Klaus Konner , M.D. – Bergisch Gladbach, Germany
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Klaus Konner , M.D. – Bergisch Gladbach, Germany |
Prof Zoccali: Doctor Konner, I see that you have an almost holistic scientific interest in vascular access. What led you to focus so deeply into this subject?
Dr Konner: Originally, I wanted to become an internist and then I joined the dialysis unit in 1971 and the care for the vascular access was very disappointing. Our patients had to be transported to the other side of town and so on and one colleague started to do the vascular access as a young nephrologist and he joined about 30 operations with access surgeons and then he started to do it and I assisted him from time to time. He left us in 1977 and from this point on I had the responsibility. We had no vascular surgery at that time in our institution and at the time the vascular surgery department was founded we had more than 1000 access operations as nephrologists. This was one aspect, the second is that doing access surgery as a nephrologist you have a high risk to be seen from outside as a non-expert and my interest was to become better educated. So, I looked for a good teacher, I found him and I learned a lot from him. The next was that I started to read a lot about this topic of blood vascular access. So I got in contact with the United States, with the surgeons, the access surgeons and this was highly interesting. The next thing your question focused on so deeply into the subject is that I documented any operation or report and in addition via sketch, via drawing that means to draw is o.k. It is a good instrument for communication with a Doctor outside the hospital. The drawing left my institution by fax the same day I did the operation but the procedure to draw something means it’s a process of self-criticism. You ask questions to yourself: Did you realise the best, the optimal solution for that? Is this angle correct or not and so on? This is this process of self-criticism and any failure was analysed very deeply and so you get into the depth of a problem.
Prof Zoccali: Notwithstanding the importance, scientific research in vascular access is in a way a relatively fresh new research area. Why is this such important issue in nephrology has remained a neglected topic for so long?
Dr Konner: This is an excellent question. I think history gives the best answer. Originally the Scribner shunt, the arteriovenous fistula and the insertion of catheters were introduced by nephrologists. We have a generation of nephrologists in Germany in the ‘60s and the beginning of the ‘70s, in Italy still today nephrologists who perform access surgery, this is a tradition and in many other countries and mostly in Germany too, nephrologists used to delegate the problems of the upcoming diabetic patients, the old patients, maybe since 1975. They delegated the problem of the vascular access to the surgeons. You can see this on the diminishing frequency of publications on that subject in nephrologic journals. This is one aspect, the next is that you know in the United States, since the midst of the ‘70s, they had an abundant use of PTFE, of graft material and this has many reasons, this is not only an issue of the surgeons but an issue of nephrology too. So people complained that the results were not good but there were no solutions and this came with 2 things, with a revival of the AV fistula in the ‘90s, also in the United States with the DOQI. The main issue of DOQI is they thought about the problem, not the detail, they thought about the problem. The fistula became the problem, a new challenge and with this o.k. times had gone, we had ultrasound, it was very, very important. Ultrasound means a good technical instrument; ultrasound means, represents an interest of nephrologists in vascular access. It’s something to do for the nephrologist with the access and the next and last what I say we have a new era now. We have immunologic techniques, we have techniques with which we can go into depth on a molecular basis, level and so on and I think it’s breathtaking what will be coming up in the next years.
Prof Zoccali: In a way you put forward the question I’m going to ask just now. Could you tell us briefly, in brief, which imaging technique you consider as the most suitable for vascular access surveillance?
Dr Konner: This is ultrasound but the results of ultrasound are the best, the best is the clinical examination that precedes ultrasound and the best results come from the combination of clinical findings and ultrasound.
Prof Zoccali: You remarked that the worldwide approach to vascular access management is desperate. In some countries like Italy, vascular access is often created and supervised directly by nephrologists. In other countries like the United States, all surgical aspects are delegated to surgeons. Could you tell us how you perceive this problem?
Dr Konner: This is a problem where the solutions are on very different levels. The question covers the worldwide aspect of the problem. I think to generalise, what we have to aim at first is to document what we do and so we will gain results and so, we can compare results and this will be the prerequisite for the quality of vascular access in detail. There maybe different ways that may lead into the future. In Germany e try now to establish vascular access reference clinics. The first one will now go into practice in Santiago de Chile next month. There are special institutions in the United States caring for vascular access with a majority of procedures on the interventional side but there’s a start of nephrologists doing the access surgery in the United States and I think these are 2 aspects; there in addition, individual solutions possible. In Germany we have one nephrologic institution, which has its own vascular surgeon to do the access.
Prof Zoccali: You remarked that vascular access management is a complex task. May you please identify just a single recommendation, the most important one for our colleagues?
Dr Konner: Use the patients, autologous vessels, be critical, be self-critical and try to optimise your expertise.
Prof Zoccali: Which is the best paper you’ve ever read and that influenced you most?
Dr Konner: It was the first paper that Scribner published in 1960. It was prophetic. He not only described the AV shunts but what he wrote on hypertension, on duration of the treatment, on the role of potassium, it was fantastic and young nephrologists should even today read this paper.
Prof Zoccali: Do you think that vascular access should be formally included as a discipline in nephrology training curricula?
Dr Konner: Absolutely, absolutely. The way maybe very long because institutional ways are long around the world but it’s not only the fact that nephrology needs this, we should include surgery, we should include radiology and maybe the combination is the best realised in the reference clinic.
Prof Zoccali: Vascular access apart, which is the second nephrology topic in your mind?
Dr Konner: I think this is the problem of the cardiovascular morbidity in our ESRD patients today and all the research that is linked with this problem. Because this problem has an impact on all we do as nephrologists, it’s not only a problem for the access surgeon.
Prof Zoccali: Which are your hobbies?
Dr Konner: First music I play the clarinet in a classical manner. I’m a student I have a teacher still and then I play, as my time will allow golf and I read a lot and I like to travel but the music is my best thing.
Prof Zoccali: Thank you very much.