本研究中涉及人类参与者的所有程序均符合杜克大学卫生系统机构研究委员会的道德标准以及 1964 年赫尔辛基宣言及其后来的修正案或类似的道德标准。根据机构标准，事先征得同意，纳入的图像是在作者自己身上进行的，以获得正常图像，并作为常规教育超声扫描的一部分进行，用于正面图像的教学目的。根据以下标准纳入患者: 任何急性肾损伤、尿量减少或任何其他怀疑肾功能异常原因的患者。排除标准包括腹部开放的患者。疼痛是超声检查的相对禁忌证，尤其是当疼痛严重到无法放置探针时（例如，腹内高压）。使用的试剂和设备列在 材料表中。
术语:身体的三个平面称为冠状面、矢状面和横向 这可能会令人困惑，因为后一个术语（"横向"）也可以用来指代单个器官的短轴，同时使用术语"纵向"来指代器官的长轴。为了尽量减少混淆，该协议将专门使用冠状、矢状和横向来指代人体的平面，并将使用长轴和短轴来指代肾脏的平面。此外，由于气囊的动态形状使其无法具有永久的长轴或短轴，因此气囊的两个视图将仅根据视图与物体平面对齐的两个视图之一来命名:矢状或横向。
1. 传感器选择
<ol><li>选择低频换能器:最好是曲线换能器 （2-5 MHz）。如果没有曲线探头，可以使用扇形阵列（又名"相控阵"，1-5 MHz）作为替代。 注:曲线换能器是通过单一视图可视化肾脏的最佳选择，因为它的足迹创造了一个大的视野，并且其低频压电晶体允许深入人体。然而，在通过肋骨观察肾脏时，曲线探头可能很难使用。</li>
</ol>2. 机器设置
<ol><li>设置深度，使肾脏出现在超声筛查的中间三分之一（典型设置在 16 厘米到 20 厘米之间）。</li>
	<li>设置增益，使肾髓质金字塔显示为无回声（黑色），肾窦复合体显示为高回声（明亮），肾皮层出现在这些极端之间。</li>
</ol>3. 模式和预设
<ol><li>选择二维 （2D） 模式，也称为亮度模式（B 模式）。这是一种二维灰度超声模式。</li>
	<li>激活 2D 模式后，选择腹部预设。</li>
</ol>4. 患者定位
<ol><li>在检查的大部分时间里，患者仰卧位。 注意:在对右肾进行成像时，可能需要将患者重新定位在左侧卧位，以便更好地观察右肾。在对左肾进行成像时，可能需要将患者重新定位在右侧卧位，以便更好地观察左肾。</li>
	<li>扫描前，暴露患者的下胸部和腹部。</li>
	<li>放置超声机的位置，使超声医师的惯用手可以握住超声探头。这允许对超声探头进行更精细的操作，并解放非惯用手来操作超声机。 注意:右撇子超声医师应将自己置于患者的右侧，反之亦然。</li>
</ol>5. 右肾成像
<ol><li>凝胶应用<ol><li>在采集每张图像之前，将凝胶直接涂抹在超声探头上，以最大限度地提高扫描效率。</li>
	</ol></li>
	<li>冠状视图<ol><li>将探针放在右侧，沿腋中线，第 5-7肋 间隙，指示器指向颅骨（图 1）。</li>
		<li>调整探头位置（向上/向下滑动，前后倾斜），直到在其最大纵向范围内看到右肾（见 图2）。</li>
		<li>从前向后扇形，以筛查肾积水和其他严重异常（视频 1）。</li>
		<li>电影剪辑采集:对于配置为回顾性图像采集的计算机，请在步骤 5.2.4 之前单击 采集 。对于配置为预期图像采集的计算机，请在步骤 5.2.4 后单击 acquire 。</li>
	</ol></li>
	<li>肾脏长轴直径测量<ol><li>将肾脏在图像中居中，单击 "冻结"，然后测量肾脏的高度（图 3）。</li>
		<li>单击 Save （或等效按钮）。</li>
	</ol></li>
	<li>横视图<ol><li>以右肾为中心后，将探针顺时针旋转 90 度，直到探针标记朝前，在横向视图中露出肾脏（图 4）。</li>
		<li>调整探针位置（向上/向下滑动，前后倾斜），直到在这个横向平面上看到右肾的最大尺寸（图 5）。</li>
		<li>从颅侧到尾部扇形，以筛查肾积水和其他严重异常（视频 2）。重复该步骤。</li>
	</ol></li>
</ol>6. 左肾成像
<ol><li>对左肾重复步骤 5.1-5.3。</li>
</ol>7. 膀胱成像
<ol><li>凝胶应用:重复步骤 5.1.1。</li>
	<li>横视图<ol><li>探头位置:将探头放置在耻骨联合的颅骨上，探头指示器指向患者的右侧（图6）。</li>
		<li>将超声束向尾部倾斜到骨盆中，直到可以看到膀胱的最大尺寸。</li>
		<li>图像优化<ol><li>调整深度，直到在屏幕的中间三分之一处可以看到气囊。</li>
			<li>调整增益，直到膀胱腔严重无声（黑色）并且膀胱正后方的组织平面略微高回声（明亮）。</li>
		</ol></li>
		<li>Cine 剪辑采集<ol><li>从颅骨到尾部扇形穿过膀胱，以可视化整个结构。重复步骤 5.2.3。</li>
		</ol></li>
		<li>横向膀胱尺寸测量<ol><li>将视图以膀胱的最大尺寸为中心，单击 "冻结 "并测量膀胱的前后和横向到内侧直径（图 7，左图）。</li>
			<li>单击 Save （或等效按钮）。</li>
		</ol></li>
	</ol></li>
	<li>矢状视图<ol><li>保持横向视图，将视图置于膀胱的中心，并将探针顺时针旋转 90 度，直到探针标记面向颅骨，在矢状面上露出肾脏（图8）。</li>
		<li>Cine 剪辑采集<ol><li>从一侧到另一侧扇形穿过气囊，以观察整个结构。重复步骤 5.2.3。</li>
		</ol></li>
		<li>横向膀胱尺寸测量<ol><li>将视图置于膀胱最大尺寸的中心，单击 "冻结 "并测量膀胱的颅侧到尾部直径（图 7，右图）。</li>
			<li>单击 Save （或等效按钮）。</li>
		</ol></li>
	</ol></li>
</ol>

