Fellows: Career Profile
Dr. Arif Asif - The Interventional Nephrologist
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.