Interventional Nephrology - Dr. Rafael P. Montepío

12/09/2026

Internal Jugular Catheter Reinsertion via Guidewire Exchange

This procedure was performed entirely by my NKTI Nephrology Fellow.

Catheter exchange over a guidewire is perhaps one of the simplest interventional nephrology procedures to learn—yet many nephrologists are not routinely trained to perform it.

For a patient with a dysfunctional dialysis catheter, this relatively simple skill can restore vascular access and allow missed or delayed hemodialysis sessions to resume without the need for an entirely new venous access.

It is a simple, practical procedure that a nephrology fellow can—and should—learn.

11/09/2026

12 Midnight Emergency IJ Catheter Insertion — with an Internal Medicine Resident.

Central venous catheter insertion is a fundamental procedural skill performed across multiple specialties—Anesthesiology, Interventional Radiology, Interventional Cardiology, Emergency Medicine, Critical Care, Vascular Surgery, General Surgery, Internal Medicine, and Nephrology.

This should never be about turf. No single specialty owns this procedure.

What matters is that a properly trained physician can safely perform it when the patient needs it—especially in an emergency.

There are still patients in the provinces whose life-saving hemodialysis is delayed simply because there is no physician available with the necessary catheter insertion skills.

Instead of debating who should be allowed to perform the procedure, we should be asking:
How can we train more physicians to perform it safely and competently?

Because when a patient needs emergency dialysis at midnight, access should never have to wait because of turf.

08/09/2026

Hands-on Lung Point-of-Care Ultrasound (POCUS) Workshop for VMMC Nephrology Fellows—combining focused instruction with active scanning practice, followed by ICU bedside rounds where the fellows performed lung ultrasound on real patients under guided supervision.

Learning by doing, from the classroom to the bedside.

06/09/2026

Basic Point-of-Care Ultrasound (POCUS) for Clinicians of Pangasinan

Bringing together clinicians from different specialties to learn and apply the basics of Point-of-Care Ultrasound (POCUS).

Continuing our advocacy of promoting the “new stethoscope”—empowering clinicians to see beyond the physical examination and make faster, more accurate bedside assessments.

04/09/2026

29/08/2026

FLUID RESPONSIVENESS VS FLUID TOLERANCE

An average clinician may give fluids based on the traditional physical exam, input and output, chest X-ray, etc.. A more advanced clinician adds point-of-care ultrasound (POCUS) to guide fluid therapy.

POCUS can help assess both fluid responsiveness and fluid tolerance—but what exactly are they?

Fluid responsiveness asks: Will giving fluid increase the heart’s output?

Fluid tolerance asks the more important safety question: Can the patient receive fluid without harming the lungs, kidneys, or other organs?

A patient can be fluid responsive but fluid intolerant. For example, a patient with ARDS may have improved cardiac output after a fluid bolus, yet the additional fluid could worsen pulmonary edema and oxygenation.

So don’t ask only, “Will fluid work?” Also ask, “Can the patient safely tolerate it?”

Fluid responsiveness predicts possible benefit. Fluid tolerance weighs that benefit against potential harm.

In my next post, I’ll discuss in more detail how to use POCUS to assess fluid responsiveness and fluid tolerance.

Original position paper co-authored by my mentor, Dr. Philippe Rola:

The Emerging Concept of Fluid Tolerance (https://pubmed.ncbi.nlm.nih.gov/35660844/)

26/08/2026

Bedside PD Catheter Removal: A Simple Advantage of Percutaneous Placement

One advantage of a percutaneously inserted PD catheter is that removal can often be performed easily at the bedside. Since the catheter is typically secured by a subcutaneous Dacron cuff, only a small area around the cuff needs to be carefully dissected to free and remove the catheter.

In this case, the patient experienced recurrent omental wrapping, resulting in repeated catheter dysfunction. As seen in the photo, omental fat has entered and filled the catheter lumen, contributing to the obstruction.

After discussing the options, the patient ultimately decided to transition to hemodialysis, and the PD catheter was removed at the bedside.

26/08/2026

Permcath Dysfunction: Exchange Without a New Incision

A CKD Stage 5 patient presented with a dysfunctional tunneled dialysis catheter (Permcath)—good inflow but persistently poor outflow despite two doses of alteplase.

