Dialysis Vascular Access Management by Interventional Nephrology Programs at University Medical Centers in the United States

Interventional Nephrology: Opportunities and Challenges

The nephrologist has a pivotal role as the leader of multidisciplinary teams to optimize vascular access care of the patient on dialysis and to promote multidisciplinary collaboration in research, training, and education. The continued success of interventional nephrology as an independent discipline depends on harnessing these efforts to advance knowledge and encourage innovation. A comprehensive curriculum that encompasses research from bench to bedside coupled with standardized clinical training protocols are fundamental to this expansion. As we find ourselves on the threshold of a much-awaited revolution in nephrology, there is great opportunity but also formidable challenges in the field - it is up to us to work together to realize the enormous potential of our discipline.

Dialysis access procedure training for the nephrologist

Historically, the placement and maintenance of dialysis access has been an integral part of nephrology training. However, in recent years, a big debate has ensued regarding whether this should be limited to trainees' understanding and counseling the patients regarding indications, alternatives, risks and possible complications of these procedures or should it actually involve more of a hands-on experience for the trainees. Some of the barriers in making these procedures a requirement across the board are the lack of standardization of procedural training across various training programs and the absence of consensus on what achieving competency in these procedures looks like. However, in the era of declining interest in nephrology, giving up "ownership" of nephrology procedures and increasing reliance on other sub specialties might be a deterrent in attracting residents to this field; we have to make a concerted effort to increase the exposure and opportunities for the trainees to perform these procedures. Moreover, we need to emphasize the implementation of a curriculum for nephrology fellows to evaluate access properly in order to decrease the burden of access related complications. Lastly, we need to continue working towards a more structured curriculum for a dedicated interventional nephrology fellowship for trainees who want to focus on procedures for their long-term career goals.

Fistula First Initiative: Historical Impact on Vascular Access Practice Patterns and Influence on Future Vascular Access Care

The vascular access is the lifeline for the hemodialysis patient. In the United States, the Fistula First Breakthrough Initiative (FFBI) has been influential in improving use of arteriovenous fistulas (AVF) in prevalent hemodialysis patients. Currently, prevalent AVF rates are near the goal of 66% set forth by the original FFBI. However, central venous catheter (CVC) rates remain very high in the United States in patients initiating hemodialysis, nearly exceeding 80%. A new direction of the of the FFBI has focused on strategies to reduce CVC use, and subsequently the FFBI has now been renamed the "Fistula First-Catheter Last Initiative". However, an AVF may not be the best vascular access in all hemodialysis patients, and arteriovenous grafts (AVG) and CVCs may be appropriate and the best access for a subset of hemodialysis patients. Unfortunately, there still remains very little emphasis within vascular access initiatives and guidelines directed towards evaluation of the individual patient context, specifically patients with poor long-term prognoses and short life expectancies, patients with multiple comorbidities, patients who are more likely to die than reach end stage renal disease (ESRD), and patients of elderly age with impaired physical and cognitive function. Given the complexity of medical and social issues in advanced CKD and ESRD patients, planning, selection, and placement of the most appropriate vascular access are ideally managed within a multidisciplinary setting and requires consideration of several factors including national vascular access guidelines. Thus, the evolution of the FFBI should underscore the need for multidisciplinary health teams with a major emphasis placed on "the right access for the right patient" and improving the patient's overall quality of life.

Outpatient removal of tunneled dialysis catheters by nephrology fellows in training at a Veterans Affairs Medical Center

BACKGROUND

Removal of tunneled dialysis catheters (TDC) usually occurs in dedicated procedure suites and is performed relatively rarely at the bedside. Scarce evidence exists in the literature to assess the safety and success of this procedure when performed during supervised academic training.

PATIENTS AND METHODS

We conducted a retrospective chart review of all TDC removals performed on an outpatient basis by nephrology fellows under faculty supervision during a 5-year period at an academic Veterans Affairs Medical Center. Data were collected regarding patient demographics, basic laboratory studies, pertinent clinical information and procedure-related variables. We evaluated the safety, success and complication rate of this procedure.

RESULTS

We identified 72 TDC removals that met the above criteria. Mean age was 63 ± 10 years. All patients were male and hypertensive, 68% were diabetic and 69% were African-American. Overall, 88% of procedures were performed in end-stage renal disease (ESRD) patients, while the rest had needed temporary dialysis for acute kidney injury. Notably, 49 patients (68%) were taking one or more of aspirin, clopidogrel or warfarin at the time of TDC removal. Overall complication rate was low (<2%). There was no increase in risk of bleeding, even in subjects receiving anti-platelet therapy; only one of the 49 patients (2%) had a minor bleeding complication.

CONCLUSIONS

Outpatient TDC removal by trainees was successful and safe in the vast majority of cases (99%). We propose that TDC removal skills should be actively pursued and acquired by all nephrology fellows. This would expand the scope of practice for future general nephrologists and facilitate timely patient care.

Emergence of Interventional Nephrology in the Asia-Pacific Region – A Report from New Zealand

Interventional nephrology is relatively a new field dealing with the procedural aspect of dialysis access. The subspecialty has focused on the nephrologist taking a lead role and learning the procedural skills needed to provide timely care to the end stage renal disease patients on dialysis. The subspecialty has been in existence for over a decade in the United States and is well accepted as a main-stream field. The safety and positive outcomes of nephrologists performing these procedures in the United States are being duplicated across the globe. The growing trend of acceptance of this field is evident in the Asia-Pacific region, which is rapidly embracing this new development. The current report from New Zealand is being presented here in this article.

Academic interventional nephrology: a model for training, research, and patient care

Dialysis vascular access dysfunction is currently a huge clinical problem. We believe that comprehensive academic-based dialysis vascular access programs that go all the way from basic and translational science investigation to clinical research to a dedicated curriculum and opportunities in vascular access for nephrologists in training are essential for improving dialysis vascular access care. This paper reviews the fundamental concepts and requirements for us to move toward this vision.