u of u school of medicine | university of utah - fellowship … · 2009-05-04 · ♦ curriculum...

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Fellowship Program Guide

Division of Nephrology

University of Utah Health Sciences Center

2007-2008

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University of Utah Nephrology Fellowship Program

Table of Contents

1. Introduction……………………………………………………………………………………..……… 2 2. Fellow Selection Policy/Process……………………………………………………..……………… 2 3. Division of Nephrology Faculty Members…………………………………………………..……… 4 4. Nephrology Fellowship Program Training Sites………………………….……………………….. 6 A. Inpatient sites……………………………………………………………………………………… 6 B. Outpatient sites……………………………………………………………………………………. 6 5. Nephrology Training Program Schedule…………………………………………………….…….. 6 A. Two Year Schedule……………………………………………………………………...………… 6 B. Monthly Schedule (1) University Hospital Rotation………………………………………………………………..… 7 (2) VA Hospital Rotation………………………………………………………………………..... 7 (3) Outpatient Nephrology and Research Rotation…………………………………….……….. 8 6. Nephrology Clinical Training Program Curriculum - Overview………………………………….. 8 A. Clinical Curriculum Introduction…………………………………………………………………. 8 B. Overview of Clinical Program Goals and Objectives………………………………………….. 8 7. Full Clinical Curriculum…………………………..………………………………………….….……. 12 A. Renal Structure and Function………………………………….…..………………………….… 12 B. General Nephrology…………………………………………………………………………..…. 13 C. Renal Transplant…………………………………………………………………………………. 35 D. Dialysis and Extracorporeal Therapy…………………………………………………………... 55 E. Special Areas…………………………………………………………………..…………….…... 75 F. Assessment and Evaluation of Attendings by Fellows………………………………….……. 76 G. Self-evaluation by Fellows………………………………………………………………………. 76 8. Nephrology Research Training Program…………………………………………………………... 76 9. Dealing with Unsatisfactory Fellow Performance…………………………………………………. 78 10. Guidelines for Promotion and Graduation…………………………………………………… …. 79 11. Nephrology Fellowship Work, Duty Hours, Moonlighting and On-Call Policy………………… 79 12. Nephrology Fellow Stipend and Benefits…………………………………………….…………… 81 13. Policy on Fellow Teaching and Supervision of Residents………………………………………. 81 14. Faculty Research Interests..................................................................................................... 81 15. Publications by Nephrology Faculty 2001-06……………………………………………........…. 87 16. Nephrology Fellows Previous Ten Years………………………................................................ 98

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1. Introduction The University of Utah Nephrology Fellowship Program is dedicated to providing the highest quality clinical and research training in the subspeciality of Nephrology. It is accredited by the Graduate Medical Education Committee of the University of Utah and by the Residency Review Committee of the ACGME. There are two programs: 1) The two year clinical program is based at the University Hospital and the Salt Lake Veterans Affairs Medical Center. Upon completion, Fellows are Board Eligible in Nephrology. This program provides primarily clinical training, however, in addition to excellent clinical training, the University of Utah Nephrology Clinical Fellowship Program is designed to provide experience in clinical research. Fellows are placed into on-going faculty clinical research projects and given an opportunity to develop related research interests of their own. 2) The three year research program. The program involves one year of clinical training and two years of basic or clinical research. The clinical year may be done at the beginning or the end of the fellowship and is structured identical to the clinical experience of a year in the two year clinical fellowship. The two years of research are spent under the direction of a faculty member within the Division of Nephrology. This guide provides comprehensive information about all aspects of the Program, including:

♦ Goals and objectives ♦ Nature of sites where training is performed ♦ Types of clinical encounters ♦ Patient case-mix characteristics ♦ Procedures and services ♦ Educational activities and resources, including didactic training and conferences ♦ Nature of supervision and evaluation of fellow’s performance ♦ Faculty research activities ♦ Fellow research opportunities and policies ♦ On-call and vacation policies ♦ Former Fellow information ♦ Fellow selection policy

2. Fellow Selection Policy/Process

1. To be eligible for a fellowship in the Division of Nephrology at the University of Utah School of Medicine, an applicant must: ♦ Be a graduate of a U.S. or Canadian medical school accredited by the Liaison Committee on

Medical Education (LCME) and have three years residency in an ACGME-approved program, OR ♦ Be a graduate of a college of osteopathic medicine in the United States accredited by the

American Osteopathic Association (AOA) and have three years residency in an ACGME-approved program, OR

♦ Be a graduate of a medical school outside of the United States who meets one or more of the following qualifications:

1. Has a currently valid ECFMG certificate plus at least one year training in an ACGME approved program, OR

2. Has a full and unrestricted license to practice medicine in a US licensing jurisdiction plus at least one year training in an ACGME-approved program, OR

3. Is a graduate of a medical school outside the United States who has completed a Fifth Pathway program provided by an LCME-accredited medical school.

♦ Be eligible for American Board of Internal Medicine prior to the time they begin training

2. The Division of Nephrology will send an applicant (upon request): ♦ Introduction letter from the Division Chief and/or the Program Director ♦ General information about the Salt Lake City area

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♦ Instructions on how to apply for the program through the Electronic Residency Application Service (ERAS)

♦ A statement that “The University of Utah School of Medicine does not discriminate on the basis of sex, face, age, religion, color, national origin, disability, or veteran’s status”.

3. The Division of Nephrology requires the following documentation for application:

♦ Completed fellowship application through ERAS ♦ Curriculum Vitae and Personal Statement through ERAS ♦ Three letters of recommendation through ERAS ♦ International Medical Graduates must include the following in addition to the above:

- Copy of green card, visa (J-1), or documentation of U.S. citizenship - Valid ECFMG certificate with Clinical Skills Assessment certification - Evidence of previous training in the United States 4. Selection Criteria for Interviewing applicants - The Nephrology faculty, in a joint meeting, reviews

applicants who meet the criteria. Based on the quality of the application and academic credentials, the applicant is subsequently invited for an interview. On the interview day, applicants receive an information packet and interview with members of the Division of Nephrology and the Nephrology fellows. At the conclusion of the interview, the interviewers complete a standard evaluation form for each applicant they interviewed. The results are tallied and form the basis of the preliminary rank order. The University of Utah Nephrology program will participate in the Match for the July, 2009 entering fellows.

5. The Guide to the Nephrology Fellowship Program is given to applicants on interview day and includes:

♦ Examples of the fellow rotation schedule, the monthly call schedule, and the monthly conference schedule

♦ Program curriculum, including goals, objectives and evaluation procedures ♦ Work hours and supervision policy ♦ Vacation/absence policy ♦ Stipend information ♦ Insurance coverage information ♦ Benefits summary ♦ University policies pertinent to fellows with regard to sexual harassment

6. The University of Utah Graduate Medical Education Committee requires that fellows have a Utah

Medical License and ACLS certification. Fellows who are not currently certified in ACLS must become so within six months of commencing their training.

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3. Division of Nephrology Faculty Members

Name Research Interests Srinivisan Beddhu, M.D. Predictors of dialysis outcomes Associate Professor Terrence Bjordahl, M.D. Clinical care in Salt Lake City Clinical Assistant Professor Wayne A. Border, M.D. Renal fibrosis Professor Diabetic nephropathy Alfred K. Cheung, M.D. Optimization of dialysis Professor Lipids in ESRD patients Scott Eppich, M.D. Clinical care in Provo, UT Staff Physician Tom Greene, Ph.D. Statistical analysis of multicenter trials Research Professor Martin C. Gregory, M.D. Alport Syndrome Clinical Professor Arsalan Habib, M.D. Clinical care in Salt Lake City Clinical Assistant Professor Yufeng Huang, M.D., Ph.D. Diabetic nephropathy Research Assistant Professor Renal fibrosis Carl Kablitz, M.D. Dialysis outcomes Clinical Assistant Professor Dialysis delivery technology Bellamkonda Kishore, Ph.D. Adenosine actions in the nephron Research Associate Professor Models of acute renal failure Donald E. Kohan, M.D., Ph.D. Thrombotic microangiopathies Chief and Training Program Director Hypertension and volume balance Professor Polycystic kidney disease Ken Leypoldt, Ph.D. Peritoneal transport characteristics Research Professor Li Li, Ph.D. Vascular access stenosis Assistant Research Professor

Nancy Noble, Ph.D. Renal fibrosis Research Professor Diabetic nephropathy Abinash Roy, M.D. Clinical care in St. George, UT Clinical Associate Professor Fuad Shihab, M.D. Chronic cyclosporine nephropathy Clinical Professor Renal transplantation outcomes

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Kevin Strait, Ph.D. Renal autacoids Research Assistant Professor Regulation of renal transport Christi Terry, Ph.D. Dialysis outcomes Research Assistant Professor Christof Westenfelder, M.D. Stem cells in renal injury Professor Renal actions of erythropoietin Chief, Renal Section, VA Medical Center Tianxin Yang, M.D., Ph.D. Macula densa signaling Research Associate Professor Collecting duct signaling

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4. Nephrology Fellowship Program Training Sites A. Inpatient sites (1) University Hospital (UH) - This is a tertiary care facility with 330 operating beds located on the

University of Utah Health Sciences Center Campus. It contains surgical, neurosurgical, burn, and medical intensive care units; a newly remodeled 3-station acute dialysis unit with support for hemodialysis, peritoneal dialysis, and continuous renal replacement therapies; radiologic services with modern renal-related procedures and diagnostic vascular and radionucleotide imaging; electron microscopy for renal biopsy material; biochemical and serologic laboratories; a nutrition support service; and relevant social services. A close working relationship exists with other services including surgery, urology, obstetrics, gynecology, pediatrics and psychiatry.

