In order to achieve the goals and objectives for the Nephrology Fellowship Training Program, the following teaching experiences have been established:
The Nephrology Ward Service is an inpatient medicine ward designed to care for patients with end-stage kidney disease (ESRD) and chronic kidney disease (CKD) who require hospitalization for renal and non-renal reasons. The ward service houses patients on the 8th floor of the Spain-Wallace building, and also houses the inpatient dialysis unit. The nursing staff is specifically trained to care for patients with renal disease, including the routine management of peritoneal dialysis. The Nephrology ward team includes the Nephrology Attending, one or two Nephrology Fellows, two upper-level and two intern-level house staff each month. Fourth-year medical students may also be included on the team.
Responsibilities of the renal Fellow on this rotation include, but are not limited to:
- Evaluating the need for dialysis in patients on the ward service
- Prescribing and adjusting hemodialysis and peritoneal dialysis prescriptions for patients with a wide range of medical problems
- Evaluating patients presenting in the emergency room with renal issues
- Performing renal biopsies in inpatients
- Learning about dialysis access issues
- Teaching the house staff the rudiments of the care of the patient with CKD and ESRD
- Supervising the house staff and providing guidance on therapy related to ESRD management.
Essential in this role is the development and refinement of clinical skills in the evaluation, diagnosis, treatment, and follow-up of patients with renal disease. These skills include developing appropriate differential diagnoses, assessing the need for hospitalization, and implementing diagnostic strategies and treatment plans. Through this experience the Fellow will also develop a comprehensive understanding of the indications, contraindications, techniques, and complications of hemodialysis, peritoneal dialysis, vascular access placement, and renal biopsies. The Fellow will also acquire skill in educating patients about these procedures and in obtaining informed consent.
2. UAB Acute Consult Service
The Acute Consult Service engages in providing the services of renal consultation to UAB (including the Center of Psychiatry and Spain Rehabilitation Center), Cooper Green Hospital, and the Eye Foundation Hospital. The Acute Consult Fellows will be exposed to a wide range of renal pathology in patients admitted to other medical and surgical services. This is a busy service with the average number of patients followed by this service being 25 to 30, and the average number of new consults being 5 per day. UAB has 8 different intensive care units, providing a broad exposure to acute renal failure in several different clinical settings. Toward this end, UAB has 18 Prisma Continuous Renal Replacement Therapy (CRRT) machines available for use at UAB ICUs (not Cooper Green Hospital), and Fellows on this rotation will gain extensive renal replacement experience in diverse critical care settings. Additionally, the Acute Consult Fellow will have an opportunity to see new presentations of glomerulonephritis, tubulointerstitial diseases, obstructive uropathy, toxic nephropathies, and a diverse array of challenging acid-base and electrolyte problems, as well as assessing the need for and performing renal biopsies. A single Nephrology Attending Physician is assigned to this service for the entire month. Three Fellows, in addition to two to four second and third-year internal medicine residents, are assigned to the Acute Consult Service in any given month. During this month, it is customary that the residents and Fellows assigned to the acute consult service also attend the Cooper Green and/or VA Nephrology Clinic. The schedule is designed to ensure that when one Fellow is in clinic there is always another Fellow available to take consults. The Acute Consult Fellow will also be responsible for any biopsies deemed necessary by the consult service. There is a Renal Consult Template to be used for all new consults.
3. UAB Chronic Consult Service
The Chronic Consult Service is designed to provide care for patients with established ESRD on other services in the hospital, with the exception of ESRD patients in an ICU. The service is staffed by a Nephrology Attending Physician and a First Nephrology Fellow. The First Year Fellow on the Chronic Consult Service provides renal replacement therapy for these patients, makes adjustments in their dialysis prescription as necessary, and learns about the challenges of dialysis access in patients with a wide range of co-morbid conditions. Hemodialysis access responsibilities consist of placement of femoral hemodialysis catheters in the inpatient dialysis unit (IDU) and the removal of tunneled catheters in the Kirklin Clinic on the 4th floor Cardiovascular Suite. This Fellow is also responsible for any chronic dialysis issues involving outpatient ESRD patients in Interventional Radiology. Of note, Interventional Radiology does not use IMPACT. This Fellow will also have ample opportunity to learn the important art of cooperating with services to achieve the best outcome for the patient. There are no residents on this service.
