India is a developing country with a large patient population suffering from end stage kidney disease (ESKD) (1). The need for kidney replacement therapy in the form of dialysis ranges from being a planned procedure to an emergency requiring immediate initiation. Optimal dialysis access planning should ideally begin in the predialysis stage. The planning depends upon the co-morbidities, patient preferences, local anatomy, demographics (age and sex), and availability of an interventional nephrologist or radiologist. The goal of dialysis access planning is to obtain successful immediate and long-term dialysis access with the least number of complications. Indeed, where there is a vein, there is a way. The question that remains is: Who will pave this way: the nephrologist or the interventional radiologist?
ESKD patients tend to stay with their treating nephrologist for a long period of time. Patients develop a level of comfort and faith through their doctors, and thus, the nephrologist is in the best situation to know the special needs of each patient. In a setting with low financial resources, the nephrologist who can diagnose, treat, and rectify vascular access issues without delay or cost escalation will need to assume the role of the interventional nephrologist! Apart from financial limitations, there is a massive dearth of nephrologists in India, especially in the rural setting. This scarcity is second only to that of interventional radiologists, making the training of the nephrologist in interventions a much more prudent plan (1).
An interventional nephrologist is trained to do kidney ultrasounds and biopsies, which with a clinical history and laboratory values help inform a quick diagnosis and initiation of treatment. Even when it comes to modality and timing of access placement for peritoneal or hemodialysis, the nephrologist is the best judge of the patient's immediate and long-term needs. The percutaneous peritoneal dialysis catheter insertion success rates by nephrologists are on a par with surgical procedures, albeit with reduced need for general anesthesia and faster healing (2). Interventional nephrologists place both tunneled-cuffed and non-tunneled catheters with good success rates (3). The ownership of the results and further dialysis prescription and complications are easier to monitor, as all services have been provided by a single individual.
Commonly, definite diagnosis and treatment in nephrology warrant tissue diagnosis in the form of a kidney biopsy. This procedure has come a long way from being done as a surgical open-wedge biopsy to a blind percutaneous procedure using surface anatomy landmarks. Success of the procedure remains inconsistent and largely operator dependent. Refinement in the technique and appropriate training in ultrasound-guided real-time biopsy remain urgent needs. The introduction of ultrasonography-guided renal biopsies likely hearlded the paradigm of incorporating technology into nephrology.
Primary arteriovenous fistula (AVF) failure rates have been described at approximately 40%, with the majority of these due to juxta anastomotic stenosis (4). The nephrologist and the dialysis team can do a simple AVF examination before every dialysis and diagnose this condition early, thereby abetting the need for a fistuloplasty. This will reduce the dependence on temporary hemodialysis catheters and reduce healthcare costs and complications. Results of these procedures have an extremely favorable complication profile when done by a nephrologist (5). A nephrologist is likely to be the first responder in the case of an acute fistula thrombosis and can quickly make a diagnosis using examination and ultrasound. This will hasten the time for a thrombectomy and not allow the clot to organize, which could be challenging for an interventional radiologist who might be busy with other procedures. With time, the thrombi get organized and adhere to the vessel wall and may be refractory to removal by percutaneous methods.
Interventional nephrology has its own set of difficulties. A hurdle unique to India is the Pre-Conception and Pre-Natal Diagnostic Techniques Act of 1994, which was passed with the original intent to prevent female feticide after determination of prenatal sex. This act makes it difficult for nephrologists to have access to an ultrasound machine, as they are not trained as radiologists, thus necessitating assistance from their institutions to get a machine. The ultrasound machine must also be registered with the chief medical officer of the district (6).
Interventional radiologists are trained exclusively for intervention and spend most of their time performing interventions, whereas nephrologists are expected to balance a busy outpatient and inpatient service as well. The interventions that are most commonly performed by nephrologists are dialysis access placements (vascular access and peritoneal dialysis catheters), percutaneous renal biopsies, and fistulograms. Most training centers in India now incorporate interventional nephrology in their curricula for nephrology fellowships. These procedures are commonly taught by the nephrology mentors. Trainees are made to observe the procedures performed by the seniors and gradually are allowed to perform the procedures under supervision until the mentor is confident the trainee can perform them independently. Usually, there is no formal examination to ensure their competence. There are very few formal interventional nephrology fellowships in India, and board-certified courses are needed. Thus, many nephrologists across the country prefer to leave the interventions in the hands of the formally trained interventional radiologists.
There is no doubt that certain complex clinical procedures demand the presence of an interventional radiologist. Interventional nephrology is probably more of a necessity, especially in a limited resource setting, than a luxury. It would be prudent and may be ideal for both to work as a team rather than engaging in a battle of wills until the procedures are more widely available.
Jha V. Current status of end-stage renal disease care in India and Pakistan. Kidney Int Suppl 2013; 3:157–160. https://doi.org/10.1038/kisup.2013.3
Dogra PM, et al. Continuous ambulatory peritoneal dialysis catheter insertion technique: A comparative study of percutaneous versus surgical insertion. Indian J Nephrol 2018; 28:291–297. doi: 10.4103/ijn.IJN_144_17
Swami R, et al. Tunnelled cuffed catheters for hemodialysis, placed by nephrologists: Success rate, efficacy & complications. Int J Med Res Prof 2018; 4:65–70. doi: 10.21276/ijmrp
Maya ID, et al. Outcomes of brachiocephalic fistulas, transposed brachiobasilic fistulas, and upper arm grafts. Clin J Am Soc Nephrol 2009; 4:86–92. doi: 10.2215/CJN.02910608
Beathard GA, et al. Effectiveness and safety of dialysis vascular access procedures performed by interventional nephrologists. Kidney Int 2004; 66:1622–1632. doi: 10.1111/j.1523-1755.2004.00928.x
Ministry of Health and Family Welfare, Government of India. Pre-Conception & Pre-Natal Diagnostic Techniques Act, 1994. https://www.indiacode.nic.in/bitstream/123456789/8399/1/pre-conception-prenatal-diagnostic-techniques-act-1994.pdf