INTERVENTIONAL NEPHROLOGY: One Stop Shop for Nephrology Services
Tushar J Vachharajani, Ashok L Kirpalani
nterventional nephrology is the wave of the millennium. The nephrologist of the last century was ill equipped to handle all the needs of a renal patient. The nephrologist of the present has not only got to be ef.cient in diagnosing and treating
the patient with kidney disease but has to provide prompt and effective therapy to maintain a proper standard of care and keep the financial burden low. In 2000, in USA, the American Society of Diagnostic and Interventional Nephrology1 was
formed precisely to impress upon the nephrologists to change their view about the practice of nephrology. The society promotes the procedural aspect of nephrology. The ideology holds true for any other country including ours and it is left to the new generation of nephrologists to develop the new subspecialty in India. CURRENT NEPHROLOGY PRACTICE
The practice of nephrology involves diagnostic and therapeutic procedures like renal sonography, kidney biopsy (native or allograft), placement of cuffed tunnelled catheter for haemodialysis, placement of Tenckhoff catheter for peritoneal
dialysis, surveillance and maintenance of adequate functioning of arterio-venous .stulas for haemodialysis and placement of Scribners shunt for dialysis. The current nephrologist has to depend on the radiologist and the vascular surgeon to assist him in taking care of the patient. This dependence on other specialities leads to long waits and multiple
hospital/of.ce visits before eventually diagnosing the disease process. A typical case scenario for a referral for nephrotic syndrome would involve a visit to the nephrologists consultation room followed by visit to the radiologist for renal sonography, followed by admission to the hospital and again waiting for the radiologist to schedule a sonographic
guided renal biopsy.
Another typical scenario would be a patient needing initiation of haemodialysis waiting for the interventional radiologist or a vascular surgeon to place a cuffed tunnelled catheter as a bridging access before he gets a permanent access. In an
ideal world all renal failure patients would have a mature permanent arterio-venous access long before the actual need for dialysis therapy. Unfortunately, it is seldom the case and hence the need for a bridging device. The radiologist or the vascular surgeon has other cases to prioritize before the poor renal failure patient gets his cuffed tunnel catheter,
since a temporary femoral or internal jugular catheter is always available as an emergent dialysis access. Such temporizing procedures often lead to complications like bacteraemia and deep venous thrombosis further delaying the placement of permanent arterio-venous access. We are all familiar with this scenario and we cannot blame the
radiologist or the surgeon the complications. A renal failure patient opts for peritoneal dialysis. A surgeon generally places a Teckhoff catheter with an open incision technique making it difficult to use the catheter for a minimum of 2 weeks to allow adequate healing to prevent leakage and peritonitis. If the dialysis is needed immediately, the
nephrologist is forced to place a temporary central venous catheter in the interim period exposing the patient to the associated complications.
We are all familiar with the above case scenarios in our routine clinical practice and it is time we take the control in our hands since who else can best understand the need of the hour but the treating nephrologist.
