Renal

The program is designed to prepare fellows for a career in academic nephrology in laboratory research, clinical research, or teaching. In addition to a year of clinical rotations, there is a 3 year period of training in research.

The specific goals of the program include, but are not limited to, the objectives outlined in the ACGME Program Requirements for Residency Education in Nephrology. These include formal instruction, clinical experience, and opportunities to acquire expertise in a wide variety of renal, hypertensive and fluid-electrolyte disorders as indicated below. They also include special experiences in the fields of renal transplantation, dialysis and extracorporeal therapy and the acquisition of technical and other skills as listed below:

1. General Nephrology

    

   1. Disorders of mineral metabolism, including nephrolithiasis osteoporosis, and renalosteodystrophy

       

   2. Disorders of fluid, electrolyte, and acid-base regulation

       

   3. Acute renal failure

       

   4. Chronic renal failure and its management by conservative and dialytic methods, including nutritional management of uremia

       

   5. End-stage renal disease

       

   6. Hypertensive disorders

       

   7. Renal disorders of pregnancy

       

   8. Urinary tract infections

       

   9. Tubulointerstitial renal diseases, including inherited diseases of transport, cystic diseases, and other congenital disorders

       

   10. Glomerular and vascular diseases, including the glomerulonephritides, diabetic nephropathy, renovascular disease and microvascular syndromes

        

   11. Disorders of drug metabolism and renal drug toxicity

       Much of the learning about disease, the acquisition of technical skills and acquisition of professional attitudes comes through the very close one-on-one supervised patient care during the clinical year. Methods of evaluation, diagnosis, management and cost effectiveness are integral parts of the work done by the fellow-faculty team during three and a half months on the Dialysis service, three and a half months on the Renal Consultation service and three and a half months on the Transplant service. The fellows will spend about half their time at each of the two major teaching hospitals (BWH and MGH). The fellows will also rotate to the West Roxbury/Jamaica Plain VA and to the Faulkner Hospital. (During the Faulkner Hospital rotation, fellows will obtain training in chronic hemo and peritoneal dialysis).

    

2. Renal Transplantation

   Each fellow will have three and a half months of experience on an active renal transplant service. Clinical experience entails supervised involvement in decision making for patients during pre and post transplant care. During the rotation the fellow will attend two to three outpatient clinics a week and participate in management decisions. This experience includes:

    

   1. Evaluation and selection of transplant candidates.

       

   2. Preoperative evaluation and preparation of transplant recipients.

       

   3. Immediate postoperative management of transplant recipients including administration of immunosuppressive drugs.

       

   4. Clinical diagnosis and management of all forms of acute and chronic rejection including laboratory, histopathologic and imaging techniques.

       

   5. Recognition and medical management of the surgical and nonsurgical complications of transplantations.

       

   6. Long-term follow-up of transplant donors and recipients in the ambulatory setting.

    

3. Dialysis and Extracorporeal Therapy

   Each fellow will be exposed to dialysis and extracorporeal therapies during the equivalent of at least three and a half months of the training. Clinical experience will entail supervised involvement in decision making for patients undergoing these therapies. This experience includes:

    

   1. Evaluation and selection of patients for acute hemodialysis or continuous renal replacement therapies.

       

   2. Evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options.

       

   3. Drug dosage modification during dialysis and other extracorporeal therapies.

       

   4. Evaluation and management of medical complications in patients during and between dialysis and other extracorporeal therapies, including dialysis access and an understanding of their pathogenesis and prevention.

       

   5. Long-term follow-up of patients undergoing chronic dialysis, including their dialysis prescription and modification and assessment of adequacy of dialysis.

       

   6. An understanding of the oversight and management of a chronic dialysis program (at the Brigham-Faulkner DCI unit at the Faulkner Hospital)

       

   7. An understanding of the principles and practice of continuous renal replacement therapy.

       

   8. An understanding of the principles and practice of therapeutic plasmapheresis.

       

   9. An understanding of how to write a peritoneal dialysis prescription and how to assess peritoneal dialysis adequacy.

       

   10. The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis.

        

   11. An understanding of the complications of peritoneal dialysis, including peritonitis and is treatment, exit site and tunnel infections and their management, hernias, pleural effusions, and other less common complications and their management.

