Background. Background. Background. Curriculum Design and Editorial Process. Creating a PD Curriculum. ASDIN HVA Core Curriculum

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Background Creating a PD Curriculum Steven Wu, MD Director of Interventional Nephrology Massachusetts General Hospital Harvard Medical School The scope of our current practice as a new subspecialty

Hemidlaysis AV access management Peritoneal dialysis catheter placement Kidney ultrasound and biopsy Renal artery stenosis and peripheral artery disease 2 ASDIN HVA Core Curriculum Background ASDIN

1 Background Creating a PD Curriculum Steven Wu, MD Director of Interventional Nephrology Massachusetts General Hospital Harvard Medical School The scope of our current practice as a new subspecialty within nephrology. Hemidlaysis AV access management Peritoneal dialysis catheter placement Kidney ultrasound and biopsy Renal artery stenosis and peripheral artery disease 2 ASDIN HVA Core Curriculum Background ASDIN Core Curriculum for Interventional Nephrology (HVA) Author: Dr. Gerald Beathard Well-written and well-perceived Available for purchasing at the ASDIN website Served as the core curriculum of hemodialysis AV access management within Interventional Nephrology 4 Background Curriculum Design and Editorial Process 5 Need of a similar core curriculum for peritoneal dialysis catheter procedures: Peritoneal dialysis catheter placement procedures represent the second largest practice by interventional nephrologists Multiple approaches A similar curriculum for peritoneal dialysis catheter procedures to meet the needs of ASDIN members. ASDIN Education Committee agendas Education Committee - Curriculum Subcommittee Chair: Steven Wu, MD Members: Loay Salman, MD Bharat Sachdeva, MD Lisa Nanovic, MD Anil Agarwal, MD Ivan Maya, MD 1

Table of the Contents Table of the Contents 7 Chapter 1. Introduction Arif Asif M.D. and Loay Salman M.D. Chapter 2.

Definition of Peritoneal Dialysis Catheter Complications and Proper Function Stephen Ash M.D., Anil Agarwal, M.D. 8 Chapter 4.

A Technique of Laparoscopic Tenckhoff catheter: Same Day Peritoneal Dialysis. Gazi Zibari, M.D., Hosein Shokouh-Amiri, MD Chapter 6.

2 Table of the Contents Table of the Contents 7 Chapter 1. Introduction Arif Asif M.D. and Loay Salman M.D. Chapter 2. Peritoneal Dialysis Catheters Designs and Overview of Placement Techniques Stephen Ash M.D., Anil Agarwal, M.D. Chapter 3. Definition of Peritoneal Dialysis Catheter Complications and Proper Function Stephen Ash M.D., Anil Agarwal, M.D. 8 Chapter 4. Surgical Placement of Peritoneal Dialysis Catheters (Dissective Placement) Amer Rajab MD, PhD, Mitchell Henry, MD; Chapter 5. A Technique of Laparoscopic Tenckhoff catheter: Same Day Peritoneal Dialysis. Gazi Zibari, M.D., Hosein Shokouh-Amiri, MD Chapter 6. Peritoneoscopic Placement of Peritoneal Dialysis Catheters Rick Mischler M.D., Jeff Packer, D.O. Table of the Contents Chapter 1 9 Chapter 7. Fluoroscopic Placement of Peritoneal Dialysis Catheters Kenneth Abreo M.D., Bharat Sachdeva, M.D., Ivan Maya, M.D. Chapter 8. Peritoneal Catheter Removal and Complications of Peritoneal Dialysis Catheters Loay Salman M.D. and Arif Asif M.D. Chapter 9. CPT Coding of Peritoneal Dialysis Catheter Related Procedures Donald Schon M.D., Shouwen Wang, M.D. Chapter 1 - Sample Page Chapter 2 2

3 Chapter 2 - Sample Figures Chapter 3 Chapter 4 Chapter 4 - Sample Table Chapter 5 Chapter 5 - Sample Figures 3

4 Chapter 5 - Sample Figures Chapter 5 - Sample Figures Chapter 6 Chapter 6 - Sample Figure Chapter 7 Chapter 7 - Sample Page with Figure 4

5 Chapter 8 Chapter 8 - Sample Table Chapter 8 - Sample Page with Figure Chapter 9. Chapter 9. Sample Tables The 1 st Edition 5

PD as a CVC Avoidance Strategy Kenneth Abreo, M.D. Professor & Chief Division of Nephrology Financial Disclosure Discussion Points None The CVC Problem The Dark Side of CVCs Why is a PD catheter preferable to a CVC?