(2) Salt Lake Veterans Affairs Medical Center (VAMC) – This is a tertiary care facility with 117 operating beds located adjacent to the University of Utah Lower Campus and approximately one-half mile from University Hospital. It contains surgical and medical intensive care units, a 10-station newly remodeled dialysis unit that performs acute and chronic hemodialysis and supports continuous renal replacement therapies and peritoneal dialysis, radiologic services with modern renal-related procedures and diagnostic vascular and radionucleotide imaging, electron microscopy for renal biopsy material, biochemical and serologic laboratories, a nutrition support service, and relevant social services. A close working relationship exists with other services including surgery, urology and psychiatry.

B. Outpatient sites (1) University Hospital Renal Clinic – Located on the A level of the University Hospital, this 11-room

clinic is the site for all general nephrology, nephrolithiasis, peritoneal dialysis, post-transplant and pre-transplant patients associated with the University of Utah.

(2) VAMC General Nephrology Clinic – Located on the 4th floor of Building 1 (main hospital building) at the VAMC, this clinic is the site of ambulatory care for VA general nephrology and post-transplant patients.

(3) VAMC Dialysis Clinic – Located within the dialysis unit, this clinic is the site of outpatient follow-up of VA hemodialysis and peritoneal dialysis patients.

5. Nephrology Training Program Schedule The two year clinical fellowship and the one clinical year of the research fellowship are comprised of three major parts that cycle throughout the year. The following schedules are based on the Program’s current policy of having three fellows doing clinical service together. A. Yearly schedule for fellows on clinical service (only 1 year for research fellows) Year 1 (1 block = 4 weeks) Block 1 2 3 4 5 6 7 8 9 10 11 12 13 U A C B A C B A C B A C B A VA B A C B A C B A C B A C B OP C B A C B A C B A C B A C Year 2 (1 block = 4 weeks) Block 1 2 3 4 5 6 7 8 9 10 11 12 13 U C B A C B A C B A C B A C VA A C B A C B A C B A C B A OP B A C B A C B A C B A C B

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University Hospital (4 months yearly) Monday Tuesday Wednesday Thursday Friday 8 am

General Ward duties (all day)

Ward duties (all day)



9 am Nephrology and 10 am PD continuity

clinic

11 am (starts at 8:30) Noon 1 pm Transplant

interdisciplinary rounds

Transplant interdisciplinary rounds

Pathology conference

2 pm Ward duties 3 pm Didactic

conference

4 pm Clinical conference

5 pm Research conference

VA Hospital (4 months yearly) Monday Tuesday Wednesday Thursday Friday 8 am

General Ward duties (all day)




9 am Nephrology and PD continuity

Monthly hemodialysis/

10 am clinic PD rounds 11 am (starts at 8:30) Noon 1 pm Monthly

hemodialysis VA general nephrology

Monthly hemodialysis

Pathology conference

2 pm rounds clinic (starts rounds 3 pm Ward duties

at 12:30 pm) Didactic

conference



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Outpatient nephrology and research (4 months yearly) Monday Tuesday Wednesday Thursday Friday 8 am

General Post-

RESEARCH DAY

RESEARCH DAY

9 am Nephrology and PD continuity clinic

transplant clinic

Pre-transplant clinic

10 am (starts at 8:30) 11 am Noon 1 pm Renal stones

clinic (every other month)

2 pm 3 pm Didactic

conference



6. Nephrology Clinical Training Program Curriculum - Overview A. Clinical Curriculum Introduction The Nephrology Fellowship Clinical Training Program is designed to provide individuals with the opportunity to achieve the fundamental knowledge, procedural skills, practical experience, and professional and ethical behavior necessary for the subspeciality of Nephrology. Fellows care for patients with the full spectrum of renal disorders at all stages of the disease process. Efforts are made at every point to emphasize the integration of fundamental medical knowledge, disease prevention, social, psychological, and economic issues. This section describes the clinical curriculum. The first part presents an outline of the Clinical Program goals and objectives. Subsequently, the full clinical curriculum is described, relating Clinical Program goals and objectives to the manner in which they are achieved. B. Overview of Clinical Program Goals and Objectives The Nephrology Fellowship Clinical Training Program is structured around goals and objectives derived from three major sources: 1) the ACGME Core Competencies; 2) the ACGME subspecialty requirements for Nephrology training programs; and 3) additional input derived from University of Utah Nephrology faculty. These various components are combined to achieve an integrated set of goals and objectives that cover all aspects of the training program. In this first section, an overview of the training program’s goals and objectives is presented, broken down by the six core competencies and then the specific Nephrology areas. This should be reviewed so that Fellows understand each of these components. The following section, devoted to the detailed curriculum, then combines the core competencies and specific nephrology issues into an integrated and comprehensive set of goals and objectives.

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Core competencies

(1) Patient care – Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to: • communicate effectively and demonstrate caring and respectful behaviors when interacting

with patients and their families • gather essential and accurate information about their patients • make informed decisions about diagnostic and therapeutic interventions based on patient

information and preferences, up-to-date scientific evidence, and clinical judgment • develop and carry out patient management plans • counsel and educate patients and their families • use information technology to support patient care decisions and patient education • perform competently all medical and invasive procedures considered essential for the area

of practice • provide health care services aimed at preventing health problems or maintaining health • work with health care professionals, including those from other disciplines, to provide

patient-focused care (2) Medical knowledge - Fellows must demonstrate knowledge about established and evolving

biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Fellows are expected to:

• demonstrate an investigatory and analytic thinking approach to clinical situations • know and apply the basic and clinically supportive sciences which are appropriate to their

discipline (3) Practice-based learning and improvement – Fellows must be able to investigate and

evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Fellows are expected to:

• analyze practice experience and perform practice-based improvement activities using a systematic methodology

• locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems

• obtain and use information about their own population of patients and the larger population from which their patients are drawn

• apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness

• use information technology to manage information, access on-line medical information; and support their own education

• facilitate the learning of students and other health care professionals (4) Interpersonal and communication skills - Fellows must be able to demonstrate interpersonal

and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Fellows are expected to:

• create and sustain a therapeutic and ethically sound relationship with patients • use effective listening skills and elicit and provide information using effective nonverbal,

explanatory, questioning, and writing skills • work effectively with others as a member or leader of a health care team or other

professional group (5) Professionalism - Fellows must demonstrate a commitment to carrying out professional

responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Fellows are expected to:

• demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development

• demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices

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• demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities (6) Systems-based practice - Fellows must demonstrate an awareness of and responsiveness to

the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Fellows are expected to:

• understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice

• know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources

• practice cost-effective health care and resource allocation that does not compromise quality of care

• advocate for quality patient care and assist patients in dealing with system complexities • know how to partner with health care managers and health care providers to assess,

coordinate, and improve health care and know how these activities can affect system performance

Specific renal competencies - Fellows will acquire expertise in: (1) An understanding of normal renal biology including: a. Renal anatomy and histology b. Renal physiology, including in the elderly c. Fluid, electrolyte and acid-base regulation d. Mineral metabolism e. Blood pressure regulation - normal and abnormal f. Renal drug metabolism and pharmacokinetics, including drug effects on renal function and

including in the elderly g. Renal function in pregnancy h. Basic immunologic principles, including mechanisms of disease and diagnostic laboratory

testing relevant to renal diseases i. Medical genetics (2) Prevention, evaluation, and management of general nephrologic disorders including: a. Acute renal failure b. Chronic renal failure c. End-stage renal disease d. Fluid, electrolyte, and acid-base disorders e. Disorders of mineral metabolism including nephrolithiasis and renal osteodystrophy (including

use of lithotripsy) f. Urinary tract infections g. Hypertensive disorders h. Renal disorders related to pregnancy i. Primary and secondary glomerulopathies including infection-related glomerulopathies. This

also entails a basic understanding of immunologic mechanisms of renal disease and the laboratory tests necessary for their diagnosis.