        

   12. An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient.

    

4. Technical and Other Skills

    

   1. The procedural skills in which fellows will be given sufficient experience to gain expertise, including the indications, contraindications, complications, and interpretation of results are:

       

      1. Urinalysis and uroscopy

          

      2. Percutaneous biopsy of native and transplanted kidneys

          

      3. Peritoneal dialysis

          

      4. Placement of temporary vascular access for hemodialysis and related procedures

          

      5. Acute and chronic hemodialysis

          

      6. Placement of peritoneal catheters

          

      7. Renal ultrasound (use and interpretation)

          

      8. Continuous hemofiltration, arteriovenous and/or venovenous

       

   2. Fellows are encouraged to develop knowledge and expertise in the following procedures, including their cost-effectiveness and application to patient care:

      1.  

      2. Radiology of vascular access

          

      3. Balloon angioplasty of vascular access

          

      4. Therapeutic plasmapheresis

          

      5. Bone biopsy

          

      6. Placement of peritoneal catheters

    

5. Research Training Program

   The Research Training Program offers opportunities for fellows to engage in either basic or clinical research

    

   1. Basic Research

      A primary objective of the training program is to develop a strong foundation in the basic principles of biomedical investigation. These principles include analysis of the biological problem, design of experimental approach, developing the appropriate rigorous methodology, and the critical interpretation of data. It is our philosophy that the individual project itself is not as important as the learning experience gained from designing a rigorous investigative approach and approach to problem solving. We feel that the research fellowship program should be one of discovery. We provide broad-based experiences in cell and molecular biology, biophysics, and biochemistry, renal physiology, as well as in outcomes and epidemiological research with a wide variety of interesting projects that can spark the individual trainee's imagination .

      The excellent role models provided by the faculty listed as preceptors, as well as our advanced fellows, ensure an environment that is comfortable, interesting, and thought-provoking for the trainee. The individual trainee is expected to be involved in all aspects of the laboratory work from conception to data presentation and publication. Every fellow is expected to present his/her work within the local community and at national and international meetings. Because of the strong cooperation and collaboration among preceptors, it is not unusual for several fellows to interact together on a scientific project, often with several faculty mentors.

       

   2. Clinical Research

      The Clinical Research Program offers fellows training in the design, implementation, analysis, and interpretation of clinical research projects in dialysis, chronic kidney disease, and intervention trials. Experience in cohort, case-control and experimental studies will be obtained. Trainees will acquire expertise in biostatistical and epidemiologic techniques, including hypothesis testing, descriptive statistics, regression model building, meta-analysis, and the ability to analyze large cohorts, such as USRDS.

      Collaborations with investigators in the Channing Laboratory and the Health Services Research unit in the General Medicine Division at the Brigham and Women's Hospital, as well as at the Harvard School of Public Health will be available. The possibility of completing an MPH or joining an NIH sponsored Clinical Scholars Program will be encouraged.

       

   3. Didactic Training

      Another primary objective of the training program is to provide sufficient didactic training to encourage intellectual growth and development in basic science. Our experience has shown that our fellows benefit from the formal programs that we have developed in our weekly lecture series, combined renal grand rounds, clinical and research journal clubs, case conferences held at the two institutions, and many Fall and Spring symposia. In addition, we strongly recommend to each fellow one of three formal didactic programs generally available although formats may vary from year to year. The are specifically designed for the new post-doctoral fellow: 1) Introduction to Laboratory Research; 2) Program in Clinical Effectiveness; and 3) Introduction to Molecular Biology. These Harvard-wide programs provide a state-of-the-art, yet non-intimidating introduction to basic and clinical research specifically targeted to the beginning post-doctoral fellow.

      Research trainees at the BWH have regular weekly conferences with their mentor, colleagues, and collaborators, currently organized into twelve working groups. These are complemented by weekly research journal clubs and seminars for all division staff and trainees. There is an opportunity for trainees to regularly present their own research in progress. At MGH, there are approximately seven working groups which have weekly conferences. These sessions provide the fellows with their first experience in a one hour-long presentation of their own research. Such exposure provides the fellow with increased opportunities for interaction with other scientists, both individually and collaboratively, and in addition provides the faculty with continued observation of the trainee's work.

      To further supplement the didactic programs described above there are a number of opportunities for trainees to enrich their fundamental scientific knowledge with courses at Harvard College, Harvard Medical School and MIT. A wide choice of relevant courses provides flexibility in structuring the overall program for a trainee. We encourage trainees to commit sufficient time to the basic research program and to related intellectual endeavors so that they will have a strong foundation upon which to achieve the status of an independent investigator. The individual mentor, in concert with the Program Director and Co-directors, constantly seek to advise and interact with the fellows to achieve the proper developmental framework appropriate for each trainee.

