CHIEF MEDICAL EDITOR'S PAGE: Hemodialysis Access: A Cinderella Story
Once upon a time, permanent hemodialysis access (Cinderella) was mostly neglected and abused by her two stepsisters, Surgery and Intervention. The surgical sister had many more important operations to do, such as hernia repair and cholecystectomy. The interventional sister dabbled in maintenance of hemodialysis access with a variety of techniques that afforded poor durability, but she didn't really care much as long as Cinderella didn't bother her on Friday afternoon or the weekend.
Well, fairy godmothers can take odd forms, and in this fable, she was seen over time as The Dialysis Outcomes and Practice Patterns Study, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative, and ultimately the Fistula First Breakthrough Initiative. Through these and other studies and programs, pumpkins were turned into carriages, mice into horses, and tattered rags into an evening gown—and Cinderella went to the ball. Unlike the fable, however, it wasn't quick or easy, and it took more time than the wave of a magic wand: approximately 15 years. But in our story, the fairy godmother prevailed, and the practice of hemodialysis access placement and maintenance finally came to the ball.
At this ball, there were surgeons who were truly interested in creating durable permanent access, interventionists who cared about maintaining these access circuits, as well as nurses, technicians, technologists, clinical coordinators, and industry who saw that things could be done better and were willing to learn, adapt, and share their knowledge to advance the care of dialysis patients. Where there were sparse data in the past, the attendees at the ball shared results from multicenter prospective trials that illuminated the problems and guided them toward solutions. At the ball, the understanding of hemodialysis access was better than ever before, although a lot remained to be done.
This Cinderella story is told in various ways and by different people. Within this edition of Endovascular Today, you will find contributions from interventional radiologists, nephrologists, and surgeons. Topics are diverse and include new concepts and challenges in maintenance of permanent access, treatment of central venous obstruction, development of vascular conduits and catheters, and considerations of how excellence can be achieved at each center.
And how about those two stepsisters? They aren't gone, and if you listen closely you will hear them thrashing about, complaining about the expense of some advances, the discomfort they feel while clinical practice patterns change around them, and possibly the worry that their income may drop because better treatment can reduce the number of return visits—therefore with fewer payments to themselves and their centers. But at the end of the fable, we know who wore the glass slipper, married the prince, and lived happily ever after.
The diversity of this edition's contributing authors highlights the fact that advances in hemodialysis access will not be the purview of any one specialty, and every specialist who cares about end-stage renal disease can play a role in this Cinderella story.
Enjoy this Dialysis Access issue of Endovascular Today, and consider it an invitation to see Cinderella at the ball—or at least join us at CiDA this October to hear the voices of all specialists who care about hemodialysis access (Controversies in Dialysis Access; October 27–29, 2010; San Francisco; www.dialysiscontroversies.org).