Interventional Nephrology

Interventional Nephrology

Autologous arteriovenous fistulae (AVF), compared with prosthetic arteriovenous grafts and central vein catheters, are the most effective hemodialysis vascular access option for patients who require renal replacement therapy because of ESKD (1). The effects of autologous AVF include lower thrombosis and infection rates, fewer hospital admissions for access revision, significantly lower mortality rates, increased life expectancy, and lower healthcare-related costs (2, 3).

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In 2019, a randomized controlled trial to evaluate the effect of arteriovenous fistula (AVF) ligation on cardiac structure and function in stable kidney transplant recipients was published in Circulation.

Kidney transplantation remains the best treatment option for patients with end stage kidney disease (ESKD). However, a dilemma faces healthcare providers when they care for ESKD patients: whether to ligate the patient’s arteriovenous (AV) access after kidney transplantation or leave it patent and maintain it. There is still considerable disagreement among providers on the best course of action when dealing with an AV access after kidney transplantation (1). In this article, I will discuss the disadvantages of ligating an AV access after kidney transplantation.

Arteriovenous fistula (AVF) is the preferred vascular access in hemodialysis patients because of its superior long-term patency and low risk of infection (1). The impact of AVF on the cardiovascular (CV) system has been an area of interest to the scientific community for decades, from the time soldiers sustained traumatic AVF in the battlefield to the first description of AVF use in dialysis patients in 1966 (2).

Peripherally inserted central catheters (PICC) are increasingly used in modern clinical practice, especially among critically ill patients (1). The main attraction to the use of PICCs in clinical practice is likely driven by their perceived safety, low procedural complication rate, ability to facilitate care transition, low cost, and ease of insertion (2, 3).

“Good morning, Dr. Ross!” the emergency medicine resident said. “Thank you for consulting on this case of acute kidney injury. We performed a sonogram of his lungs, heart, kidneys, and bladder. We’ve determined that he is volume depleted and has no signs of urinary obstruction.”

“Good evening, Dr. Ross!” the critical care fellow said. “We need to pull fluid on bed 12; he’s got B lines on lung ultrasonography.”

Forty percent of end stage kidney disease (ESKD) patients have a history of heart failure, and 39% have a history of ischemic disease at baseline [Hemodialysis (HEMO) study]. An arteriovenous (AV) access is the preferred access for dialysis, as it reduces risks of infections and hospitalizations and need for interventions. It is well documented that the creation of AV access can cause or aggravate heart failure (1). Typically, this occurs when an AV access turns into a high flow circuit, with resultant high output cardiac failure.

Hemodialysis vascular access remains both the lifeline and an Achilles heel for patients receiving hemodialysis (HD). Vascular access management was revolutionized by the Fistula First initiative, which led to a robust increase in arteriovenous fistula (AVF) placement in prevalent hemodialysis patients in the United States. However, >80% of dialysis patients still start HD with a central venous catheter (1).

I have been a dialysis or transplant patient since 1988. Alport’s syndrome, a familial illness, struck my family in 1971. That year, one of my older brothers became sick at 16 years of age and died later that year. My other two brothers got sick in 1973 and progressed to dialysis. Both received transplants in 1975, but my oldest brother succumbed to an opportunistic infection a year later. My younger brother is still living.

In 1996, the Kidney Disease Outcomes Quality Initiative (KDOQI) was created by a multidisciplinary group of physicians with the support of the National Kidney Foundation. It was the first literature-based practice guideline and was developed with the hope of measurably improving the quality of life and clinical outcomes for dialysis patients. To achieve this objective, four work groups were created, one of which was dedicated to clinical practice guidelines related to vascular access for patients requiring hemodialysis (HD) (1).

“Interventional Nephrology: Evolution, Challenges, and Opportunities” is the theme of this special issue of Kidney News. The field of interventional nephrology covers an area that is common to nephrologists, vascular surgeons, and interventional radiologists. In 2000, the American Society of Diagnostic and Interventional Nephrology (ASDIN) was founded, with the mission of promoting excellence in dialysis access care and improving outcomes for patients with kidney disease.

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).

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.