About

Sadichhya Lohani is an Assistant Professor of Clinical Medicine specializing in Renal-Electrolyte and Hypertension at the University of Pennsylvania's Perelman School of Medicine. He holds an MBBS degree from Tribhuvan University, Kathmandu, Nepal, obtained in 2012. Dr. Lohani serves as the Co-director of the Core Renal Course and is the Director of the Home Dialysis Program at Davita Buttonwood Dialysis. His research and clinical interests focus on nephrology, including home hemodialysis, point-of-care ultrasound for evaluating cardiac function in dialysis patients, and the assessment of volume status and pulmonary congestion in patients with kidney disease. He has contributed to various scholarly publications and presentations related to nephrology, dialysis, and ultrasound diagnostics, emphasizing advancements in patient care and innovative diagnostic techniques in renal medicine.

Research topics

• Medicine
• Internal medicine
• Environmental health
• Intensive care medicine
• Pathology

Selected publications

• Integrative Volume Status Assessment

  POCUS Journal · 2022-02-01 · 30 citations

  reviewOpen accessSenior author

  Volume status assessment is a critical but challenging clinical skill and is especially important for the management of patients in the emergency department, intensive care unit, and dialysis unit where accurate intravascular assessment is necessary to guide appropriate fluid management. Assessment of volume status is subjective and can vary from provider to provider, posing clinical dilemmas. Traditional non-invasive methods of volume assessment include assessment of skin turgor, axillary sweat, peripheral edema, pulmonary crackles, orthostatic vital signs, and jugular venous distension. Invasive assessments of volume status include direct measurement of central venous pressure and pulmonary artery pressures. Each of these has their own limitations, challenges, and pitfalls and were often validated based on small cohorts with questionable comparators. In the past 30 years, the increased availability, progressive miniaturization, and falling price of ultrasound devices has made point of care ultrasound (POCUS) widely available. Emerging evidence base and increased uptake across multiple subspecialities has facilitated the adoption of this technology. POCUS is now widely available, relatively inexpensive, free of ionizing radiation, and can help providers make medical decisions with more precision. POCUS is not intended to replace the physical exam, but rather to complement clinical assessment, guiding providers to give thorough and accurate clinical care to their patients. We should be mindful of the nascent literature supporting the use of POCUS and other limitations as uptake increases among providers and be wary not to use POCUS to substitute clinical judgement, but integrate ultrasonographic findings carefully with history and clinical examination.

  PublisherOA PDFDOI

• The Rise, Fall, and New Rise of Home Hemodialysis

  2021-09-01

  articleSenior author
  Publisher

• Lung Ultrasound to Diagnose Pulmonary Congestion Among Patients on Hemodialysis: Comparison of Full Versus Abbreviated Scanning Protocols

  American Journal of Kidney Diseases · 2021-06-03 · 22 citations

  article
  PublisherDOI

• Point-of-Care Ultrasound for Evaluation of Systolic Heart Function in Outpatient Hemodialysis Units

