University of Virginia Health System

Inpatient Consult Rotation: Fellows Curriculum

Outpatient Rotation: Fellows Curriculum

1. General Description
    
   1. During their two years, Nephrology fellows will spend 4-6 months on the outpatient rotation
   2. Responsibilities *
      1. Initial evaluation and management of all walk-in patients in the Kidney Center (KC) Clinic
      2. Initial evaluation and management of KC dialysis patients with clotted vascular accesses, to include placement of temporary dialysis catheter if necessary
      3. Peritoneal dialysis clinic Wednesday mornings
      4. First call for patient problems in the KC dialysis unit when the nurse practitioner is out of town
      5. Involvement and responsibility for other issues/problems in the KC dialysis unit as directed by outpatient attending
      6. To become familiar with economic and business issues pertaining to the practice of nephrology
      7. Optional rotation in Lynchburg  , Virginia where fellows can learn techniques of nocturnal home hemodialysis

* All patients seen will be discussed with the outpatient attending nephrologist, except in the transplant clinic where they will be discussed with the transplant attending nephrologist.

2. Goals and Objectives

1. 1. Become familiar with the equipment as well as the procedures and techniques involved in chronic hemodialysis:
      1. Participate in the setup, use, and breakdown of a hemodialysis machine under the supervision of one of the dialysis nurses. This may be done over a period of 1-5 days depending on the interest of the fellow. Become familiar with the principles and techniques of dialyzer reuse
      2. Become familiar with the principles and practice of chronic hemodialysis:
   2. Become familiar with the principles and practice of chronic hemodialysis:
      1. Evaluation and selection of patients for chronic hemodialysis, as well as, counseling regarding dialytic options
      2. Selection and maintenance of an appropriate dialysis prescription to include assessment of adequacy of dialysis (Kt/V) and nutrition (PCR)
      3. Evaluation and management of acute complications of dialysis to include hypotension, chest pain, dyspnea, muscle cramps, first use syndrome, vascular access problems, etc.
      4. Evaluation and therapy of long-term complications including metabolic bone disease, neuropathy, arthropathy, cardiomyopathy, atherosclerosis, hypertension, and anemia
      5. Drug dosing and modification during hemodialysis
      6. Indications, placement, and complications of acute hemodialysis catheters
      7. Indications, performance, and complications of bone biopsy for metabolic bone disease
      8. Understand dialysis water treatment and delivery systems
      9. Become familiar with artificial kidneys, including the issues of biocompatibility and reuse
      10. Observe the placement of a vascular access in the O.R. with the vascular access surgeon
   3. Become familiar with the principles, practice, and procedures of peritoneal dialysis:
      1. Evaluation and selection of patients for peritoneal dialysis
      2. Recognize the advantages/disadvantages of the different peritoneal catheters
      3. Understand the differences and advantages/disadvantages between CAPD, CCPD, IPD, and tidal peritoneal dialysis
      4. Understand and write an appropriate peritoneal dialysis prescription
      5. Assessment of peritoneal dialysis efficacy using the peritoneal equilibration tests (PET)
      6. Assessment of adequacy of peritoneal dialysis using Kt/V
      7. Evaluation and therapy of infectious complications to include peritonitis, exit site infections, and tunnel infections
      8. Evaluation and management of long-term complications including low back pain, hernias, and pleural effusions
      9. Understand the special nutritional requirements of peritoneal dialysis
      10. Drug dosing and modification during peritoneal dialysis
      11. Observe the placement of a Tenchkoff peritoneal dialysis catheter

3. Recommended Texts

1. Nissenson and Fine: Dialysis Therapy
2. Daugirdas and Ing: Handbook of Dialysis
3. Gokal and Nolph, Textbook of Peritoneal Dialysis

Chronic Inpatient Rotation: Fellows Curriculum

1. General Description
   
   
   1. During the 2-year fellowship, each fellow will spend 3-5 one-month rotations on the chronic inpatient service
   2. The Nephrology chronic inpatient fellow is responsible for the initial evaluation and subsequent management of all hospitalized chronic dialysis patients (hemodialysis and peritoneal dialysis). He/she will work in concert with the ward residents and medical students as well as the Nephrology patient care coordinator to provide the necessary care, and will be overseen by the Nephrology/Medicine ward attending.
   3. The timing and frequency of rounds is at the discretion of the Nephrology/Medicine ward attending
   4. On-call schedule: The chronic inpatient fellow takes 2 weeks of 1st call for the consult service (sharing it with the acute consult fellow) during each one month rotation. As detailed above: ACGME regulations for duty hours are strictly enforced and monitored.
   5. Attendance and participation in the previously listed conferences is expected
      
2. Goals and Objectives

Refer to those listed under “Outpatient Rotation”.

Transplant Rotation: Fellows Curriculum

1. General Description
   
   
   1. The Fellow will gain experience in the initial work-up of transplant candidates and long-term follow-up
   2. During the two years, Nephrology fellows will spend a total of 4-6 months (one month rotations) on the transplant service, usually equally divided between the first and second years
   3. Responsibilities include the initial evaluation, management, and follow-up of patients on the inpatient transplant service, including pre and post-transplant care
   4. Fellows will also participate in Transplant Clinic one half-day per week during their Transplant rotations. This will be in addition to the regularly scheduled half-day of Nephrology Clinic
   5. Call schedule: Nephrology fellow takes call for nephrologic problems on the transplant service during the month of the rotation, including weekends
   6. Clinic and conferences: Participation and attendance in the usual scheduled clinic and conferences is expected
   7. It is expected that fellows will develop longitudinal care relationships with at least 20 post-transplant patients during these months.

