Current State and Future Direction of Vascular Access Training in the United States

Visual Abstract

Abstract

Key Points

• Hands-on training is crucial for vascular access training.

• A multidisciplinary approach to vascular access training is paramount.

• Creation of a multifaceted vascular access curriculum is needed in all training programs.

Background

This study seeks to provide insights into the current state of vascular access education in adult nephrology fellowship programs in the United States and to identify areas for improvement.

Methods

A total of 63 adult nephrology programs and 71 second-year adult nephrology fellows were randomly selected for participation in a roundtable. Virtual roundtable discussions preceded by a survey were conducted to gather information on the delivery of vascular access education. Descriptive statistics were used for analysis.

Results

Among the respondents invited to the roundtable discussions, 42 individuals (30 faculty and 12 fellows) completed the survey, while 21 individuals (13 faculty and eight fellows) also participated in the roundtable discussion. Of these respondents, most (67%) didactic lectures on vascular access in fellowship programs were delivered by general nephrologists, with 57% provided by interventional nephrologists, 36% by surgeons, and 17% by interventional radiologists (respondents were able to select multiple disciplines). The respondents reported limited exposure to proceduralists, including interventional nephrologists and vascular access surgeons during fellowship training. Faculty and fellows were less comfortable with physical examination skills related to vascular access, particularly in using point-of-care ultrasound and interpreting vascular imaging as compared with naming and identification of vascular access. Both groups emphasized the importance of hands-on modalities in vascular access education.

Conclusion

Roundtable discussions highlighted the need for enhanced hands-on training, multidisciplinary collaboration, and standardized curricula in vascular access education. Recommendations were formulated in alignment with the three levels of competency outlined by the American Society of Nephrology Task Force on the Future of Nephrology, aiming to address gaps and improve the quality of vascular access education in nephrology fellowship programs. This study underscores the importance and need for a comprehensive vascular access education in nephrology fellowship training. By implementing the identified recommendations, programs can better prepare fellows to manage vascular access-related challenges in clinical practice.

Introduction

As of 2021, the United States had over 475,000 individuals undergoing hemodialysis.¹ A functional hemodialysis access is pivotal for the continued success of chronic hemodialysis, ensuring patients receive vital care without interruption. Nephrologists are central to the effective management of hemodialysis access, from initial patient preparation to advocating for suitable access types, and ongoing complication monitoring.^2–4 For example, arteriovenous fistulas for chronic hemodialysis have shown a reduced risk of infectious complications when compared with arteriovenous grafts and central venous catheters.^5,6 The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Nephrology state that fellows must demonstrate knowledge of the principles of dialysis access (central venous catheters, chronic vascular access, and peritoneal dialysis access), including indications, techniques, and complications (including infectious and mechanical). Moreover, fellows must have formal instruction regarding indications and interpretation of the results of balloon angioplasty of vascular access and other procedures used to maintain vascular access patency.⁷ Despite the critical role that nephrologists play, past surveys among nephrology fellows have revealed concerns about inadequate training in hemodialysis access management, indicating a need for enhanced educational initiatives in this essential aspect of patient care.^8,9

We evaluated various educational resources available to current nephrology fellows pertaining to vascular access. Nephrology fellows use a variety of educational resources including a high use of digital resources, both paywalled and free open access medical education (FOAMed).¹⁰ Although FOAMed material is readily accessible, it may not undergo the same rigorous quality appraisal as other resources.¹¹ A search for educational material on hemodialysis access management revealed a variety of resources ranging from YouTube videos to journal articles to modules created by a nephrologist as part American Society of Nephrology (ASN) Innovations in Education contest to material published by the American Society of Diagnostic and Interventional Nephrology (Table 1).

Table 1.