4. VA Consult Service
The Birmingham Veteran’s Hospital provides Nephrology services through an autonomous hemodialysis unit, a weekly Nephrology clinic and a Consultation service. The consult service is covered by Nephrology Fellows in the second year of training. However, some of first-year Fellows will have an opportunity to participate in the weekly Nephrology clinic throughout the year. The service is staffed by a VA Nephrology Attending Physician and typically a Second Year Nephrology Fellow. There are no residents on this service. Second year Fellows are on call during the weekends from 7AM to 12PM Saturday and Sunday. Their responsibilities include rounding on patients seen by the consult service during the week. Patients will be discussed with the Acute Consult Attending on call at UAB. The weekend rounding at the VA/Highlands will be divided among the Second Year Nephrology Fellows and assigned monthly along with the General Nephrology Call Schedule.
5. UAB Highlands Consult Service
In 2006, UAB Hospitals purchased Healthsouth Hospital and renamed it UAB Highlands. The hospital is designed to admit patients primarily with orthopedic and elective surgeries. A Hospitalist service will care for these patients. The Highland Consult Fellow is a Second Year Fellow who will be responsible for all consults, acute and chronic, at Highlands. All consults will be staffed with the Chronic/Access Attending. The Highlands Consult Fellow is also responsible for attending VA dialysis rounds, the VA Chronic Kidney Disease Clinic, and helping the VA Consult Fellow when he or she is in clinic.
6. UAB Nephrology Transplant Ward Service
UAB boasts one of the largest Nephrology transplantation programs in the country, with over 320 combined living-donor and cadaveric-donor transplants per year. The transplant ward service provides an opportunity to see transplant recipients at all stages of the process, including newly transplanted patients, patients with existing allografts with other medical problems requiring hospitalization, and patients with allograft dysfunction. The relationship between the transplant Nephrologists and surgeons is very good, and Fellows often benefit from the synergy of the interaction, as the Nephrology and surgical teams have made it a habit of rounding together. The transplant service is staffed by a Nephrology Transplant Attending, a Nephrology Fellow, and Nurse Practitioners.
The Fellow on the transplant ward service will have an opportunity to do a number of renal transplant biopsies (15-20/month is not unusual), learn the basics of immunosuppression, see a variety of post-transplant complications (medical and surgical), participate in their management, and if interested, view renal transplants in the operating room. Exposure to current topics in transplantation will be provided through participation in weekly conferences dedicated to discussion of current research articles relating to transplantation.
UAB is one of the few programs in the country that offers a separate Nephrology transplant Fellowship to interested and motivated Nephrology Fellows. Successful completion of the general Nephrology Fellowship, along with completion of the transplant Fellowship is currently sufficient to become board-certified in transplant Nephrology by the American Society of Transplantation.
7. UAB Nephrology Transplant Consult Service
In 2007 the Transplant consult service was established for 2nd year Nephrology Fellows. This rotation will give the 2nd year Fellows continued exposure to Transplant topics. The Fellow will help other teams manage transplant patients not admitted to the medical Transplant floor. Consults will usually consist of transplant patients admitted to ICUs or surgical floors outside of S7s. The Consult Transplant Fellow will also aid in outpatient transplant biopsies performed on S7 in the mornings.
8. UAB Nephrology Transplant Evaluation Service
The Division of Transplant Nephrology is also responsible for the pre-operative evaluation of both potential transplant recipients and potential living donors. This service gives Fellows the opportunity to gain experience in the evaluation of patients with end stage renal disease (ESRD) for renal transplantation. The goals of this experience are to learn to evaluate ESRD patients to determine if they are potential and acceptable candidates, to learn the appropriate work-up of ESRD patients for either living donor transplantation or placement on the cadaver list, to learn the appropriate work-up of individuals as potential living related and living non-related donors, and learn the fundamentals of HLA matching and histocompatibility testing. The evaluation service is an outpatient clinic that coordinates a multidisciplinary group of consultants needed for transplant evaluation, including Nephrology, surgery, and social services. The transplant evaluation Fellow will see patients and write an evaluation, coordinating the results of an interview, medical, laboratory and radiologic information into a formal transplant evaluation. The Fellow will be responsible for presenting these patients at a weekly transplant evaluation conference, attended by representatives from transplant Nephrology, transplant surgery, blood bank and tissue typing, and social services. An experienced transplant Nephrology Attending staffs the evaluation clinic.
