CJASN ePress. Published on October 7, 2010 as doi: 10.2215/CJN.03990510 Special Feature

Successful Models of Interventional Nephrology at Academic Medical Centers

Tushar J. Vachharajani,* Shahriar Moossavi,* Loay Salman,† Steven Wu,‡ Ivan D. Maya,§ ʈ Alex S. Yevzlin, Anil Agarwal,¶ Kenneth D. Abreo,** Jack Work,†† and Arif Asif† * Access Group of Wake Forest University School of , Department of , Winston-Salem, North Carolina; †Interventional Nephrology, University of Miami Miller School of Medicine, Miami, Florida; ‡Interventional Nephrology, Massachusetts General -Harvard University, Boston, Massachusetts; ʈ §Interventional Nephrology, University of Alabama, Birmingham, Alabama; Interventional Nephrology, University of Wisconsin, Madison, Wisconsin; ¶Interventional Nephrology, Ohio State University, Columbus, Ohio; **Interventional Nephrology, Louisiana State University Health Sciences Center, Shreveport, Louisiana; and ††Dialysis Access Center of Atlanta, Emory University, Atlanta, Georgia

The foundation of endovascular procedures by nephrologists was laid in the private practice arena. Because of political issues such as training, credentialing, space and equipment expenses, and co-management concerns surrounding the performance of dialysis-access procedures, the majority of these programs provided care in an outpatient vascular access center. On the basis of the improvement of patient care demonstrated by these centers, several nephrology programs at academic medical centers have also embraced this approach. In addition to providing interventional care on an outpatient basis, academic medical centers have taken a step further to expand collaboration with other specialties with similar expertise (such as with interventional radiologists and cardiologists) to enhance patient care and research. The enthusiastic initiative, cooperative, and mutually collaborative efforts used by academic medical centers have resulted in the successful establishment of interven- tional nephrology programs. This article describes various models of interventional nephrology programs at academic medical centers across the United States. Clin J Am Soc Nephrol 5: ●●●–●●●, 2010. doi: 10.2215/CJN.03990510

he steady increase in the incidence of chronic developed systems for training, quality assurance, and certifi- disease (CKD) in the United States has led to increased cation currently remain in evolution (3). The first AMCs to T demands for dialysis access-related procedures and im- initiate interventional nephrology services were established in posed a tremendous burden on the system. While the late 1990s and early 2000s and have provided excellent nephrologists’ and colleagues have made patient care (3,8). concerted efforts to deliver timely care, treatment delays persist The most common AMC-based programs can be broadly (1–3). To optimize care, procedural aspects of nephrology have defined as: (1) hospital-based programs; (2) free-standing out- steadily evolved over the past decade. Gerald Beathard (4,5), in patient dialysis-access centers; (3) interventional nephrology private practice, laid the foundation for endovascular proce- programs collaborating with cardiac catheterization laborato- dures to be performed by nephrologists and initiated this spe- ries; and (4) interventional nephrology programs collaborating cialty’s much-needed training component. The American Soci- with . In this report, we describe pro- ety of Diagnostic and Interventional Nephrology (ASDIN) was grams successfully established in academic settings across the founded in 2000, and its published training guidelines gener- United States. It is anticipated that the description of these ated a renewed interest among nephrologists not only to master programs will encourage other AMCs to evaluate their re- procedural skills but also to participate actively in coordinating sources and develop their own interventional nephrology ser- and becoming team leaders in dialysis-access care (6,7). vices. Early interventional nephrologists’ initiatives led to signifi- cant improvements in the fragmented and suboptimal proce- dural aspects of nephrology, with a steady growth of such Model of a Hospital-based Program programs at academic medical centers (AMCs), although well- Louisiana State University Health Sciences Center, Shreveport (LSUHSC-S) The Interventional Nephrology Program of LSUHSC-S was

