Interventional Nephrology: A Call to Action

made in the performance of nephrology-related procedures. Today, many nephrologists are routinely performing renal ultrasonography, ultrasound-guided renal biopsy, tunneled hemodialysis catheter insertion and percutaneous endovascular interventions. Recent data have demonstrated that the performance of nephrologyrelated procedures by an interventional nephrologist can provide effective, efficient and prompt care to the patient with renal disease and that these procedures can be safely and successfully performed by a nephrologist trained in interventional nephrology (IN) (1-15). The “renal ultrasonography by the nephrologist” concept was first introduced by Charles O’Neill in the United States in the 1990’s (3). Ultrasound is a safe and simple tool that can be employed effectively by nephrologists as a critical element in the diagnostic workup of a patient with renal disease. Since interpretation of these studies relies a great deal on clinical correlation, nephrologists are ideally suited to perform renal sonography (3, 8, 11). When performed by the nephrologist, ultrasonography yields prompt diagnostic information that can be incorporated into a differential diagnosis and allow treatment plans to be quickly formulated. Both diagnostic sonography and ultrasound-guided renal biopsy can be safely performed at the bedside, thus avoiding scheduling, transportation and radiology suite time restrictions (1, 5). In contrast, ultrasounds obtained through radiology are often subject to delays which are inherent in system and are usually performed by a technician which further requires interpretation by the radiologist. Moreover, most renal biopsies are performed in a radiology suite, increasing the cost and introducing the possibility of further delays. By performing renal biopsy at the bedside a nephrologist can minimize delays and provide care in a timely manner. Indeed, data from our center (a busy academic teaching hospital) showed that the time required to obtain a renal ultrasound on an outpatient basis was markedly reduced from 46.5 ± 2.4 days (mean ± SE) using radiology to 4.7 ± 0.7 days (mean ± SE) when performed by the IN service (5). Emory was the first university to offer a comprehensive ultrasonography course exclusively for nephrologists. In addition, the first “Atlas of Renal Ultrasonography” was published in an effort to familiarize nephrologists with renal sonography (16). The most common indications for renal ultrasound include acute and chronic renal failure, hematuria, severe hypertension, neoplasms, nephrolithiasis, infections, renal allograft dysfunction, anatomical urinary tract abnormalities and ultrasound guidance for percutaneous renal biopsy (8,11,15). Through comprehensive training focused on renal ultrasonography (17) and application of cl inical and laboratory data, a nephrologist can utilize this tool to its maximum potential in the evaluation of renal disease. Recent data have emphasized that many nephrologists are routinely performing peritoneoscopic insertion of peritoneal dialysis catheter routinely (4, 7, 9, 10, 12, 17). This technique offers the advantage of direct visualization of intraperitoneal structures (bowel loops, omentum, adhesions), allows for quick diagnosis of intraperitoneal bleeding and determines the most suitable site for catheter placement (4, 7, 9, 10, 12,). This approach minimizes chances of visceral injury and placement of the catheter in an undesired location (upper quadrants, omentum). A few important issues should be highlighted in terms of PD catheter placement by the nephrologist. First, the procedure can be safely performed in a procedure room, interventional lab or an intensive care unit using standard precautions for infection control (4, 7, 10). Since tissue dissection is minimal with this technique, the postoperative course is brief and the catheter can be used immediately for dialysis (4, 12), although a two-week postoperative period for wound healing is recommended (3). Conversely, the open surgical technique requires a surgeon, operating room facilities and staff and general anesthesia. The latter approach introduces delays and restrictions inherent in the system and increases costs. At our center, the average time between the initial contact with the IN team and PD catheter insertion was markedly shortened to 6.4 ± 0.9 days (mean ± SE) in contrast to our prior experience with catheters placed by the surgeons Editorial The International Journal of Artificial Organs / Vol. 26 / no. 6, 2003 / pp. 447-451