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The development of interventional nephrology has undoubtedly led to an improvement in patient care at many facilities across the United States. However, these services have traditionally been offered by interventional nephrologists in the private practice arena. While interventional nephrology was born in the private practice setting, several academic medical centers across the United States have now developed interventional nephrology programs. University Medical Centers (UMCs) that offer interventional nephrology face challenges, such as smaller dialysis populations, limited financial resources, and real or perceived political "turf" issues." Despite these hurdles, several UMCs have successfully established interventional nephrology as an intricate part of a larger nephrology program. This has largely been accomplished by consolidating available resources and collaborating with other specialties irrespective of the size of the dialysis population. The collaboration with other specialties also offers an opportunity to perform advanced procedures, such as application of excimer laser and endovascular ultrasound. As more UMCs establish interventional nephrology programs, opportunities for developing standardized training centers will improve, resulting in better quality and availability of nephrology-related procedures, and providing an impetus for research activities., (© 2011 Wiley Periodicals, Inc.)

The purpose of our study was to evaluate the use of a transcatheter extractor (TCE) device in removing cuffed tunneled dialysis catheters without a surgical cutdown. We report eight cases where a TCE was used to successfully remove cuffed tunneled dialysis catheters through the exit site that would have otherwise required a second incision. The cuff was above the clavicle in all cases and varied 3-5 cm from the exit site. The method included inserting the device over the catheter through the exit site and engaging it over the cuff. A to-and-fro motion was then used in the same plane as the catheter to dissect the cuff from the surrounding tissue. Once the cuff was freed, the catheter was removed easily without resistance. The fibrous cuff was removed intact in all cases. We conclude that the use of this device may help avoid a cutdown and minimize trauma to the patient. It is an effective technique to remove tunneled dialysis catheters and is particularly useful in catheters with ingrown cuffs further from the exit site., (© 2011 Wiley Periodicals, Inc.)

The Centers for Medicare and Medicaid Services (CMS) recently revised the requirements that end-stage renal disease (ESRD) dialysis facilities must meet to be certified under Medicare. The CMS ESRD Interpretive Guidance Update states that the dialysis facility must now have an ongoing program of hemodialysis vascular access surveillance. Surveillance usually refers to monthly access blood flow or static dialysis venous pressure measurements combined with preemptive correction of stenosis. However, surveillance as currently practiced does not accurately predict synthetic graft thrombosis or prolong graft life. There is limited evidence that monthly surveillance may reduce native arteriovenous fistula thrombosis without prolonging fistula life, but the effect on thrombosis awaits further confirmation. Thus, the CMS surveillance requirement is not evidence based. We recommend the following changes to the ESRD Interpretive Guidance Update: only monitoring (e.g., physical examination) is required, whereas the proper role of surveillance awaits the results of further research. Such changes would allow nephrologists to apply the clinical judgment and individualized care that is most beneficial to their patients.

Purpose: Catheter-related blood stream infections pose a significant risk for patients living with vascular catheters. The cost to manage these infections is substantial. Although the etiology of these infections is multifactorial, tap water has been implicated as a significant causative factor. This retrospective review evaluates the effectiveness of a surgical dressing, the CD-1000, at protecting catheters and exit site wounds from fluid and debris when patients engage in high risk activities like showering., Methods: All patients who received the CD-1000 from a single national medical supplier from September 2006 through to March 2007 were contacted to participate in this retrospective review; 209 patients, representing 34 states and 175 unique physicians, participated in this study. Effectiveness of the dressing along with prior and current history of catheter events was queried., Results: The CD-1000 was 95% effective at keeping the catheter and exit site dry while patients engaged in high risk activities like showering. Prior to using the CD-1000, the 209 patients reported a historical catheter infection rate of 1.83 per 1000 catheter days. While using the CD-1000 the 209 patients reported a catheter infection rate of 0.47 per 1000 catheter days., Conclusion: The CD-1000 catheter specific composite dressing adequately protects vascular catheters and exit sites when patients engage in high risk activities like showering. In this geographically diverse retrospective review, use of the CD-1000 was associated with a 75% reduction in catheter associated infections.

Purpose: To compare the performance and safety of a fully subcutaneous vascular access device, the LifeSite hemodialysis access system, versus a tunneled hemodialysis catheter, the Tesio-Cath, at 1 year after implantation., Materials and Methods: Sixty-eight patients who required hemodialysis received implantation of the LifeSite device or a Tesio-Cath device as a part of this multicenter study. Thirty-four patients were treated in each group. The endpoints observed included blood flow rates and associated venous pressures, overall and device-related adverse events, the need for thrombolytic infusions, device-related infections (DRIs) and associated hospitalizations, and technical device survival., Results: During the 12-month observation period, significantly higher venous pressures were required in patients with the Tesio-Cath to achieve blood flow rates comparable with those achieved with the LifeSite device. Patients in the LifeSite group experienced a significantly lower rate of non-device-related adverse events (P < .001), device-related adverse events (P < .016), need for thrombolytic infusions (P < .002), and DRIs (P < .013) compared with patients in the Tesio-Cath group. There was a trend toward a lower number of hospital days per month for DRIs in the LifeSite group, with the rate for the Tesio-Cath group being twice that in the LifeSite group. The use of the LifeSite device was also associated with a significantly higher probability of device survival for 12 months after censoring for planned removals (P < .031)., Conclusions: The results of the present study demonstrate superior device performance and technical device survival, reduced complications, and the need for fewer interventions with the LifeSite hemodialysis access system compared with a standard hemodialysis catheter during a 1-year time period after implantation.