j. Diabetic nephropathy k. Tubulointerstitial nephritis including papillary necrosis l. Genetic and developmental renal diseases including renal cystic diseases, hereditary

glomerulopathies and interstitial nephritis, phakomatoses, systemic diseases with renal involvement, congenital malformations of the urinary tract, maternally inherited mitochondrial diseases, and renal cell carcinoma.

m. Vascular diseases including atheroembolic disease n. Disorders of drug metabolism and renal drug toxicity o. Renal disorders associated with the elderly including altered drug metabolism p. Renal cystic diseases without a recognized genetic basis q. Nutritional management of general nephrologic disorders

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(3) Pre- and post-renal transplant care including: a. Pre-transplant selection, evaluation and preparation of transplant recipients and donors b. Immunosuppressant drug effects and toxicity c. Immediate postoperative management of transplant recipients d. Immunologic principals of types and mechanisms of renal allograft rejection e. Clinical diagnosis of all forms of rejection including laboratory, histopathologic and imaging

techniques f. Prophylaxis and treatment of allograft rejection g. Recognition and medical management of nonrejection causes of allograft dysfunction

including urinary tract infections, acute renal failure, and others h. Understanding major causes of post-transplant morbidity and mortality i. Fluid, electrolyte, mineral and acid-base regulation in post-transplant patients j. Long-term follow-up of transplant recipients in the ambulatory setting including economic and psychosocial issues k. Principles of organ harvesting, preservation and sharing l. Renal disease in liver, heart and bone marrow transplant recipients (4) Dialysis and extracorporeal therapy including: a. Evaluation and selection of patients for acute hemodialysis or continuous renal replacement

therapies b. Evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options c. Drug dosage modification during dialysis and other extra-corporeal therapies d. Evaluation and management of medical complications in patients during and between

dialyses and other extra-corporeal therapies, and an understanding of their pathogenesis and prevention

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

f. An understanding of the principles and practice of peritoneal dialysis including the establishment of peritoneal access, the principles of dialysis catheters, and how to choose appropriate catheters.

g. An understanding of the technology of peritoneal dialysis including the use of cyclers h. Assessment of peritoneal dialysis efficiency using peritoneal equilibration testing and the

principles of peritoneal biopsy i. An understanding of how to write a peritoneal dialysis prescription and how to assess

peritoneal dialysis adequacy j. The pharmacology of commonly used medications and their kinetic and dosage alteration

with peritoneal dialysis k. An understanding of the complications of peritoneal dialysis including peritonitis and its

treatment, exit site and tunnel infections and their management, hernias, plural effusions and other less common complications and their management

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

m. An understanding of the psychosocial, economic and ethical issues of dialysis n. An understanding of dialysis water treatment, delivery systems and dialyzer reuse o. An understanding of end-of-life care and pain management in the care of patients undergoing

chronic dialysis. (5) Personally conducting the following procedures: a. Urinalysis b. Percutaneous biopsy of native and transplanted kidneys c. Peritoneal dialysis d. Placement of temporary vascular access for hemodialysis and related procedures including

use of vascular ultrasound guidance e. Acute and chronic hemodialysis f. Continuous renal replacement therapies

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(6) Understanding indications, complications (if relevant), and interpretation of the following procedures: a. Placement of peritoneal catheters b. Renal imaging - ultrasound, CT, IVP, MRI, angiography, and nuclear medicine studies c. Therapeutic plasmapheresis d. Radiology, angioplasty and declotting of vascular access (7) Special areas in the management of patients of renal diseases including: a. Psychosocial and economic issues confronting patients with renal disease b. Ethical issues relevant to care of patients with renal disease c. Optimizing the relationship of the nephrologist with other health care providers d. Optimizing mechanisms towards achieving life-long learning as a nephrologist e. Quality assessment and improvement, patient safety, risk management, preventative

medicine, and physician impairment as it relates to the nephrologist Progressive objectives The objectives of the nephrology fellowship program are designed to reflect a progressive increase in learning. The learning principles are based on Bloom's taxonomy, describing progression through the six learning domains: knowledge, comprehension, application, analysis, synthesis and evaluation. In practice, the program's objectives change every 6 months of the 2-year training period. These four 6-month periods' progressively changing objectives are summarized in the sections addressing the three major rotations - general nephrology, dialysis and transplantation. These progressive objectives are reviewed with the fellows by the Program Director at the beginning of each 6 month rotation, i.e., each time the objectives change. 7. Full Clinical Curriculum - in this section, specific Clinical Program goals and objectives, as outlined

above, are related to the methods by which they are achieved. The methods of achieving the Clinical Program goals include: ♦ Types and locations of clinical encounters ♦ Patient characteristics including case-mix, population size, sex, age, and race ♦ Relevant procedural training ♦ Relevant educational training, including resources and teaching methods ♦ Nature of supervision ♦ Means of feedback and evaluation of Fellow’s performance

A. Renal structure and function - Fellows will acquire expertise in understanding normal renal biology including renal anatomy and histology, renal physiology, fluid and electrolyte regulation, acid-base balance, mineral metabolism, blood pressure regulation, renal drug metabolism and pharmacokinetics, drug effects on renal function, renal function in pregnancy, renal functional changes with aging, and basic immunologic principles. 1) Educational training

a. Handouts - At the beginning of the Fellowship, Fellows are given several books for their personal use. The books include: Clinical Nephrology (Johnson and Feehally), NKF Primer on Kidney Diseases, Urinalysis (Sister Martine Graf), Handbook of Dialysis (Daugirdas and Ing), and Handbook of Renal Transplantation (Danovitch). Fellows are also given access to UpToDate. While many of these sources primarily deal with renal disorders, they provide fundamental information on normal renal biology as well.

b. Didactic sessions - While normal renal biology is discussed during more informal sessions (attending rounds, renal clinics) it is recognized that a structured approach is necessary to guarantee coverage of the basics of normal renal biology. To accomplish this, a didactic conference is held each Wednesday from 3-4 PM for 2 years. This conference is based on Clinical Nephrology (Johnson and Feehally). The Fellows are responsible for reading the assigned material in advance - a yearly schedule is provided. During the session, a faculty member facilitates discussion of the assigned material. A one-hour session is devoted to each

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of the following normal renal biology topics: water handling, potassium balance, sodium and volume, acid-base balance, Ca/Mg/PO4 metabolism, renal immunology, blood pressure regulation, and renal function in pregnancy. Drug metabolism is discussed during several sessions dealing with antihypertensives, immunosuppressants, and other topics. Renal anatomy and histology are extensively discussed during several sessions on glomerular and interstitial diseases in which diseased kidneys are compared to normal kidneys.

c. Conferences - A renal pathology conference is held each Friday from 1-2 PM. Diseased kidneys are compared to normal kidneys throughout this conference. A multiheaded microscope is used for simultaneous viewing by all Fellows.

2) Nature of supervision - A faculty member facilitates discussion of the assigned material during the didactic sessions. A renal pathology attending supervises discussion of the cases during the pathology conference.

3) Means of Fellow evaluation - Faculty members give Fellows immediate feedback on their knowledge base during the didactic sessions. At the end of each year of didactic sessions, the Fellows take an in-house MKSAP test in Nephrology and Hypertension. Fellows are counseled on areas of weakness by the Program Director. Also, please see information on knowledge base assessment in the General Nephrology section – much of the information covered in basic renal structure and function overlaps with that required for General Nephrology.

B. General Nephrology 1) Goal Fellows will become competent in caring for patients with general nephrology problems. 2) Objectives

Detailed objectives for general nephrology are described in the General Nephrology table. There are 4 separate tables that address objectives for each rotation on general nephrology. A rotation is defined as a 6-month period, so there are separate objectives for the 1st, 2nd, 3rd and 4th 6-month rotations. These objectives reflect a progressive increase in expectations for fellows' competency achievement. While these are discussed in detail in the table, the essence of the objectives for each 6-month rotation are as follows: 1. Months 1-6 - Fellows function at least a the level of accurate reporting of the history, physical and

other data, i.e., they correctly recall and state the relevant facts. Fellows begin to understand or comprehend this information, reviewing and reporting the relevant facts in an organized and efficient manner. Fellows begin to describe how to apply this information to make diagnostic and therapeutic decision.

2. Months 7-12 - Fellows are able to accurately interpret the history, physical examination and data. The information is analyzed and an accurate differential diagnosis is formulated. Fellows are able to perform urinalysis accurately. Fellows continue in their abilities to design a diagnostic plan and therapeutic interventions.

3. Months 13-18 - Fellows are able to correctly manage general nephrology patient care. This extends previous expectations to formulating a correct diagnostic plan, making the correct diagnosis. They should be beginning to critically analyze literature relevant to the care issues.

4. Months 19-24 - Fellows are competent in all six core competencies. They function as self-educators, reading and analyzing the literature, and adjusting their care based on this analysis. They also function as educators in a larger context, using their clinical experience and information they have obtained from the literature to teach their colleagues, staff and faculty.

