The State of Procedures in Nephrology Fellowships
Nephrology fellows have seen a decline in the number of procedures performed over the last several years. In fact, some have questioned whether or not it is even necessary to continue training nephrologists to perform certain procedures. Most private practice nephrologists do not perform their own kidney biopsies and rarely place dialysis catheters. A recent perspective article in AJKD by Sachdeva et al. reports on a national survey of nephrology fellows about their experiences and attitudes toward procedures in nephrology. They discuss results on typical “nephrology” procedures such as temporary hemodialysis catheter placement and kidney biopsies. They also report results of hands-on experience performing kidney ultrasonography for diagnostic purposes. This is not currently an ACGME fellowship training requirement.
Let’s review the ACGME required procedures in nephrology (pages 17-18):
The minimum number of each “procedure” is not stated, and the ACGME simply requires that fellows be “competent” in each of these procedures. This survey was conducted in May 2014 and solicited through the US nephrology training program directors and coordinators. A total of 200 respondents completed the survey, approximately 21% of the total number of fellows during the 2013-2014 academic year.
What is happening with temporary HD catheter placement?
Prior surveys by Berns & O’Neill (2007) and Holley & Piraino (1992) reported that a vast majority of temporary HD catheters were placed in the femoral over internal jugular vein. In contrast, Sachdeva et al. report that the number of femoral and internal jugular vein catheters were roughly equal. Of concern, they report that 25% of graduating fellows had not placed a temporary internal jugular catheter, and 20% had not placed a temporary femoral catheter. What is not reported is how many graduating fellows placed no catheters. The availability of interventional radiology and nephrology to place tunneled catheters is surely a factor affecting this rate. In many circumstances, it may be better for the patient to have a permanent catheter rather than a temporary one.
How many catheters does a fellow need to perform to become competent? Five? Ten? Twenty? Maybe a minimum number would be helpful. We performed an open poll on the Renal Fellow Network in 2010, in which we asked how many temporary catheters fellows were placing per year. There was huge variability, but most were in the range of 10-100. However, 23% stated they placed less than five per year, and a few super-users (4%) placed more than 200! It continues to be debated whether temporary catheter placement should remain a requirement. I, for one, feel it is an important skill for any nephrologist to learn, and we should continue requiring this skill—a point echoed by the authors of this study.
What about kidney biopsies?
It is not surprising that hardly anyone is doing blind kidney biopsies anymore. Instead, most are relying on direct visualization of the kidney with ultrasound guidance, and a few are even doing CT guided biopsies. Five percent of respondents who identified as graduating fellows reported not performing a single native or transplant kidney biopsy. Again, the ACGME does not set a minimum number of biopsies required, but instead uses the “competency” language again. In this regard, approximately 25% of respondents reported not having a mandatory required number of biopsies to perform. The majority (Table 1) of fellows are performing between five and 20 kidney native and transplant biopsies.
What about kidney ultrasound, and ultrasound of the lungs for volume overload?
From this survey it is clear that hardly any of the fellows are being trained in kidney ultrasonography. In fact, 83% have no formal training at all. This is likely reflective of the fact that it is not mandated by the ACGME. Are we missing an important opportunity to enhance the skill of our future nephrology workforce? Interestingly, 96% of respondents to this survey would have liked formal training in ultrasonography. What scope would this training entail? Is it the ability to rule out obstruction and hydronephrosis? How many training sessions would be required, and when would competence be reached? Lastly, is there a role for lung ultrasonography in the evaluation of volume status, particularly in patients on dialysis? This may be an opportunity to expand the use of ultrasonography in our training programs and clinical practice. Many internal medicine–based fellows that did not choose nephrology indicated the lack of procedures as a major reason.
It is clear that procedures in nephrology are declining, and the reason for this is multifactorial. The rise of interventional radiology services in the hospital might be a major cause of this downtrend, and maybe we are doing some benefit for the patients, as many of the “temporary” catheters were simply not needed. The placement of cuffed permanent catheters, or even fistulas, might prove the biggest winner for patients. From the data provided in this survey, kidney biopsies are still being performed with the vast majority of fellows doing anywhere between five and 20, with a quarter doing more that 25. Almost all of these are being done with ultrasound guidance. The clear opportunity is to expand the use of ultrasonography for excluding acute urinary obstruction and a lung examination to aid in the diagnosis of volume overload. Will the nephrology community identify these as adding value to our services, or will they be seen as more “time sinks”? I think a critical appraisal of the literature coupled with studies that clearly demonstrate benefit will be needed. Overall, I applaud the authors for undertaking this study. Nephrology is at a crossroads, and building new skills and procedures to help guide therapy is welcome.