       

   4. Choice of Preceptor and Research Problem

      At the BWH trainees generally choose a mentor prior to beginning the fellowship. During the interview process, they have the opportunity to learn about the work being done in the various laboratories, to discuss the training program with current fellows, to select a mentor, and consider specific research projects. They meet with the chosen mentor and develop a plan for the research years. They are encouraged to write a brief research grant proposal under the guidance of the mentor. This process ensures better organization of the trainee's plans and a clear understanding of research goals. It also provides useful and realistic training for writing future grant proposals.

      A seminar program provides the opportunity for clinical fellows and M.D./Ph.D. or graduate students to sequentially review the work of the individual preceptors in the training program. This series, held in July and August, has been particularly helpful to the M.D. clinical fellows who have had little prior research experience. Following a series of seminars, the trainees are then encouraged to meet with all of their potential preceptors in the training program to further discuss their career development plans. In addition, first-year clinical fellows are encouraged to discuss their goals with more senior fellows, both for general advice and for more detail about the overall research directions previously chosen by other fellows. In this manner, the trainees enter the research training program already familiar with the skills and interests of the entire faculty as well as personal knowledge of potential mentors.

      Many fellows start their fellowship in the laboratory and complete their clinical training in the last year of the fellowship. This process provides a smooth transition into the research arena, and presents the appropriate environment where enthusiasm among faculty and colleagues can be readily displayed to the young trainees in helping them choose such a career.

       

   5. Guidance and Evaluation Of Trainees and Duration of Training

      Direct guidance of the trainee is the immediate responsibility of the individual preceptor. The preceptor and collaborators usually provide close interactions sufficient to satisfy any training issues and questions that may arise. The fellowship will be overseen by a supervisory committee made up of two staff members/mentors from each Hospital. The entire clinical faculty meet twice a year to review progress of all clinical fellows.

      Each trainee has adequate exposure to the entire faculty from presentations of his/her own work at the many laboratory meetings described above. The trainees are therefore given the opportunity for frequent short presentations and, at least twice a year, lengthy presentations of their work to allow for adequate evaluation of development in technical proficiency, study design, critical interpretation of data, and appropriate understanding of the scientific problem. The fellows thus participate, both as speakers and as members of the audience, in ongoing scientific dialogue not only with faculty members, but also with outside investigators who enhance the intellectual experience of these meetings.

1.  

2. One-on-one teaching by the supervising faculty member in the course of evaluating and managing in-patients and out-patients on the consultation, dialysis and transplant services. This also includes informal teaching sessions involving students and residents on renal elective. This hands-on experience in traditionally the core of clinical learning.

    

3. Guided reading/Seminars. In a series of structured sessions led by faculty, topics from several texts and syllabi are covered. The material used includes:

    

   1. The Kidney edited by B.M. Brenner

       

   2. Renal Pathology, edited by Tisher and Brenner

       

   3. An extensive notebook of important articles in each area of general nephrology, emphasizing fluid and electrolyte and glomerular disease, has been organized by the faculty

       

   4. An extensive Dialysis Curriculum with reprints

       

   5. Transplant and Transplant Immunology Curriculum with reprints

       

   6. Dialysis Manual by Daugirdas and Ing (portions)

       

   7. Primer on Transplantation of American Society of Transplantation

       

   8. Continuous Ambulatory Peritoneal Dialysis Curriculum & CAPD Policy and Procedure Manual

       

   9. MKSAP Selected Articles in the Subspecialty of Nephrology This is a selection of 60 of the landmark articles in the field of nephrology

       

   10. The MGH Renal Unit Nephrology Case Collection. This collection includes some classic cases with pathological correlations and some paper cases for study when an actual patient with a particular condition is not available for observation. It is supplemented by the Renal Unit slide collection.

        

   11. Presentations and didactic material is posted on "eproject.com".

    

4. Independent reading from The Kidney, Brenner and/or Diseases of the Kidney, Schrier and Gottschalk. Other texts and journals, as well as bibliographic search capabilities, in the Renal Division libraries at both BWH and MGH, the housestaff libraries at both hospitals, and the Harvard Countway Library are available. Bibliographic searches are also available through the hospital computer system on each floor of the teaching hospitals.