3) Types of clinical encounters and supervision 1. Inpatient general nephrology encounters – Fellows spend 8 months/year on the inpatient service, 4

months at the UH and 4 months at the VAMC. The Fellows have direct patient care responsibilities for all Nephrology Service inpatients at the UH and VA, including transplant and dialysis patients. The Fellow is the first person from the Nephrology Service to evaluate a new inpatient, including a history, physical examination, and urinalysis (the latter faculty-supervised). The Fellow follows all

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nephrology inpatients with daily history and examinations and, after discussion with faculty, charts recommendations or writes orders. The Attending conducts didactic sessions each day on material relevant to the in-house cases. The Fellow is responsible for arranging outpatient renal follow-up and for providing a dictated discharge summary for use in renal clinic. The Attending is on-call with the Fellow 24 hours a day.

2. Outpatient encounters a. UH General Nephrology Clinic - Each Monday morning from 8:30 AM - noon, all Fellows,

regardless of rotation, attend a general nephrology clinic at the University covering all aspects of nephrology except transplantation and dialysis. Patients are assigned to Fellows and followed on a continuity basis throughout their fellowship (2 years for clinical fellows and three years for research fellows). The clinic is staffed by Drs. Kohan and Gregory who are there solely to supervise and train the Fellows. Each Fellow is given 1/2 hour for follow-up visits and 1 hour for new patients.

b. VA General Nephrology Clinic – Each Tuesday afternoon from 12:30-4:30 PM, the Fellow based at the VA and internal medicine residents assigned to the Nephrology services at either UH or the VAMC attend a general nephrology clinic at the VA covering all aspects of nephrology except transplantation and dialysis. These patients are followed on a non-continuity basis. All patients are presented to the VA Nephrology Attending who is in the clinic solely to supervise and teach.

c. UH Renal Stones Clinic – Every other month, on Monday from 1-4:30 PM, the Fellow on the OP rotation attends a clinic that sees only patients with renal stones. Dr. Westenfelder staffs this clinic; patients are his and are seen by the Fellows on a non-continuity basis.

4) Patient characteristics (number, demographics) 1. Inpatients - The average inpatient General Nephrology census is 15-20 patients at UH and 6-8

patients at the VA (these numbers include dialysis patients). Approximately 30% of inpatients are in the intensive care units at both hospitals. Ninety percent of VA patients are male (mean age – 58 years) and 10% are female (mean age – 49 years); the SLVAMC has the widest geographic referral area of any VA in the nation and sees a broad spectrum of general nephrology problems. Approximately 50% of UH patients are male; ages for both sexes range from 20-90 years. Because Salt Lake City is situated over 400 miles from any other city with a major medical center, it receives a wide variety of referrals with an extremely broad range of renal disorders covering all aspects of general nephrology. In addition, genetic diseases are prevalent in this region providing a tremendous learning opportunity..

2. Outpatients a. UH General Nephrology and Nephrolithiasis Clinics - Over the course of two years, each Fellow

will follow a total of approximately 150 general nephrology patients on a continuity basis. These patients come from Idaho, Utah, Nevada, Wyoming, Colorado, and Montana. All aspects of general nephrology are represented with equal numbers of male:female patients and ages ranging from 20-90 years. The majority of patients are Caucasian, however there are significant numbers of Hispanic, Native American, and South Pacific (Tonga and Samoa) patients. African American patients are seen although they represent the smallest minority. The Nephrolithiasis and General Nephrology clinics see about 6-7 patients per clinic.

b. VA General Nephrology Clinic – An average of 15 patients are seen in each clinic on a non-continuity basis. Demographics are similar to those for SLVAMC inpatients. A broad range of renal disorders are seen with particular emphasis on diabetes, hypertension, renal vascular disease, urinary tract obstruction, drug toxicity, primary glomerulopathies, and collagen vascular diseases.

5) Procedural training (see General Nephrology Table) 1. Percutaneous biopsy of native kidneys – Performed by the Fellow on inpatients on their inpatient

service at UH, outpatients they follow on a continuity basis, and VA outpatients when the Fellow is based at the VA. Fellows perform about 20 native renal biopsies yearly.

2. Urinalysis – Performed by the Fellow on most new inpatients and outpatients, and on follow-up evaluation as necessary.

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3. Renal ultrasound – Fellows observe these during all renal biopsies. 4. Lithotripsy – Performed by the Urologists. Fellows are given didactic instruction in its use,

indications, complications and outcomes. 5. Therapeutic plasmapheresis – Performed by the Blood Bank staff. Fellows are given didactic

instruction in its indications, contraindications and outcomes. 6) Teaching methods (see General Nephrology Table) 1. Educational training

a. Handouts - At the beginning of the Fellowship, Fellows are given several books and access to UpToDate. The books include: Clinical Nephrology (Johnson and Feehally), NKF Primer on Kidney Diseases, and Urinalysis (Sister Laurine Graff). Recent articles may be provided at the beginning of the Fellowship on interpretation of urine electrolytes and osmolality, management of the nephrotic syndrome, diagnostic strategies in disorders of fluid, electrolyte and acid-base homeostasis, clinical disorders of water metabolism, nondialytic management of acute renal failure, hypokalemic and hyperkalemic states, clinical findings and therapy of glomerulonephritis, hyponatremia and hypernatremia, pathogenesis and treatment of kidney stones, prevention of progression in chronic renal disease, pathophysiology of chronic renal failure, diagnosis of acute glomerulonephritis, management of urinary tract infections in adults, and medical management of diabetic nephropathy, and other areas.

2. Didactic sessions a. Weekly didactic conference – General nephrology issues are covered in detail in the didactic

conference held each Wednesday from 3-4 PM for 2 years. This conference is based on Clinical Nephrology (Johnson and Feehally) and other sources. The Fellows are responsible for reading the assigned material in advance - a yearly schedule is provided. During the session, a faculty member facilitates discussion of the assigned material. A total of 85-90 sessions are held covering dialysis, renal transplantation, renal physiology, fluid and electrolyte disorders, glomerulopathies, interstitial nephritis, renal diseases of pregnancy, congenital urinary tract malformations, acute and chronic renal failure, inherited renal diseases, primary and secondary hypertension, nephrolithiasis, radiologic imaging of the kidney, surgical and radiologic issues relevant to vascular access, ESRD economics, epidemiology, statistics, study design, informed consent, psychosocial aspects of ESRD, special issues of the elderly and others. In addition, fellows receive a series of 4 lectures on biostatistics. Finally, 4 sessions each year are devoted to NephSap review. Fellows and the assigned faculty review the questions in NephSAP (Nephrology Self-Assessment Program) distributed by the American Society of Nephrology. In advance of this meeting, the Fellows meet with a designated faculty who is expert in the particular topic to review the text (typically around 50 pages of NephSAP text on which the questions are based).

b. Primer Course: At the beginning of the Fellowship, a 2 day course is given to provide trainees with a basic level of instruction regarding several issues in Nephrology. While it is geared primarily towards a basic level of instruction regarding topics in Nephrology that the fellow is unlikely to have covered during residency and will need to understand at the outset of their fellowship (mechanics of dialysis and transplant protocols), some general nephrology issues are discussed.

3. Conferences – Fellows must attend the following conferences: a. Nephrology Clinical Conference – held every other Wednesday from 4-5 PM. The conference is

divided into cycles of 4 weeks each: 1) Journal club (week 1 of the cycle) - This consists of a journal club in which fellows and faculty

briefly present an article of interest from the current literature. Fellows review assigned journals, identify and read important articles, and discuss these with faculty. All major nephrology journals are covered as well as some general research and clinical journals.

2) Case presentations (weeks 2 and 4 of the cycle) - Fellows and residents on the Nephrology Service prepare a 25 minute presentation including 5-10 minutes of case presentation followed by 15-20 minutes for review of relevant literature. Discussants pick the topic at least one week in advance and review their selection with their Attending. The discussant hands

16

out one good review or original article, however their discussion should be based, at least in part, on review of original literature. The goal is to cover in-depth one, focused area pertinent to the case. In doing so, Fellows are closely critiqued and advised on interpretation of original articles, including study design, methods and data interpretation. Each Fellow presents once a month and keeps a log of cases they presented.

3) Landmark articles (week 3 of the cycle) - Fellows and faculty review landmark articles in a given area in nephrology. These are the key articles that define the current state of practice. At least one week in advance of this, Dr. Beddhu discusses the articles with the fellows. This review is held every other month. Fellows keep a log of articles presented.

