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.
Historically, interventional nephrology began in the private practice sector. It was stimulated by a poorly functioning system that provided fragmented care, delayed treatment, and often resulted in poor vascular access care for hemodialysis patients (1). Nephrologists recognized a need for
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. However, PICC lines are now often chosen as the first-line access option in patients with difficult venous access regardless
Frederic Rahbari-Oskoui and William Charles O’Neill
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).
In nephrology, ultrasonography is ideally suited for visualizing the kidneys, bladder, and blood vessels and is essential for the diagnosis and treatment of patients with kidney diseases. However, formal training in ultrasonography is rarely included in nephrology training programs.
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). Indeed, it is likely that the growth of interventional nephrology as a distinct discipline within nephrology has played an important role in the success of process-of-care initiatives, such as Fistula First, which has raised the arteriovenous fistula (AVF) prevalence rate from 34 percent in December 2003 at the start of this initiative to 59.5 percent as of August 2011 (2).
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. Renal Data System (1). More than 20 percent of prevalent patients become or remain dependent on long-term TDC use,
Arterial calcification is a common problem in advanced kidney disease and contributes to the high prevalence of cardiovascular disease. There are two forms: neointimal calcification, associated with atherosclerosis, and medial calcification. The former is not exclusive to renal failure and occurs in anyone with atherosclerosis. It is unclear whether this has any clinical significance other than being a convenient marker of atherosclerosis. Medial calcification is independent of atherosclerosis and is strongly linked with chronic kidney disease (CKD). Recent data based on mammography show that there is a more than threefold risk of medial calcification in ESRD and that this risk
Keith Hruska, MD, chief of pediatric nephrology at Washington University in St. Louis, becomes the new president of the American Society for Bone and Mineral Research (ASBMR) at this month’s annual meeting of the ASBMR in San Diego. He will be the first nephrologist to hold this prestigious position in the history of the society.
“The bone–kidney connection has changed with new understanding of the pathophysiology of chronic kidney disease (CKD)-mineral bone disorder (MBD),” said Hruska, a longstanding member of the American Society of Nephrology (ASN). “The nephrology contingent in the ASBMR used to be much stronger. Hopefully we can
Phosphate is a true uremic toxin. Cross-sectional studies in patients undergoing dialysis uniformly demonstrate an increased risk of mortality with increasing phosphate levels. The population-attributable risk of mortality in dialysis patients is markedly greater for phosphate than anemia or urea reduction ratio. Additional cross-sectional studies in patients with and without chronic kidney disease (CKD) who are not yet receiving dialysis have demonstrated that phosphate levels in the upper quartile or tertile within this normal range have increased cardiovascular and/or all-cause mortality. In vitro, animal, and some human studies demonstrate that control of extracellular phosphate levels attenuates the process of vascular
One might think that rare diseases are rare. But if one were to combine all the rare diseases that affect Americans, the overall prevalence is not rare at all. In fact, 30 million Americans, or roughly 10 percent of the population, are affected by a rare disease. Many of these disorders are severe and lead to a significant effect on people’s lives and life expectancy. To bring new and concentrated attention to these often poorly studied disorders, 19 collaborative consortia were funded in 2009 by the Rare Disease Clinical Research Network, a project jointly sponsored by the National Institutes of
Of longstanding interest to nephrologists, vitamin D has now become a hot topic in the general medical and lay literature. While the beneficial effects of vitamin D on mineral metabolism have been appreciated for a century, a burgeoning body of literature attests to a multitude of other effects including modulation of the immune system, anti-infectious and anti-neoplastic effects, anti-proteinuric effects, antagonism of the renin angiotensin system with attendant cardiovascular benefits, and insulin-sensitizing effects.
Low vitamin D levels have been correlated with a greater incidence of several cancers including prostate and breast; autoimmune diseases such as multiple sclerosis; and metabolic syndrome.