Advancing Bedside Care: A Multidisciplinary Guide to Kidney-Genitourinary POCUS

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MAS 报告收到 Elsevier-Nephrology Secrets 的酬金;担任美国内科肾脏病学委员会的成员;因在 NephMadness 执行委员会任职而获得 NKF 的酬金;获得 Medscape 的 CKD 播客系列酬金;因担任 ASN Journals Portfolio（JASN、CJASN、Kidney360）的通信编辑而获得酬金。YSB 报告称，美国麻醉医师协会 （American Society of Anesthesilogists） 因编辑委员会在床旁超声方面的工作而获得酬金，并因创建与 POCUS 相关的教育内容而获得 OpenAnesthesia.org 酬金。其余作者没有披露。

AKI 常见于危重住院患者，增加了死亡风险。为了熟练执行上述步骤并区分正常和病理结果，必须全面了解正常解剖结构和超声表现，并严格遵守方案的具体步骤。
方案中的关键解剖学/步骤 肾脏 - 肾脏是位于体内斜冠状平面的腹膜后器官，需要将换能器倾斜定位才能进行准确成像。为了帮助可视化左肾和右肾，临床医生可以将脾脏和肝脏分别用作声学窗...

急性肾损伤 （AKI） 由多种病因引起，是住院患者中常见的医学诊断。AKI 导致肾功能突然下降，导致细胞外液、尿素和其他含氮废物的积累，以及电解质失调。此外，AKI 的诊断预示着更差的短期和长期结果，并且与消耗更多的医疗保健资源有关1。根据美国肾脏数据系统 （USRDS） 的数据，在 2020 年医疗保险按服务收费受益人中，AKI 住院率为每 1000 名患者年 62 例2。此外，对采用肾脏病改善全球结局 （KDIGO） AKI 诊断标准的 154 项研究的系统评价发现，在这些试验的 3,585,911 人中，主要来自北美、北欧和东亚，不同住院环境中的 AKI 发病率为 20%-32%3。在住院环境中，AKI 通常在重症监护病房中被发现，并且与死亡率增加有关4。床旁超声 （POCUS） 机器在 ICU 等环境中很容易获得，但尽管诊断性肾 GU 超声能够快速评估 AKI5 的几种病因，但往往未得到充分利用。
与会诊超声相比，在会诊超声中，患者的主要提供者要求放射技师进行正式的超声检查并由放射科医生读取，而诊断性 POCUS 则由患者的主要提供者在护理点进行和解释6。越来越多的证据表明，非放射科医生可以有效和准确地将诊断 POCUS 用于各种疾病7。例如，2019 年住院医师手术加压超声检查:床旁超声研究 （HOCUS-POCUS） 前瞻性队列研究将住院医师进行的深静脉血栓形成 （DVT） 压迫 POCUS 与会诊技术人员/放射科医生进行的血管 DVT 超声检查进行了比较。该研究表明，住院医师进行的 POCUS 与技术员/放射科医生进行的会诊血管超声的准确性相似，敏感性为 100%，特异性为 96%8。同样，2020 年的一项研究发现，与计算机断层扫描扫描相比，由具有不同经验的急诊科提供者进行的肾 GU POCUS 在检测肾积水方面具有中等准确性（特异性为 72%，敏感性为 77%）9。重要的是，与技术人员/放射科医生成像相比，初级提供者执行的 POCUS 可以更及时地进行诊断和干预。
AKI 的病因可分为肾前性（血流动力学介导的损伤）、肾内（肾小球或间质病变）和肾后性（泌尿系统病因，最常见的是梗阻性尿路病）。尤其是后者，可以被诊断为 POCUS。梗阻性尿路病的年发病率为每 1000 人 1.7 例，估计约占急性和慢性肾病的 10%10。从前列腺增生到肾结石，尿路梗阻的原因有很多。这些病症在肾脏水平的主要病理表现是肾积水。这在 POCUS 上很容易可视化，并且诊断速度对于治疗急性肾衰竭患者至关重要。 
