Fellows: Career Profile

Dr. Arif Asif - The Interventional Nephrologist

Dr. Arif Asif

Interventional nephrology was born in the private practice arena and directly evolved out of the need to improve patient care for vascular access. During my nephrology fellowship, the division chief highlighted similar challenges that renal patients were faced with at academic medical centers. This led to the development of an interventional nephrology program at our institution. Herein, I describe the nature of interventional nephrology and the lifestyle that the specialty affords.

Interventional nephrology includes renal ultrasonography, placement and removal of tunneled hemodialysis and peritoneal dialysis catheters, angiography and balloon angioplasty for vascular access stenosis, endovascular stent and coil placement for dialysis access dysfunction, and thrombectomy procedures for clotted vascular access. Dedicated outpatient vascular access centers (VACs) specifically deal with vascular access (VA) dysfunction. In general there are three types of setups available for access centers: 1) Hospital-owned VAC with inpatient and/or outpatient management of VA: If a hospital is willing to provide an interventional nephrology suite to nephrology practice, this is a relatively economical option without need for large financial outlay. Reimbursement for the activity is based on relatively high facility fees and lower professional reimbursement. Disadvantages to the patient relate to inherent inconvenience of travel to the hospital, administrative barriers to rapid and convenient care within the hospital and scheduling conflicts. 2) Free standing VAC as an extension of practice: The most important advantage of a freestanding facility is its autonomy of operations. Because VAC is considered an extension of office practice the regulatory control is less rigorous and cost of setting up the center is less. The fees reimbursed for such a center include both the professional fees as well as the technical components. 3) Ambulatory Surgical Center (ASC): ASC, also known as outpatient surgery center or same day surgery center, is geared toward providing specialty surgery in the outpatient setting. There are strict requirements for providing care at ASC and more strict regulations. The ASC does not have facility for overnight stay that differentiates it from a hospital.

The first and foremost requirement for any center is the availability of a dedicated, welltrained interventionalist. However, the opportunities for training remain rather limited at this time, with only a small number of fellows being trained each year. At present there are no accredited fellowship programs for interventional nephrology. Nevertheless, training courses focusing on endovascular procedures are available at many medical centers across the United States. The American Society of Diagnostic and Interventional Nephrology (ASDIN) is playing an active role in this arena to facilitate recruitment of such centers. ASDIN has highlighted the number of procedures required for certification. In the future, the development of a one-year fellowship program that would ensure the performance of optimal number of procedures would most likely meet the demand for training. Note that at least two interventional nephrologists are required to initiate a program.

Interventional nephrology has had a very positive impact on the procedural aspect of patient care at our center. The service is provided on an outpatient basis; consequently a great majority of patients do not have to be admitted to the hospital. This has improved care in a cost effective way in this fiscally responsible era. Because the service is provided by nephrologists, interventional nephrology has allowed continuity of care to our patients. In general, the lifestyle of an interventional nephrologist is somewhat different from a general nephrologist. In this specialty, a major focus is placed on procedures with minimal coverage of general nephrology issues. In busy academic medical centers an interventional nephrologist might cover general nephrology minimally. In other situations where multiple nephrologists participate in interventional nephrology, opportunities to serve on nephrology ward rotations exist. Interventional nephrology practice can be physically demanding. Because a fluoroscope is used, performance of endovascular procedures requires lead aprons to protect against radiation exposure. In this context, an eight to ten hour day with multiple cases can be physically taxing.

Interventional nephrology has been a personally and professionally rewarding venture. Our interventional nephrology program has demonstrated improved patient care, continued growth, productivity and academic recognition at national and international levels. Although academic centers are rapidly becoming aware of this emerging specialty, there are at present only a handful of universities providing this care who are capable of providing training as well. Major opportunities exist for nephrology fellows to establish interventional nephrology programs and initiate clinical and basic research into the pathobiology of arteriovenous dialysis access stenosis.