Also, the Transplant Evaluation Fellow will also be responsible for performing outpatient native renal biopsies in the outpatient vascular/heart center on the 6th floor of the North Pavilion. Patients typically arrive at 6:30 AM. The Attending Physician should be contacted when the patient has been evaluated and is ready for biopsy. The biopsy will be performed and closely monitored in recovery in the same area.
9.The Outpatient Dialysis Experience
All outpatient hemodialysis activities are supervised by the specific outpatient dialysis unit’s Medical Director. Each Second-Year Fellow will be assigned to an outpatient dialysis unit and is expected to round on an assigned shift of patients twice a month. Fellow responsibilities include writing and updating hemodialysis orders, evaluation and management of patients’ hemodialysis accesses, dry weights, blood pressures and extracellular fluid balances, hemodialysis prescriptions, nutritional status, osteodystrophy status, anemia status; and reviewing monthly and other non-routine labs and cultures. The Fellow will also address and triage patient medical complaints. Rounds will be made with the Medical Director. As a result of these patient evaluations, notes are made on each patient by the Fellow, which address the above issues. The Fellow will also meet with the hemodialysis staff to review the water treatment facilities and the set-up and running of a dialysis machine and attend monthly patient-care conferences. These are multidisciplinary conferences attended by the head nurse, the on-site social worker, and the Medical Director. The purpose of the conference is to review all medical, social, and dietary issues that pertain to a patient on chronic hemodialysis and to address Quality Assurance and Quality Improvement.
Second year Fellows are required to attend UAB’s Peritoneal Dialysis Academy (PDA) in October. This is a three day all day conference in which Fellows will receive extensive training in peritoneal dialysis. The curriculum for PDA includes peritoneal dialysis lectures by expert guest lecturers, interactive problem sessions, and hands-on workshops. Fellows will be excused from all clinical activities during this time. Fellows from other training programs are invited to attend. Following PDA, Dr. Zipporah Krishnasami, the Medical Director of the HTU, will assign to each Fellow at least three peritoneal dialysis patients to follow for the rest of the year. Fellows will see and examine these patients in the HTU as needed and report to the patient’s Attending Physician. Fellows will be involved in adjusting peritoneal dialysis prescriptions and addressing access issues, dry weights, blood pressure, extracellular fluid balance, nutritional status, dialysis adequacy, osteodystrophy status, and anemia status. The Fellow will also be responsible for reviewing treatment of a patient’s peritonitis or exit site infection if applicable.
Some First Year Fellows may also have a month long opportunity to send time in one of our outpatient dialysis units. This will serve as an introduction to the basics of hemodialysis, dialysis adequacy, calcium/phosphorus management, diet management, and other issues including water management. This rotation will also allow the Fellows to see and examine grafts, fistulas, and permcaths.
10. The Ambulatory Nephrology Experience
All Fellows will be required to maintain the equivalent of a half-day clinic per week at the Kirklin Clinic during each year of Fellowship to see patients with renal diseases and problems related to renal disease. This clinic sees new outpatient consultations and continued follow-up of established patients. This experience will continue with progressive responsibility through the Fellowship and will be appropriately supervised by dedicated Attending faculty members. The goal of this experience will be for the Fellows to gain expertise in the outpatient evaluation and management of kidney problems. The experience provides an opportunity to develop an understanding of the natural history of these conditions over an extended period of time. Each Fellow should, on average, be responsible for four to eight patients during each half day session. After initially evaluating the patient, Fellows will present the patient to the Clinic Attending, discuss the patient, and then evaluate the patient with the Clinic Attending. Fellows are responsible for dictating patient encounters through the UAB phone dictation system. Dictations are electronically transcribed into the UAB CDA system and are available for editing by the Nephrology Attending within 1 to 2 days of dictation. Dictations must be completed within 24 hours. The notes are electronically signed by the Clinic Attending. Of note there are two different dictations systems used by the Clinic Attendings in our division. All Fellows will be responsible for contacting their specific Attending’s secretary to find out which system their attendings use.
All Fellows will also have the opportunity to participate in weekly half-day Nephrology clinics at the VA and Cooper Green Hospital.
In addition, Second Year Fellows will spend a half-day clinic per week in Nephrology transplant clinic at the Kirklin Clinic. Through the transplant clinics, Fellows will obtain outpatient longitudinal follow-up renal transplant experience. Fellows will follow no fewer than 20 patients as required by the ACGME. The goals of this experience are to learn about immunosuppressive drugs and regimens used in the management of renal transplants, to learn the side effects, complications and drug interactions of immunosuppressive drugs, to learn to evaluate and treat post-transplant complications including infection, hypertension, malignancy, de novo glomerular disease and recurrent glomerular disease, to learn to recognize and treat acute rejection, to learn to recognize and treat chronic rejection, and finally, to learn the fundamentals of HLA matching and histocompatibility testing.