除了 AKI，POCUS 仍然是评估慢性肾病的一种经济高效且安全的方式。POCUS 可用于识别指示肾细胞癌的病变，因为它能够可视化大于或等于 3 cm 的囊肿，并区分被认为与恶性肿瘤有关的特征11。POCUS 允许快速评估常染色体显性遗传性多囊肾病 （ADPKD），避免不必要的肾活检安排和昂贵的实验室工作。此外，与金标准基于磁共振的身高调整总肾体积测量 （htTKV） 相比，肾长的超声测量显示可预后早期 ADPKD 的进展风险 （htTKV）12。 
虽然计算机断层扫描在检测肿瘤、结石和钙化方面具有优势，但尚未证实计算机断层扫描在诊断 AKI 病因方面优于超声检查13。此外，一些患者可能病得太重而无法走出他们的房间，从而无法运送到 CT 扫描仪甚至放射科套房，以便技术人员/放射科医生进行会诊超声检查。在这些情况下，POCUS 提供了一种安全可靠的诊断替代方案。尽管如此，诊断肾 GU POCUS 仍然是一种未得到充分利用的工具，可能是由于一线临床医生缺乏培训14。为了解决这一知识差距，本叙述性综述汇集了多个专业（医院医学、重症监护、麻醉学和肾病学）的专业知识，提出了一种循证肾脏 GU POCUS 图像采集方案，包括适应症/禁忌症、患者定位、换能器选择、采集顺序和检查限制。最后，我们描述了肾脏 GU 超声图像解释的基本概念，包括每个执行这种方式的床边临床医生都应该知道的关键异常发现。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Curvilinear Transducer</td>
			<td>Philips</td>
			<td>C5-2 USB</td>
			<td>2-5 MHz, also called the abdominal probe</td>
		</tr>
		<tr>
			<td>Curvilinear Transducer</td>
			<td>SonoSite</td>
			<td>C5-1</td>
			<td>1-5 MHz, also called the abdominal probe</td>
		</tr>
		<tr>
			<td>Edge 1 ultrasound machine</td>
			<td>SonoSite</td>
			<td></td>
			<td>Used to obtain a subset of the Figures and Videos</td>
		</tr>
		<tr>
			<td>Phased-Array Transducer</td>
			<td>Philips</td>
			<td></td>
			<td>1-5 MHz, also called the cardiac probe</td>
		</tr>
		<tr>
			<td>Phased-Array Transducer</td>
			<td>SonoSite</td>
			<td>P5-1</td>
			<td>1-5 MHz, also called the cardiac probe</td>
		</tr>
		<tr>
			<td>Ultrasound system</td>
			<td>Philips</td>
			<td>Affiniti30</td>
			<td>Used to obtain a subset of the Figures and Videos</td>
		</tr>
	</tbody>
</table>