4) Morbidity and Mortality conference (week 3 of the cycle) - Fellows and faculty present M&M cases that were encountered over the past 2 months. Correctable problems are identified and action plans initiated as appropriate. Fellows send potential M&M cases to the Training Program Director, Dr. Kohan, in advance of the meeting so that appropriate cases can be identified, including those that require more immediate attention. This conference is held every other month. Fellows keep a log of cases they presented.

b. 5 PM Nephrology Conference – held each Wednesday from 5-6 PM. About 70% of the conferences are based on local or visiting faculty research, while the remaining 30% are an in-depth review of clinical topics by the faculty.

c. Renal Pathology Conference - held each Friday from 1-2 PM during the two years. All biopsies performed at University Hospital are reviewed as well as interesting historical cases. The conference is led by the Renal Pathologist using a multi-headed microscope and is attended by all Fellows. Renal biopsies performed at the VA are reviewed by the Fellow, Attending and VA Renal Pathologist independent of this conference.

4. Inpatient attending rounds – See under Types of Clinical Encounters above. 7) Assessment and evaluation of Fellows (see General Nephrology Table) 1. Clinical encounters – A variety of instruments are used to assess Fellow performance. The specific

evaluation utilized is indicated in the General Nephrology Table. These include: a. Checklist

1) Fellows are evaluated at the end of each 2-week block with a given attending. The attending uses a scale from 1-9 to assess patient care knowledge, skills, attitudes and behaviors. Fellows review these orally with the attending and both individuals sign the review form. If there is any significant issue, the attending immediately communicates this to the Program Director who meets with the attending and fellow to develop an action plan to address the issue. The Fellow’s performance in this area is then reassessed, by Checklist by the inpatient attendings, in one month and reviewed with the Program Director. During the first 6 months of fellowship, all scores must be "5" (satisfactory) or higher; scores under this will be reviewed with the Program Director, specific problem areas identified, and the appropriate corrective action taken. The problem areas are re-evaluated in one month. During the second 6 months (7-12 months of training), scores must average "6" or over; during the third 6 months (13-18 months of training), scores must average "7" or over; and during the fourth and final 6 months (19-24 months), scores must average "8" or above. If these ratings are not obtained, the same steps are taken as discussed above.

2) Fellows are evaluated by the Program Director every 6 months. First, the goals and objectives of the upcoming 6 month general nephrology rotation are reviewed. The Director uses a scale from 1-9 to evaluate the Fellow’s patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice as it pertains to general nephrology. Fellows review this with the Program Director. The evaluation is based on review of the attending checklists, 360 degree evaluations (see below), and any other pertinent information. If any significant issues exist, an action plan is developed and the fellow re-evaluated by the Program Director in 6 months using the same evaluation measurements as above. Importantly, this evaluation is also based on semi-annual discussions between all the clinical faculty and the Program Director. In addition, even if no significant issues are identified, goals are established for the fellow to work

17

on over the next 6 months. These goals typically do not reflect needed attention to sub-par performance, but instead are intended to help the Fellow focus efforts. For example, faculty may note that the fellow did relatively few native kidney biopsies or that attending comments reflected a need to increased general nephrology knowledge base – appropriate recommendations to work on these areas would be made, and progress evaluated at the next semi-annual Program Director review.

b. 360 evaluation – this evaluation is completed by administrative assistants, secretaries, renal social workers, renal dieticians, nurses, pharmacists, technicians, nurse practitioners, and physician assistants in order to give a broad sense of how the Fellow delivers patient care and interacts with members of the general nephrology health care interdisciplinary team. It is completed every 6 months. Fellows review this with the Program Director. Problem areas (scores under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with particular attention to these problem areas.

c. Patient surveys – Over the course of the year, 10-20 different patients are asked to complete a form rating Fellow’s general nephrology clinic patient interaction. These are reviewed annually with the Program Director. Areas in need of improvement (defined as greater than 10% of patients responding negatively) are identified and reassessed, by patient survey, within 6 months.

d. Written exam – At the end of the first year, Fellow’s are given the MKSAP written examination (250 question multiple choice style). Their performance is reviewed with the Program Director. General nephrology areas in need of improvement (defined as missing more than 2 questions in that area) are identified and an action plan is developed to address these. Fellow’s fund of knowledge in these areas is reassessed in 6 months by performance on the relevant NephSAP, if available, or by questioning by the Program Director.

e. Chart-stimulated recall – At the end of the first year, Fellow’s review up to 8-12 cases with the combined clinical faculty, lasting no longer than two hours. This session is not exclusively devoted to general nephrology, but contains at least 4 cases pertinent to major general nephrology issues. The questions are not standardized, but each faculty member asks questions that are designed to evaluate the Fellow’s analytic, investigative and patient care skills, knowledge and attitudes. Areas in need of improvement (defined as incorrectly answering any questions about major concepts in that area) are identified and an action plan formulated with the Program Director. Fellow’s fund of knowledge in these areas is reassessed in 6 months by performance on the relevant NephSAP, if available, or by questioning by the Program Director. These evaluations are intended to be formative, not summative.

f. Resident portfolio – This is partly intended to evaluate Fellow’s practice-based learning and improvement. Several approaches are utilized:

1) Faculty or fellow-initiated CQI project. The Fellow catalogues over time questions and issues that arose during patient care activities and identifies, with a faculty mentor, and issue to address. Once identified, an action plan is developed, the rationale expound (including identifying data sources used), actions taken, and the effect of such interventions assessed. This is reviewed every 6 months with the Program Director and the faculty mentor.

2) Practice Improvement Module (PIM) from ABIM. In place of a fellow or faculty-initiated CQI project, fellows may participate in the PIM in Hypertension, Specialty Referrals, or other areas. Dr. Martin Gregory mentors this experience which involves identifying an area in need of improvement within the given PIM topic, modifying the practice accordingly, and assessing the impact of such changes.

3) Morbidity and mortality conference. Identification of practice and/or system-based problems contributing to morbidity and mortality is an important aspect of meeting these core competencies. Fellows attendance at these conferences, and identification of the issues discussed and actions taken, is documented and included in the portfolio.

4) Case-based presentations. Each fellow does approximately 8 case-based presentations yearly. These presentations assist in improving the fellow's practice, detailing how they researched a topic relevant to a case they encountered and how such research impacted

18

their care, or plan for subsequent care. The topics covered are listed in the portfolio and the presentation itself is added to the reference database in the web-based "Fellows Lounge" on the Nephrology Division website. This latter activity helps improve the practice of all fellows and faculty.

5) Journal club. Each fellow does approximately 8 journal club presentations yearly. The article that they presented is listed in the portfolio. This helps document the fellow's commitment to improving their analysis of the literature relevant to care of their patients.

6) Log of adverse events and actions taken. Fellows keep a computer log of this, independent of their M&M presentations.

7) Summative evaluations. All summative fellow evaluations are included in the portfolio to enable the fellow to review their progress and facilitate making any necessary changes. While this information can largely be obtained by each fellow using their unique logon access to the web-based evaluation system (MyEvaluations.com), having a written list facilitates discussion with, and review by, the Program Director.

8) Procedures. All procedures completed are listed here - see details in following section. g. Fresno Test – This is a validated test of evidence-based medicine. Fellows are given it, then

results analyzed and discussed, to assist in obtaining competence in this area. h. Mini-clinical examination (Mini-CEX) – These are given about 4 times during the first year, in the

inpatient and outpatient setting, to provide formative input on the fellow’s progression towards obtaining clinical competence relevant to general nephrology patient care.

2. Procedures – Fellows are required to keep a log of all native kidney biopsies, indicating date, attending, patient identifier, indication and complications. Fellows are required to perform at least 10 native biopsies per year. These biopsies are always done in the presence of an attending, regardless of fellow competency and experience. Fellows are not required to keep a log of urinalyses, but must be certified as competent in these by the Program Director, based on faculty input, prior to being able to conduct these unsupervised.

3. Conferences – Fellows attendance at conferences is documented as described above. Participation in journal clubs, M&M, case-based presentations, and Landmark articles review, as they relate to general nephrology, is discussed with the Program Director during the 6-month evaluation.

4. Final (summative) evaluation - This evaluation includes a review of the Fellow’s performance during the final period of education, and verifies that the Fellow demonstrated sufficient professional ability to practice competently and independently

8) Assessment and evaluation of attendings by Fellows - discussed in section below devoted to this topic.