  Kidney Medicine · 2021-02-10 · 1 citations

  articleOpen access1st authorCorresponding

  Heart failure with reduced ejection fraction is a significant cause of morbidity and mortality in patients receiving hemodialysis.1National Kidney FoundationK/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients.Am J Kidney Dis. 2005; 45: S1-S153Google Scholar,2Loutradis C. Sarafidis P.A. Papadopoulos C.E. Papagianni A. Zoccali C. The ebb and flow of echocardiographic cardiac function parameters in relationship to hemodialysis treatment in patients with ESRD.J Am Soc Nephrol. 2018; 29: 1372-1381Crossref PubMed Scopus (17) Google Scholar Interdialytic volume overload results in increased preload and afterload, increasing ventricular chamber size, elevating filling pressures, and worsening diastolic dysfunction.2Loutradis C. Sarafidis P.A. Papadopoulos C.E. Papagianni A. Zoccali C. The ebb and flow of echocardiographic cardiac function parameters in relationship to hemodialysis treatment in patients with ESRD.J Am Soc Nephrol. 2018; 29: 1372-1381Crossref PubMed Scopus (17) Google Scholar Guidelines recommend evaluating ejection fraction at the time of dialysis initiation, when patients reach dry weight, and then every 3 years.1National Kidney FoundationK/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients.Am J Kidney Dis. 2005; 45: S1-S153Google Scholar However, echocardiography is infrequently performed at these intervals, limiting the timely detection of asymptomatic left ventricular (LV) dysfunction.3Pandey A. Golwala H. DeVore A.D. et al.Trends in the use of guideline-directed therapies among dialysis patients hospitalized with systolic heart failure: findings from the American Heart Association Get With The Guidelines-Heart Failure Program.JACC Heart Fail. 2016; 4: 649-661Crossref PubMed Scopus (13) Google Scholar,4Chang S.M. Hakeem A. Nagueh S.F. Predicting clinically unrecognized coronary artery disease: use of two- dimensional echocardiography.Cardiovasc Ultrasound. 2009; 7: 10Crossref PubMed Scopus (19) Google Scholar There is growing interest from nephrologists to learn and use point-of-care ultrasound (POCUS) to assess cardiac function.5Mullangi S. Sozio S.M. Hellmann D.B. et al.Integrative point-of-care ultrasound curriculum to impart diagnostic skills relevant to nephrology.Am J Kidney Dis. 2019; 73: 894-896Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In this study, we sought to determine whether focused cardiac POCUS can successfully ascertain ejection fraction in patients undergoing outpatient hemodialysis without interfering with dialysis clinic operations. We conducted a cross-sectional study at 2 outpatient hemodialysis clinics from September to November 2018 (Fig S1; IRB00132750). We trained a nephrology fellow (S.L.) and a third-year medical student (S.A.; “operators”) to obtain POCUS-derived cardiac parasternal long-axis views using a Vscan device (maximum depth, 24 cm; GE healthcare).5Mullangi S. Sozio S.M. Hellmann D.B. et al.Integrative point-of-care ultrasound curriculum to impart diagnostic skills relevant to nephrology.Am J Kidney Dis. 2019; 73: 894-896Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,6Mullangi S. Sozio S.M. Segal P. Menez S. Martire C. Shafi T. Point-of-care ultrasound education to improve care of dialysis patients.Semin Dial. 2018; 31: 154-162Crossref PubMed Scopus (12) Google Scholar We obtained the images in the first 30 minutes of hemodialysis to avoid the risk for misinterpretation due to the potential for myocardial stunning with intradialytic hypotension. We also abstracted information from dialysis and health records. We calculated ejection fraction from the cardiac parasternal long-axis view using the E-point septal separation method7Massie B.M. Schiller N.B. Ratshin R.A. Parmley W.W. Mitral-septal separation: new echocardiographic index of left ventricular function.Am J Cardiol. 1977; 39: 1008-1016Abstract Full Text PDF PubMed Scopus (94) Google Scholar, 8McKaigney C.J. Krantz M.J. La Rocque C.L. Hurst N.D. Buchanan M.S. Kendall J.L. E-Point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction.Am J Emerg Med. 2014; 32: 493-497Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 9Ginzton L.E. Kulick D. Mitral valve E-point septal separation as an indicator of ejection fraction in patients with reversed septal motion.Chest. 1985; 88: 429-431Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and categorized patients into ejection fraction < 45% or ejection fraction ≥ 45% groups (Fig S2). All images were interpreted by the POCUS operator, followed by a blinded review by an echocardiographer with 30 years of experience (C.M.). A cardiologist (S.Z.) then reviewed all abnormal results and an additional 10% of random images. We compared ejection fraction assessment by the operator (index test) versus echocardiographer (reference standard) and calculated 95% CIs for the performance metrics using bootstrapping (10,000 resamples). We completed POCUS on 57 participants; all studies were performed in the first 30 minutes of hemodialysis without interrupting patient-care tasks. Of the 57 patients, 52 (93%) had satisfactory images for interpretation and comprised the analytic cohort. The 5 patients with unsatisfactory images were due to obesity (n = 3), mitral stenosis (n = 1), and errors in saving images (n = 1). Mean age was 65 ± 13 years, 96% were