Educational material used for vascular access education

Education Material by Type	Material Available
FOAMed
Online module/book/blog posts	• Hemodialysis Access 101 by Krishnan, Yale15 • Physical Examination of Dialysis Vascular Access by Beathard16 • Atlas of Vascular Access by Vachharajani on UKidney17 • Dialysis and Vascular Access Cases on NephSIM18 • Renal Fellow Network Interventional Nephrology Series coproduced with ASDIN19  ○ Twenty blog posts covering a wide variety of topics pertaining to vascular access
YouTube videos	• Physical Examination of AV Fistula by Vachharajani20 • Assessment of the upper arm AV fistula by ESRD National Coordinating Center21 • AV Fistula Doppler by Kupinsk22 • Washington University in St. Louis Nephrology Web Series—Bedside Examination of Vascular  Access with Hentschel23 • Washington University in St. Louis Nephrology Web Series—Vascular Access Part 2 with  Hentschel24
Digital Paywalled
Medical society educational material	• American Society of Diagnostic and Interventional Nephrology  ○ Vascular access primer  ○ Video: dialysis access ultrasound and pathologies  ○ Video: associate case studies  ○ Video: POCUS of the dialysis access
Traditional material
Journal Articles	• AJKD—Core Curriculum in Nephrology “Vascular Access: Core Curriculum 2008”25 • CJASN—“Interventional Nephrology Physical Examination as a tool for Surveillance for the hemodialysis AV access”4 • JAMA—AV access for hemodialysis: A review 202426 • AJKD—POCUS for vascular access27

ASDIN, American Society of Diagnostic and Interventional Nephrology; AJKD, American Journal of Kidney Disease; AV, arteriovenous; CJASN, Clinical Journal of American Society of Nephrology; FOAMed, free open access medical education; JAMA, Journal of the American Medical Association; POCUS, point of care ultrasound.

Development of validated FOAMed material for use in education surrounding hemodialysis vascular access management has the potential to improve and standardize training of nephrology fellows as well as improve patient outcomes. Furthermore, it is crucial for both the nephrology community and patients undergoing KRT to enhance education, establish best practices, and allocate adequate resources for fellowship programs. However, little is known about how this is currently taught in nephrology fellowship training or how successful this education is. Therefore, in this study, we aim to better understand the current delivery of hemodialysis access management education as well as to identify areas where education gaps exist.

Methods

We used a random number generator to select adult nephrology program directors from the ACGME database and second-year adult nephrology fellows from the ASN member database. To minimize bias and to avoid potentially saturating our respondents with programs/fellows with robust vascular access educational programs, we elected to randomly select fellows and programs. This was performed in lieu of sending invitations to all fellows/programs as our goal was to fill recorded and transcribed roundtable discussions. A total of 63 program directors received invitations to join the roundtable discussions through e-mail, wherein they (or their faculty designees) were encouraged to complete a survey (Microsoft Forms), participate in a virtual roundtable, or both. The survey was anonymous, and we did not collect demographics such as age or sex. The survey questions were drafted by the ASN Transforming Dialysis Access Together (TDAT) Medical Training Workgroup (Supplemental Data). Thirty faculty members successfully completed the survey, whereas 13 engaged in the live roundtable discussions. Each of the 13 faculty members participating in the roundtable also contributed to the survey results. In addition, we extended invitations to 71 second-year nephrology fellows invited to join our recorded and transcribed roundtable discussions, with 12 fellows completing the survey and 8 fellows joining the roundtable sessions. Each of the eight fellows participating in the roundtable also contributed to the survey results. The roundtable discussions were recorded, with ASN staff documenting details on three separate roundtables (two for faculty and one for fellows). Transcribed data and notes from the discussions were used to manually identify themes that emerged from the discussions. Moderation of these discussions was facilitated by members of the ASN TDAT Medical Training Workgroup. The results are presented qualitatively without the use of inferential statistics.

Results

Respondent Demographics

Of the 224 adult nephrology fellowship programs listed in the ACGME database in 2023 and the 458 second-year adult nephrology fellows contained in the ASN member database, 63 (28%) programs and 71 (16%) second-year nephrology fellows were randomly selected to participate in a survey and join a roundtable discussion regarding how vascular access education is delivered at their respective institutions (Table 2). Of the 63 adult nephrology programs that were randomly selected, 30 (48% of selected and 13% of total programs) answered the survey and 13 (21% of selected and 6% of total program) participated in the roundtable. Of the 71 second-year adult nephrology fellows randomly selected, 12 (17% of selected and 3% of total fellows) answered the survey and 8 (11% of selected and 2% of total fellows) participated in the roundtable (Table 2). There was a broad geographical distribution of participants across the Northeast, Southeast, Midwest, and Southwest who answered the survey from both fellows and faculty. However, there was only one fellow and no faculty members from the West who participated (Figure 1).