19 General Nephrology Table - Months 1-6 Competency category

Competency objectives General Nephrology objectives relevant to competency Teaching Methods Evaluation Methods

Acceptable Performance

Patient care

Exhibit caring and respectful behaviors

Exhibit caring and respectful behaviors towards general nephrology patients

Attending teaching Conferences Orientation Core lectures

Patient surveys 360 evaluation Checklist Mini-CEX

≤10% unacceptable ≥ 5 ≥ 5 Formative

Gather essential and accurate information about their patients

Gather essential information about fellow’s general nephrology patient

Attending teaching Conferences Core lectures

Checklist 360 evaluation Mini-CEX

≥ 5 ≥ 5 Formative

Make informed decisions about diagnostic and therapeutic interventions

Begin to understand the basics of making informed decisions about diagnostic and therapeutic interventions in general nephrology patients


Checklist

≥ 5

Develop and carry out patient management plans

Begin to develop general nephrology patient management plans


Checklist 360 evaluation

≥ 5 ≥ 5

Counsel and educate patients and families

Counsel and educate, with direct attending supervision, general nephrology patients and families with regard to their disease, socioeconomics, support systems, diet, lifestyle, medications




Use information technology

Use information technology to assist caring for general nephrology patients, including UpToDate, NIH information and databases, NephSAP, electronic medical records, PubMed, and other sources

Attending teaching Orientation Conferences

Checklist ≥ 5

Perform: Physical exam

Examine the general nephrology patient, particularly with regard to the renal examination and organ systems affected by renal dysfunction


Checklist Mini-CEX

≥ 5 Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and understand the correct procedural techniques for: 1. Percutaneous native renal biopsy Understand interpretation and the correct technique for: 1. Urinalysis


Checklist ≥ 5

Provide preventative health care services

Understand preventative health care services relevant to general nephrology patients

Conferences Attending teaching

Checklist

≥ 5

Work within a team of health care professionals

Work within the general nephrology health care team, including attendings, nurses, dieticians, social workers, physician extenders, pharmacists and administrative assistants

Conferences Attending teaching Orientation


≥ 5 ≥ 5

20

Medical knowledge

Demonstrate investigatory and analytic thinking about clinical situations

Begin to demonstrate investigatory and analytic thinking about clinical general nephrology situations

Attending teaching Core lectures Conferences Journal club Clinical meetings Orientation

Checklist Mini-CEX

≥ 5 Formative

Know and apply the basic and clinically supportive sciences

Fellows will gather the data and begin to develop the fund of knowledge necessary for prevention, evaluation, and management of general nephrologic disorders in: a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal

osteodystrophy (including use of lithotripsy) e. Urinary tract infections and pyelonephritis f. Hypertensive disorders g. Renal disorders related to pregnancy h. Primary and secondary glomerulopathies, including understanding of

immunologic mechanisms of renal disease and the laboratory tests necessary for their diagnosis

i. Diabetic nephropathy j. Tubulointerstitial nephritis including papillary necrosis k. Genetic and developmental renal diseases including renal cystic

diseases, hereditary glomerulopathies and interstitial nephritis, phakomatoses, systemic diseases with renal involvement, congenital malformations of the urinary tract, maternally inherited mitochondrial diseases, and renal cell carcinoma

l. Vascular diseases including atheroembolic disease m. Disorders of drug metabolism and renal drug toxicity, including in

geriatric patients n. Renal disorders associated with geriatric patients o. Renal cystic diseases without a recognized genetic basis Understand nutritional management of general nephrologic disorders Understand indications and interpretation of renal imaging, including

ultrasound, CT, IVP, MRI, angiography, nuclear medicine studies Understand indications, complications and outcomes in therapeutic

plasmapheresis


Checklist Mini-CEX

≥ 5 Formative

21

Practice-based learning and improvement

Analyze own practice and perform practice-based improvement using a systematic methodology

Fellow will hold up a mirror to themselves to document, assess, and improve their practice. This will involve: a. Monitoring their practice b. Reflecting on or analyzing their practice to identify learning

or improvement needs c. Begin a learning or improvement plan

Attending teaching Case-based presentations

on fellow’s own pts. Journal club Participation in CQI activities Exit rounds on patient

discharge M&M on fellow’s own

patients Conferences Log of significant events and

plan to address Assigned faculty mentor PIM

Resident portfolio (Fellow catalogues over time questions and issues that arose during patient care activities along with copies of the data sources used, and actions taken, to address the specific question or issue).

6 case-based talks* 6 journal clubs* 1 M&M* ≥ 5 on checklists Log of 1 significant event and how addressed CQI project started *Conference performance evaluated by TPD

Use evidence from scientific studies related to patients’ health problems

Use evidence from scientific studies related to general nephrology patients’ health problems


on fellow’s own pts. Journal club

Checklist Fresno Test

≥ 5 Formative

Apply knowledge of study designs and statistical methods to appraising clinical studies and other information

Begin to understand study designs and statistical methods to appraising clinical studies and other information

Statistics and epidemiology course

Conferences Journal club Assigned faculty mentor


≥ 5 Formative


Use information technology as itemized in Patient Care above Attending teaching Orientation Conferences

Checklist Resident portfolio

≥ 5 See “Analyze own practice…” above

Facilitate the learning of others

Facilitate the learning of others, including, residents, fellows, physician extenders, nurses and dialysis technicians. Initially, this is based on assigned literature review.

Role models Attending teaching Conferences


≥ 5 ≥ 5

Interpersonal & communication skills

Maintain a therapeutic and ethical relationship with patients

Maintain a therapeutic and ethical relationship with general nephrology patients

Role models Attending teaching Conferences Core lectures

Checklist 360 evaluation Patient surveys

≥ 5 ≥ 5 ≤10% unacceptable

Demonstrate effective listening and writing skills

Demonstrate effective listening and writing skills Role models Attending teaching



22

Professionalism Demonstrate respect, compassion, and integrity

Demonstrate respect, compassion, and integrity Role models Attending teaching

Checklist 360 evaluation Patient surveys Mini-CEX

≥ 5 ≥ 5 ≤10% unacceptable Formative

Demonstrate an ethically sound practice

Demonstrate an ethically sound practice Role models Attending teaching Conferences


≥ 5 ≥ 5

Demonstrate sensitivity to patients’ culture, age, gender, and disabilities





Systems-based practice

Understand interaction of their practices with the larger system

Begin to understand interaction between fellow’s practice and the hospital and clinic staff, administration, surgical service, radiology, and medical consult services


360 evaluation ≥ 5

Understand types of medical practice and delivery systems

Begin to understand how types of general nephrology practice and providers deliver care


Checklist ≥ 5

Practice cost-effective health care

Begin to understand how to practice cost-effective general nephrology patient care

Conferences Core lectures Attending teaching


≥ 5 ≥ 5

Advocate for quality patient care

Begin to understand how to advocate for general nephrology patient quality care

Attending teaching Participation in CQI Conferences


≥ 5 ≥ 5

23

General Nephrology Table - Months 7-12 Competency category



Patient care












Synthesize data to begin to make informed decisions about diagnostic and therapeutic interventions in general nephrology patients


Checklist Chart-stimulated

recall

≥ 6 Formative


Develop general nephrology patient management plans. Understand how to carry out such plans.


Checklist 360 evaluation Chart-stimulated

recall



Counsel and educate general nephrology patients and families with regard to their disease, socioeconomics, support systems, diet, lifestyle, medications






Attending teaching Conferences

Checklist ≥ 6




Checklist Mini-CEX

≥ 6 Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and demonstrate the correct procedural techniques for: 1. Percutaneous native renal biopsy Understand interpretation and demonstrate the correct technique for: 1. Urinalysis


Checklist ≥ 6


Provide preventative health care services relevant to general nephrology patients



recall

≥ 6 Formative





≥ 6 ≥ 6

24

Medical knowledge


Demonstrate investigatory and analytic thinking about clinical general nephrology situations

Attending teaching Core lectures Conferences Journal club Clinical meetings


recall Written exam

≥ 6 Formative ≤4 incorrect in each general nephrology area


Fellows will continue to acquire the fund of knowledge necessary for prevention, evaluation, and management of the general nephrologic disorders below. They will begin to apply this information. a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis


Written exam Chart-stimulated recall Mini-CEX

≤4 incorrect in each general nephrology Area Formative Formative

25




or improvement needs c. Engaging in a learning or plan improvement







12 case-base talks* 12 journal clubs* 2 M&M* ≥ 6 on checklists Log of 2 significant events and how addressed CQI project data analyzed and improvement plan developed *Conference performance evaluated by TPD





Chart-stimulated recall Written exam

Formative ≤4 incorrect each theme






Formative ≤4 incorrect each general nephrology area






Facilitate the learning of others, including faculty, residents, fellows, physician extenders, nurses and dialysis technicians



≥ 6 ≥ 6











26








≥ 6 ≥ 6








Understand interaction between fellow’s practice and the hospital and clinic staff, administration, surgical service, radiology, and medical consult services




Understand how types of general nephrology practice and providers deliver care


Written exam ≤4 incorrect each theme


Understand cost-effective general nephrology patient care and begin to apply these principles



≥ 6 ≥ 6


Advocate for general nephrology patient quality care by demonstrating proactive efforts towards general nephrology patient care



≥ 6 ≥ 6

27




Patient care




Patient surveys 360 evaluation Checklist

≤10% unacceptable ≥ 7 ≥ 7





≥ 7 ≥ 7


Make informed decisions about diagnostic and therapeutic interventions in general nephrology patients