Black, and 44% were women (Table 1). The average time to obtain images was 3.2 ± 1.7 minutes. Image interpretation concordance was 64% between the operator and echocardiographer and 100% between the echocardiographer and cardiologist. Operator-assessed low ejection fraction (<45%) was 93% sensitive and 51% specific, with a positive predictive value of 44% and negative predictive value of 95% (Fig 1). Among the 15 participants with low ejection fraction, 40% did not have a prior heart failure diagnosis and 53% were not receiving renin-angiotensin system–blocking medications. Fifty participants had undergone formal echocardiography in the prior 3 years (Table S1). Notably, 42 had an ejection fraction ≥ 45%, and of those, 8 (19%) had a low ejection fraction detected using POCUS evaluation.Table 1Baseline Characteristics of the 52 ParticipantsCharacteristicResultsNo. of patients52Age, y64.8 ± 13.0Race, African American50 (96.2%)Sex, female23 (44.2%)Body mass index, kg/m228.9 ± 7.9Weight, kg83.7 ± 27.3Duration of dialysis, mo34.3 [11.3-56.3]Clinical diagnosis of heart failure20 (38.5%)β-Blockers38 (73.1%)ACEi/ARB16 (30.8%)Both β-blockers and ACEi/ARB12 (23.1%)Day of scan Monday or Tuesday27 (51.9%) Wednesday or Thursday18 (34.6%) Friday or Saturday7 (13.5%)Note: Data are mean ± standard deviation, median [25th-75th percentile], or number (percent), with percentages based on the total number in the corresponding column.Abbreviations: ACEi, angiotensin-converting enzyme inhibitor, ARB, angiotensin receptor blocker. Open table in a new tab Note: Data are mean ± standard deviation, median [25th-75th percentile], or number (percent), with percentages based on the total number in the corresponding column. Abbreviations: ACEi, angiotensin-converting enzyme inhibitor, ARB, angiotensin receptor blocker. The results of our study support the use of focused cardiac POCUS in patients undergoing hemodialysis in the outpatient setting. In most patients, POCUS can quickly obtain diagnostic images to screen for low ejection fraction without burdening patients or hindering care. Initial POCUS interpretation by the operator was reasonably reliable in excluding significant LV dysfunction; however, <50% of patients with abnormal findings were noted to have a low ejection fraction by the echocardiographer and cardiologist. Thus, our findings suggest that operator interpretation of POCUS is a useful screening tool for low ejection fraction, but a formal review of abnormal findings is necessary before initiating further diagnostics and cardiac treatments. Of note, POCUS imaging is helpful for more than just determining ejection fraction. It can also be used to obtain a limited echocardiogram (Current Procedural Terminology code 93308) in the hemodialysis clinic to provide information on chamber size, aortic root diameter, LV hypertrophy, pericardial and pleural effusions, and inferior vena cava. Therefore, there may be even more utility in considering POCUS in the outpatient dialysis setting, with careful oversight from echocardiographers and imaging cardiologists. Our pilot study was potentially limited by the use of POCUS on varied days of the week, which can affect imaging parameters depending on the amount of interdialytic intravascular congestion. In addition, we used the E-point septal separation method for ejection fraction estimation, which is not accurate in the presence of mitral stenosis, aortic regurgitation, or atrial fibrillation and is less accurate than ejection fraction assessment using traditional echocardiographic parameters. Despite these limitations, our study demonstrates the potential to bring cardiac POCUS to the dialysis clinic, help detect low ejection fraction, and guide medical care in this high-risk population. In summary, our study suggests that focused cardiac POCUS is feasible in US dialysis clinics and can be used to screen for low ejection fraction and guide management. Further studies are needed to evaluate large-scale implementation strategies and whether timely imaging can improve outcomes for patients treated with hemodialysis. Sadichhya Lohani, MBBS, Surekha Annadanam, MD, Carol Martire, RDCS, RDMS, Sammy Zakaria, MD, MPH, Seungyoung Hwang, MS, MSE, Bernard G. Jaar, MD, MPH, Stephen M. Sozio, MD, MHS, MEHP, and Tariq Shafi, MBBS, MHS. Research idea and study design: TS, SL, SA; data acquisition: SL, SA; data analysis/interpretation: SL, SA, CM, SZ; statistical analysis: SH; supervision or mentorship: TS, BJ, SMS. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. This work was supported by the Johns Hopkins Center for Innovative Medicine (CIM), United States . Dr Shafi was a CIM Scholar. The funder of this study did not have any role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication. The authors declare that they have no relevant financial interests. The authors thank the patients, staff, and physicians of DaVita dialysis clinics and the Nephrology Center of Maryland for their support. Parts of this work were presented at the National Kidney Foundation 2019 Spring Clinical Meeting, May 8–12, 2019, Boston, MA. Received June 12, 2020. Evaluated by 1 external peer reviewer, with direct editorial input from the Statistical Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form November 21, 2020. Download .docx (.17 MB) Help with docx files Supplementary File (PDF)Figure s S1-S2, Table S1

