Nephrology Fellowship

PGY4

Hospital ward rotation

The Division of Nephrology-Hypertension operates a full-time hospital service with a small (5-10) number of primary care dialysis patients and a much larger consultative service of 15–20 patients. The rotations this year have changed to 1week blocks. There has been more time allotted for elective, outpatient clinic, and exposure to Home HD/PD for the first-year fellows. The rotation implementation for the second-year fellows is 1 week of hospital service a month in the second half of the year. This allows extra elective time for first year fellows and sharpens hospital skills for second year fellows.

Consultative patients include, but are not limited to, patients with:

• Acid-base disorders
• Electrolyte/metabolic disorders
• Chronic and acute renal diseases
• Systemic diseases
• Renal replacement therapies

More than 1,200 renal replacement treatments are done yearly in the hospital, with conventional HD and some PD. CVVH, CVVHD, conventional HD and SLED are done in the ICU with more than 500 sessions/year.

The hospital service operates with one nephrology staff, one or two nephrology fellows and usually one upper-level medical resident and one intern. Occasional urology interns and fourth-year medical students also participate.

The nephrology fellows are responsible for review of all cases seen and evaluated by the team members, giving directions and advice and direct care when needed. The fellows direct work rounds as well as team preparation for "teaching rounds." Final patient care decisions are the responsibility of the senior nephrology staff on service.

Transplant rotation

The transplant service consists of one nephrology staff and two transplant surgeons staffing the service, with one upper-level surgical/urology resident and one nephrology fellow.

The transplant program averages about 40 renal transplants per year (and six pancreas transplants) with an average hospital census of about four to eight primary patients. Exposure on this service includes two full days per week of transplant clinic, where the service follows more than 600 transplant patients at various stages post-transplant, as well as donor and recipient evaluations for upcoming transplants.

The nephrology fellows see all admissions to the transplant service, as well as consults, and follow those patients with the transplant staff. Fellows are also responsible for the evaluation of any patient called for an urgent deceased donor renal transplant. Final patient care decisions are the responsibility of the senior transplant staff physician on service.

This service also includes nephrology continuity clinic plus one half-day general nephrology clinic.

PGY5

Rotation schedule

Elective rotation

Two months separated in a block from among several options, to include:

• ICU/critical care under the guidance of pulmonary/critical care staff
• Interventional radiology to include dialysis fistula/graft interventions, dialysis catheter placements for chronic use and renal radiology
• Pediatric nephrology
• Other nephrology related electives as approved by the fellowship director

All electives must be approved by the fellowship director.

Home dialysis/nephrology clinic/hypertension clinic

Home dialysis

A four-month block of two to four half-days of exposure to home dialysis under the guidance of the director of the home dialysis unit. There is exposure to approximately 15 home hemodialysis and approximately 30 peritoneal dialysis patients on their monthly visits in addition to acute evaluations.

Nephrology clinic

A four-month block of four to six full days in nephrology and chronic kidney disease clinic. Emphasis is placed on nephrology consultation and CKD management.

Hypertension clinic

The hypertension clinic is a three- to four-month block of one half-day clinic exposure to the hypertension clinic. Emphasis is placed on difficult-to-control hypertension and secondary forms of hypertension, not including CKD patients.

Outpatient dialysis rotation

In PGY-5, the second-year nephrology fellows are assigned 10-12 chronic hemodialysis patients in the outpatient hemodialysis unit (preferably one shift only). This will be supplemented by new hemodialysis patients from the fellow’s nephrology clinic. These patients will be followed for the full one year under the guidance of a staff nephrologist.

Continuity clinic

Throughout the full two years of the fellowship, each fellow has one half-day (3.5-4 hours) of continuity clinic under the supervision of one or two staff members for one full year.

This clinic sees four to eight patients per week, encompassing all areas of consultative nephrology as well as primary nephrology and CKD care.

Baylor Scott & White continuing care hospital rotation

During the six months of clinical rotations, the second-year fellow will also rotate on the Baylor Scott & White Continuing Care Hospital (CCH) Rotation. This Monday-Wednesday-Friday morning service consists of two to six dialysis dependent patients, plus consults at the CCH with the attending nephrologist.

Procedures

Percutaneous native renal biopsy

PGY-4 and PGY-5 will be instructed to perform native renal biopsies under ultrasound guidance or localization. All biopsies will be done with nephrology staff at the bedside.

Femoral dialysis catheter placement

PGY-4 and PGY-5 fellows will be instructed by nephrology staff on the placement of temporary dialysis catheters.