The Fellow also will be provided with opportunity to pursue experiences in other disciplines whose expertise is required in the care of patients with Nephrology diseases. These disciplines include: 1) intensive care medicine, 2) cardiology, 3) Nephrology transplantation surgery, 4) general and vascular surgery, 5) pediatric Nephrology 6) Nephrology imaging, and 7) urology. The goal of these experiences is for the Fellow to appreciate the approach to the specific conditions that relate to Nephrology disorders within these subspecialties. These interdisciplinary interactions can occur in the form of a clinical rotation, multidisciplinary conference, etc. Clinical experiences should be under the direction of Attending Physicians in the respective specialty or subspecialty who participate fully in the educational goals of the rotation.
In addition, the Plasmapheresis rotation is a four week elective supervised by Dr. Marisa Marques. The goals of the rotation are for the Fellow to understand the fundamentals of plasmapheresis, including indications, technique, complications, and effectiveness. This rotation is offered to interested Second Year Fellows
Finally, Second Year Fellows can elect to train in Interventional Nephrology with Dr. Roman Shingarev. This rotation is typically 2-6 months of exposure depending on the Fellow’s goals. Fellows will be exposed to permcath placement, vascath placement, permcath exchange, fistula and graft thrombectomies and angioplasties, PD catheter insertion, Ligations of grafts and fistulas, and stent placement in Grafts and Fistulas.
Conferences will be held on a regularly scheduled basis with attendance required of all Fellows and divisional faculty. These conferences are usually multifaceted and because of the nature of topics under discussion, cover a combination of tasks and topics including but not limited to literature review, discussion of clinical cases, evaluation and presentation of research, and concepts of Nephrology basic science. Weekly conferences include the Nephrology Research and Training Center conference, a research conference; Fellows’ Conference, a subspecialty conference given by the Fellows on clinically relevant topics; Fellows’ Journal Club, a clinically oriented forum for discussion of current articles in Nephrology and relevant internal medicine literature; and the Nephrology Histopathology (biopsy) conference. These conferences will occasionally include lectures from faculty in divisions outside of Nephrology or outside of the Department of Medicine and guest faculty who are visiting UAB.
VII. BIRMINGHAM VETERANS AFFAIRS MEDICAL CENTER (BVAMC) NEPHROLOGY SERVICE
Paul W. Sanders, MD
Chief, VA Nephrology Section
Dan Balkovetz, MD, PhD
Director, VA Renal Clinic
Edgar Jaimes, MD
Medical Director, BVAMC Dialyis Unit
Anupam Agarwal, MD
Roslyn Mannon, MD
VA Renal Transplant Physician
Michal Mrug, MD
VA Renal Transplant Physician
This program is part of the Division of Nephrology of the University of Alabama at Birmingham Medical Center, and part of the Department of Medicine in that institution. The Nephrology Service is the only such service in a Veterans Hospital in the State of Alabama. Therefore, the Birmingham VA Hospital serves as a tertiary referral center for veterans with renal problems throughout Alabama. Other nearby VA Hospitals having dialysis facilities are located in Nashville, Tennessee to the north; Gainesville, Florida to the south and Atlanta, Georgia to the east.
1. VA chronic Dialysis Unit
The ten-station Chronic Dialysis Unit located in the VA Hospital is designed to provide in-center dialysis support for about 34 veterans and back-up dialysis support for about 40 patients contracted to private, nongovernmental dialysis throughout the state. The VA dialysis unit also provides acute dialytic support for inpatients throughout the VA Hospital with acute renal failure and other medical conditions requiring dialysis. The VA dialysis unit serves those veterans with end-stage renal disease admitted to the hospital with other problems. The small size of the unit allows the Nephrology Fellows to learn how to manage dialysis patients in the outpatient setting and develop the necessary skills to manage a dialysis unit.
2. The VA Consultation Service
The VA Consultation Service is staffed by a second-year fellow and lead by one of the VA attending physicians. This service provides the fellow a unique opportunity to interact with a faculty member in a one-on-one fashion.
3. The VA Transplant Service
Inpatient services are profided by the consult service. outpatient services are provided by the VA faculty led by Dr. Roslyn Mannon.