  PublisherDOI

• An Unusual Presentation of Atypical Hemolytic Uremic Syndrome in a Patient with Skin Ulcerations

  Journal of the American Society of Nephrology · 2020-10-01

  articleSenior author

  Introduction: Atypical hemolytic uremic syndrome (aHUS), characterized by microangiopathic anemia and acute kidney injury (AKI), is a rare and debilitating disease, but its diagnosis can be difficult because of potential overlap with several other autoimmune conditions. We present a case of aHUS-induced acute renal failure with skin ulcerations as initial presentation. Case Description: A 61-year-old female presented with progressively worsening skin ulcerations on her hands after two cycles of rituximab and bendamustine for B-Cell chronic lymphocytic leukaemia. She also reported cocaine use. On presentation, her physical exam was notable for bilateral ulcers on her knuckles and ankles. She was treated empirically for osteomyelitis without improvement. Skin biopsy was non-diagnostic. She was noted to have anemia, thrombocytopenia and AKI with nephrotic-range proteinuria. Other remarkable labs included a low haptoglobin and a high LDH. Urinalysis revealed dysmorphic red blood cells, and peripheral smear showed schistocytes. An autoimmune process was suspected; thus, pulse steroids was initiated. A renal biopsy was suggestive of thrombotic microangiopathy (TMA). A full immunological work-up eventually returned unremarkable. Plasmapheresis was initiated before her ADAMTS13 activity resulted at > 10%. She was then started on eculizumab. After one session of plasmapheresis and four doses of weekly eculizumab 900 mg, her platelet counts improved. However, she required initiation of renal replacement therapy. TMA panel and genetic testing showed a low factor H level and dysregulated complement cascade consistent with aHUS despite negative CFH-CFHR5 mutation. She had some improvement in urine output but continued to require hemodialysis on discharge. Biweekly eculizumab 1200 mg was continued with plan to closely monitor for renal recovery. Discussion: Although a rare disease with features that may overlap with other autoimmune processes, aHUS can cause rapid decline in renal function, thus requiring early recognition and treatment. CHF-CFHR5 mutation can be negative in ˜40% of the patients. In the presence of the dysregulated complement cascade, microangiopathic process and renal failure, early treatment with eculizumab is crucial in renal recovery, but the renal response to treatment can be delayed compared to the hematologic response.

  PublisherDOI

• In The Era of Precision Medicine- Where Does the Diagnosis “Hypertensive Kidney Disease” Fit?

  Archives of Clinical and Medical Case Reports · 2020-01-01

  articleOpen access1st authorCorresponding

  Hypertension has been labeled as a cause of non-diabetic chronic kidney disease for decades. In today’s era of precision medicine, labeling benign hypertension as the initial etiology for chronic kidney disease might not be accurate. We discuss an example of a 55-year-old African American patient with pathologic findings of nephrosclerosis without history of hypertension. The pathologic findings of nephrosclerosis can be as a result of obesity, aging, genetic susceptibility and variety of other previously undiagnosed primary renal disease, and hence shouldn’t automatically mark the diagnosis of hypertensive nephrosclerosis. Multiple studies to date have failed to prove or refute causality between benign hypertension and non-diabetic chronic kidney disease. Genome sequencing of non-diabetic kidney diseases have identified mutations in Apolipoprotein L1 gene, MYH9 gene and uromodulin gene as a risk factors for chronic kidney disease. There is no question that uncontrolled hypertension leads to progression of kidney disease, and hence blood pressure should be controlled adequately. The relationship between hypertension and kidney dysfunction should be viewed as an association and broad differential diagnoses should be pursued.

  PublisherDOI

• Contrast Media—Different Types of Contrast Media, Their History, Chemical Properties, and Relative Nephrotoxicity

  Interventional Cardiology Clinics · 2020-05-26 · 24 citations

  review1st authorCorresponding
  PublisherDOI

• Urinalysis and Urine Electrolytes Among Patients with COVID-19 Infection and AKI

  Journal of the American Society of Nephrology · 2020-10-01

  article

  Background: Determining intravascular volume status for patients who have COVID-19 infection and AKI is critical for guiding decisions about fluid management and treating AKI. In this study, we present data on urinalysis and urine electrolytes among patients with COVID-19 infection who developed AKI at our hospital. Methods: This is a cohort of patients with COVID-19 who were diagnosed with AKI at our center in Spring of 2020 and had a urinalysis performed within 48 hours of diagnosis of AKI. When applicable we used Mann-Whitney test to compare groups. Results: 34 patients had AKI, 21 (61%) were female, and 21 (61%) were Black race. All patients had a urinalysis, 23 (68%) had a urine sodium (UNa), and a 21 (61%) had a urine FeNa (fractional excretion of sodium). The median urine specific gravity (SG) was 1.019 (IQR 1.04 - 1.026). The median UNa was 39 (IQR 24 - 55). The median FeNa was 0.69% (IQR 0.18% - 1.07%). Figure 1 shows the distribution of urine SG by FeNa. The median serum creatinine at the time of diagnosis was 2.42 (IQR 1.52 - 3.92). A diagnosis of ATI (acute tubular injury) was made by the treating physician in 17 (50%) patients. The median creatinine at the time of diagnosis for patients who were diagnosed with ATI was 3.35 (IQR 2.29 - 5.16), and for those without ATI was 1.61 (IQR 1.48 - 2.63), p-value 0.0641. The median FeNa for patients who were diagnosed with ATI was 0.85% (IQR 0.56%-1.97%), and for those without ATI was 0.33% (IQR .12%-1.27%), p-value 0.105. Conclusions: In our cohort, the majority of patients with AKI had urine studies consistent with volume depletion, suggesting that volume depletion is common. Implementation of urine studies in COVID-19 patients as part of regular care might help guide treating physicians deciding about fluid management.