    

5. Formal Conferences (Weekly)

    

   1. Renal Grand Rounds

      These are hour and a half conferences held jointly between the two hospitals. The first 45 minutes are devoted to a case conference presented on alternate weeks by each hospital. The next 45 minutes are devoted to a didactic talk. These are formal presentations in areas of science underlying renal physiology, renal disease and nephrology practice. The goal is for fellows to understand the relevant science underlying clinical practice.

       

   2. Transplant Grand Rounds (Monthly)

      Formal presentations of principles of transplantation as well as the clinical experience locally and world-wide. The objective is for the fellows to learn transplant and immunology science as they relate to the clinical practice of transplantation.

       

   3. Clinical Renal Conference (Weekly)

      These weekly conferences range from case presentations, (involving the consultative service, the dialysis service, the transplant service, the pediatric service and the outpatient service) to other didactic sessions including Journal Club and talks by fellows. At BWH fellows are expected to write a detailed literature review on a topic presented in Journal Club. Since fellows in all years of training participate in this exercise supervised by a faculty member, each individual fellow may present one to two times per year. Trainees have submitted reviews based on this exercise for publication. The objective is to become proficient in clinical practice and the pertinent nephrology literature.

       

   4. Clinical Journal Club (Weekly)

      There is a regular journal club each Friday morning. Fellows and faculty choose from recently published articles in NEJM, Lancet, Annals, JASN, KI and the like fort analysis and discussion. The conference prepares the fellows in the critical analysis of papers, the assessment of design and statistical methodss, and the ability to make a cogent anlysis and presentation of scientific material to an audience.

       

   5. Renal Pathology Conference

      The goal is to learn how to perform and interpret renal biopsies and make correlations between the clinical and pathological findings. At BWH fellows meet at the microscope with Dr. Helmut Rennke to review current renal pathology material.

       

   6. Dialysis Review (Weekly)

      While reviewing the progress of hemodialysis and peritoneal dialysis patients the fellows develop skills in management of patients in these areas.

       

   7. Transplant Conference (Weekly)

      This weekly conference with a staff physician in transplantation uses current cases to teach important elements in the immunology of transplantation and in management of rejection and of infectious complications.

      In addition to the formal conferences listed above, a series of lectures is given at the beginning of the year on dialysis, transplantation and the care of renal emergencies. The Dialysis Review is held each Thursday morning and is a multidisciplinary meeting attended by the fellow, faculty, key nursing staff, the dietician, and the social worker. There is also a weekly CRRT Review each Wednesday morning that reviews CRRT care in the hospital.

    

6. Other Meetings

   Each fellow has the opportunity to attend a national nephrology meeting such as the annual meeting of the American Society of Nephrology , the spring Clinical meetings of the National Kidney Foundation, or the American Society of Transplantation meeting. These offer several days of intense learning, mixing lectures, original reports, panels, debates and reviews. Research fellows attend these meetings to present their abstracts in poster or presentation format. Prior to attending the meetings the entire division meets for a practice session, during which fellows learn the skills of presentation. Fellows also attend the two annual nephrology postgraduate courses put on by BWH, which attracts audiences from U.S. and abroad.

    

7. Learning Through Teaching

   The fellows are responsible for several types of teaching:

   Bedside and conference sessions are held for the Harvard Medical Students on Renal Elective and for the Medical Residents on a Renal Rotation.

   Fellows each prepare formal talks to be presented to the Renal Division staff on three or more occasions each year.

   Fellows are intensely involved in patient education in the areas of chronic end-stage renal disease management including dialysis, and also regularly in areas of blood pressure control, nutrition and in the principles of general health maintenance.

   Many fellows participate in teaching renal physiology to first- year students and renal pathophysiology to second-year students at the Harvard Medical School. Faculty at BWH and MGH are involved in leadership roles in these courses.

    

8. Responsible Conduct of Research

    

   1.  

   2. Responsible Conduct of Research

      All research trainees participate in a program reviewing the principles of scientific integrity. The promotion and maintenance of scientific integrity is a basic tenet for the conduct of research at MGH/BWH. Our training philosophy and operational doctrine include the emphasis on personal responsibility for one's development as an independent investigator. Personal, intellectual, and scientific growth are actively encouraged though a network of concerned leadership, involved supervision and open collegial communication.

    

9. The Fellowship Orientation Handbook

   This practical description of the Renal Fellowship is designed to acquaint new fellows with the components of the program and the structure of their learning process. It includes expectations for their performance and show lines of responsibility for patient care.