Published online ahead of print. Publication date available at www.cjasn.org. established in 1995 under the direction of Jack Work, then Chief of Nephrology. Procedures were performed in a single suite Correspondence: Dr. Tushar J. Vachharajani, Internal Medicine/Nephrology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, next to the acute unit. LSUHSC-S was one of the NC 27157. Phone: 336-716-8341; Fax: 336-716-4318; E-mail: [email protected] first AMCs to establish a nephrologist-run facility with the sole

Copyright © 2010 by the American Society of Nephrology ISSN: 1555-9041/511–0001 2 Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol 5: ●●●–●●●, 2010 purpose of providing vascular and peritoneal access for dialysis lar access interventions and does not perform kidney patients. Other AMCs have since followed their lead and es- or catheter placements. Endovascular pro- tablished hospital-based interventional nephrology programs, cedures include fistulograms, percutaneous balloon angioplas- including St. Louis University, University of Louisville, Uni- ties, thrombectomies, and advanced procedures such as intra- versity of Oklahoma, University of Kentucky, University of vascular coil and stent insertions. Catheter-related procedures California, Davis, and University of Michigan. include tunneled and nontunneled catheter placements, ex- Staffing, Equipment, and Patient Care Services. The cur- changes, and fibrin sheath disruptions. rent facility has two suites, each containing an operating table, Most (62%) of the patients at WFUSM have arteriovenous two operating room lights, an ultrasound machine, and a C- fistulas (AVFs), and 15% have arteriovenous grafts as their arm. Additional rooms are available for vascular ultrasound vascular access. A cuffed tunneled catheter is the initial vascu- studies, catheter removals, computerized data recording, and lar access in 80% of the incident dialysis population, with 26% general storage. Its proximity to the acute hemodialysis unit is remaining catheter-dependent, similar to national data re- convenient for providing hemodialysis to patients before and ported in the United States Renal Data System database. The after procedures. Some nurses are cross-trained in hemodialy- center has successfully performed 2624 procedures since its sis and can provide assistance in the acute hemodialysis unit. inception, an average of 1.53 procedures per patient per year. Initially, the program at LSUHSC-S provided limited ser- Fellow Training. The nephrology fellows of WFUSM are vices, restricted to placing peritoneal dialysis catheters, cuffed currently trained in interventional procedures. Additional re- tunneled hemodialysis catheters, and thrombolysis/angio- sources are being organized to offer a third year of training for plasty for clotted arteriovenous grafts. The program gradually candidates interested in obtaining certification and pursuing expanded to include advanced procedures, such as stent place- interventional nephrology as a career. Didactic lectures on di- ments and obliterating accessory veins of immature arterio- alysis access have been incorporated into the regular venous fistulas. The referral base is from diverse sources: 250 to syllabus as part of general nephrology training. 