In one of the select presentations at the American Society of Diagnostic and Interventional Nephrology (ASDIN) 19th Annual Scientific Meeting (17–19 February, Orlando, USA) to receive a mid-lecture round of applause, Victoria Teodorescu, associate professor of vascular surgery at Emory University (Atlanta, USA), posed the question: should nephrologists create surgical arteriovenous fistulas (sAVFs)? The rapturous response came as she answered in the affirmative.
This resounding answer, which began the presentation, “needs a little bit of explanation,” Teodorescu stipulated. She then drew up numbers illustrating just how many patients on dialysis and requiring access there are in the USA. Taking information from the United States Renal Data System Annual Data Report, she pointed out that the number of patients receiving in-centre haemodialysis in the USA almost doubled between 2000 and 2020 from around 250,000 to around 500,000. This raises the question, she suggested, of “who exactly is going to do the access surgery?” for this expanding patient population. The solution, she suggested, may lie with nephrologists.
Historically, the surgeries necessary for haemodialysis access have been done by general surgeons, Teodorescu said. This made sense because general surgery training included a lot of vascular education, but more recent surgical training has seen this “drop off quite significantly, especially in arteriovenous (AV) access”, noting a 15-year decline (p=0.0218) according to the Accreditation Council for Graduate Medical Education (ACGME) Review Committee for Surgery. Teodorescu notes that the committee designates 10 dialysis accesses as the defined category minimum number for general surgery residents—something she says is “extraordinarily minimal experience”.
“There have been studies,” Teodorescu contended, “that show you need at least 25 fistula access creations to be able to do this appropriately once you are an attending physician.” She referred listeners to the results of the Dialysis Outcomes and Practice Patterns Study from 2008, led by Rajiv Saran (University of Michigan, Ann Arbor, USA) as well as a Kidney International-published investigation by Ann M O’Hare (VA Medical Center, San Francisco, USA) et al from 2003 which found that “future strategies to improve AV fistula placement rates should target surgeons and surgical centres” in addition to “patients, nephrologists, and primary care providers”. To this she added reference to the Dialysis Outcomes and Practice Patterns Study, which she said backed her minimum 25 AVF assertion.
“Not all programs are created equal,” she continued, making use of the National Resident Report in the US for 2021–2022 to argue that “there are programmes where they do very little dialysis access”. Teodorescu said that in 2022 63 residents graduated from the 0+5 integrated vascular surgery training program, which she said was a “tiny, tiny number to do all of vascular surgery”—particularly when many showed a greater interest in aneurysms and lower extremities than dialysis access. “Just because you have finished with this particular training does not mean you know a lot about dialysis access,” she posited.
“This is not to say that we do not finish our fellows with extremely broad interventional skills, including aortas and other lower extremity interventions—other cases requiring a high degree of catheter skills,” Teodorescu said, “but we do not really have any education in dialysis itself or what is happening in the unit. We have surgeons adept in the techniques of vascular surgery but not necessarily in renal failure.”
Next, Teodorescu turned to the ASDIN recommendations for training nephrologists to bridge the gap she identified. She concurred with them, particularly in their urging the improvement of competency-based education “in all aspects of dialysis, including questions on board exams”. Teodorescu stressed this point especially in light of the fact that, in her view, future nephrologists will be charged with the responsibility for access in the dialysis unit.
The next recommendation with which she concurred was to ensure that fellows receive sufficient training in placing temporary dialysis catheters: “You should not actively give up any procedures you are doing—it limits your knowledge base and pushes you aside for other interventional specialists to take them.”
Fellowships in interventional nephrology, she said, were also important. Access requires knowledge of dialysis, renal failure, and surgery, as well as intervention skills, she said: “We must develop a cadre of specialists who know everything about surgery, intervention, and what is going on in the dialysis unit—someone who knows why we might be having difficulty cannulating. We need the access specialist.”
This, she concluded, will pave the way for studies that will more effectively examine what is the best solution for a given patient: surgery or intervention. “We do not really have that right now,” Teodorescu remarked, “and until we each come out of our silos and know everything there is to know about everybody else’s field – nephrology, interventional nephrology and vascular surgery, we will not be serving our end-stage renal disease patients well.”
Speaking exclusively to Renal Interventions after the presentation, Teodorescu stated: “Providing the right access for the right patient requires a much broader set of skills than what any of our current training paradigms can provide. The difficult task of creating and maintaining dialysis access belongs in the hands of a new type of specialist, fully trained in surgical and interventional techniques as well as medical care of renal failure patients.”