Percutaneous transplant renal biopsies

PGY-4 and PGY-5 fellows will be instructed on performance of renal transplant biopsies under ultrasound guidance by the transplant nephrologist and transplant surgeon on service.

Urinalysis

PGY-4 and PGY-5 fellows will be instructed on performance and interpretation of urinalysis.

Conferences

Nephrology conferences

Board review

Review by one staff (or more) with the fellows covering all basic nephrology topics following the format of Comprehensive Clinical Nephrology 3^rd Edition by Feehally, Floege and Johnson. The entire book is covered in one year.

Case management

An informal review of cases seen recently in the hospital or clinic with emphasis on teaching points, diagnostic pearls, interesting findings, etc. Led by staff and the hospital fellow.

Quality of care conference

Case presentation (one or two) with emphasis on a specific topic and how to improve diagnostic evaluation, therapy, etc. Presented by one fellow and attended by nephrology staff.

Journal club

Review of usually two recent literature articles of basic science or clinical (usually one of each) by the first-year fellow with staff attendance.

Renal biopsy conference

Review of recent renal biopsies and occasionally older renal biopsies with presentation of the case pre-biopsy and, at times, follow-up of therapeutic responses. Led by first-year fellow on nephrology hospital service plus pathology fellow and pathology staff.

Renal transplant grand rounds

Review of literature article, topics of transplant interest and case reviews of recent transplant problems. Led by the transplant fellow with assistance of faculty. Guest speakers are occasionally invited to give transplant-related talks in their fields of expertise.

Basic science/renal physiology conference

An in-depth review by the second-year nephrology fellow of a basic science/renal physiology topic with emphasis at the genetic and cellular levels.

Pathology review series

A series of 18–24 sessions (lasting approximately one hour each), consisting of a review of multiple renal histologic lesions in both native and transplant renal biopsies. This is led by renal pathology staff and routinely attended by the nephrology fellows. Slides of light microscopy, immunofluorescence and electron microscopy are reviewed in depth.

Additional special lecture series

Introduction to biostatistics

A weekly one-hour course for four weeks during the first quarter every other fellowship year, used to introduce and update fellows on statistics in medical research. This is taught by the director of biostatistics for Baylor Scott & White and supplemented by biostatistics and nephrology staff. An appropriate reference book is provided.

Basic science lecture series

A series of one-hour lectures held during the year by basic scientists on a wide array of basic science topics. Required fellow attendance with selection of topics of interest to the field of nephrology chosen by the fellowship director.

Nephrology core lectures

• Basic Principles of Dialysis
  (HD, CVVH, CVVHD, PD): Part 1 – Part 6
• Anemia Management
• Ca – PO4 Rx with CKD
• Basic Immunology
• Immunology/Drugs of Transplantation
• Hyperkalemia Management in CKD
• Hyponatremia Evaluation/Therapy
• Pharmacologic Principles and CKD, Parts 1 & 2
• Dialysis Access
• Hypertension Emergencies & Therapy in CKD
• Principles of Acid – Base
• Evaluation of AKI
• Nutrition in Kidney Disease
• Transplant 101, Parts 1 & 2
• Renal Radiology

Various nephrology conferences are held from noon to 1 p.m. daily, Monday through Thursday, with Medical Grand Rounds every Friday at noon. In July of each year, approximately 20 Nephrology Core Lectures are given in place of the standard conference schedule.

Supplemental nephrology core lectures

A series of renal-related topics presented by senior staff, spread throughout the year and designed to supplement the core curriculum series of July and to cover topics otherwise not discussed in detail at other conferences.

Topics include:

• Renal Lithiasis
• Urology of Renal Lithiasis
• Pregnancy – Volume and
  Hormonal Changes
• Pregnancy – Preeclampsia and Renal Disease
• Peritoneal Dialysis
• Peritoneal Dialysis Complications
• Kidney in Liver Disease
• Atherosclerosis in CKD
• Various Alcohol Poisonings
• Drug Overdoses and Dialysis
• Multiple Cholesterol Emboli Syndrome
• Estenosis de la arteria renal

Investigación

During both the PGY-4 and PGY-5 years, each nephrology fellow will be expected to be involved in clinical research consistent with RRC requirements. The vast array of clinical cases, the electronic medical record retrieval system and the varied nephrology faculty interests make this a very reasonable task.

Six consecutive months of basic science research is mandatory in the second year. Fellows choose their research areas and research mentors from the multitude of Texas A&M research faculty on campus with the advice and consent of the fellowship director.