Not All Leg Swelling Is Volume Overload: Point-of-Care Ultrasound and Sirolimus-Associated Lymphedema After Combined Heart-Kidney Transplant.

A 65-year-old man, one year post combined heart-kidney transplant, presented with acute kidney injury, dyspnea, and progressive leg edema unresponsive to escalating diuretics. Despite suspicion for volume overload, multi-organ point-of-care ultrasound (POCUS) revealed bilateral A-lines without B-lines or effusions, a small collapsible inferior vena cava, and preserved biventricular function, all inconsistent with cardiogenic congestion. The edema was attributed to sirolimus-associated lymphedema. Diuretic cessation and transition from sirolimus to everolimus improved renal function. This case illustrates the utility of integrated multi-organ POCUS in challenging assumptions about volume status and underscores the importance of contextualizing findings across multiple sonographic windows.