Key result
Clinical exam misses subclinical pulmonary congestion in ~55% of hemodialysis patients compared to lung ultrasound.
Why the study?
Accurate volume assessment in maintenance hemodialysis patients is challenging because no single bedside method fully characterizes extracellular fluid overload.
Cross-Sectional (n=116)
Blinded assessors
No
Effect estimate: κ = 0.28 (95% CI 0.11-0.45)
Discordance among clinical examination, bioimpedance spectroscopy, and abbreviated lung ultrasound is common in maintenance hemodialysis patients, with abbreviated lung ultrasound frequently identifying clinically occult pulmonary congestion in apparently euvolemic patients.
Clinical examination may miss subclinical congestion in hemodialysis patients; this cross-sectional observation leaves open whether lung ultrasound improves volume management.
Background and objectives Accurate volume assessment in maintenance hemodialysis remains challenging because no single bedside method fully characterizes extracellular fluid overload. We evaluated discordance among clinical examination, bioimpedance spectroscopy, and abbreviated six-zone lung ultrasound, the prevalence of subclinical pulmonary congestion, and factors associated with pulmonary congestion. Methods In this single-center cross-sectional study, 116 adults receiving maintenance hemodialysis without clinically recognized heart failure underwent standardized clinical examination, whole-body bioimpedance spectroscopy, and predialysis six-zone lung ultrasound. Subclinical pulmonary congestion was defined as a prespecified total B-line count of ≥3 in clinically euvolemic patients. Agreement was assessed using Cohen’s kappa, and independent associations were evaluated using multivariable Poisson regression. Results Among 49 clinically euvolemic patients, 27 (55.1%) had subclinical pulmonary congestion, representing 23.3% of the cohort. Clinical examination showed fair agreement with lung ultrasound for ≥3 B-lines (κ = 0.28; 95% CI, 0.11–0.45), whereas agreement between lung ultrasound and bioimpedance-defined overhydration was slight (κ = 0.16; 95% CI, −0.03 to 0.35). Bioimpedance-derived overhydration, but not interdialytic weight gain, was independently associated with subclinical pulmonary congestion. Conclusion Discordance among clinical examination, bioimpedance spectroscopy, and lung ultrasound was common and is consistent with the hypothesis that these modalities capture partially distinct aspects of volume status and pulmonary congestion. Abbreviated lung ultrasound frequently identified clinically occult pulmonary congestion despite apparent clinical euvolemia, supporting a multidimensional approach to bedside volume assessment in maintenance hemodialysis.
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Benites-Flores et al. (2026) conducted a cross-sectional in Maintenance hemodialysis without clinically recognized heart failure (n=116). Standardized clinical examination vs lung ultrasound vs bioimpedance spectroscopy was evaluated on Agreement between clinical examination and lung ultrasound for detecting subclinical pulmonary congestion (≥3 B-lines) (κ = 0.28, 95% CI 0.11-0.45). Standardized clinical examination showed only fair agreement with abbreviated lung ultrasound (κ = 0.28) and failed to detect subclinical pulmonary congestion in 55.1% of apparent clinically euvolemic hemodialysis patients.
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