We Need to Train the Trainers

The clinical practice of nephrology is heavily weighted toward dialysis, and nephrologists caring for patients on dialysis spend a large portion of their time dealing with issues related to dialysis vascular access (1, 2). The nephrologist’s required role in this area is very broad. The new nephrologist who enters practice without a basic knowledge of dialysis vascular access is entering practice unprepared to manage a major source of patients’ problems, problems that contribute significantly to both morbidity and mortality.

The study by McQuillan et al. (3) in this issue of the Clinical Journal of the American Society of Nephrology is very interesting and certainly raises an important point: where dialysis vascular access is concerned, there are deficiencies in both the trainee and the trainer. However, we feel that the problem noted in relationship to the placement of temporary dialysis catheters in this report actually only represents the tip of the iceberg. Nephrology fellows do not receive adequate training in dialysis vascular access.

The nephrologist in practice is required to deal with a wide range of issues related to dialysis vascular access beginning with patient and family education. Decisions concerning vascular access must be a collaborative effort between the physician and the patient. In a recent study (4), it was found that the preferences of patients and the priorities of the nephrologist in this important area were not the same. To assure meaningful patient participation in decision making, vascular access education is essential. Nephrologists must take the lead in this process. To do so, they must be well versed in the basic issues related to dialysis access.

A detailed and complete evaluation of a patient with ESRD in preparation for the placement of a peripheral venous access is extremely important (5). Proper patient selection will materially enhance the opportunity to place an arteriovenous fistula (AVF). With the advancing age of the dialysis population, multiple comorbidities are common (6). Patients must be assessed for risk factors, such as obesity, advancing age, diabetes mellitus, heart failure, and vascular disease, which can affect the success of AVF placement. Failure of fistula maturation, also known as primary fistula failure, ranges from 20% to 60% (7). The clinical consequences of immature fistulas include prolonged dependence on bridging catheters with all of their attendant complications, patient inconvenience, the need for additional attempts at permanent access surgery, and risk for eventual patient refusal (8,9). Patients with a very low likelihood for fistula maturation, despite optimal salvage procedures, might benefit from having an arteriovenous graft (AVG) placed instead.

Additionally, studies have shown that dialysis may not confer a survival advantage in patients with two or more of the following: age 75 years old and older, high comorbidity scores, marked functional impairment, and severe chronic malnutrition (10). For patients with ESRD, the surprise question (would I be surprised if this patient died in the next year?) is a strong predictor of 6- to 12-month mortality and can be used together with the above risk factors to estimate prognosis (11). In such patients, the nephrologist will be offering only palliative dialysis (12). What type of vascular access is indicated in the situation? Should it be an AVG or a dialysis catheter (13)? In-depth knowledge of vascular access is required in counseling the patient and their family and arriving at an appropriate decision.

An important responsibility of the nephrologist is making the surgical referral for vascular access creation. To do this, knowledge concerning vascular access is required. The nephrologist’s responsibility in this area has been listed in Change Concepts 3 and 4 of The National Vascular Access Improvement Initiative (Fistula First) (14). These state that nephrologists should communicate standards and expectations to surgeons performing dialysis vascular access (e.g., Kidney Disease Outcomes Quality Initiative minimal standards for AVF placement and training in current techniques for AVFs). They should refer to surgeons willing and able to meet the standards and expectations. The skill of the surgeon available to create vascular access varies and can affect the success of AVF creation (15–17). Surgical training is key to both AVF placement and survival. In a study designed to investigate whether intensity of surgical training influenced type of vascular access placed and AVF survival, prospective data from 12 countries in the Dialysis Outcomes and Practice Patterns Study were analyzed (18). It was found that, during training, United States surgeons created fewer AVFs (United States mean =16 versus 39–426 in other countries) and noted less emphasis on vascular access placement compared with surgeons elsewhere. Significant predictors of AVF versus AVG placement included number of AVFs placed during training and degree of emphasis on vascular access creation during training. Risk of primary AVF failure was 34% lower when placed by surgeons who created ≥25 (versus <25) AVFs during training. Surgeon selection is the nephrologist’s responsibility.