Evaluation of the fellows is performed at the end of each rotation by the fellow's principal supervisor during that month. These written evaluations are reviewed three times a year by the Fellow Evaluation Committee.

Any deficiency as well as general feedback is reported to the fellow at the end of each rotation. At the end of the year, the Program Director summarizes the year's comments, including areas of strengths, deficiencies and growth during the year and shares the finding with the Fellow. In addition, written evaluations of faculty by fellows are also solicited. Evaluation is conducted using the guidelines of the American Board of Internal Medicine.

1. American Board of Internal Medicine Guidelines for Evaluation

   The board defines the certifiable nephrologist at the completion of required training as being competent to provide comprehensive and specialized medical care based on a high standard of demonstrated component skills. These skills should clearly exceed those demonstrated by the certified internist. Specifically, the Board asks program directors and their faculties to evaluate the following components of clinical competence:

   1.  

   2. Clinical Judgment

      This is the process by which clinical decisions are made. Good clinical judgment encompasses a) integrating medical facts and clinical data, b) weighing alternatives, c) understanding the limitations of knowledge, d) recognizing complications of disease and side-effects of treatments, e) instituting prompt measures to deal with serious or life-threatening clinical manifestations, f) incorporating the consideration of risks and benefits to the patient, and g) developing a logical plan for evaluation and both immediate and long-term management. It implies that the individual can adapt to changes in medicine throughout his/her career.

       

   3. Medical Knowledge

      This is defined as the specialized, current knowledge necessary to function as an expert clinical nephrologist. This includes a broad base of knowledge of the pathogenesis, natural history and management of congenital and acquired diseases of the kidney and urinary tract; renal physiology; disorders of fluid, electrolyte and acid base regulation; normal and disordered mineral metabolism; acute and chronic renal failure; the management of patients receiving immunosuppressive therapy; and the management and diagnosis of severe hypertension. The clinical nephrologist also must be proficient in the principles and applications of various forms of renal replacement therapy including the management and systems operations of hemodialysis, peritoneal dialysis and renal transplantation.

       

   4. Clinical Skills

      These refined abilities include a) obtaining appropriately directed medical histories that are precise, logical, thorough and reliable; b) conducting expert, focused physical examinations that elicit subtle findings and are directed toward the patient's problems; and c) demonstrating understanding and proficiency while minimizing risk and discomfort to patients in the performance of certain diagnostic and technical procedures.

       

   5. Humanistic Qualities

      These are integrity, respect, and compassion as demonstrated in the care of patients and their families. They include the abilities to be honest, involved, and responsive to the patient's wishes; to respect the patient's need for information; to establish the patient's trust; to provide empathy; and to maintain credibility and rapport with patients and their families.

       

   6. Professional Attitudes and Behavior

      The attitudes, behaviors and communication skills defined as essential in relating to patients and educating them, their families, and other health care professionals. These include the ability and willingness to describe the diagnosis and likely clinical course to the patient and the family; explain therapeutic options (including benefits and side-effects); accept responsibility; and prepare comprehensive consultation notes in medical records and letters to referring physicians, patients and appropriate agencies.

       

   7. Medical Care

      The outcome of the integration of the foregoing component skills is the ability to manage patients effectively and responsibly. Excellent medical care results from the consistent ability to apply appropriate, comprehensive care of high quality; to be responsive to the patient's needs; to use laboratory test, consultations and diagnostic procedures efficiently, effectively and in the patients best interest; and to maintain the patient's welfare as the physician's primary concern.

       

   8. Commitment to Scholarship

      This encompasses the commitment to maintain and update clinical skills throughout one's professional career, to acquire new knowledge through computer access and by reading the current medical literature, to participate in the design and conduct of clinical studies or related research, to attend scientific and clinical meetings for nephrologists and to evaluate critically the new medical scientific information relevant to the subspecialty.

       

   9. Moral and Ethical Behavior

      This implies the consistent demonstration of a high standard of moral and ethical behavior expected within the clinical setting and of the medical profession. The ABIM considers it unethical for a physician to refuse to treat a patient solely on the basis of that patient's disease, when that disease is within the physician's area of competence. This philosophy has particular relevance to patients with AIDS or HIV seropositivity.

    

2. Evaluation of Teaching

   At each formal teaching conference a written sheet documents those attending the conference as well as elicits anonymous comments and ratings of the speaker or seminar leader, as well as the usefulness and practicality of the topic presented.

   Feedback from the fellows about the quality of the teaching and the general experience is formally elicited by the program director at the end of each rotation.