300 maintenance hemodialysis patients followed by faculty, private practice patients, / referrals for University of Miami Miller School of Medicine port catheter placements, and hematology/oncology, neurol- Staffing, Equipment, and Patient-care Services. Univer- ogy, and medicine referrals for central venous catheters, sity of Miami Miller School of Medicine’s program began about trauma lines, and tunneled catheters for and a decade ago with an ultrasound program and peritoneal and cytapheresis. tunneled catheter-related procedures. It has since expanded to Fellow Training. All nephrology fellows have the oppor- offer a wide range of endovascular services, similar to those tunity to train in interventional nephrology for 4 months dur- noted above, and currently performs 750 to 900 procedures per ing their general nephrology fellowship. Four fully trained year. The program was one of the first AMCs to report its faculty members perform all procedures and supervise the experience and has made major contributions to the literature. fellows. The center has two procedure rooms, a pre- and postprocedure recovery area, C-arms, a portable ultrasound machine, and a Models of Free-standing Outpatient Access peritoneoscope. Two ASDIN-certified interventional nephrolo- Centers gists serve as team leaders. Renal fellows and the nephrology Wake Forest University School of Medicine (WFUSM) staff form the backbone of the program. WFUSM operates 14 outpatient dialysis facilities across Fellow Training. The program offers rotations to fellows northwestern North Carolina and is one of the nation’s largest to familiarize them with a variety of interventional nephrology university-run programs, managing over 1200 dialysis patients. procedures. Over 25 nephrologists have received endovascular Approximately 50% of the patients are managed by several training at this program. nonacademic community nephrology groups. WFUSM’s off- campus vascular access center, Dialysis Access Group, was Emory University established in January 2007. The renal ultrasonography program at Emory began in Jan- Staffing, Equipment, and Patient-care Services. Dialysis uary 1994. Since then, over 5900 ultrasound studies have been Access Group uses two ASDIN-certified interventional neph- performed, with approximately 100 currently performed each rologists and has two procedure rooms, a nine-station pre- and month (general study topics shown in Table 1). postprocedure recovery area, and required clean and dirty The interventional nephrology program began in June 2001. storage areas. Major equipment includes two C-arms, a porta- Initially the program was hospital-based, located first in inter- ble ultrasound machine, two radiology procedure tables, car- ventional radiology and then in a cardiac catheterization labo- diac monitors, a crash cart, infusion pumps, and bedside blood ratory. The Dialysis Access Center of Atlanta, a freestanding monitoring devices. center, opened in January 2003 as an extension of the Emory Referrals from various dialysis centers are on the basis of . regular monitoring of the vascular access by trained dialysis Staffing, Equipment, and Patient-care Services. The cen- personnel using Kidney/Dialysis Outcomes Quality Initiatives ter, staffed by three ASDIN-certified nephrologists, has two (K/DOQI) guidelines and a blood flow surveillance program. procedure rooms and a pre- and postprocedure recovery area At present the center limits procedures to hemodialysis vascu- and is equipped similarly to other freestanding centers. Since Clin J Am Soc Nephrol 5: ●●●–●●●, 2010 Interventional Nephrology at AMCs 3

