Interventional Nephrology

Interventional Nephrology

The incidence of ESRD is increasing, with a current prevalence of over half a million patients in the United States. Most ESRD patients are treated with hemodialysis (HD) and the number of patients receiving peritoneal dialysis (PD) has steadily declined over the past several decades. According to the U.S. Renal Data System 2011 annual report, approximately 7 percent of patients were being treated with PD at the end of 2009, reflecting gross underuse of this form of therapy (1).

Interventional nephrology has become a growing and distinct discipline within nephrology. The first two articles in this special section deal with everyday issues that practicing nephrologists, dialysis nurses, and technicians encounter.

In “The PICC Conundrum: Vein Preservation and Venous Access,” Dr. Pflederer provides background on the increasing use of PICC lines and how their use impacts CKD patients who will require vascular access. Indeed, Dr. Pflederer’s article may serve as a resource for developing a PICC line use policy.

Over the past four decades, ultrasonography has become an indispensable tool because of its safety, availability, and low cost. Accordingly, many specialties have incorporated ultrasonography into their core training programs for visualization of relevant organs and guidance of procedures (e.g., echocardiograms in cardiovascular medicine, pelvic ultrasounds in gynecology and obstetrics, thyroid ultrasounds in endocrinology, abdominal ultrasounds in trauma and emergency medicine).

Hemodialysis (HD) sustains life for those with ESRD. Currently, nearly 400,000 individuals in the United States receive HD as management of ESRD (1). Sustainable vascular access that provides high-volume blood flow rates (Qb) above 300 mL/min is essential, whether through arteriovenous autologous fistulas, synthetic grafts, or tunneled dialysis catheters (TDCs) (2). Unfortunately, the overwhelming majority of incident patients begin HD treatments with a TDC: 82 percent, according to the most recent data from the U.S.

Interventional nephrology is in the midst of an exponential growth phase, with data from the U.S. Renal Data System suggesting that at least 25 percent of total vascular access procedure costs are billed by nephrologists (1).

Nephrologists enjoy an unusually close and extended relationship with their patients, often lasting decades through the evolution of chronic kidney disease to the eventual long-term management of ESRD. Their unique perspective on the importance of dialysis access has led to an intense interest in the field, resulting in the emergence of a distinct discipline within nephrology: interventional nephrology.

Peripherally inserted central venous catheters (PICC lines) are being used with increasing frequency in the hospital and outpatient settings for patients who require venous access. Originally intended as a less invasive way to obtain long-term central venous access, PICC lines are now being used for a growing number of indications. Patients who require an extended course of antibiotics or other medications were often chosen to have a PICC line placed after treatment was begun with a peripheral intravenous (IV ) catheter.