St. Luke’s Cornwall Hospital

Could you walk us through your journey and your current responsibilities?

I am a board-certified nephrologist who has been practicing for 20 years, mostly in private practice. I partner with a group practice called Advanced Kidney Care based in New York City. In addition to this, I am also the chairman of the Department of Medicine at St. Luke’s Cornwall Hospital and Associate Professor of Clinical Medicine at Albert Einstein College of Medicine.

Together with my patient care duties, I also do resident teaching, where I educate the medical residents at St. Luke’s Cornwall Hospital. So my responsibilities can be broken down as 30 percent in the dialysis unit, 30 percent in the hospital, and the rest in my office.

Can you elaborate on the prominent challenges you see in the dialysis space today?

The foremost challenge facing the space is patients’ negative approach toward dialysis. Nobody is willing to undergo dialysis unless they absolutely have to, and it is seen in how patients deliberately avoid going to nephrologists. However, it is proven that a patient who consults a nephrologist at an early stage has a better chance for delayed onset of End-Stage Renal Disease (ESRD), compared to patients who consult at a stage where dialysis is the only option.

“The industry has been promoting home dialysis lately, meaning doing dialysis at home. Even the government is motivating it by incentivizing.”

Proper education about the role of a nephrologist and dialysis procedure is vital to bring people out of this mindset. A senior nephrologist can educate patients about the various dialysis options they have and prepare them for dialysis access, which should begin with educating them on the multiple vascular access techniques.

The first type of access is using a tunneled catheter. This method is usually used on patients who come unprepared, meaning without consulting a nephrologist before. However, this method is considered the least efficient option as the patient can be prone to infection and blood clotting around the catheter.

The second access option is called an Arteriovenous (AV) graft. In this technique, a synthetic material is implanted into the patient, connecting their vein and artery. It is usually done on patients with smaller veins, and the procedure takes a preparation time of about three weeks. An AV graft is always preferred over tunneled catheter as it is less prone to infections, although it can sometimes cause periodic clotting thrombosis.

The third and best kind of vascular access in dialysis is called AV fistula, in which the patient’s blood vessel is used to create a connection between their artery and vein. The procedure is associated with the least amount of infection and clotting, and lasts longer than the other two options.

What are some of the recent trends in dialysis?

The industry has been promoting home dialysis lately, meaning undergoing dialysis at home. Even the government is motivating it by incentivizing. The procedure is of two types; peritoneal dialysis and home hemodialysis. Around 10 to 15 percent of the population is currently undertaking home dialysis, for which the patient needs to be pretty motivated, relatively intelligent, and responsible.

In peritoneal dialysis, the process is done through the patient’s abdomen, exchanging fluid from the abdomen. As it has been longer available than the other home dialysis options, most home dialysis patients are seen undergoing peritoneal dialysis. It basically involves a catheter in the belly and using it to exchange fluid from the stomach. The only issue with peritoneal dialysis is it can be hard for older and weaker people.

Home hemodialysis is a relatively new method, which I consider the best choice. It enables four dialysis rounds in a week in short durations of two and a half an hour, with better outcomes. The process helps in easy blood pressure management, and maintaining a better diet, where the patient can eat as much as they want. It also makes people feel better and less tired after dialysis. The process is comparatively expensive and requires a tech-savvy and handy partner at home to ensure that the machine works well, which are the only two things patients find difficult.

On top of these trends, there are talks among people regarding artificial kidneys taking over dialysis. However, it is something that is impractical in the near future. Even though implanting a kidney is practical, creating a conduit to excrete urine and connecting it to the bladder is a challenge. Moreover, bringing a foreign object into the body can lead to infections. The only possible way to overcome these challenges is to grow a kidney from the person’s stem cells, but it is a whole new idea that will take decades to develop.

Can you talk about any initiatives for kidney care delivery in your organization, or any latest innovations that can transform the domain?

Our organization is  planning on expanding our care for home hemodialysis patients.

A new interesting and intriguing machine called the Tablo Hemodialysis System is revolutionizing the hemodialysis space. It is portable, mobile, and has an in-built RO system, which is the mainstay of dialysis water purification. As it carries the RO system, hospitals no longer have to build and maintain big RO infrastructure. Unlike the traditional dialysis equipment, which needs to be placed separately in settings, Tablo can be holistically used everywhere, be it the ICU setting, inpatient unit, or outpatient unit.

While most home hemodialysis equipment requires a lot of troubleshooting and technically educated people, Tablo is the least challenging in these aspects.

What would be your piece of advice to beginners in this field?

Choosing nephrology as your field of specialization is undoubtedly a good decision. It is one of the most demanding medical sections as the number of ESRD patients are growing. Nephrology can be practiced in inpatient settings like critical care units and outpatient patient settings, so professionals can choose what they wish to do, giving them a sense of flexibility.

Nephrology is also competent with other internal medicine fields in terms of compensation. If you are an ordinary nephrologist, you make a bit more than other internal medicine practitioners. But if you are an industrious and capable nephrologist who starts partnering with dialysis providers to open your own dialysis unit, you can even make more than cardiothoracic surgeons at times.

Moreover, it is one of the fields with the lowest malpractice insurance premiums as it is in a low risk position.