Table 1. Ultrasound examination performed at Emory formed are similar to other academic interventional programs. University This program has enjoyed yearly growth over its 5-year lifes- pan, with success and complication rates well within Kidney/ Diagnostic studies of native kidneys and allografts Dialysis Outcomes Quality Initiatives guidelines. Screening of end-stage kidneys for carcinoma Fellow Training. UWSMPH nephrology fellows before Guidance for percutaneous renal 2008 were trained in these procedures as part of their general Diagnostic studies of urinary bladders and nephrology training. Didactic lectures on dialysis access have measurement of post-void bladder volume been incorporated into the regular fellowship syllabus as part Visualization of veins for central venous catheterization of general nephrology training. In 2008, a third year of ad- vanced interventional training was added. To date, two fellows have completed this training. opening in 2003, the center has performed over 10,800 proce- dures. Models of Collaboration with Interventional Fellow Training. Formal, comprehensive ultrasound train- Radiology ing is incorporated into the nephrology fellowship training Ohio State University (OSU) program. Fellows rotate through the ultrasound service for The Interventional Nephrology program at OSU College of several months, performing all studies under faculty supervi- Medicine and was established in 2004 to provide sion and participating in the interpretation of data and gener- vascular access care to hemodialysis patients. The center is ation of reports. The number and type of studies performed by located in one of the affiliated , utilizing their inter- each fellow are recorded, and fellows receive certificates doc- ventional radiology suites. umenting their training and experience in ultrasonography. Staffing, Equipment, and Patient-care Services. Three in- Over 40 clinical fellows have received this training. Training for terventionalists share the responsibility of performing proce- invasive procedures is offered both to practicing dures. There are two well-equipped suites primarily used by and to fellows. interventional nephrology but also by interventional radiology, interventional , , and pain medicine. Model of Collaboration with Cardiac The center has a seven-bed pre- and postoperative observation Catheterization Laboratories area. University of Wisconsin School of Medicine and Public The clinical nephrology program at OSU manages approxi- Health (UWSMPH) mately 200 dialysis patients at eight centers. The dialysis access UWSMPH has been involved in vascular access care through is routinely monitored at the dialysis centers with online access the University of Wisconsin Hospital cardiovascular medicine flow measurements. The total number of procedures performed laboratory since January 2005. General nephrology operates is limited by the size of the dialysis population. However, three outpatient dialysis facilities, directly managing approxi- because the service at the access center is expeditious, approx- mately 175 hemodialysis patients. Another 125 patients receive imately one-third of the patients seen at the center are referred hemodialysis care locally in a private group. While care of these by competing nephrology groups in the community. Besides patients was initially provided by interventionalists at a non- the core endovascular procedures, native and transplant renal university hospital, the academic program has now become a biopsies are performed on a regular basis. local referral resource for this practice. Additionally, over the Fellow Training. OSU nephrology fellows are offered 3 past 5 years, the center has witnessed a marked growth in months of rotation in the interventional suite each year to fulfill referrals from the region, representing a geographic radius of ASDIN certification requirements. Fellows uninterested in per- approximately 150 miles. forming procedures are allowed to trade their elective rotations Staffing, Equipment, and Patient-care Services. The on- with those who are. Currently, due to the limited number of campus, in-hospital vascular access center uses two ASDIN- procedures performed, the training is not offered to nephrolo- certified interventional nephrologists. The cardiovascular labo- gists in practice. ratory is a state-of-the-art facility that has five procedure rooms and a 14-station pre- and postprocedure recovery area. Major University of Alabama, Birmingham equipment includes five stationary C-arms, a portable ultra- Staffing, Equipment, and Patient-care Services. The Divi- sound machine, multiple cardiac monitors, crash carts, infusion sion of Nephrology of the University of Alabama, Birmingham, pumps, automated injectors, and bedside blood monitoring provides care to approximately 500 hemodialysis and 100 peri- devices. In addition, the laboratory is equipped with several toneal dialysis patients under the supervision of 12 nephrolo- endovascular devices that are not typically associated with gists. In July 2004, the departments of medicine and radiology interventional nephrology but that have been used to perform developed a combined interventional nephrology-radiology various advanced techniques in patients with challenging ac- service. Two access coordinators schedule and maintain a pro- cesses. spective, computerized database of all vascular access proce- The center only performs hemodialysis vascular access-re- dures (9). The procedures offered include kidney biopsy under lated procedures, not kidney biopsies or peritoneal dialysis real-time ultrasonography, peritoneal catheter placement, ve- catheter placements. The core endovascular procedures per- nous mapping, and core endovascular procedures as per- 4 Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol 5: ●●●–●●●, 2010 formed at other