point-of-care kidney and genitourinary ultrasound in adults: image acquisition

涉及肾脏和膀胱的一系列疾病可能导致威胁器官的并发症，如果通过诊断性影像学检查及时诊断，这些并发症是可以预防的。常见的影像学检查方式包括计算机断层扫描或诊断性超声检查。传统上，肾脏泌尿生殖系统超声检查需要会诊团队，包括一名进行图像采集的超声医师和一名进行图像解读的放射科医生。然而，诊断性床旁超声 （POCUS） 最近已成为在床旁解决急性肾损伤的有用工具。研究表明，可以培训非放射科医生对一定数量的重要情况进行高精度的肾脏和膀胱诊断 POCUS。目前，肾脏泌尿生殖系统诊断性 POCUS 在实际临床实践中仍未得到充分利用。这可能是因为大多数临床医生在遇到急性肾损伤的专科中不熟悉该器官系统的图像采集，包括初级保健、急诊医学、重症监护、麻醉学、肾脏病学和泌尿学。为了解决这一多专业教育差距，本叙述性综述由一个多学科小组开发，旨在为肾脏泌尿生殖系统 POCUS 图像采集提供一个与专业无关的框架:适应症/禁忌症、患者定位、换能器选择、采集顺序和检查限制。最后，我们描述了肾脏泌尿生殖系统超声图像解释的基本概念，包括每个执行这种方式的床边临床医生都应该了解的关键异常发现。