6 PD as a CVC Avoidance Strategy Kenneth Abreo, M.D. Professor & Chief Division of Nephrology Financial Disclosure Discussion Points None The CVC Problem The Dark Side of CVCs Why is a PD catheter preferable to a CVC? Strategy s for CVC avoidance Barriers to PD selection PD in the early and late referred CKD patient AVF placement in the PD patient Discussion Points The CVC Problem The Dark Side of CVCs Why is a PD catheter preferable to a CVC? Strategy s for CVC avoidance Barriers to PD selection PD in the early and late referred CKD patient AVF placement in the PD patient The CVC Problem 82% of patients in the US initiated HD with a CVC in 2006 Hakim & Himmelfarb, KI 2 6

7 The CVC Problem 75% of patients followed by Nephrologists for > 6 months initiated HD with a CVC Hakim & Himmelfarb, KI 2 Discussion Points The CVC Problem The Dark Side of CVCs Why is a PD catheter preferable to a CVC? Strategy s for CVC avoidance Barriers to PD selection PD in the early and late referred CKD patient AVF placement in the PD patient The Dark Side of CVCs Inadequate HD with CVC when compared to AVF and AVG CVC induced central vein stenosis and thrombosis poses a threat to successful AVF and AVG placement Most important, a very high incidence of catheter-associated associated blood stream infections resulting in a high mortality % Vascular Access Infections 5 0 AVF AVG CATH <3MO CATH>6MO CRB ranges from episodes per 1000 catheter-days K/DOQI guideline RR 1 MORTALITY RR of Death by Access Prevalence CVC AVG AVF DM NO DM Discussion Points The CVC Problem The Dark Side of CVCs Why is a PD catheter preferable to a CVC? Strategy s for CVC avoidance Barriers to PD selection PD in the early and late referred CKD patient AVF placement in the PD patient Dhingra PK et al KI, 2001;60(4) 7

8 Why is a PD catheter preferable to a CVC? PD catheters have lower infection rate than CVC Superior early survival (debated) Better outcome after renal transplantation Lower risk of HBV and HCV infections Better QOL and autonomy Preservation of vascular real estate Ref: Ishani et al, KI 68:311, 2005; Foley et al, JASN 15:1038, 2004; Biesen et al, JASN 11:116, 2000; Rubin et al JAMA 291:697, 2004; Kutner et al, NDT 20:2159, 2005 Access Related Infection in the USRDS Wave 2 Study PC AVF PD HR 95%CI PC TC AVG AVF 1 Ref Ishani PD et 0.96 al, KI :311, Why is a PD catheter preferable to a CVC? PD catheters have lower infection rate than CVC, comparable to AVFs Superior early survival (debated) Better outcome after renal transplantation Lower risk of HBV and HCV infections Better QOL and autonomy Preservation of vascular real estate Discussion Points The CVC Problem The Dark Side of CVCs Why is a PD catheter preferable to a CVC? Strategy s for CVC avoidance Barriers to PD selection PD in the early and late referred CKD patient AVF placement in the PD patient Strategies for Avoiding CVC Role of Nephrologist: Early referral for AVF placement (egfr rule, 6 m before use) Patient related factors: Early education Role of Vascular Surgeon: Training in surgical techniques Prompt intervention by Interventionalist Role of Insurance Industry Peritoneal Dialysis as bridge therapy Discussion Points The CVC Problem The Dark Side of CVCs Why is a PD catheter preferable to a CVC? Strategy s for CVC avoidance Barriers to PD selection PD in the early and late referred CKD patient AVF placement in the PD patient 8

