Interventional nephrology: from episodic to coordinated vascular access care.

In recent years, nephrologists have taken the initiative of performing vascular access-related procedures themselves. Because of their unique clinical perspective on dialysis access and better understanding of the intricacies of renal replacement therapy, nephrologists are ideally suited for this activity. This approach has minimized delays, decreased hospitalizations and decreased the use of temporary catheters, thereby improving medical care, decreasing costs and increasing patient convenience. Vascular access interventions commonly employed by nephrologists include vascular access education, vascular mapping, percutaneous balloon angioplasty, thrombectomy, intravascular coil and stent insertion and tunneled hemodialysis catheter-related procedures. While the performance of these procedures by nephrologists offers many advantages, appropriate training to develop the necessary procedural skills is critical. Recent data have emphasized that a nephrologist can be successfully trained to become a competent interventionalist. In addition to documenting excellent outcome data, multiple reports have demonstrated the safety and success of an interventional nephrology approach. The last decade has been a period of significant advances in this new field. This has been driven in part by the formation of the American Society of Diagnostic and Interventional Nephrology (ASDIN), whose mission includes training, quality assurance and certification. Recently, the ASDIN has published guidelines for training in nephrology-related procedures and has begun certifying physicians in specific procedures related to chronic kidney disease. It is anticipated that this will promote the skillful performance of these procedures by nephrologists and lead to substantial improvements in the care of renal patients. Challenges for the future include awareness of this subspecialty and development of training programs at academic centers on a larger scale.