Acute kidney injury (AKI), resulting from a variety of etiologies, is a frequent medical diagnosis identified in hospitalized patients. AKI precipitates an abrupt decrease in kidney function that leads to an accumulation of extracellular fluid, urea, and other nitrogenous waste products, along with the dysregulation of electrolytes. Moreover, the diagnosis of AKI portends worse short-term and long-term outcomes and is associated with the consumption of greater healthcare resources1. According to the United States Renal Data System (USRDS), among Medicare Fee-For-Service beneficiaries in 2020, the rate of hospitalization with AKI was 62 admissions per 1000 patient years2. Furthermore, a systematic review of 154 studies that adopted the Kidney Disease Improving Global Outcomes (KDIGO) AKI diagnostic criteria found that among the 3,585,911 people in these trials, primarily from North America, Northern Europe, and Eastern Asia, the incidence of AKI in different inpatient settings ranged from 20%-32%3. In the inpatient setting, AKI is commonly identified in the intensive care unit and is associated with increased mortality4. Point-of-care ultrasound (POCUS) machines are readily available in settings such as the ICU, but diagnostic kidney-GU ultrasound is often underused despite being able to quickly evaluate several etiologies of AKI5.
Compared to consultative ultrasound, in which a patient's primary provider orders a formal ultrasound to be performed by a radiology technician and read by a radiologist, diagnostic POCUS is performed and interpreted by a patient's primary provider at the point of care6. There is growing evidence that non-radiologists can effectively and accurately use diagnostic POCUS for a variety of conditions7. For instance, the 2019 Hospitalist-Operated Compression Ultrasonography: a Point-of-Care Ultrasound Study (HOCUS-POCUS) prospective cohort study compared hospitalist-performed deep vein thrombosis (DVT) compressive POCUS to consultative technician/radiologist performed vascular DVT ultrasound. The study showed similar accuracy of hospitalist-performed POCUS to technician/radiologist-performed consultative vascular ultrasound with sensitivity of 100% and specificity of 96%8. Similarly, a 2020 study found kidney-GU POCUS performed by Emergency Department providers of varied experience had moderate accuracy (specificity of 72% and sensitivity of 77%) in detecting hydronephrosis when compared to computed tomography scan9. Importantly, primary-provider performed POCUS allows for more timely diagnosis and intervention compared to technician/radiologist imaging.
Causes of AKI can be divided into pre-renal (hemodynamically mediated injury), intra-renal (glomerular or interstitial pathologies), and post-renal (urologic etiologies, most commonly obstructive uropathy). The latter, especially, can be diagnosed with POCUS. Obstructive uropathy has an annual incidence of 1.7 per 1000 people and has been estimated to account for about 10% of acute and chronic kidney disease10. From prostatic hyperplasia to nephrolithiasis, there are many causes of urinary obstruction. The main pathologic manifestation of these conditions at the level of the kidney is hydronephrosis. This is easily visualized on POCUS, and speed in diagnosis can be critical in treating acutely ill patients with kidney failure. 
Beyond AKI, POCUS remains a cost-effective and safe modality for evaluating chronic kidney disease. POCUS can be used to identify lesions indicative of renal cell carcinoma, given the ability to visualize cysts greater than or equal to 3 cm and to discriminate characteristics deemed concerning for malignancy11. POCUS allows for the rapid evaluation of autosomal dominant polycystic kidney disease (ADPKD), avoiding unnecessary scheduling of kidney biopsies and expensive lab work. Additionally, ultrasonographic measurement of kidney length was shown to prognosticate risk of progression in early ADPKD when compared to the gold standard magnetic resonance-based, height-adjusted total kidney volume measurement (htTKV)12. 
While computed tomography scans have an advantage in detecting neoplasms, stones, and calcifications, there has been no proven benefit of computed tomography over ultrasonography in the diagnosis of AKI etiologies13. Furthermore, some patients may be too sick to move out of their rooms, precluding transport to the CT scanner or even the radiology suite for a technician/radiologist to perform the consultative ultrasound. In these cases, POCUS provides a safe and reliable diagnostic alternative. Despite this, diagnostic kidney-GU POCUS remains an underused tool, likely due to a lack of training among frontline clinicians14. To address this knowledge gap, this narrative review brings together the expertise of multiple specialties (hospital medicine, critical care, anesthesiology, and nephrology) to propose an evidence-based kidney-GU POCUS image acquisition protocol, including indications/contraindications, patient positioning, transducer selection, acquisition sequence, and exam limitations. Finally, we describe foundational concepts in kidney-GU ultrasound image interpretation, including key abnormal findings that every bedside clinician performing this modality should know.

