The dialysis outcomes quality initiative: get your copy now!

INTERVENTIONAL radiologists play an important role in the overall management of patients undergoing hemodialysis, and this role has increased dramatically during the past few years. Often, we have been frustrated by roadblocks to our providing what we believe to be optimal care for these patients (ie, disagreements as to the appropriate [surgical versus percutaneous] management of failed and failing access, as well as repeated rejections of our procedures by third party payers, in particular Medicare). As with many other areas in interventional radiology, often it was a lack of published literature that contributed to these impediments. However, our contributions to this area of patient management have gradually found their way into the interventional radiology and nephrology literature and we have seen the tide begin to turn. Interventional radiology’s contributions to access creation and management have not gone unnoticed in the Nephrology community. Accompanying the September and October issues of the American Journal of Kidney Diseases are two supplements which contain the National Kidney Foundation Dialysis Outcomes Quality Initiative Clinical Practice Guidelines (1–4), a set of documents long awaited by the nephrology community. These guidelines, more than 2 years in the making, encompass four areas of dialysis: Anemia, Peritoneal Dialysis Adequacy, Hemodialysis Adequacy, and Vascular Access. It is the latter document which should be of greatest interest to interventional radiology: our place in the management of vascular access is firmly entrenched in these guidelines. The Vascular Access document contains 38 separate guidelines, each carefully referenced and justified by published literature, expert opinion, or both. There are over 200 references, culled from an initial list of more than 3,000. The guidelines cover all aspects of dialysis access creation and management, and the majority of them have direct bearing on interventional radiology. Anyone with current or anticipated involvement in the care of hemodialysis patients must obtain a copy of the Vascular Access Guidelines and read it carefully. It will have a far-reaching impact on dialysis access management as we move into the 21 century: already, HCFA policy has been altered in response to some of the guidelines even before their official publication. Areas of specific interest to interventional radiologists include a thrust toward increasing the percentage of native fistulas in this country, avoiding central venous stenosis by using ultrasound and fluoroscopically guided internal jugular dialysis catheter placement, increased use of preoperative venography and postoperative fistulography, and the firm support of the National Kidney Foundation for the practice of prophylactic intervention for failing hemodialysis access, to name but a few. Some might be surprised to learn that the document falls short of recommending percutaneous procedures such as percutaneous transluminal angioplasty (PTA) and declotting over surgical alternatives. However, in preparing the document the Vascular Access Workgroup (made up of five nephrologists, two surgeons, two dialysis nurses, and an interventional radiologist) was simply unable to make such a recommendation due to the lack of prospective randomized trials in those areas. In the end, the Workgroup recommended that each center decide what worked best for their patients based on local expertise and interest. What does the DOQI mean to practicing interventional radiologists? Simply reading the document will make this eminently clear, but here are a few of the repercussions. Because we will see more native fistulas (the goal is 40% up from the current 15%), it is not too early to begin studying the role of our interventions in such accesses, and learning from our counterparts in Europe, Canada and the Far East, where the majority of accesses are native fistulas. We will almost certainly see an increased role of interventional radiology in tunneled dialysis catheter placement, and we will probably see less of the vexing problem of central venous stenosis as a widespread shift to internal jugular catheters occurs. Those interventional radiologists who This article first appeared in J Vasc Interv Radiol 1998; 9:1–2.