NEPHROLOGIST OF THE MILLENNIUM
The new nephrologist is better equipped to handle the above situations promptly and save the patient a lot of mental and physical inconvenience. One stop, stop nephrology service should be the standard of care as it saves time and money in the longer run. The nephrologist of the millennium will be trained to perform renal ultrasound and preferably have an ultrasound machine in his office for easy and quick diagnosis and then perform the renal biopsy without any wait and have the renal tissue for the pathologist in less than 48 hrs. He will be an expert in placing cuffed tunnelled catheters and hence the patient will be spared the agony of undergoing multiple temporary catheters. A nephrologist in India is trained to place catheters for acute peritoneal dialysis, so the percutaneous technique of placement of Tenckhoff catheter is just an extension of the current training. A peritoneal catheter placed by a nephrologist makes it possible to initiate peritoneal dialysis within 48 hrs rather than 15 days. In many parts of the world an arteriovenous graft is the primary permanent access for providing haemodialysis. Arterio-venous grafts have a relatively short survival period as they frequently clot and develop stenosis at the venous anastomosis, requiring declotting and angioplasty to maintain patency. We are fortunate that majority of our patients have native arterio-venous .stulas and hence this is less of a problem, but still these accesses tend to develop stenosis at the anastomotic site and balloon angioplasty can improve the blood flow and prevent access recirculation. Nephrologists in certain parts of India, place Scribners shunt as a primary arterio-venous access for dialysis to enable internalization at a later date into a native arterio-venous .stula.2 The endovascular techniques can be further extended to assess the vascular tree for central venous stenosis and possible angioplasty
INTERVENTIONAL TRAINING PROGRAMME
An interventional training programme can be easily developed in the existing nephrology training centres with the assistance of dedicated interventional radiologists, ultrasonologists and vascular surgeons. Guidelines for the training
programme can be established based on the recently finalized guidelines from the American Society of Diagnostic and Interventional Society.3-5 The programme should specifically include training in:
Renal sonography including ultrasound guided renal biopsy.
Cuffed tunnel catheter placement.
Endovascular procedures like fistulogram thrombectomy and angioplasty of the arteriovenous .stula/graft.
Percutaneous placement of Tenckhoff catheter.
Placement of Scribners shunt.
Guidelines for the proper certification for each procedure and accreditation of the training programme should be established and endorsed either by the National Board of Examiners or the University Boards. Once the programme gains
momentum and adequate training centres are established, stenting of endovascular lesions and renal arteriography and angioplasty can be included to gain complete control in the care of renal disease.
Thus leaving the complex cases for the more experienced radiologists and the vascular surgeons.
If cardiologists can perform their own endovascular procedures why cant a nephrologist take control of his endovascular issues? A question every nephrologist needs to ask himself.
1. American Society of Diagnostic and Interventional Nephrology : www.asdin.org
2. Murthy ML, Niyamathullah MM, Hariharan S, Kirubakaran MG, Shastry JC. Conversion of arteriovenous shunts to
.stulae for maintenance haemodialysis: its applicability in a developing country. J Assoc Physicians India 1989; 37
(3) : 220-1.
3. ONeill WC, Ash SR, Work J, Saad TF. American Society of Diagnostic and Interventional Nephrology section editor
: Stephen Ash, Guidelines for training certification, and accreditation. Semin Dial 2003; 16 (2) : 173-6.
4. American Society of Diagnostic and Interventional Nephrology. Guidelines for training, certification and accreditation in renal sonography. Semin Dial 2002; 15 (6) : 442-4.
5. American Society of Diagnostic and Interventional
HANDWASHING AND DIARRHOEA RISK
`Diarrhoeal diseases today are ranked third as cause of death and second as cause of healthy life years lost due to premature mortality and disability'
At least 20 viral, bacterial, and protozoan enteric pathogens multiply in the human gut, exit in excreta, and cause diarrhoea in new hosts. Interventions to prevent faecal material entering the domestic environment of the susceptible child are likely to be of greatest signi.cance for public health. In the May issue of The Lancet Infectious Diseases Val Curtis and Sandy Cairncross present a systematic review of how handwashing with soap affects diarrhoea risk in the community. Although efforts to modify human behaviour are complex and can only expect to be successful if built on an understanding of what motivates, facilitates, and hinders adequate handwashing behaviour, modern methods of promoting handwashing can be effective and cost effective on a large scale.
Lancet Infect Dis 2003; 3 : 275-81.
TREATING ACUTE RHEUMATIC FEVER
So many years, and yet we do not know if steroids should be used.
Ultimately there is no conclusive evidence to indicate that the use of corticosteroids in patients with acute rheumatic fever will prevent heart disease in the long term. Further randomised controlled studies examining corticosteroids with less outdated formulations - for example, prednisone and intravenous methylprednisone are warranted.
Antoinette Cilliers, BMJ, 2003; 327 : 631.