Table 2.

Constituents of the faculty and fellow survey and roundtable

Constituent	Total, n	Selected, n (% of Total)	Survey, n (% of Selected, Total)	Roundtable, n (% of Selected, Total)
Faculty	224 adult programs	63 (28)	30 (48, 13)	13 (21, 6)
Fellows	458 second-year adult nephrology fellows	71 (16)	12 (17, 3)	8 (11, 2)

Figure 1.

Geographic distribution of respondents to the survey.

Educational Content Delivery for Vascular Access in Adult Nephrology Fellowships

Among the 42 respondents to the roundtable invitation, including 30 faculty members and 12 fellows, 67% reported that didactic lectures on vascular access during fellowships were conducted by general nephrologists. In addition, 57% identified interventional nephrologists as lecturers, 36% cited vascular access surgeons, and 17% mentioned interventional radiologists (see Figure 2A). Respondents had the option to select more than one type of individual who delivered didactic lectures because several lectures are given on this topic per academic year. Thirty-three percent of respondents indicated that fellows in their fellowship program never rotate clinically with an interventional nephrologist. Only 24% indicated that fellows rotate once or twice and 12% three or four times with an interventional nephrologist (Figure 2B). A very small number (5%) indicated that they rotate clinically six times or more with interventional nephrology; only 17% had interventional nephrology faculty available (Figure 2B). An even higher percentage (71%) reported that fellows in their program never round with a vascular access surgeon throughout their fellowship, and only 21% rounded once or twice (Figure 2C). Twenty-six percent of respondents indicated that fellows often (weekly) examine vascular access used for hemodialysis during inpatient rotations, whereas 38% report that fellows examining accesses three or four times and 19% once or twice during the entirety of fellowship (Figure 2D).

Figure 2.

Who delivers educational content in nephrology fellowship programs of the invited roundtable participants? (A) Who gives lectures on vascular access. (B) Rounding with interventional nephrology (Int Neph). (C) Rounding with vascular surgery. (D) Examine access during inpatient rotations. (E) Examine access in hemodialysis (HD) unit.

Comfort Level of Nephrology Fellows and Faculty in Performing a Variety of Vascular Access Physical Examinations

To pinpoint the aspects of vascular access physical examination requiring greater educational emphasis, we posed a series of questions to both fellows (N=12) and faculty members (N=30). Across all eight questions asked, faculty members were quantitatively more comfortable than fellows in performing all examinations (Figure 3). However, it was observed that both faculty and fellows exhibited less confidence in using point-of-care ultrasound (POCUS) and interpreting vascular imaging for access dysfunction compared with their proficiency in physical examination, identifying/naming accesses, and understanding vascular access pathologies (Figure 3).

Figure 3.

Comfort level of fellows and faculty members invited to the roundtable discussion in regards to various hemodialysis access examinations.

Themes and Recommendations Identified during Roundtable to Improve Dialysis Vascular Access Education

Theme 1: Hands-On Initiatives

The first theme arising from the roundtable discussions highlighted the necessity of impactful hands-on educational initiatives for dialysis vascular access training. Concerns were raised regarding the insufficient hands-on experience among many fellows. In addition, there is a noted scarcity of access to interventional nephrologists within the fellowship programs. Roundtable participants agreed that interventional nephrologists are ideally suited to contribute to teaching and integrate their expertise into the program. Owing to patients often undergoing dialysis treatments during rounds, hands-on physical examination opportunities are scarce. The faculty's proficiency in dialysis access plays a significant role in the effectiveness of training. Moreover, with the constraints of time and the high volume of patients, assessing vascular accesses becomes challenging (Table 3).

Table 3.