Author Spotlight: Developing a Bedside Protocol for Kidney and Genitourinary Ultrasonography

成人床旁肾脏和泌尿生殖系统超声:图像采集

超声检查正常
正常肾脏超声 肾包膜的回声性和有限的解剖变异性（除了偶尔的盆腔肾或更罕见的马蹄肾）使得床旁 POCUS 很容易识别肾脏。肾脏将具有典型的豆形外观，平均尺寸为 9-13 厘米，但大小随患者的身高和体重而变化（图 2， 视频 1）。外皮层相对于相邻的脾脏和肝脏通常为低回声。皮层内部是肾髓质，?...

肾脏和泌尿生殖系统（肾-GU）的床旁超声（POCUS）可以帮助筛查肾功能障碍的某些原因。然而，尽管具有临床实用性，但由于临床医生缺乏培训，肾 GU POCUS 仍然未得到充分利用。为了解决这一差距，本文介绍了肾脏 GU 图像采集和解释。

A range of conditions involving the kidneys and urinary bladder can cause organ-threatening complications that are preventable if diagnosed promptly with ...

急性肾损伤和/或低尿量的病情检查通常需要使用肾生殖器泌尿系统超声检查。虽然肾 GU 超声传统上由速记员和放射科医生作为咨询服务进行，但我们的论文定义了一种基于证据的床旁肾 GU 超声图像采集方案。我们的多学科小组开发了一种专业不可知的肾 GU 床旁超声图像采集方案。该协议包括适应症、限制、患者定位、换能器选择和图像优化。我们的方案简化了床旁肾脏和 GU 超声的入路并实现了标准化，减少了对会诊超声检查的需求并加快了诊断速度。

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JoVE Journal

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Medicine

Point-of-Care Kidney and Genitourinary Ultrasound in Adults: Image Acquisition

Unit 1

The Urinary System

SCIENTISTS IN ACTION

685 次观看.  Duke University School of Medicine. 急性肾损伤和/或低尿量的病情检查通常需要使用肾生殖器泌尿系统超声检查。虽然肾 GU 超声传统上由速记员和放射科医生作为咨询服务进行，但我们的论文定义了一种基于证据的床旁肾 GU 超声图像采集方案。我们的多学科小组开发了一种专业不可知的肾 GU 床旁超声图像采集方案。该协议包括适应症、限制、患者定位、换能器选择和图像优化。我们的方案简化了床旁肾...

视频: Author Spotlight: Developing a Bedside Protocol for Kidney and Genitourinary Ultrasonography

A range of conditions involving the kidneys and urinary bladder can cause organ-threatening complications that are preventable if diagnosed promptly with diagnostic imaging. Common imaging modalities include either computed tomography or diagnostic ultrasound. Traditionally, ultrasound of the kidney-genitourinary system has required consultative teams consisting of a sonographer performing image acquisition and a radiologist performing image interpretation. However, diagnostic point-of-care ultrasound (POCUS) has recently emerged as a useful tool to troubleshoot acute kidney injury at the bedside. Studies have shown that non-radiologists can be trained to perform diagnostic POCUS of the kidneys and bladder with high accuracy for a set number of important conditions. Currently, diagnostic POCUS of the kidney-genitourinary system remains underused in actual clinical practice. This is likely because image acquisition for this organ system is unfamiliar to most clinicians in specialties that encounter acute kidney injury, including primary care, emergency medicine, intensive care, anesthesiology, nephrology, and urology. To address this multi-specialty educational gap, this narrative review was developed by a multi-disciplinary group to provide a specialty-agnostic framework for kidney-genitourinary POCUS image acquisition: indications/contraindications, patient positioning, transducer selection, acquisition sequence, and exam limitations. Finally, we describe foundational concepts in kidney-genitourinary ultrasound image interpretation, including key abnormal findings that every bedside clinician performing this modality should know.

Point-of-care ultrasound (POCUS) of the renal and genitourinary (renal-GU) system can help to screen for certain causes of kidney dysfunction. However, despite its clinical utility, renal-GU POCUS remains underutilized due to a lack of training among clinicians. To address this gap, this article describes renal-GU image acquisition and interpretation.