The Fellows Behind the Lead: Interventional Nephrology Training in the US

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An interventional nephrologist is a nephrologist who performs vascular access related procedures in hemodialysis (HD) patients. Dialysis vascular access remains the Achilles’ heel of hemodialysis. Despite the Fistula First Initiative, catheter dependence remains high among incident HD patients. Even though significant progress has been made in the understanding of the pathophysiology of arteriovenous fistula (AVF) failure, much remains unknown. High prevalence of dialysis catheters coupled with high rates of primary AVF failure places a significant economic burden on the healthcare system. In 2013 alone, Medicare paid 2.8 billion dollars for dialysis vascular access related services , accounting for 12% of the total ESRD related payments. The vascular access related costs are 2-3 times higher for AVFs with primary and secondary patency loss, and 4 times higher for AVFs with primary failure.

Vascular access related issues can be frustrating for dialysis patients and their healthcare providers. Interventional nephrologist can make a substantial difference in the lives of these patients. Studies have shown that interventional nephrologists can perform vascular access related procedures safely and effectively. In addition to  the intricate analytical processes involved in nephrology patient consults or office visits, interventional nephrologists can troubleshoot a dysfunctional access and perform a therapeutic procedure in a timely fashion – and ultimately improve a suboptimal Kt/V for an ESRD patient or resolve a troublingly enlarging aneurysm. Interventional nephrology often allows for instant impact and gratification in patient care. 

The field of interventional nephrology originated in the United States in the mid-1980s, and interest has grown since then among nephrology trainees. In 2000, the American Society of Diagnostic and Interventional Nephrology (ASDIN) was established.

Nephrology fellows Crystal Farrington, DO (left, University of Alabama at Birmingham) and Bhavnish Bucktowarsing, MD (right, Ohio State University) in the middle of interventional nephrology training. 

To become an interventional nephrologist, one needs to be board certified in nephrology and certified by the ASDIN. (Briefly, a total of 125 procedures over 24 calendar months is needed.) These procedures may be distributed among angiography for AVF, angioplasty, thrombolysis/thrombectomy, endovascular stent placement and tunneled dialysis catheter placement/removal. 

Procedural training often begins during the second year of the nephrology fellowship, alongside core nephrology training. Accredited interventional nephrology training programs often have interventional teams with whom fellows work closely. Training programs consist of hands-on procedural training, vascular access research, and caring for end stage kidney disease patients in both inpatient and outpatient settings. Interventional training can also continue once one graduates from nephrology fellowship, as long as the required procedures are completed within 2 years. Interventional nephrology fellows may also have opportunities to teach residents and fellows how to place temporary dialysis catheters as well.  

For trainees interested in interventional nephrology,  membership to the ASDIN and attendance at the annual ASDIN meeting is recommended as well as review of the Journal of Vascular Access, Journal of Interventional Nephrology, and Journal of Vascular Surgery.

Post by: Crystal Farrington (@nephrogeek1), DO & Bhavnish Bucktowarsing, MD (@Buck1486)
ASDIN Education Committee Fellows

Acknowledgments: This post is part of a collaboration between the Renal Fellow Network and the American Society of Diagnostic and Interventional Nephrology (ASDIN), whose mission is to provide excellence in dialysis access care to improve outcomes for patients with kidney disease. Special thanks to Tushar Vachharajani, Aisha Shaikh, Edgar Lerma, and the Education Committee of ASDIN for their comments and suggestions for this post. For more information about the ASDIN mission or membership, click here.

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