A major issue continues to be the number of patients that initiate dialysis with a catheter. According to US Renal Data System from 2012, 80% of all patients started their hemodialysis treatments using a catheter (19,20). This high usage is true regardless of the patient’s interaction with a nephrologist. One would like to think that a patient being followed by a nephrologist would be evaluated and sent for a permanent dialysis vascular access before their need for dialysis; however, this does not seem to be the case. Along with the high utilization of dialysis catheters comes the responsibility of being able to recognize and manage the complications associated with these devices. This cannot be done without in-depth knowledge and understanding of these issues.

A thorough evaluation of a new AVF 4–6 weeks after creation should be considered mandatory to detect problems as early as possible (21,22). The maturation of a newly created AVF, if it is going to happen, should be apparent by this time. Waiting longer places the patient at significant risk. They fall into one of two categories: they have either already started dialysis with a catheter or are at risk of starting with a catheter. Both of these alternatives are problematic. Although some surgeons are well equipped to provide this evaluation, many are not. It is not uncommon to see situations where a patient with a well developed, mature AVF is required to wait a standard period of time before it is used simply because that is the surgeon’s policy. The nephrologist responsible for the patient on dialysis needs to be able to evaluate and recognize a mature fistula to avoid an unnecessary delay to use the fistula. Physical examination has been shown to be very accurate in assessing an AVF and is not difficult to learn (23–25). If the AVF does not appear to be developing adequately for eventual use as a dialysis vascular access, a detailed physical examination of the vascular access will, in most instances, reveal the cause of the arrested maturation (26,27). Unfortunately, in many nephrology fellowship programs, adequate training in this area is not provided.

In the dialysis facility, a mixture of AVFs, AVGs, and dialysis catheters provides a continuous requirement for vascular access surveillance. No type of vascular access can be considered to be permanent or without problems. Complications occur, and they should be recognized early and managed appropriately. To do this, detailed knowledge of vascular access is required, and management should be evidence based.

A comprehensive coverage of dialysis vascular access should be a part of the nephrology training program. As illustrated by the report from McQuillan et al. (3), some of this training should be directed toward interventional procedures. However, whereas becoming well versed in dialysis vascular access issues should be a requirement for all nephrology fellows, becoming an interventionalist is not necessary. Table 1 presents an outline of what should be included in a basic curriculum. A major problem in attaining this goal is availability of faculty to provide the training. This deficiency in training is long standing. Most nephrologists who possess in-depth knowledge of vascular access have gained this by becoming interventional nephrologists. However, this is clearly not a necessity. One only has to conduct a cursory literature search on the subject to realize that there are a number of academic nephrologists with outstanding vascular access expertise who have made major contributions to this field. Unfortunately, more are needed. Not only do we need to train the trainees, we also need to train the trainers.

Table 1.

Proposed vascular access curriculum

Hemodialysis Access
Arteriovenous fistula
General characteristics of arteriovenous fistulas
Optimum time for fistula creation
Patient evaluation before access placement
Arteriovenous fistula development
Complications and management
Secondary arteriovenous fistula
Arteriovenous graft
General characteristics of arteriovenous grafts
Complications of arteriovenous grafts
Monitoring and surveillance
Rationale for surveillance
Testing modalities
Utility of testing modalities
Central vein stenosis
Etiology of central vein stenosis
Management of central vein stenosis
Hand ischemia
Distal hypoperfusion ischemic syndrome
Diagnosis
Management
Ischemic monomelic neuropathy
Diagnosis
Management
Dialysis access catheters
Acute dialysis catheters
Catheter placement technique
Complications and management
TDCs
Applications
Routine monitoring of patient with a TDC for dysfunction
Complications and management
Physical examination of the hemodialysis access
Basics of physical examination
Immature arteriovenous fistula
Mature arteriovenous fistula
Arteriovenous graft

TDC, tunneled dialysis catheter.

Disclosures

None.