In the early 1950s and 1960s, peritoneal dialysis (PD) was used primarily to treat patients with acute renal failure. Continuous ambulatory peritoneal dialysis (CAPD) was introduced in 1976 and continues to gain popularity as an effective method of renal replacement therapy for patients with end-stage renal disease (ESRD). The PD catheter is inserted into the abdominal cavity either by a surgeon, interventional radiologist, or nephrologist. We have adopted a percutaneous approach with fluoroscopic guidance for PD catheter insertion that is easy, safe, and provides good patency and infection rate results. In this article we describe the technique and our results. From August 2000 to May 2003, 34 PD catheters out of 36 were successfully inserted using the percutaneous fluoroscopic technique in selected patients referred from the nephrology clinic. All the PD catheters were placed in our Interventional Nephrology Vascular Suite by nephrologists.

Background: The LifeSite Hemodialysis Access System is a subcutaneous access device designed to maximize blood flow while minimizing access-related complications. The purpose of this study was to compare the efficacy and safety of the LifeSite System to a similar but transcutaneous access device, the Tesio-Cath Hemodialysis Catheter., Methods: The study was conducted in two phases. A multi-center randomized prospective design was utilized for the first phase (Phase 1) where thirty-four patients were enrolled in the Tesio-Cath group and 36 patients into the LifeSite group where 0.2% sodium oxychlorosene was used as an antimicrobial solution for the LifeSite. A nonrandomized, but otherwise identical, second phase of the study followed where a 70% isopropyl alcohol solution was utilized as the antimicrobial solution for 34 additional LifeSite patients (Phase 2)., Results: Device function was evaluated in Phase 1 of the trial. Actual blood flow (determined by ultrasound dilution) was greater in the LifeSite versus the Tesio-Cath group (358.7 vs. 331.8 mL/min, P < 0.001 for machine-indicated blood flow of 400 mL/min). Infection comparisons were performed for all three groups encompassing Phase 1 and 2 of the trial; Tesio-Catheter, LifeSite System with oxychlorosene, and LifeSite System with 70% isopropyl alcohol. Device-related infections were defined as systemic bacteremia without another obvious site of origin and exit site infections requiring systemic antibiotics or device removal. This revealed infection rates per 1000 device use days of 1.3 for the LifeSite alcohol group, 3.3 for the Tesio-Cath group, and 3.4 per for the LifeSite oxychlorosene group. There was no statistically significant difference in device related infection rates between the Tesio-Cath and the LifeSite oxychlorosene groups. There were significant differences in infection rate between LifeSite alcohol group and the other two groups (P < 0.05). Device thrombosis was defined by the need for instillation of thrombolytic agents to maintain blood flow>300 mL/min. There was no difference in the need for thrombolytic infusions between the LifeSite oxychlorosene group and the Tesio-Cath group (P = 0.1496); however, the LifeSite alcohol group required significantly fewer thrombolytic infusions than the Tesio-Cath group (P = 0.0295) to maintain adequate blood flow. Device survival at 6 months after stratification by diabetic status and adjusting for age was significantly better in the LifeSite alcohol group (89.9%) than in the LifeSite oxychlorosene group (64.8%, P = 0.0286) and in the Tesio-Cath (69.1%, P = 0.0292) group., Conclusions: The LifeSite Hemodialysis Access System, when used with 70% isopropyl alcohol as an antimicrobial solution, provides superior performance with a lower infection rate and better device survival than a standard cuffed tunneled hemodialysis catheter.

Percutaneous placement of cuffed tunneled catheters for hemodialysis access has become a firmly established method of providing vascular access to patients with end-stage renal disease. Considerable evidence supports the right internal jugular vein as the preferred site for catheter insertion. The use of real-time imaging using both ultrasound and fluoroscopy permits simple, safe, and effective placement of the catheter for hemodialysis. The use of these imaging techniques has significantly reduced the number of and severity of complications associated with catheter placement. A specific method of placement is described including variations for specific catheter types. The new subcutaneous port as an alternative to the cuffed tunneled catheter appears to provide another option for vascular access; preliminary data suggests higher flow rates and lower infection rates compared with externalized cuffed tunneled catheters. Finally, the criteria for obtaining training and proficiency in placement of cuffed tunneled catheters are outlined., (Copyright 2002, Elsevier Science.)

Since the 1997 publication of the Disease Outcomes Quality Initiative (DOQI) vascular access guidelines for cuffed, tunneled catheter placement, additional evidence supporting these recommendations has been published, including additional documentation supporting the right internal jugular vein as the preferred site for insertion. Placing the catheter tip in the right atrium rather than in the superior vena cava will provide adequate blood flow to support effective hemodialysis. The right atrial positioning of the catheter tip will also accommodate catheter tip retraction and decrease the likelihood of malfunction. Overwhelming evidence now supports the use of ultrasound guidance to assist cannulation of the internal jugular vein. This evidence is based on several studies documenting anatomical variations of the internal jugular vein. Ultrasound guidance has significantly decreased the incidence of serious complications of jugular vein cannulation. Finally, a specific technique of catheter placement with variations for catheter types is described.