Themes identified during roundtable discussions and potential solutions

Theme 1: need for hands on training  • Many fellows lack sufficient hands-on experience | Hands-  on experiences should be mandatory component of fellowship training  • Limited access to interventional nephrology | Consider   partnering with nearby practices who have interventional nephrology  • Limited hands-on physical examination opportunities when   rounding because patients are actively receiving dialysis treatments | Faculty members should consider rounding on patients while not receiving dialysis occasionally to focus on physical examination  • Faculty comfort level in dialysis access examination is the   biggest factor to effective training | Ensure each program has a well-trained vascular access champion who is able to teach others  • With limited time to round and many patients, it is difficult   to examine the vascular access. | Prioritizing vascular access education is paramount to success Theme 2: multidisciplinary approach to education  • Fellow/faculty/nurse/technician collegial relationship   building is needed | Ensuring a culture of collegiality and respect is paramount  • Multidisciplinary group training to include common daily   issues related to dysfunction/emergencies | Multidisciplinary educational session where all can discuss how to approach vascular access emergencies  • Monthly vascular access multidisciplinary meetings   attended by fellows, nephrology faculty, vascular surgery, nursing, technician, interventional nephrology, and interventional radiology | Establish a monthly vascular access multidisciplinary meeting  • Need for basic ultrasound skills to assess depth and   diameter at bedside by nephrologists and dialysis staff | Consider incorporating vascular access POCUS training into fellowship program  • Need for vascular surgeons and interventional nephrologists   to be involved in giving lectures, not just nephrologists. | Ensure didactic lectures scheduled with a variety of specialists who deal with vascular access Theme 3: need for standardized curriculum across institutions  • There is currently variable educational content at   fellowship programs   ○ Some programs with no curriculum and some with    minimal curriculum   ○ Some programs have an outpatient access center with 3–4    interventional nephrologists allowing fellows to rotate through as many as 8 wk total throughout 2 yr of fellowship   ○ Some programs rotate with interventional radiologists    only. Difficult to time when an actual vascular access procedure is taking place, making this challenging for fellows

Recommendations to improve vascular access education during fellowship  • Train the trainer  • Establish a local champion  • Multidisciplinary approach  • Interventional nephrology, nursing, technician,   interventional radiology, vascular surgery, and general nephrology should be included  • Hybrid educational components—hands on, videos, online   modules, and plus didactics  • Attendance at national or regional conferences focused on   vascular access  • OSCEs should be incorporated into fellowship training   focusing on vascular access examination skills  • Standardized curriculum endorsed by ASN and ASDIN   ○ Level 1 Expected knowledge, skills, values, and attitudes    of every graduating nephrology fellow Accomplished during a standard 2-yr training program in nephrology, often the focus of the first 12 mo of training    ■ Longitudinal training    ■ Defined number of lectures    ■ Defined content to cover    ■ Case-based access dysfunction modules, when to order     angiogram, and how to troubleshoot calls from dialysis nurse/technician in regards to access    ■ Mentorship with faculty dedicated to teaching     vascular access    ■ Knowledge of vascular access emergencies    ■ How to manage peritoneal dialysis catheter dysfunction    ■ How to read an interventional procedure report   ○ Level 2 training beyond general nephrology that provides    fellows with opportunities to perform advanced procedures or clinical care level 2 can be achieved during the standard 2-yr nephrology fellowship program, depending on the fellow's career goals and use of elective periods    ■ Minimum time spent observing interventions (coming     to the vascular access center)    ■ Ultrasound training to achieve competency for     vascular access   ○ Level 3 higher degree of proficiency that offers distinct    career opportunities in specialized areas of nephrology. Level 3 cannot generally be achieved during the standard 2-yr nephrology fellowship and requires advanced training in a specialized program, often during a third year of training. The use of a third year of training will be limited to very specific educational programs (e.g., transplant nephrology)    ■ Performing interventional procedures    ■ Portfolio as dictated by ASDIN

ASDIN, American Society of Diagnostic and Interventional Nephrology; ASN, American Society of Nephrology; OSCE, objective structured clinical examination; POCUS, point-of-care ultrasound.