9 Barriers to PD Selection Survey of 1365 patients starting HD in Network 18 1/3 of patients were unaware of their kidney disease and saw a nephrologist <4 months before HD 1/2 of patients were presented with treatment options either after or <1 month before the first HD 2/3 of patients were not presented with PD as a treatment option Discussion Points The CVC Problem The Dark Side of CVCs Why is a PD catheter preferable to a CVC? Strategy s for CVC avoidance Barriers to PD selection PD in the early and late referred CKD patient AVF placement in the PD patient Mehrotra et al, KI 68:378, 200 Early Referral and Selection of PD as a Treatment Modality Early referral defined as first visit to a nephrologist 4 months before initiation of dialysis Early referral combined with a responsible, well- balanced presentation of therapeutic options is associated with increased selection of PD as the initial therapy Who is more likely to select PD over HD? Young age, white race, fewer co-morbid conditions Employed, married, living with someone, more autonomous or more accomplished educationally Seen earlier (>4 months) and more frequently (> 2 visits) by a Nephrologist Ref: Prichard, PDI 1996; USDS Wave 2, AJKD 1997; Obrador & Pereira, AJKD 1998; Schmidt et al, AJKD 1998; Diaz-Buxo, PDI 1998; Van Biesen et al, PDI 1999 Stack A, JASN 13:1279,200 Can PD be Initiated in the Late-Referred ESRD Patient (no vascular access or immature AVF)? 52 patients with ESRD started on 12-hour APD Coiled, double-cuffed Tenkhoff catheters inserted by open surgery under local anesthesia and without the use of prophylactic antibiotics Exceptionally good surgical support 7 days a week Standard prescription for acute APD was: 12h overnight, total volume 10L with maximum dwell volume 1.2L (BW<60 Kg) or 14L with maximum dwell volume 1.5L (BW>60Kg), tidal volume 50-75% Supine at night, free to walk during dry day Povlsen & Ivarson, NDT 200 Comparison of Acute vs Planned PD Acute Planned P 52(%) 52(%) Infectious complications 10 (19.2) 11 (21.2) NS Mechanical complications 15 (28.9) 4 (7.7) <0.01 Surgical replacement 10 (19.2) 2 (3.9) < PD technique survival at 3 mo. 39/52 (75) 45/52 (86.5) NS PD technique survival, censored for death & transplantation 39/45 (86.7) 45/50 (90) NS Povlsen & Ivarson, NDT 20 9

10 Discussion Points The CVC Problem The Dark Side of CVCs Why is a PD catheter preferable to a CVC? Strategy s for CVC avoidance Barriers to PD selection PD in the early and late referred CKD patient AVF placement in the PD patient PD Patients Can Benefit from a Back Up AVF Permanent transfer from PD to HD: Recurrent peritonitis, inadequate small solute clearance (uremia), UF failure (volume XS, HTN, CHF) and patient burn out Temporary transfer from PD to HD: Volume overload, hernia repair, intra-abdominal abdominal surgery AVF should be placed at the time of or soon after PD catheter placement to allow maturation Having an AVF will avoid the placement of a CVC Conclusions Yes, it is possible to place a PD catheter as a CVC avoidance strategy It involves education of the patient and in some instances the nephrologist In some instances the patient may choose to stay on PD permanently Patients on PD may benefit from having a back up AVF ULTRASOUND AND HEMODIALYSIS ACCESS Vandana Dua Niyyar, MD Assistant Professor of Medicine, Division of Nephrology, Emory University UTILITY OF ULTRASOUND AVF: Pre-operative arterial & venous AVF A Maturity Stenosis Angioplasty Thrombosis Clot Burden Steal syndrome AVG: Stenosis Angioplasty PseudoaneurysmP d Peri-graft infection Central Venous Catheters: Placement 10

ADVANTAGES DISADVANTAGES Non-invasive No need for contrast/radiation Widely available, Mobile Inexpensive Provides information on both morphology (vessel anatomy) and function (blood flow) of

11 ADVANTAGES DISADVANTAGES Non-invasive No need for contrast/radiation Widely available, Mobile Inexpensive Provides information on both morphology (vessel anatomy) and function (blood flow) of vascular Dependent on operator expertise Time consuming Limited it field of view provides focal imaging Difficult to visualize central/more proximal stenosis due to depth limitations TECHNICAL CONSIDERATIONS B-Mode: Sound wave travels through tissue and reflected back towards transducer Velocity of sound independent of tissue type can be converted to anatomic depth 2-dimensional image produced based on time interval and intensity of sound TECHNICAL CONSIDERATIONS Color Doppler Color superimposed on B-Mode image Degree of color saturation Flow velocity Hue Direction of flow BART: Blue Away, Red Towards TECHNICAL CONSIDERATIONS Spectral Doppler Waveform analysis Quantitative measurement of velocity (PSV, RI) Power Doppler Power of signal related to the number of RBC s (not velocity) Useful in slow flow/near occlusion SPECTRAL WAVEFORM RESPIRATORY PHASICITY Guidelines for noninvasive vascular laboratory testing. Journal of the American Society of Echocardiography Malovrh. The Role of USS in planning AVF for HD. Seminars in Dialysis

HIGH-RESISTANCE ARTERY LOW-RESISTANCE AVF Malovrh. The Role of USS in planning AVF for HD.