Checklist

≥ 7


Develop and carry out general nephrology patient management plans



≥ 7 ≥ 7





≥ 7 ≥ 7




Checklist ≥ 7




Checklist

≥ 7

Perform: Procedures



Checklist ≥ 7




Checklist

≥ 7





≥ 7

28

Medical knowledge




Checklist

≥ 7


Fellows will acquire the fund of knowledge necessary for prevention, evaluation, and management of general nephrologic disorders in: a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis


Checklist ≥ 7

29




or improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement







18 case-base talks* 18 journal clubs* 3 M&M* ≥ 7 on checklists Log of 3 significant events and how addressed CQI project - intervention/begin data analysis *Conference performance evaluated by TPD





Checklist ≥ 7





Checklist

≥ 7









≥ 7 ≥ 7










≥ 7 ≥ 7

30








≥ 7 ≥ 7














Checklist ≥ 7


Practice cost-effective general nephrology patient care Conferences Core lectures Attending teaching


≥ 7 ≥ 7


Advocate for general nephrology patient quality care by demonstrating proactive efforts towards dialysis CQI



≥ 7 ≥ 7

31




Patient care










≥ 8 ≥ 8





recall

≥ 8 Formative





recall






≥ 8 ≥ 8




Checklist ≥ 8




Checklist

≥ 8

Perform: Procedures



Checklist ≥ 8





recall

≥ 8 Formative





≥ 8

32

Medical knowledge





recall

≥ 8 Formative


Fellows will acquire the fund of knowledge necessary for prevention, evaluation, and management of general nephrologic disorders in the areas below. They will serve as educators for other fellows, faculty and staff in these areas, whenever possible. a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis


Checklist Chart-stimulated recall

≥ 8 Formative

33



Fellow will hold up a mirror to themselves to document, assess, and improve their practice. This will involve: a. Monitoring their practice b. Reflecting on or analyzing their practice to identify learning or

improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement e. Monitoring the impact of the learning or improvement







24 case-base talks* 24 journal clubs* 4 M&M* ≥ 8 on checklists Log of ≥4 significant events and how addressed CQI project - analysis & reporting *Conference performance evaluated by TPD





Chart-stimulated recall

Formative






Formative


Use information technology as itemized in Patient Care above Attending teaching Conferences




Facilitate the learning of others, including faculty, residents, fellows, physician extenders, nurses and dialysis technicians. The degree of such education is one of the main differences from the preceding six months.



≥ 8 ≥ 8










≥ 8 ≥ 8

34








≥ 8 ≥ 8











≥ 8 ≥ 8




Checklist ≥ 8




≥ 8 ≥ 8





≥ 8 ≥ 8

35 C. Transplant 1) Goal Fellows will become competent in caring for renal transplant patients and patients with renal

complications of non-renal transplants. 2) Objectives

Detailed objectives for transplant are described in the Transplant table. There are 4 separate tables that address objectives for each rotation on transplant nephrology. A rotation is defined as a 6-month period, so there are separate objectives for the 1st, 2nd, 3rd and 4th 6-month rotations. These objectives reflect a progressive increase in expectations for fellows' competency achievement. While these are discussed in detail in the table, the essence of the objectives for each 6-month rotation are as follows: 1. Months 1-6 - Fellows function at least a the level of accurate reporting of the history, physical and





3) Types of clinical encounters and supervision 1. Inpatient transplant encounters – Each Fellow spends 4 months/year on the UH rotation. It is during

the UH rotation that the Fellow has inpatient transplant encounters. All UH patients admitted for surgical renal transplantation are admitted to the Transplant Surgery Service. These patients are followed by the Fellow on the UH rotation during the perioperative period. The Fellow discusses perioperative care with the Transplant Surgery Team each day. Subsequent admissions of renal transplant recipients are made to the Nephrology service (unless the problem is likely to require surgery); the Fellow is the primary provider for these patients, seeing them and writing notes on a daily basis. The Fellow makes sit-down interdisciplinary rounds with the renal transplant team on Mondays and Thursdays from 1-2 PM in which the patient’s current status and care plan are discussed. Post-transplant patients are very infrequently admitted to the VA. The Attending sees the patients together with the Fellow after the Fellow has done the initial evaluation. The Attending is on-call with the Fellow 24 hours a day. A Transplant Nephrologist is on-call 24 hours each day for back-up of difficult transplant issues.

2. Outpatient transplant encounters a. UH Post-Transplant Clinic - Each Tuesday morning, the Fellow on the outpatient nephrology

(OP) rotation attends this clinic. In all, Fellows attend 4 months/year of weekly UH Post-Transplant Clinic on a non-continuity basis. All patients are initially evaluated by the Fellow or residents. Renal transplant coordinators are present to facilitate patient care. All patients are staffed with the Transplant attending.

b. UH Pre-Transplant Clinic – Fellows attend this clinic every Wednesday morning while on the OP rotation. In all, each Fellow attends this clinic for 4 months/year. The Fellow initially evaluates pre-transplant candidates. Renal transplant coordinators are present to facilitate this process. All patients are staffed with the Transplant attending.

36

4) Patient characteristics (number, demographics) 1. Inpatients - The average inpatient renal transplant census is 2-6 patients at UH and very

infrequently at the VAMC. Approximately 80 patients received renal transplants at UH in 2005 of which about 25 were living-related donors. Patient demographics are similar to those for general nephrology patients. VA patients are transplanted at UH but admitted to the VA subsequently. About 3-5 VA patients are transplanted each year.

2. Outpatients – Over 600 patients are followed in the UH Post-Transplant Clinic. An average of 15-20 patients are seen in the weekly UH Post-Transplant Clinic. The UH Pre-Transplant Clinic evaluates up to four patients each week. Patient demographics are similar to those for general nephrology patients.

5) Procedural training (see Transplant Table) 1. Percutaneous biopsy of transplanted kidneys – performed by the Fellow on inpatients on their

service or outpatients they have seen in Post-Transplant Clinic. All renal transplant biopsies on inpatients are performed by the Fellow in the presence of the Attending. Each fellow performs about 15-20 renal transplant biopsies yearly.

6) Teaching methods (see Transplant Table) 1. Educational training

a. Handouts - At the beginning of the Fellowship, Fellows are given the Handbook of Renal Transplantation (Danovitch) and access to UpToDate. Additionally, they are given the Handbook of Renal Transplant Protocols for the University of Utah.

2. Didactic sessions a. Weekly didactic conference – Renal transplant issues are covered in detail in the didactic

conference held each Wednesday from 3-4 PM. Sessions are devoted to recipient evaluation, mechanisms of allograft rejection, immunosuppressive drugs, prophylaxis and treatment of graft rejection, non-rejection causes of graft dysfunction, major causes of post-transplant morbidity and mortality, and renal disease associated with liver, heart and bone marrow transplantation.

b. Primer Course - At the beginning of the Fellowship, a 2 day course is given to provide a basic level of instruction regarding several issues in Nephrology. Those covered relevant to transplant include renal transplantation and UH Protocols, chronic immunosuppression, and approach to an elevated creatinine or fever in a transplant recipient.

3. Conferences – Fellows must attend the following conferences: a. Nephrology Clinical Conference - See General Nephrology Section for details. General

nephrology, dialysis and transplant cases are discussed in the setting of case-based presentations, Landmark articles, M&M, and journal club.

b. 5 PM Nephrology Conference – See General Nephrology section for details. Several conferences are devoted to transplant yearly.

c. Renal Pathology Conference – The conference is held each Friday from 1-2 PM during the two years. All biopsies of transplanted kidneys performed at University Hospital are reviewed as well as interesting historical cases. The conference is led by the Renal Pathologist using a multi-headed microscope and is attended by all Fellows

4. Inpatient attending rounds – See under Types of Clinical Encounters above. 7) Assessment and evaluation of Fellows (see Transplant Table) 1. Clinical encounters – A variety of instruments are used to assess Fellow performance. The specific

evaluation utilized is indicated in the Transplant Table. These include: a. Checklist

1) Fellows are evaluated at the end of each 2-week block with a given attending. The attending uses a scale from 1-9 to assess patient care knowledge, skills, attitudes and behaviors. Fellows review these orally with the attending and both individuals sign the review form. If there is any significant issue, the attending immediately communicates this to the Program Director who meets with the attending and fellow to develop an action plan to address the

37

issue. The Fellow’s performance in this area is then reassessed, by Checklist by the inpatient attendings, in one month and reviewed with the Program Director. During the first 6 months of fellowship, all scores must be "5" (satisfactory) or higher; scores under this will be reviewed with the Program Director, specific problem areas identified, and the appropriate corrective action taken. The problem areas are re-evaluated in one month. During the second 6 months (7-12 months of training), scores must average "6" or over; during the third 6 months (13-18 months of training), scores must average "7" or over; and during the fourth and final 6 months (19-24 months), scores must average "8" or above. If these ratings are not obtained, the same steps are taken as discussed above.