centers. Approximately 1400 procedures are content to avoid visiting major hospitals for procedures (10). performed each year. Mishler and Schon (11), who started a free-standing center in Fellow Training. Training is jointly supervised by inter- the private arena, have now established a close affiliation with ventional nephrology and radiology faculty members. A sepa- the University of Arizona, successfully maintaining the mission rate 1-year fellowship has been offered for the past 2 years. of training fellows and providing ideal patient care. However, Additionally, fellows have the opportunity to use interven- AMCs with dialysis populations of less than 300 to 400 may tional nephrology as an elective rotation. To date, seven fellows find it financially difficult to sustain a free-standing center. have completed training to achieve certification from ASDIN. Furthermore, being an outpatient clinic, hospitalized patients need separate arrangements for dialysis vascular access proce- Massachusetts General Hospital, Harvard dures, and co-morbidities such as mechanical heart valve, (MGH) known severe anaphylactic radiocontrast , compromised MGH’s program began in November 2004 in collaboration pulmonary or hemodynamic status, and morbid could with the vascular interventional radiology division. Nephrolo- be limiting factors in performing these procedures in outpatient gists at MGH originally had minimal input into dialysis vascu- settings. lar access. Discontent and discord were prevalent in nephrol- Collaboration allows the addition of advanced procedures ogy, vascular interventional radiology, and transplant surgery. such as excimer laser, endovascular ultrasound, endoluminal To improve the quality of care and create a mutually beneficial atherectomy devices (12); (13); renal artery intervention (14); work environment, collaboration between nephrology and vas- and tethered tunnel catheter removal using laser sheath (15). cular interventional radiology was explored. The collaboration Collaboration creates a bond among services, leading to a has resulted in a significant reduction in the number of late shift healthy work environment. Regular multi-specialty dialysis dialysis treatments and has improved utilization of nursing vascular access conferences improve understanding of associ- time and financial resources (S.W., unpublished data). Commu- ated problems and overall quality of care. Treatment plans for nication among nephrology and vascular interventional radiol- patients with difficult vascular access can be effectively formu- ogy staff, nurses, and technologists has also improved. The lated and implemented as a team, avoiding delays and unnec- combined program, equipped with a dedicated procedure essary multiple visits. room and a full-time access coordinator, has seen a steady increase in referrals since 2005. Major Hurdles in Establishing AMC-based Programs Fellow Training. MGH nephrology fellows are offered There is a potential for political “turf” issues and/or dis- training as an elective rotation. Establishment of a formal train- agreements over financial matters if there is a lack of strong ing program jointly supervised by interventional nephrology support from the administration and leaders of various divi- and radiology faculty members is under consideration. sions (16). The training and credentialing of nephrologists re- main major hurdles for AMC-based programs. Several AMC- Pros and Cons of Interventional Nephrology based programs were established by nephrologists trained in at AMCs the private sector. Privileges to perform procedures were on the Hospital-based programs offer several unique advantages, basis of empirical observations until ASDIN published defini- highlighted in Table 2. However, a major disadvantage of hos- tive guidelines and criteria. The privilege to perform advanced pital-based programs is the lengthy process used by hospitals techniques (such as stent deployment and coil embolization) by in the procurement of new equipment. nephrologists currently remains institution-dependent. An un- Free-standing outpatient provide convenience, timeli- derstanding between interventional radiology and nephrology ness, and reduced anxiety for patients, who generally experi- at WFUSM to divide the patient workload on the basis of their ence minimal disruption of their dialysis schedule and are hospitalization status has been beneficial in improving patient care. Existing centers have managed to circumvent these prob- lems effectively, but nevertheless the hurdle remains; however, Table 2. Advantages of a hospital-based interventional the authors believe that available resources can be pooled and nephrology program an effective vascular access team can be created in most set- tings. The interventional fellow can take care of all acute noncuffed central lines, leaving the consult fellow to devote all his/her time doing consults. Achievements of AMCs Patient Care. Successful AMC-based programs have seen Surgeons and code team are available for back-up improvement in the overall care of dialysis-access patients, in case there is a surgical or medical emergency with equal success for patients on peritoneal dialysis and those in the interventional suite. on hemodialysis. For example, peritoneal dialysis utilization It is easy to collaborate and share resources with improved by 32% at the University of Miami after the interven- other interventional physicians in the hospital. tional nephrology program’s establishment (2). Peritoneal dial- In-patients requiring vascular access procedures ysis catheters placed by nephrologists have been reported to can be accommodated along with the out- survive longer with lower incidence of leaks and peritonitis patients. compared with surgical placements (17,18). Clin J Am Soc Nephrol 5: ●●●–●●●, 2010 Interventional Nephrology at AMCs 5