2003. CENTRAL VENOUS EVALUATION Frequent use of central catheters results in central vein stenosis

of central venous abnormality using Slide Courtesy: Dr Work lt d CENTRAL VENOUS EVALUATION Patel et

phasicity as a predictor of complete central AVF MATURITY FOR USE THROMBOSED GRAFT AVF MATURITY FOR

4 cm or greater, the chance that it would be adequate for dialysis was 89% versus 44% if size was

12 HIGH-RESISTANCE ARTERY LOW-RESISTANCE AVF Malovrh. The Role of USS in planning AVF for HD. Seminars in Dialysis Malovrh. The Role of USS in planning AVF for HD. Seminars in Dialysis CENTRAL VENOUS EVALUATION Frequent use of central catheters results in central vein stenosis Ultrasound unable to visualize the subclavian and brachiocephalic vein But may get indirect evidence of central venous abnormality using Slide Courtesy: Dr Work lt d CENTRAL VENOUS EVALUATION Patel et al Subclavian and internal jugular veins at Doppler US: abnormal cardiac pulsatility and respiratory phasicity as a predictor of complete central AVF MATURITY FOR USE THROMBOSED GRAFT AVF MATURITY FOR USE If fistula diameter was 0.4 cm or greater, the chance that it would be adequate for dialysis was 89% versus 44% if size was less. If fistula blood flow was 500 ml/min or greater, the chance that it would be adequate was 84% versus 43% if it was less. Combining the two variables, the chance that it would be adequate was 95% versus 33% if neither of the criteria were met. Experienced dialysis nurses had a 80% accuracy in predicting the ultimate utility of a fistula for dialysis. Robbin et al. Radiology 2002; 225:

STENOSIS Luminal diameter reduction > 50% Peak systolic flow velocity (PSV) > 400 cm/sec PSV ratio across stenosis >2.

cf. angiography Middleton et al. CD of HD access: comparison with angiography.

PSV 91 cm/s PSV 636 cm/s 12 HD Access USS. Lockhart & Robbin. Ultrasound Quarterly 2001.

steadily increasing RR of thrombosis AVF Measure at feeding brachial artery/avf Flow < 500 ml/min access dysfunction Grogan et al.

Color Doppler USS in Dialysis Access NDT (2004) 19: 195 ACCESS FLOW VOLUME Weise et al.

13 STENOSIS Luminal diameter reduction > 50% Peak systolic flow velocity (PSV) > 400 cm/sec PSV ratio across stenosis >2.0 High resistance Doppler waveform Decrease in access flow volume Percent stenosis: (Original lumen residual lumen)/ Original lumen Sensitivity 76-87% cf. angiography Middleton et al. CD of HD access: comparison with angiography. Am J Radiol 1989; 152: Tordoir et al Duplex USS in assessment of AVF for HD: comparison with DSA J Vasc Surg AVF JUXTA- ANASTOMOTIC STENOSIS PSV 91 cm/s PSV 636 cm/s 12 HD Access USS. Lockhart & Robbin. Ultrasound Quarterly (3), AVF JUXTA-ANASTOMOTIC STENOSIS PS V 13 0 PSV 438 ACCESS FLOW VOLUME PTFE AVG Measure anywhere along the access Flow < 650 ml/min steadily increasing RR of thrombosis AVF Measure at feeding brachial artery/avf Flow < 500 ml/min access dysfunction Grogan et al. Freq of critical stenosis in primary AVF: Shd Duplex USS be std of care? J Vasc Su Weise et al. Color Doppler USS in Dialysis Access NDT (2004) 19: 195 ACCESS FLOW VOLUME Weise et al. Color Doppler USS in Dialysis Access NDT (2004) 19: 19 ANGIOPLASTY Duplex guided balloon angioplasty Small, uncontrolled studies Successful in both grafts 1 and fistulae 2 May be used intra-operatively for arterial stenosis May be used post-operatively operatively for immature/failing AVF 1. CD USS PTA of grafts. Bacchini et al. Journal of Vascular Access 2007; 8:81-2. Duplex-guided balloon angioplasty of AVF: A new office-based procedure. Asc Surg 2009; 50:

