American Society of Diagnostic and Interventional Nephrology (ASDIN) certification and accreditation chairman Daniel Patel is the medical director for interventional nephrology at the Volusia-Flagler Vascular Center, which he founded in his hometown of Daytona Beach, USA. He speaks to Renal Interventions to discuss everything interventional nephrology (IN), connecting with patients, and the unlikely similarity between snowboarding and doing procedures.
What drew you to a career in medicine and IN?
My father is a retired nephrologist and was part of bringing dialysis to Central Florida in the late 1970s. Growing up, I saw the passion and commitment he had towards his patients— which inspired me to go into medicine. He never pointed me towards it, but he definitely served as a role model for me as I went through my training. He always genuinely enjoyed the science and art of medicine, and was well respected in his field. The inflection point came at the end of high school, when I had been accepted to a business programme at an Ivy League university, and I had also been accepted into an accelerated combined medical programme at the University of Miami. It was a difficult decision at the time, but I chose a path in medicine—I wanted to pursue a career in helping others.
Who are your mentors and who has inspired you during your career?
As a third-year medical student in 2003, I attended an internal medicine grand rounds on IN by Arif Asif. At the time, he was a pioneer in the field—I was amazed at the procedures he was performing, and he allowed me to spend some time in his lab at the University of Miami. He took me under his wing, and greatly influenced my early career. I later learned that as a trainee Asif had been considering a career in transplant nephrology, but had been encouraged to consider a career in IN by a friendly physician he met at a Florida Society of Nephrology meeting—who we later learned was my father. I was also fortunate to have been accepted to Emory University in Atlanta, which had a thriving IN programme at the time led by Jack Work, Monnie Wasse, and Vandana Niyyar. As another pioneer in the field, Work supported my pursuit of IN training, and was a fantastic mentor.
How do you see the progress and future of IN?
There has been significant progress in the field of IN over my career. Early battles with surgeons and interventional radiologists have given way to a much more collaborative and congenial relationship between the specialties. We all deal with a very complex patient population, and dialysis access can be a challenging area to fully understand and manage. I think there is a shared passion for taking care of these patients—and this shared commitment has brought the various fields together. Dialysis access could be considered its own specialty, and demand for such specialists will increase as the population of patients needing access care increases. Looking to the future, advances in technology and treatments along with growing interest in research in vascular access have made the field more and more exciting.
What do you hope to see in kidney care through the work of ASDIN?
ASDIN has been a fundamental part of my career, from my early days as a student to my current active involvement with the organisation. ASDIN remains as the foundation for IN in the USA, and now has gained an international reach to help support interventional nephrologists worldwide. The scope has gone beyond only nephrologists, with more and more surgical and radiology involvement in the society over the years as well. Nurses are now also represented on the council, and I hope to see a continued focus on research, mentorship, and patient advocacy. Continued strong support for reimbursement will be vital to maintain the success of the field, which ultimately will allow for quality access to care for our patients. ASDIN has collaborated better with other vascular societies over the years as well, which has fostered a better foundation for research and teaching in the field of vascular access as a whole.
What changes would you like to see in dialysis access care?
Ideally, we will see continued investment and focus on innovation to improve outcomes. But these investments must be something that healthcare systems will pay for. Without adequate reimbursement, there will be a stifling of further investment into dialysis access innovation. A more ideal scenario would be greater access to renal transplants and less dialysis in general, but until we get there we will continue to need innovation in dialysis access care.
What is your current view of the drug-coated
balloon (DCB) space?
The conventional management of dialysis access stenosis with plain balloon angioplasty is a relatively crude treatment approach, with poor long-term patency and frequent recurrent stenosis. Treating dialysis access stenosis at a more fundamental biological level is intriguing, and the DCB space is an exciting new area of development in the field of dialysis access management. The IN.PACT AV paclitaxel data is particularly compelling, showing significant long-term benefits of DCB use in AV access lesions, but the lack of reimbursement in the United States is very frustrating. Ideally, there would be better payment systems which recognise the research showing DCBs’ cost effectiveness, and that would better allow for their application.
What advice would you give to young physicians interested in IN and vascular access?
Unfortunately, training in IN and vascular access in general is somewhat limited in the USA and across the world. Only a handful of academic centres in the USA even offer training in IN, and fewer and fewer academic interventional radiology and vascular surgery programmes have specific dedication to dialysis access. Therefore, I would recommend trainees and even established physicians go to vascular access meetings and get involved with dialysis access societies. I attended my first ASDIN meeting as a medical student, and regularly attended all the major dialysis access meetings in the USA. Not only are these meetings valuable for all the learning opportunities, but the contacts and friendships that you make at these meetings can last a lifetime—and it is good to share ideas and cases with colleagues, particularly early on in your career.
What do you see as the biggest unresolved question in kidney care?
I think we need a better understanding of the nature of dialysis access stenosis, and the best management options. For years, our main tool has been plain-balloon angioplasty. Drug coatings have been introduced, but we are essentially applying drug treatments that were designed for arterial stenosis to the dialysis access. Is there a better drug to treat dialysis access stenosis? Is dialysis access stenosis different on a biological level than arterial stenosis? I suspect that there is a heterogeneity to dialysis access stenosis, and we may be treating neointimal hyperplasia, calcification, scar tissue and/or a combination of pathologies leading to stenosis. Central lesions may be different biologically than peripheral lesions. If we can better understand the underlying pathophysiology, we may be able to better tailor treatments for access stenosis. Stent grafts have been revolutionary in the management of dialysis access grafts, and studies are now demonstrating more compelling applications in AV fistulas. Further research here could help us achieve more durable outcomes in AV access management.
What is your philosophy as a physician?
I was always trained to have a “patient-first” mentality, and this manifests in many ways. It is my responsibility to try to stay as cutting-edge and up to date as possible to provide the highest-quality care I can. At the end of the day it is about making a connection with the patient. Our patients come from all walks of life, but they all share the burden of a significant disease state. Making that personal connection makes the doctor-patient relationship much more meaningful on both sides. We play music in our centre—usually classics from the seventies and eighties that I heard as a kid, like Elton John, Stevie Wonder and the Eagles—and that puts the patients at ease. At the end of the day, it is a privilege to help these patients, and it is an honour and responsibility to be able to do it.
What are your interests outside of medicine?
As I get older, I really enjoy learning new things again. Getting out of my element and learning new things keeps life fun. I am learning to race cars, and I am also an avid snowboarder. Perfecting a corner on a race track or refining skills on a snowboard are great feelings, and they take me back to the feeling I had when I did my first procedures and learned new techniques. I also love to travel with my family, my wife and two girls.
Fact file
Current appointments:
- Medical director, interventional nephrology, Volusia- Flagler Vascular Center (Daytona Beach, USA)
- Consultation Nephrology, Nephrology Consultants PA, (Ormond Beach, USA)
Education:
- 1997–1999: Honours Programme in Medical Education (Six-year accelerated medical programme)
- 2000–04: University of Miami School of Medicine
- 2009: Nephrology and Interventional Nephrology fellowship, Emory University
Honours (selected):
- 2005: American Society of Nephrology Resident’s programme travel grant for 2005 annual meeting 2006: American College of Physicians, travel grants for Advocacy Meetings in Washington DC 2007: University of Miami Department of Medicine, “Eliseo Perez –Sable M.D.” Professionalism Award
- 2007: University of Miami, Pat Caralis Award, Ethics and Professionalism
- 2007: ASDIN member
- 2008: Emory University, Fellow of the Year award
- 2016: ASDIN fellow 2018: Journal of Vascular Access editorial board member
- 2022: Chairman, ASDIN Credentialing Committee
