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Access surgery and the role of nephrologists
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CORRESPONDENCE
phism with early onset of ESRF in PKD1 adult polycystic kidney disease. Kidney Int 52:607-613, 1997 6. Ioannidis JP, Ntzani EE, Trikalinos TA, ContopoulosIoannidis DG: Replication validity of genetic association studies. Nat Genet 29:306-309, 2001 7. Cooper DN, Nussbaum RL, Krawczak M: Proposed guidelines for papers describing DNA polymorphismdisease associations. Hum Genet 110:207-208, 2002 © 2003 by the National Kidney Foundation, Inc. PII: S0272-6386(03)00293-2
ACCESS SURGERY AND THE ROLE OF NEPHROLOGISTS To the Editor: We read with interest the paper by Ravani et al1 stating that the creation of vascular access can be an option for renal physicians, especially for those sharing experience, working with other access surgeons for many years. Among the excellent data presented, we focus on the surgical decision-making by only 1 or 2 nephrologists, and their awareness of vascular surgery. We are not questioning the surgical outcome obtained by the authors, but we do wonder if other centers, with renal physicians as the leading team for performing vascular access surgery, are able to replicate the excellent results presented by Ravani et al and also by other nephrologists.2 That is, is the average nephrologist able to produce, as stated by the authors, the potential advantage of direct involvement in the management of vascular access surgery and also able to duplicate these results not only on an autogenous first access but also on every subsequent access during revision surgery? The decision as to who should perform access surgery has been much debated, and perhaps depends on local conditions3 and the priorities of surgeons at certain periods of time.1 It seems, however, that characteristics of the surgeon regulate the short- and long-term outcome of access procedures in renal disease.4,5 Can nephrologists do it better? Perhaps sometimes yes,1,2 but this conclusion cannot necessarily be applied to all units. Expertise in surgery, nephrology, and radiology is needed for good outcomes, focusing not only on the first access but also on every subsequent access. The results in every unit might be better if a multidisciplinary effort is applied. George S. Georgiadis, MD Department of Vascular Surgery Alexandros Polychronidis, MD Second Department of Surgery Demokritos University of Thrace Alexandroupolis, Greece
REFERENCES 1. Ravani P, Marcelli D, Malberti F: Vascular access surgery managed by renal physicians: The choice of native arteriovenous fistulas for hemodialysis. Am J Kidney Dis 40:1264-1276, 2002
2. Konner K, Hulbert-Shearon TE, Roys EC, Port FK: Tailoring the initial vascular access for dialysis patients. Kidney Int 62:329-338, 2002 3. Lazarides MK, Iatrou C, Tzilalis VD, et al: Influence of surgeons’ specialty on the selection of vascular access for hemodialysis treatment. Blood Purif 20:338-341, 2002 4. Prischl FC, Kirchgatterer A, Brandstatter E, et al: Parameters of prognostic relevance to the patency of vascular access in hemodialysis patients. J Am Soc Nephrol 6:1613-1618, 1995 5. Gibson KD, Caps MT, Kohler TR, Hatsukami TS, Gillen DL, Aldassy M: Assessment of a policy to reduce placement of prosthetic hemodialysis access. Kidney Int 59:2335-2345, 2001
© 2003 by the National Kidney Foundation, Inc. PII: S0272-6386(03)00294-4
In Reply: We thank Drs Georgiadis and Polychronidis for their thoughtful remarks. Of note, they stress vascular access management should be multidisciplinary, irrespective of the specialty responsible for surgery. We agree that nephrologists alone may be overwhelmed to attend to the multiple aspects of care (physical, psychological, and social) in this patient group. Unfortunately, when communication between specialists is inadequate and financial resources are lacking, it is easier (and unavoidable) to acquire other skills in the patient’s interest. As explained in the article,1 Italian nephrologists had to manage all vascular access surgery (including all access types as well as peritoneal surgery) because “it was not a priority” of our surgeons for several years. However, the “average nephrologist” in all countries could achieve the same results,2,3 including access revision procedures. Vascular access surgery demands precision and patience rather than complex technical skills, and success depends on the experience acquired in the operating theater. Nephrologists do not necessarily “do it better,” but the direct involvement of the physician responsible for the day-to-day care of dialysis patients has a clear motivational and goaloriented advantage. Pietro Ravani, MD Daniele Marcelli, MD Fabio Malberti, MD Istituti Ospedalieri Cremona Cremona, Italy
REFERENCES 1. Ravani P, Marcelli D, Malberti F: Vascular access surgery managed by renal physicians: The choice of native arteriovenous fistulas for hemodialysis. Am J Kidney Dis 40:1264-1276, 2002 2. Ravani P, Brunori G, Mandolfo S, et al: Survival of the first arteriovenous fistula in patients starting hemodialysis: A multicenter study. J Am Soc Nephrol 13:410A, 2002 3. Brunori G, Ravani P, Mandolfo S, et al: Short term outcomes of the first arteriovenous fistula in patients begin-