Theme 2: Multidisciplinary Approach

The second theme highlighted in the roundtable discussions underscored the necessity of embracing a multidisciplinary approach to education. It was emphasized that involving vascular access surgeons and interventional radiologists in delivering lectures, alongside nephrologists and interventional nephrologists, is essential. Moreover, there was a consensus on the critical importance of cultivating strong collaborative relationships among fellows, nurses, and technicians. A recommendation emerged for organizing multidisciplinary group training sessions aimed at addressing common issues and emergency situations associated with vascular access dysfunction and infectious complications. This approach aims to ensure that nephrologists are adequately prepared to respond promptly and effectively to calls from nursing or technician staff. Furthermore, the establishment of monthly vascular access meetings, attended by a diverse team comprising fellows, faculty, vascular access surgeons, interventional nephrologists, interventional radiologists, and nursing professionals, was proposed. Recognizing the significance of ultrasound skills in assessing depth and diameter of the vascular access at the bedside, it was emphasized that nephrologists should possess basic proficiency in ultrasound techniques. This capability enhances their ability to provide comprehensive care and make informed decisions regarding vascular access management (Table 3).

Theme 3: Standardized Curriculum

The third theme to emerge during the roundtable discussion focused on the need for a standardized curriculum in vascular access education across institutions. Disparities were observed among programs, with some lacking a structured curriculum entirely, whereas others had only minimal frameworks in place. Notably, certain programs boasted outpatient access centers with three to four interventional nephrologists, enabling fellows to undergo rotations totaling up to 8 weeks over the course of their 2-year fellowship. By contrast, some programs opted to rotate with interventional radiologists, although the unpredictable timing of access procedures, among other interventions offered by this specialty, made this rotation less than ideal (Table 3).

Discussion

This study provides insights into the delivery and efficacy of vascular access education in adult nephrology fellowship programs. The findings highlight several areas for improvement in current educational curricula and offer recommendations to enhance the quality of vascular access training. One finding is the predominance of didactic lectures on vascular access delivered by general/interventional nephrologists, with limited exposure to interventional radiologists and vascular access surgeons during fellowship training, potentially affecting fellows' preparedness for clinical challenges. Conversely, we acknowledge the importance of ensuring that general nephrologists are both eager and proficient in delivering didactic lectures on the topic of vascular access. We did identify that both fellows and faculty who participated in our roundtable exhibit less confidence in performing certain aspects of vascular access physical examinations, particularly in using POCUS and interpreting vascular imaging. It is also important to note that significant structural variations in clinical practice across institutions likely contribute to differing levels of opportunity. This variability warrants further investigation in future studies.

Several recommendations to improve medical education in vascular access were distilled by the TDAT Medical Training Workgroup after reviewing the roundtable results. These recommendations were structured in alignment with the three levels of competence delineated by the ASN Task Force on the Future of Nephrology.¹² Level 1 competency denotes the expected knowledge, skills, values, and attitudes attained by every graduating nephrology fellow within the standard 2-year fellowship. Level 2 competency involves training beyond the scope of general nephrology, yet it can be attained through the standard 2-year curriculum. Level 3 competency typically exceeds the scope of a standard 2-year nephrology fellowship and necessitates advanced training in a specialized program, often extending into a third year of training.¹³ These recommendations are presented in Table 3. These three levels of competence differ from the ACGME's five-level “Milestones” framework. The ACGME Milestones apply to a wide range of clinical scenarios, skills, and procedures, allowing learners to be assessed from novice (level 1) to expert (level 5). Achieving level 4 or 5 typically indicates readiness for unsupervised practice by the end of training. By contrast, the three levels defined by the ASN Task Force aim to categorize competencies specifically: level 1 includes clinical scenarios, skills, or procedures that are mandatory within a 2-year fellowship; level 2 covers optional competencies that can be completed within a 2-year fellowship; and level 3 includes competencies that would require an additional year of training. The roundtable discussions underscore the need for enhanced hands-on training, multidisciplinary collaboration, and standardized curricula in vascular access education. The scarcity of hands-on experience among fellows and limited access to specialized expertise pose significant challenges. The ACGME Program Requirements for Graduate Medical Education in Nephrology mandate fellows to exhibit proficiency in understanding dialysis access principles, encompassing acute and chronic vascular and peritoneal access, alongside education in interpreting results and indications for procedures like balloon angioplasty for maintaining chronic vascular access patency.⁷ The proposed recommendations aim to address these issues and enhance vascular access education across fellowship programs by embracing a multidisciplinary approach, involving vascular access surgeons along with nephrologists in delivering lectures, and standardizing curricula. The recommendations formulated are in alignment with the three levels of competency outlined by the ASN Task Force on the Future of Nephrology provide a structured framework for enhancing vascular access education across institutions.¹² By implementing these recommendations, programs can better equip fellows with the necessary knowledge and skills to manage vascular access-related challenges in practice. In addition, emphasizing hands-on training modalities, including POCUS¹⁴ and participation in endovascular interventions, can further enhance fellows' preparedness for clinical practice.

