Neghae Mawla

Neghae Mawla (Dallas Nephrology Associates, Dallas, USA) of the American Society of Diagnostic and Interventional Nephrology (ASDIN) is an interventional nephrologist (IN) and a passionate advocate for the specialty. He speaks to Renal Interventions to explore interventional nephrology’s unique position in dialysis access care, the technologies that most excite him, as well as his award-winning barbecue products.

How did you develop your interest in interventional nephrology?

I knew I would end up in nephrology early on, but it just so happened my nephrology fellowship—at St Louis University (St Louis, USA)—was also an interventional programme. Before that, I did not know it existed, but after I got my feet wet doing the technical side I thought, “this is really cool”. The more I did, the more I liked it. My pathway into the interventional side of nephrology was not planned.

What is your philosophy as a physician, particularly in the dialysis space?

My philosophy is about figuring out what you do best and focusing on it. Nephrology is so general, but I focused purely on intervention after some time in both general and interventional. I realised I am more suited for this pathway, these patients and this particular technology, where my skill can really be focused. Other physicians can do in-office or in-hospital better than I can—why do I need to keep them? I redirected my focus to the procedural element, including the creation and maintenance of endovascular arteriovenous fistula (endoAVF). I think I can provide that service in a very capable manner, even next to some surgeons that are in the field. I really worked on picking specific skills and trying to better them.

Is there a case that has stayed with you and, if so, why?

There is always that case where it clicks. Part of learning and doing my fellowship was follow- ing step A, step B, and so on. It was actually a thrombectomy case where it finally clicked that “oh, I am doing this because of that”—all the reasons behind the steps became clear. I was no longer walking through the motion of a procedure but now finally understood how I approached that procedure. It is about learning to approach this particular patient. That is when the growth begins. Otherwise, you are just doing the same thing every day and it is not necessarily as impactful. I have to think about why I do what I do and what could be different next time. When you start thinking about these things is when they really start to shift.

What are your goals and what would you hope to see for IN as a specialty?

I would hope to see IN as the leader in access care not only from a technical perspective but also as the drivers of what happens with the patient and their access. The nephrology background—the understanding of dialysis and how it works—puts us at an advantage to guide what needs to happen with a graft or fistula. We could be the leaders that guide dialysis access care.

What are the most exciting technological advances bringing new life into your practice?

The biggest one for me is endoAVF, using both Ellipsys (Medtronic) and WavelinQ (BD) devices. I have been using them for several years and they have given me ways to serve patients in ways I have not been able to before. There are so many other developments that are coming, too—the Surfacer device (Bluegrass Vascular) for catheters has a big role to play. Technology developers are finally showing interest in dialysis patients, and that is a good thing.

What would you say your unique learnings have been from your experience with endoAVF?

The learning curve for endoAVF has been about figuring out when I can make the anastomosis and which patient actually gets a good, working, viable fistula from it. There have been several cases where I have said, “I can make a connection, but is it going to be what you need for dialysis? Maybe not.” Identifying those patients that are better off with a surgical arteriovenous fistula (sAVF) is important. I know what I can do, but should I do it? The red flags are anatomical. My screening process has changed over the years, since someone may even be an anatomical candidate but functionally not.

What is the research question you would really like to see answered?

The biggest question we would all like to see an answer to is, “How does an endoAVF really compare to an sAVF?” It is neither the same anastomosis, nor is it the same location. Some will say you cannot compare an endoAVF to an sAVF because there are different vessels and physiology. The question on everyone’s mind is: are they functionally as good, or is one better? It may be a difficult question to answer.

How do you think endoAVF has impacted dialysis care, and what are your thoughts on central venous catheters?

I think the patient convenience factors, expansion of services and providers and shorter wait times for patients of endoAVF have impacted dialysis care. As far as central venous catheters go, for some patients, it is completely appropriate. It goes back to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines: it is about the right access for the right patient.

What do you do radically differently in your practice compared to 10 years ago?

The mindset is about always growing. Today I think about treatment in terms of the whole lifespan of the access, and how I can address it for a longer impact. There are things I may or may not do as I look forward. Earlier in my career it was about “this patient, today’s problem, fix it, go home”. Now, it is about thinking about beyond today.

What advice would you give to young physicians interested in dialysis care?

Dialysis care is a fascinating field with complex patients requiring a dedicated physician. That is what enticed me into nephrology in general. It is a complicated specialty with so many components that make you stop and think. The interventional side is similar but different. There is a technical component, but it is still very intellectual. Some think it is just a technical discipline, but there is a lot of intellectual thought that could go into dialysis access. My advice to young physicians is to come to the specialty both with a big heart and a big mind.