Friday, April 20, 2018

Kidney biopsies, we are at crossroads in Nephrology

The kidney biopsy has been a procedure that has been lived under Nephrology for years. Slowly and surely, nephrologists are being pulled in many different directions- dialysis patients, CKD patients , urgent K related consults and leaving the procedures behind to other specialties such as vascular for access placement and interventional radiology for kidney biopsies. 

A survey done nationally in 2014 hinted towards a downward trend of procedures done by Nephrology fellows. A more recent CJASN paper surveyed a single center graduating fellows and training program directors nationally on trends on kidney biopsies of renal fellows.
In reality, most private practicing nephrologists don’t perform their own biopsies. Radiologists have taken on that realm. Few academic nephrologists still perform biopsies along with fellows. When the graduates were asked the biggest barriers from doing their own kidney biopsies, they cited
1. System based logistics, and 2.time as the two most common factors.  One commented: “Doing only one would … wipe out 1/2 day of clinic … I can fill out and fax a request in 5 minutes …” Another: “The main reason (we) stopped was efficiency—(we) were at the mercy of the ultrasound suite.” Logistics require that the nephrologist coordinate access to an interventional suite with nursing support, conscious sedation, specialized equipment, and the necessary intra- and postprocedure monitoring.  Moreover, the 2017 Medicare national average physician reimbursement for kidney biopsy (CPT code 50200) was only US $135. Other concerns included skill loss when numbers dip under ten/year.  
Interestingly, more biopsies were performed when “IR” would do it rather than “nephrologist” due to time constraints. 

Program directors said the same thing. The most common barriers to achieving fellow competence were the same faced by our graduates: time (45%) and logistics (45%). Other commonly cited barriers were that graduates were unlikely to perform biopsies (41%), and faculty unwillingness to supervise (30%). High-volume programs (>100 biopsies/year, 15 of 74 programs) are likely to have dedicated facilities, equipment, and faculty—their systems allow logistic and time efficiency. Also, many junior faculty don’t feel comfortable supervising and the skill is being lost eventually.
The debate continues as we are deciding between “pragmatism” vs “ needed education”. As most graduates don’t use the skill of a kidney biopsy, should we abandon that procedure to be required in training of renal fellows. Is it required for fellows to know how to do the kidney biopsy? A rich debate has spurred about this topic on twitter and some are “for” and some are “against” keeping renal biopsies as requirements. 

A mid way approach: 
1.       Few specialized interested nephrologists maintain the skill per institution and teach interested fellows and it be only an elective requirement in our field.  There might be institutions where no nephrologist is interested in doing these and radiologist do all the biopsies.
2.       Rather than learning the actual procedure of “using the biopsy gun”, the fellows focus on indications, how to do the procedure, watch 5 procedures and log them and have a working knowledge of complications associated with the procedure. It is also important that the specimen received is cortex as often when not done by nephrologist- medulla is obtained. The procedure perform physician has to be explained to get more cortex especially when evaluating for glomerular diseases.
3.       Robust nephropathology education is required to supplement this on how the specimen is collected,  and cut and eventually reviewing pathology findings at each institution

While utterly disappointing, we are at crossroads in nephrology where we are losing procedures. Access placement is downtrending and now it is the kidney biopsies. We can get angry or frustrated or disappointed but this is the reality.  Data don’t lie!
We should be pragmatic and as mentioned in recent kidneycon 2018 guest speaker Jeff Amerine said –think about our customers- the patients and the fellows when designing our teaching product( lean canvas model approach).  The safety of patients matter- who can do it safely and with experience should be doing the procedure.  Our fellow market recipients are mostly not interested in learning kidney biopsy skills as most won’t use that skill in clinical practice.
A nice editorial by Scott Gilbert also was recently e published in CJASN.                

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