CORRESPONDENCE
phism with early onset of ESRF in PKD1 adult polycystic kidney disease. Kidney Int 52:607-613, 1997 6. Ioannidis JP, Ntzani EE, Trikalinos TA, ContopoulosIoannidis DG: Replication validity of genetic association studies. Nat Genet 29:306-309, 2001 7. Cooper DN, Nussbaum RL, Krawczak M: Proposed guidelines for papers describing DNA polymorphismdisease associations. Hum Genet 110:207-208, 2002 © 2003 by the National Kidney Foundation, Inc. PII: S0272-6386(03)00293-2
ACCESS SURGERY AND THE ROLE OF NEPHROLOGISTS To the Editor: We read with interest the paper by Ravani et al1 stating that the creation of vascular access can be an option for renal physicians, especially for those sharing experience, working with other access surgeons for many years. Among the excellent data presented, we focus on the surgical decision-making by only 1 or 2 nephrologists, and their awareness of vascular surgery. We are not questioning the surgical outcome obtained by the authors, but we do wonder if other centers, with renal physicians as the leading team for performing vascular access surgery, are able to replicate the excellent results presented by Ravani et al and also by other nephrologists.2 That is, is the average nephrologist able to produce, as stated by the authors, the potential advantage of direct involvement in the management of vascular access surgery and also able to duplicate these results not only on an autogenous first access but also on every subsequent access during revision surgery? The decision as to who should perform access surgery has been much debated, and perhaps depends on local conditions3 and the priorities of surgeons at certain periods of time.1 It seems, however, that characteristics of the surgeon regulate the short- and long-term outcome of access procedures in renal disease.4,5 Can nephrologists do it better? Perhaps sometimes yes,1,2 but this conclusion cannot necessarily be applied to all units. Expertise in surgery, nephrology, and radiology is needed for good outcomes, focusing not only on the first access but also on every subsequent access. The results in every unit might be better if a multidisciplinary effort is applied. George S. Georgiadis, MD Department of Vascular Surgery Alexandros Polychronidis, MD Second Department of Surgery Demokritos University of Thrace Alexandroupolis, Greece
REFERENCES 1. Ravani P, Marcelli D, Malberti F: Vascular access surgery managed by renal physicians: The choice of native arteriovenous fistulas for hemodialysis. Am J Kidney Dis 40:1264-1276, 2002
2. Konner K, Hulbert-Shearon TE, Roys EC, Port FK: Tailoring the initial vascular access for dialysis patients. Kidney Int 62:329-338, 2002 3. Lazarides MK, Iatrou C, Tzilalis VD, et al: Influence of surgeons’ specialty on the selection of vascular access for hemodialysis treatment. Blood Purif 20:338-341, 2002 4. Prischl FC, Kirchgatterer A, Brandstatter E, et al: Parameters of prognostic relevance to the patency of vascular access in hemodialysis patients. J Am Soc Nephrol 6:1613-1618, 1995 5. Gibson KD, Caps MT, Kohler TR, Hatsukami TS, Gillen DL, Aldassy M: Assessment of a policy to reduce placement of prosthetic hemodialysis access. Kidney Int 59:2335-2345, 2001
© 2003 by the National Kidney Foundation, Inc. PII: S0272-6386(03)00294-4
In Reply: We thank Drs Georgiadis and Polychronidis for their thoughtful remarks. Of note, they stress vascular access management should be multidisciplinary, irrespective of the specialty responsible for surgery. We agree that nephrologists alone may be overwhelmed to attend to the multiple aspects of care (physical, psychological, and social) in this patient group. Unfortunately, when communication between specialists is inadequate and financial resources are lacking, it is easier (and unavoidable) to acquire other skills in the patient’s interest. As explained in the article,1 Italian nephrologists had to manage all vascular access surgery (including all access types as well as peritoneal surgery) because “it was not a priority” of our surgeons for several years. However, the “average nephrologist” in all countries could achieve the same results,2,3 including access revision procedures. Vascular access surgery demands precision and patience rather than complex technical skills, and success depends on the experience acquired in the operating theater. Nephrologists do not necessarily “do it better,” but the direct involvement of the physician responsible for the day-to-day care of dialysis patients has a clear motivational and goaloriented advantage. Pietro Ravani, MD Daniele Marcelli, MD Fabio Malberti, MD Istituti Ospedalieri Cremona Cremona, Italy
REFERENCES 1. Ravani P, Marcelli D, Malberti F: Vascular access surgery managed by renal physicians: The choice of native arteriovenous fistulas for hemodialysis. Am J Kidney Dis 40:1264-1276, 2002 2. Ravani P, Brunori G, Mandolfo S, et al: Survival of the first arteriovenous fistula in patients starting hemodialysis: A multicenter study. J Am Soc Nephrol 13:410A, 2002 3. Brunori G, Ravani P, Mandolfo S, et al: Short term outcomes of the first arteriovenous fistula in patients begin-