With catheter dysfunction unresolved, Permcath exchange/reinsertion over a guidewire was performed.

Guidewire exchange is a commonly used technique for non-tunneled dialysis catheters. With tunneled cuffed catheters (Permcaths), however, the presence of the subcutaneous tunnel and fibrosed cuff makes the procedure more technically involved.

In this case, the exchange was performed without creating a new incision. The existing cuff was carefully freed through blunt dissection from the exit site, followed by guidewire insertion, removal of the dysfunctional catheter, and placement of a new Permcath through the existing tract.

A minimally invasive approach that preserves the existing tract and avoids creating a new access site while restoring reliable dialysis access.

24/08/2026

CLINIC SCHEDULES:

Online Clinic
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National Kidney & Transplant institute (NKTI)
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- Monday 10 AM to 12 Noon, Wednesday 3 to 5 PM
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- 0948-8928444

Clinica Antipolo Hospital and Wellness Center, Inc. (CAHWCI)
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Antipolo Doctors Hospital (ADH)
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For more info and booking, please visit:
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23/08/2025

Bakit Mas Maganda ang Kidney Transplant Kaysa Hemodialysis?

Ano ang CKD?

Ang Chronic Kidney Disease (CKD) ay isang sakit kung saan unti-unting humihina ang paggana ng mga bato. Kapag hindi na gumagana nang maayos ang bato, hindi na nito nalilinis ang dugo mula sa lason at sobrang tubig, kaya kinakailangan ng kapalit na paraan ng paglilinis.

Dalawang Pangunahing Opsyon

1. Hemodialysis (HD) – Paglilinis ng dugo gamit ang makina, karaniwang ginagawa 3 beses sa isang linggo, tig-4 na oras bawat session.

2. Kidney Transplant – Pagpapalit ng sirang bato ng pasyente sa isang malusog na bato mula sa donor (kamag-anak o mula sa ibang tao).

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Bakit Mas Mabuti ang Kidney Transplant?

1. Mas Mahaba ang Buhay

Ang mga pasyenteng na-transplant ay may mas mataas na survival rate kumpara sa mga naka-dialysis lang.

Ang bagong bato ay tuloy-tuloy na nagtatrabaho 24 oras bawat araw, samantalang ang dialysis ay pansamantala lang at limitado sa ilang oras bawat linggo.

2. Mas Magandang Kalidad ng Buhay

Sa transplant, hindi na kailangan ng regular na dialysis na nakakapagod at kumakain ng oras.

Mas nakakapagtrabaho, nakakapag-aral, at nakakapamuhay nang normal ang pasyente.

Hindi na rin kailangan laging mag-bantay ng schedule sa dialysis center.

3. Mas Malaya sa Diyeta at Likido

Ang mga nasa dialysis ay mahigpit ang bawal sa pagkain at pag-inom (limitado ang tubig, prutas, gulay, asin, atbp.).

Sa transplant, mas maluwag ang diet at mas nagiging normal ang pagkain at lifestyle.

4. Mas Mura Pangmatagalan

Sa simula, magastos ang operasyon at gamot pagkatapos ng transplant.

Ngunit sa pangmatagalan, mas mura ang transplant kaysa tuloy-tuloy na dialysis na gagawin habang buhay.

5. Mas Magandang Pangkalahatang Kalusugan

Mas kaunti ang komplikasyon tulad ng anemia, buto’t kasu-kasuan na problema, at panghihina.

Mas nakakaiwas din sa paulit-ulit na impeksyon mula sa mga access (fistula o catheter) ng dialysis.

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Kailan Hindi Pwede ang Transplant?

Kung may malubhang sakit sa puso o baga.

Kung may aktibong impeksyon o cancer.

Kung hindi kayang uminom ng maintenance na gamot laban sa rejection.

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Konklusyon

Ang hemodialysis ay nakakatulong upang mabuhay ang pasyente habang naghihintay ng transplant. Ngunit kung may pagkakataon na makahanap ng donor at ma-transplant, ito ang pinakamagandang opsyon. Sa kidney transplant, mas mahaba ang buhay, mas maganda ang kalidad ng pamumuhay, at mas nakakalaya ang pasyente sa bigat ng CKD.