Similarly, endovascular interventions for dialysis vascular access by nephrologists have resulted in a greater number of patients dialyzing with an AVF. This improvement can be attributed to the greater awareness of the entire dialysis team and active implementation of timely and coordinated care. As shown in Figures 1 and 2, the AVF rate steadily improved at two AMCs after they established interventional programs with active nephrologist participation. Research. Vascular access research has been reported in the radiology, surgical, and nephrology literature. The effect of nephrologists’ active involvement in the care of dialysis vascu- lar access is evident in studies published since the development of interventional nephrology. Kian and Asif (19) reported that nephrologists have contributed to 57% of the studies published in peer-reviewed journals over the past decade, either indepen- dently or in collaboration (Figure 3), a significant number of which were from established AMCs. Moreover, of the total 1747 studies they noted, almost 50% were published in nephrology journals with high impact factors (Figure 4); however, the ma- Figure 2. Prevalent dialysis vascular access at Wake Forest jority were observational or review articles, with only 2.9% on University School of Medicine after establishing the free stand- basic science. Although AVF-related studies increased from ing access center. eight in 1997 to 57 in 2009, there remains a paucity of basic science research and randomized controlled studies. Incorpo- ration of dialysis-access teaching into general nephrology train- rising demands of the CKD population and has resulted in ing and more centers for basic vascular biology research are increased complication-related health care expenditures. There needed. are too few physicians in a single specialty to effectively man- age the vascular problems of the ever-growing dialysis popu- Rationale for the Development of Interventional Nephrology lation. Programs at AMCs A team approach is an effective, efficient way of providing A decade ago, radiologists and surgeons were the primary comprehensive care for dialysis access. Nephrologists can be vascular access care providers. However, their lack of key team leaders, coordinating care with other team members. A knowledge about dialysis, combined with minimal understand- nephrologist’s background knowledge and understanding of ing of issues related to access complications and their effect on dialysis patients’ needs can be combined with other team mem- quality of life, often resulted in apathetic, suboptimal, frag- bers’ surgical and procedural skills. Management of clinical mented, and delayed care and ultimately dissatisfied patients problems related to cardiac, endocrine, and metabolic disor- (20). A major obstacle in achieving efficient and comprehensive ders, along with vascular access surveillance and educating vascular access care for the CKD population is lack of a wide- dialysis personnel and patients, remain the primary responsi- spread mechanism of providing this care. The current para- bility of the nephrologist. Procedural skills make nephrologists digm of disorganized care between radiology and surgical ser- excellent team leaders, and the interventional radiology com- vices is clearly inefficient and insufficient in sustaining the munity recognizes that radiologists need to understand better the needs of the dialysis patient (21,22). A multidisciplinary approach is more beneficial to the dialysis population (23). A team approach in an academic environment provides fer- tile ground for proper exchange of ideas and optimal interven- tion. A regular case-directed conference attended by the team broadens understanding and creates opportunities for training. Active participation by residents from nephrology, radiology, and surgical training programs fills voids evident in individual training curricula. After graduation, trainees will be better pre- pared to cooperate and coordinate care rather than be preoc- cupied with unrelated “turf” issues. A major obstacle in providing optimal vascular access care is a shortage of physicians with necessary procedural skills. Na- tional -matching program statistics show that almost 30% of training spots in interventional radiology programs Figure 1. Arteriovenous fistula prevalence rate at the University have remained vacant every year since 2005 (http://www. of Wisconsin. nrmp.org/data/index.html). A collaborative effort is needed in 6 Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol 5: ●●●–●●●, 2010

1800 1600 1400 Other 1200 1000 800 Nephrology collaboration 600 57% 400 Nephrology alone 200 0 Articles

Figure 3. Nephrology contribution in peer-reviewed articles published in the last decade (adapted from reference 19).

improve both patient care and understanding of the vascular of dialysis access (24–26). Optimal utilization of resources and its economic benefits even in smaller hospitals is well-recognized and is applicable to academic vascular access programs (27,28).

Acknowledgments Amanda Goode, MA, Research Program Development Manager, De- partment of Internal Medicine, WFUSM, is acknowledged for invalu- able editorial assistance with manuscript writing.

Disclosures None.

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