However, several limitations should be acknowledged. The low response rate for both the survey and roundtable discussions may introduce selection bias, despite efforts to mitigate this by randomly selecting programs and fellows. The voluntary nature of participation and reliance on self-reporting could introduce recall and social desirability biases. Furthermore, limited geographical representation, especially from West Coast states, and the focus primarily on nephrology fellows and faculty and not other specialties such as vascular access surgeons, interventional nephrologists, nurses, and technicians may restrict the generalizability of findings. Importantly, our study focused on hemodialysis vascular access and not peritoneal dialysis, which is an important topic of future research as well.

In conclusion, this descriptive study highlights the current state of vascular access education within adult nephrology fellowship programs and offers valuable insights for improvement. The recommendations formulated provide a structured framework for enhancing vascular access education across institutions, which could ultimately lead to improved patient outcomes, reduce infections, and improve quality of care. The urgency of this issue cannot be overstated. As more fellows with limited training and exposure to vascular access education transition into teaching faculty roles, the risk of perpetuating incomplete training grows. Without immediate attention, this cycle may become deeply embedded in our fellowship programs, compromising the quality of training. Moving forward, collaboration among disciplines is essential to prioritize initiatives aimed at optimizing vascular access education in nephrology fellowship programs.

Supplementary Material

cjasn-20-539-s001.pdf ^{(1.4MB, pdf)}

cjasn-20-539-s002.pdf ^{(109KB, pdf)}

Disclosures

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/CJN/C184.

Funding

This work was supported by Centers for Disease Control and Prevention.

Author Contributions

Conceptualization: Atlee Baker, Anna Burgner, Chyi Chyi Chong, Dalia Dawoud, Jeffrey Hull, Koyal Jain, Sam Kant, Vandana Dua Niyyar, Bharvi Oza-Gajera, Christopher R. Ramos, Prabir Roy-Chaudhury, Bharat Sachdeve, Matthew A. Sparks, Adina Voiculescu.

Data curation: Vandana Dua Niyyar, Matthew A. Sparks.

Formal analysis: Vandana Dua Niyyar, Matthew A. Sparks.

Investigation: Vandana Dua Niyyar, Matthew A. Sparks.

Methodology: Vandana Dua Niyyar, Prabir Roy-Chaudhury, Matthew A. Sparks.

Project administration: Joseph Kessler, Kerry A. Leigh, Vandana Dua Niyyar, Shane B. Perry, Matthew A. Sparks.

Software: Matthew A. Sparks.

Supervision: Vandana Dua Niyyar, Matthew A. Sparks.

Writing – original draft: Vandana Dua Niyyar, Matthew A. Sparks.

Writing – review & editing: Atlee Baker, Anna Burgner, Chyi Chyi Chong, Dalia Dawoud, Jeffrey Hull, Koyal Jain, Sam Kant, Kerry A. Leigh, Vandana Dua Niyyar, Bharvi Oza-Gajera, Christopher R. Ramos, Prabir Roy-Chaudhury, Bharat Sachdeve, Matthew A. Sparks, Adina Voiculescu.

Data Sharing Statement

All data is included in the manuscript and/or supporting information. Raw data is available upon request to corresponding author.

Supplemental Material

This article contains the following supplemental material online at http://links.lww.com/CJN/C185.

Survey questions from the ASN TDAT Medical Training Workgroup