  PublisherDOI

• Persistent Interferon Production by Double Negative T Cells and Collapsing Focal Segmental Glomerulosclerosis

  ˜The œNephron journals/Nephron journals · 2020-10-15 · 2 citations

  articleOpen access1st authorCorresponding

  Collapsing glomerulopathy has multiple associations, including viral infections, medications like bisphosphonates and interferon, autoimmune diseases, and genetic predisposition. We report a case of collapsing focal segmental glomerulosclerosis associated with persistently high levels of interferon gamma produced by T-cell receptor αβ (+), CD4- CD8- (double negative) T lymphocytes that progressed despite treatment and improvement of other cytokine levels. Double negative T cells are elevated and activated in autoimmune lymphoproliferative syndrome (ALPS). Production of elevated interferon gamma levels from double negative T cells in ALPS despite treatment provides insight to the pathophysiology of collapsing glomerulopathy, guiding future research for collapsing glomerulopathy.

  PublisherOA PDFDOI

• Point-of-Care Ultrasound Findings Among Dialysis Patients with COVID-19

  Journal of the American Society of Nephrology · 2020-10-01

  article1st authorCorresponding

  Background: Dialysis patients are vulnerable in the COVID-19 pandemic due to advanced age, comorbidities, and obligate travel with frequent healthcare contacts. Pointof-care cardiac and lung ultrasound (US) has been used to enhance the physical exam in dialysis patients and is a potent tool for assessment COVID-19, comparing favorably to computed tomography. Here we report findings of focused cardiac and lung US among dialysis patients in an acute care setting. Methods: This is a cohort of dialysis patients who presented to our institution in Spring of 2020 with COVID-19. All patients started dialysis prior to the index acute care visit. Focused 5-view cardiac assessment and 12-zone lung US were obtained according to published protocols. Results: 25 patients were included. 88% were African American. 64% were female. Mean age was 61.96 and body mass index was 25.8 kg/m2. 56% had history of heart failure, 28% lung disease. 15 (60%) were discharged with mean length of stay 10 days. 36% required invasive mechanical ventilation and 56% intensive care unit admission. 23 patients had cardiac US. 17 had an ejection fraction (EF) >55%, 3 had EF 30-55%, 1 had EF <30%. 23 had inferior vena cava (IVC) assessment, 18 had a normal or collapsed IVC, and 5 had a full, non-collapsing IVC. 3 had pericardial effusion. 4 had right-ventricular dysfunction. 25 completed anterior lung US zones and 12 also had posterior lung US. In at least 1 lung zone 16 (64%) had confluent B-lines, 16 (64%) consolidations, 16 (64%) isolated B-lines, and 17 (68%) pleural thickening. 8 had pleural effusions (3 bilateral). Figure 1 details lung US findings across anatomical zones. Conclusions: We showed a high prevalence of thickened pleural lines, subpleural consolidations, and multifocal or confluent B-lines among dialysis patients with COVID-19. Most had a normal or collapsed IVC and intact cardiac function. Pleural and pericardial effusions were uncommon. More study is needed to determine whether US findings can help guide fluid management in dialysis patients.

  PublisherDOI

Frequent coauthors

• S Shrestha

  Nepal Development Research Institute

  12 shared

• Nathaniel Reisinger

  University of Pennsylvania

  7 shared

• Bernard G. Jaar

  Johns Hopkins University

  6 shared

• Anubhav Poudel

  National Academy of Medical Sciences

  4 shared

• Sammy Zakaria

  Johns Hopkins Medicine

  4 shared

• Seeprata Parajuli

  4 shared

• Usha Ghimire

  Dhulikhel Hospital

  4 shared

• Pranawa Koirala

  Mountain Medicine Society of Nepal

  4 shared

Labs

• Sadichhya Lohani LabPI