2. Goals and Objectives
   
   
   1. Become familiar with the principles and practice of the following:
      1. Selection and evaluation of transplant candidates
      2. Preoperative evaluation of prospective transplant recipients and prospective organ donors
      3. Organ harvesting and preservation
      4. Postoperative management of transplant recipients, including immunosuppressive therapy
      5. Diagnosis and therapy of all forms of rejection including hyperacute, acute cellular, acute vascular, and chronic rejection, to include the interpretation of Doppler ultrasound, radio nucleotide scans, and renal histopathology
      6. Biology and immunology of histocompatibility testing
      7. Mechanism of action and use of immunosuppressive agents
      8. Recognition and management of short and long-term complications of transplantation such as postoperative complications, infectious complications, etc.
      9. Psychosocial issues in of organ donation and transplantation
      10. Long-term care and follow-up transplanted patients in the ambulatory setting
          
3. Recommended reading and references

Histopathology Rotation: Fellows Curriculum

1. General Description
   
   
   1. The fellow will spend one month examining real biopsy specimens with renal pathology faculty (Dr. Helen Cathro). This will be in addition to monthly pathology conferences. The fellow will be responsible for examining biopsy specimens obtained during the month. In addition the fellow will review other biopsy specimens that are in the teaching file
      
2. Goals and Objectives
   
   
   1. Become familiar with the preparation of renal biopsy specimens:
      1. Type of solutions used for light (LM), immunofluorescence (IF), and electron microscopy (EM) specimens immediately post-biopsy
      2. The basics of specimen preparation for LM, IF, and EM
   2. Explain the uses and advantages of specific stains to include hematoxylin and eosin, periodic acid
   3. Schiff, Trichrome (Masson), silver-stains, elastin stain, congo red, methyl violet, thioflavine T, immunoperoxidase staining
   4. Recognize the histopathologic characteristics of normal kidney on LM, IF, and EM
   5. Recognize the histopathologic characteristics of the following disease states on LM, IF, and EM (using a combination of actual cases and teaching slides)
      1. Minimal change disease
      2. Focal glomerulosclerosis
      3. Membranoproliferative GN
      4. Membranous GN
      5. World Health Organization classes of lupus nephritis
      6. IgA nephropathy
      7. Diabetic nephropathy
      8. Amyloidosis
      9. Myeloma kidney
      10. Crescentic GN to include Wegener's granulomatosis, PAN, and idiopathic RPGN
      11. Anti-GBM disease
      12. Post-infections GN (especially PSGN and SBE)
      13. Renal vasculitis
      14. Scleroderma kidney
      15. Hypertensive nephropathy/nephrosclerosis
      16. Thrombotic microangiopathy
      17. Interstitial nephritis, chronic and acute
      18. Acute tubular necrosis
      19. Transplant
          1. Acute cellular rejection
          2. Acute vascular rejection
          3. Cyclosporine toxicity
          4. Chronic rejection
   6. Obtain adequate clinical background and information from the appropriate nephrologist submitting the specimen to allow optimal interpretation of the biopsy
   7. Upon completion of the rotation, a 45-60 minute presentation of cases and discussion that demonstrates the acquisition of the above knowledge. This can be done at Renal Grand Rounds where biopsy interpretation is part of a case presentation and discussion
      
3. Recommended reading and references
   
   
   1. Renal Disease: Atlas of Glomerular Diseases by Jacob Churg
   2. Tischer and Brenner, Renal Pathology
   3. Those suggested by Dr. Cathro

Pediatric Nephrology Rotation: Fellows Curriculum

1. General Description
   
   
   1. One month during the second year of Adult Nephrology Fellowship will be spent in Pediatric Nephrology. During that time the participant will function as a clinical Pediatric Nephrology fellow, assuming responsibility for the care of both inpatients and outpatients under the direction of the Pediatric Nephrology attending staff
      
2. Goals and Objectives
   
   
   1. Attend and participate in Pediatric Nephrology conferences, as well as Renal Grand Rounds and Journal Club/Biopsy Conference with Adult Nephrology
   2. Become familiar with the pathogenesis, clinical presentation, differential diagnosis, management, and therapy of the following:
      1. Acute renal failure in children
      2. Hematuria, to include the following specific diseases
         1. Post-Streptococcal GN
         2. IgA nephropathy
         3. Sickle cell nephropathy
         4. Familial hematuric syndromes to include Alport's Syndrome and benign familial hematuria
         5. Henoch-Schönlein purpura
         6. Hypercalciuria
      3. Nephrotic Syndrome
      4. Childhood and adolescent hypertension
      5. Vesicoureteral reflux
      6. Other disease states encountered during the rotation
   3. Understand the different problems and management of uremia in children with reference to:
      1. Presentation of uremia
      2. Mode of dialysis
      3. Complications of uremia and dialysis
   4. Understand the principles and management of children in reference to transplantation, including evaluation, immediate post-transplant care, and long-term follow-up
   5. Recommended texts and reading
      
3. Recommended reading and references
   
   
   1. Malcolm Holliday: Pediatric Nephrology, (ed.)
   2. Those suggested by the Pediatric Nephrology faculty