ANGIOPLASTY May be used intra-operatively for arterial stenosis 7 patients with

balloon decided d pre- operatively by USS Wires, balloons and stents inserted through

2 AVF (stents) unsuccessful Intra-op USS guided angioplasty of arterial stenosis during

Journal of Vascular Access 2007 ANGIOPLASTY 32 office-based procedures on 25 patients

used for dialysis within 3 months after last procedure Primary cumulative patency at 1,

Color Doppler USS in Dialysis Access NDT (2004) 19: 1956-1963 Weise et al.

14 ANGIOPLASTY May be used intra-operatively for arterial stenosis 7 patients with arterial stenosis, diagnosed pre- operatively by USS Dimensions i of angioplasty balloon decided d pre- operatively by USS Wires, balloons and stents inserted through the arteriotomy; inflation 8-13 atm for 30 sec 5 AVF matured and were successfully used 2 AVF (stents) unsuccessful Intra-op USS guided angioplasty of arterial stenosis during u AVF creation. Napoli et al. Journal of Vascular Access 2007 ANGIOPLASTY 32 office-based procedures on 25 patients Non-maturing (27) and failing (5) AVF All 5 failing AVF salvaged 24/27 successfully used for dialysis within 3 months after last procedure Primary cumulative patency at 1, 3 and 6 months: 96%, 76% and 53% Duplex-guided balloon angioplasty of AVF: A new office-based procedure. Ascher et al. J Vasc S THROMBUS BURDEN COLOR DOPPLER - STEAL Weise et al. Color Doppler USS in Dialysis Access NDT (2004) 19: Weise et al. Color Doppler USS in Dialysis Access NDT (2004) 19: 195 COLOR DOPPLER - STEAL NORMAL GRAFT 7 HD Access USS. Lockhart & Robbin. Ultrasound Quarterly (3), HD Access USS. Lockhart & Robbin. Ultrasound Quarterly (3),

15 VECTRA GRAFT GRAFT STENOSIS CD USS of polyurethane vascular graft for HD. Wiese et al. NDT (2003) 18:139 Toya et al. Periodic duplex USS with elective PTA in AVG. Surg Today GRAFT STENOSIS OUTFLOW VEIN STENOSIS PSV PSV HD Access USS. Lockhart & Robbin. Ultrasound Quarterly (3), THROMBOSIS PERI-GRAFT INFECTION HD Access USS. Lockhart & Robbin. Ultrasound Quarterly (3), HD Access USS. Lockhart & Robbin. Ultrasound Quarterly (3),

GRAFT PSEUDOANEURYSM ULTRASOUND IN CATHETER PLACEMENTS Blind cannulations should not be

cannulation is mandatory 6 HD Access USS. Lockhart & Robbin. Ultrasound Quarterly 2001.

contrast/radiation Relatively inexpensive May be used across the spectrum for HD access pre-,

16 GRAFT PSEUDOANEURYSM ULTRASOUND IN CATHETER PLACEMENTS Blind cannulations should not be routinely done No excuse technology is readily available Complication rate 5% Ultrasound guided cannulation is mandatory 6 HD Access USS. Lockhart & Robbin. Ultrasound Quarterly (3), ANATOMICAL VARIATIONS SUMMARY Non-invasive Widely available Avoids exposure to contrast/radiation Relatively inexpensive May be used across the spectrum for HD access pre-, intra- and post-operatively operatively An excellent tool in the interventionist s armamentarium Slide Courtesy: Dr Work 16

ASDIN 7th Annual Scientific Meeting DISCLOSURES TECHNICAL CONSIDERATIONS TECHNICAL CONSIDERATIONS UTILITY OF ULTRASOUND IN EVALUATING ACCESS

ASDIN 7th Annual Scientific Meeting DISCLOSURES TECHNICAL CONSIDERATIONS TECHNICAL CONSIDERATIONS UTILITY OF ULTRASOUND IN EVALUATING ACCESS DISCLOSURES UTILITY OF ULTRASOUND IN EVALUATING ACCESS DYSFUNCTION None Vandana Dua Niyyar, MD Assistant Professor of Medicine, Division of Nephrology, Emory University UTILITY OF ULTRASOUND IN ACCESS