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 better vascular access care and seized the opportunity to intervene. Numerous outpatient vascular access centers opened up across the United States, and now there are more than 130 outpatient vascular access centers that specifically provide care for hemodialysis patients.
Although many outpatient vascular access centers were started to improve patient care, others have been motivated by the financial benefits received by performing vascular access procedures. A major barrier to starting an access center in private practice is obtaining the start-up funding to build a center. The Centers for Medicare and Medicaid Services has continued to cut reimbursement for vascular access procedures since 2005. As a result, at least 600 ESRD patients are required for an independent interventional center to make a modest profit.
The typical business model for these centers is either full ownership by the nephrology group practices or a joint venture with a vascular access management company. Unfortunately, many small practice groups simply cannot add a program to their practice and continue to rely on surgeons and radiology to provide service to their patients. In addition to financial barriers, nephrologists have difficulty obtaining the appropriate training to perform access procedures. Few training centers exist, and as a result, training for interventional nephrologists in private practice is variable. Many private training programs offer a 6-week training period, and others offer only 3 weeks. These limited programs provide inadequate training to handle complications with vascular access procedures and offer only a superficial knowledge base for the scope of interventional procedures.
The growth of interest in and need to improve patient care has also spurred growth in academic centers nationally. Currently, there are 14 academic centers in the United States that are dedicated to training fellows in the field of interventional nephrology. Academic centers have unique barriers to adding an interventional program into their nephrology divisions. Many university-based practices are challenged by barriers from hospital credentialing, lack of recognition of expertise, and turf battles with surgeons and radiologists. These issues can even delay interventional nephrologists who are certified by the American Society of Diagnostic and Interventional Nephrology from obtaining privileges at their own academic centers. This sometimes leads to nephrologists seeking privileges outside their university practices in the private setting. Private hospitals are not often swayed by egos and turf battles. They simply look for the bottom line.
A few university-based interventional practices have also started in the hospital cardiac catheterization laboratory. Given that cardiologists are also members of their departments of medicine, they are sometimes more willing to allow nephrologists time and space in their laboratories to perform procedures. However, this setting is less than ideal. Commonly, patients with ESRD are delayed in favor of patients with more acute conditions. This leads to longer wait times and extremely frustrated physicians and patients, especially when vascular access procedures are usually scheduled on the patient’s day off from dialysis.
In 2009, the American Society of Nephrology (ASN) recognized the importance of interventional nephrology in the care of patients with kidney disease and convened the Interventional Nephrology Advisory Group (INAG). The first initiative of the INAG committee was to create a comprehensive interventional nephrology curriculum for academic-based nephrology training programs, which is now available on the ASN website. The importance of this standardized curriculum cannot be understated. The curriculum provides a detailed outline for an ideal academic program that includes all procedures related to the care of patients with chronic kidney disease: endovascular procedures, tunneled dialysis catheter procedures, preoperative vessel mapping, peritoneal catheter procedures, and diagnostic renal ultrasound. In addition, it also includes a strong research component, which is essential for the continued expansion of the field.
Barriers and challenges exist for private nephrologists and for academic nephrologists. Interventional nephrology began in the private practice arena. However, for the field to move forward, interventional nephrology training must continue only in the academic setting. Training must be standardized, well-designed prospective research studies must be initiated, and new academic training programs must be developed.