patients themselves[45,46]. Research frontiers of POCUS implementation is continuously expanding: The remotely supervised self-administration of POCUS has been subject of clinical trials with interesting results[47], but the substantial potential of AI in this field will require future research exploration with prospective trials (e.g. on AI-augmented POCUS in home dialysis).

CONCLUSION

The integration of POCUS into clinical practice has the potential to significantly improve the quality of workflows in nephrology wards, leading to more timely and accurate diagnoses. By facilitating rapid bedside assessments, POCUS can help reduce reliance on unnecessary diagnostic tests, prevent delayed treatments and unnecessary hospitalizations, ultimately contributing to more cost-effective healthcare delivery. Implementing a standardized and certifiable POCUS curriculum within undergraduate medical education and residency training represents a challenging but feasible goal. Such an initiative holds the promise of transforming nephrology practice by equipping future clinicians with essential diagnostic skills from the outset of their careers.