Matthew Sparks, MD
AJKD Blog Advisory Board Member
Fellows should also be trained in Placement of temporary and double cuff PD catheters . But given the declining popularity of CAPD in US there may not be many takers for my suggestion…. Nephrology trainees in India do get good exposure to both acute and chronic PD catheter placement.
IMO it is a sad state to see our procedures annexed by other specialties. As important as radiology is as a field, nephrologists need to be doing their own kidney biopsies. As a renal fellow, it is easy to look at private practice and say “Hey, I won’t be doing lines or biopsies then, so I really don’t need to be trained in them” but that is a dangerous mentality. There are already studies being published by anesthesiologists who are doing their own CVVHD (without the input from nephrologists!). We have to take back the ground that it is slowly giving up to other specialties – interventional nephrology is a great way to do that and I hope to see more of it in the future.
We Have to Look for Ways to Improve Our Knowledge and Skills in Intervenional Nephrology:
It is really strange to see that Nephrologist’s are discussing whether to leave all the skills of the specialty or not! Any specialist in medicine may have the right to choose on where to intensify one’s studies / skills, on the other hand we have to remember that Nephrology is a specialty (not a hobby) just like Gastroenterology or Cardiology is.
I am wondering why Cardiologists and Gastroenterologists continue on to develop their minimally invasive (or may be truely invasive) skills in diagnostic and therapeutic arsenal for their patients, and virtually no one shows up to object to them with the great concerns for the possible risks of the procedures that they undertake. Are the Cardiologists who are doing coronary anjiyography in the wrong way because they do not quit the job for Cardiovascular surgeons? Do you really think that Gastroenterologists are insane?
Just to keep it short, even a single tablet of medicine may carry a life threatening risk, therefore any medical or surgal interventions are performed under potential risks. There is not any single example of surgeon or radiologist who is born with the skills or knowlegde, and niether medical specialists. As a results, undaubtedly Nephrologists must push forward to learn and perform all sorts of invasive procedures related to Nephrology, such as kidney biopsy, CVCs, tunneled HD catheters, arteriovenous fistula, fistula angiography, renal ultrasound, vascular ultrasound etc. In addition, we also have to be the key role players in research and development in these areas. For example, there are many Nephrologists who are performing arteriovenous fistula with great success and contributing to the development of this field.
A question: There is patient who has the features of RPGN and you ask a radiologist for a kidney biopsy. The radiologist replies that she/he does not agree with you that the kidney biopsy is necessary. What sould you do next?
I totally agree with the comments above. We have to look beyond outpatient dialysis and expand the scope of Nephrology practice. Nephrologists should atleast be doing lines (tunneled and non tunneled), Kidney ultrasound and declotting fistulas and grafts. These should be in the core Nephrology training curriculum. PD catheter and primary AVFs being optional (just like GI does advanced endoscopy fellowship and cards do interventional fellowship).
I completely agree that we should continue to embrace procedures in nephrology. The increased interest of interventional nephrology should continue to be encouraged. All training programs need to incorporate learning these skills (temporary as well as tunneled catheter placement) as well as advanced training for those interested in a career in interventional nephrology. The use of ultrasonography to image the kidney, perform biopsy, and guide volume status is also intriguing and hope to see this being incorporated into training programs. I also agree that we need to keep searching for novel therapeutic interventions for our patients and we should be leading the way for this.
I completely agree with you and your opinion. Great!!!
Landscape is certainly changing in nephrology. Many young fellows we interviewed are not comfortable placing temporary lines. I think it’s dangerous; one might be in the position to need to acutely dialyze a hyperkalemia or an intoxication and have no help around. Why limit yourself and be at the mercy of IT or intensivists? It’s really sad
Completely agree. We should broaden our scope, not limit ourselves. Interventional Nephrology makes our work more efficient, reducing waiting times and improving our patient’s care. Also, you avoid discussions many times with other specialties (like when requesting an US for a patient with AKI or placing a catheter, you can plan any biopsy you need without arguing how urgent ir is…).
In fact, temporary catheters, renal biopsies, US and shunts were all implemented by nephrologists! So we are trying to keep those techniques, not “steal”…