The multidisciplinary approach to hemodialysis vascular access at the Mount Sinai Hospital.

A majority of the quarter of a million end-stage renal disease patients nationwide are treated with hemodialysis. Important and frequent causes of morbidity and mortality, when they undergo this procedure, include vascular access infection and thrombosis associated with the use of catheters and, to a lesser extent, grafts. Therefore, an arteriovenous (AV) fistula is the preferred hemodialysis access. A multidisciplinary approach, including nephrologists, vascular surgeons, interventional radiologists, nurses, nephrology fellows, and nephrology physician assistants, meeting together weekly, should improve hemodialysis outcomes by promoting the use of AV fistulas. The specific roles of the interventional radiologist, vascular surgeon, nephrologist and other members of the multidisciplinary team are reviewed. Important additional components of this program are Doppler ultrasound for preoperative hemodialysis access vein mapping and screening techniques for early detection of arteriovenous graft stenosis. The use of arteriovenous fistulas in the Mount Sinai outpatient hemodialysis program has increased from 15% to 43% (p<0.001) and substantially limited catheter use since 1998, when the multidisciplinary program began.