2) Fellows are evaluated by Transplant Director (Dr. Shihab) and Program Director every 6 months. First, the goals and objectives of the upcoming 6 month transplant rotation are reviewed. The Transplant and Program Directors use a scale from 1-9 to evaluate the Fellow’s patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice as it pertains to transplant. Fellows review this with the Program and Transplant Directors. The evaluation is based on review of the attending checklists, 360 degree evaluations (see below), and any other pertinent information. Importantly, this evaluation is also based on semi-annual discussions between all clinical faculty and the Transplant and Program Directors. If any significant issues exist, an action plan is developed and the fellow re-evaluated by the Program and Transplant Directors in 6 months using the same evaluation measurements as above. In addition, even if no significant issues are identified, goals are established for the fellow to work on over the next 6 months. These goals typically do not reflect needed attention to sub-par performance, but instead are intended to help the Fellow focus efforts. For example, faculty may note that the fellow did relatively pre-transplant evaluations, did relatively few renal transplant biopsies, or that attending comments reflected a need to increased transplant knowledge base – appropriate recommendations to work on these areas would be made, and progress evaluated at the next semi-annual Program and Transplant Director review.

b. 360 evaluation – this evaluation is completed by transplant nurses, social workers, dieticians, pharmacists, and nurse practitioners in order to give a broad sense of how the Fellow delivers patient care and interacts with members of the transplant health care interdisciplinary team. It is completed every 6 months. Fellows review this with the Program Director. Problem areas (scores under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with particular attention to these problem areas.

c. Patient surveys – Over the course of the year, about 10 different patients are asked to complete a form rating transplant patient interaction. These are reviewed annually with the Transplant Director. Areas in need of improvement are identified and reassessed, by patient survey, within 6 months. These evaluations are not fellow-specific, since fellows do not follow transplant patients on a continuity basis. However, fellows are involved in discussion of the patient surveys and identification of areas for improvement.

d. Written exam – At the end of the first year, Fellow’s are given the MKSAP written examination (multiple choice style). Their performance is reviewed with the Program Director. Transplant areas in need of improvement are identified (defined as missing more than 2 questions in that area) and an action plan is developed to address these. Fellow’s fund of knowledge in these areas is reassessed in three months by performance on the relevant NephSAP or by satisfactorily answering questions from the Transplant Director.

e. Chart-stimulated recall – At the end of the first year, Fellow’s review up to 8-12 cases with the combined clinical faculty, lasting no longer than 2 hours. This session is not exclusively devoted to transplant, but contains at least 2 cases pertinent to transplant. The questions are not standardized, but each faculty member asks questions that are designed to evaluate the Fellow’s analytic, investigative and patient care skills, knowledge and attitudes. Areas in need of improvement are identified (defined as incorrectly answering any questions about major concepts in that area) and an action plan formulated with the Transplant Director. Fellow’s fund of knowledge in these areas is reassessed in 6 months by performance on the relevant

38

NephSAP, if available, or by questioning by the Transplant Director. These evaluations are intended to be formative, not summative.

f. Resident portfolio – Please see details under General Nephrology section. A fellow's project may be in the transplant area, if deemed appropriate by the Transplant Director.

g. Fresno Test – This is a validated test of evidence-based medicine. Fellows are given it, then results analyzed and discussed, to assist in obtaining competence in this area.

h. Mini-clinical examination (Mini-CEX) – These are given about four times in the first year in the inpatient and outpatient setting, to provide formative input on the fellow’s progression towards obtaining clinical competence relevant to transplant patient care.

2. Procedures – Fellows must keep a log of all transplant kidney biopsies indicating date, attending, patient identifier, indication and complications. Fellows must do at least 5 transplant kidney biopsies each year. However, at no time may a Fellow do a biopsy without attending supervision.

3. Conferences – Fellows attendance at conferences is documented. Participation in journal clubs, case-based presentations, and NephSAP review, as they relate to transplant, is discussed with the Program Director during the 6-month evaluation.



39 Transplant Table - Months 1-6 Competency category

Competency objectives

Transplant objectives relevant to competency Teaching Methods Evaluation Methods


Patient care


Exhibit caring and respectful behaviors towards transplant patients





Gather essential information about fellow’s transplant patient





Begin to understand the basics of making informed decisions about diagnostic and therapeutic interventions in transplant patients


Checklist

≥ 5


Begin to develop transplant patient management plans Attending teaching Conferences Core lectures


≥ 5 ≥ 5


Counsel and educate transplant patients and families with regard to renal transplant types, socioeconomics, support systems, diet, lifestyle, medications





Use information technology to assist caring for transplant patients, including UpToDate, NIH information and databases, NephSAP, electronic medical records, PubMed, and other sources


Checklist ≥ 5


Examine the transplant patient, particularly with regard to transplant-related problems, including examination of the transplant site


Checklist Mini-CEX

≥ 5 Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and understand the correct procedural techniques for: 1. Renal transplant biopsy


Checklist ≥ 5


Understand preventative health care services relevant to transplant patients



recall

≥ 5 Formative


Work within the transplant health care team, including attendings, nurses, nurse coordinators, social workers, physician extenders, pharmacists, and administrative assistants



≥ 5 ≥ 5

40

Medical knowledge


Begin to demonstrate investigatory and analytic thinking about clinical transplant situations


Checklist Mini-CEX

≥ 5 Formative


Fellows will gather the data and begin to develop the fund of knowledge necessary for: a. Pre-transplant selection, evaluation and preparation of

transplant recipients and donors b. Understanding of immunosuppressant drug effects and

toxicity c. Immediate postoperative management of transplant

recipients d. Understanding of immunologic principals of types and

mechanisms of renal allograft rejection e. Clinical diagnosis of all forms of rejection including

laboratory, histopathologic and imaging techniques f. Prophylaxis and treatment of allograft rejection g. Recognition and medical management of nonrejection

causes of allograft dysfunction, including urinary tract infections, acute renal failure, and others

h. Understanding major causes of post-transplant morbidity and mortality

i. Understanding of fluid, electrolyte, mineral and acid-base regulation in post-transplant patients

j. Long-term follow-up of transplant recipients in the ambulatory setting including economic and psychosocial issues

k. Understanding of principles of organ harvesting, preservation and sharing

l. Understanding of renal disease in liver, heart and bone marrow transplant recipients


Checklist Mini-CEX

≥ 5 Formative




or improvement needs c. Engaging in a learning or plan improvement While these objectives are relevant to transplant care, the

Fellow may do this PBLI project as part of another area (dialysis, general nephrology).

Attending teaching Case-based

presentations Journal club Participation in CQI Exit rounds on patient

discharge M&M on own patients Conferences Log of significant

events and plan to address

Assigned faculty mentor

Fellow portfolio (Catalogue of questions and issues that arose during patient care along with copies of the data sources used, and actions taken, to address the specific question or issue).


41

Use evidence from

scientific studies related to patients’ health problems

Use evidence from scientific studies related to transplant patients’ health problems


presentations on fellow’s own pts.

Journal club


≥ 5 Formative






≥ 5 Formative


Use information technology as itemized in Patient Care above





Facilitate the learning of others, including faculty, residents, fellows, physician extenders and nurses. Initially, this is based on assigned literature review.



≥ 5 ≥ 5



Maintain a therapeutic and ethical relationship with transplant patients















≥ 5 ≥ 5






42



Begin to understand interaction between fellow’s practice and the transplant staff, administration, surgical service, radiology, medical consult services, the clinic, and the hospital

Interdisciplinary rounds Conferences Attending teaching



Begin to understand how transplant programs are organized


Checklist ≥ 5


Begin to understand how to practice cost-effective transplant care



≥ 5 ≥ 5


Begin to understand how to advocate for transplant patient quality care



≥ 5 ≥ 5

43

Transplant Table - Months 7-12 Competency category




Patient care












Synthesize data and begin to make informed decisions about diagnostic and therapeutic interventions in transplant patients



recall

≥ 6 Formative


Develop transplant patient management plans. Understand how to carry out such plans.



recall










Checklist ≥ 6




Checklist Mini-CEX

≥ 6 Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and demonstrate the correct procedural techniques for: 1. Renal transplant biopsy


Checklist ≥ 6


Provide preventative health care services relevant to transplant patients



recall

≥ 6 Formative





≥ 6 ≥ 6

44

Medical knowledge


Demonstrate investigatory and analytic thinking about clinical transplant situations



recall Written exam

≥ 6 Formative ≤4 incorrect each area


Fellows will continue to acquire the fund of knowledge necessary for: a. Pre-transplant selection, evaluation and preparation of














≤4 incorrect each area Formative Formative




or improvement needs c. Engaging in a learning or plan improvement While these objectives are relevant to transplant care, the









45

Use evidence from





Journal club


Formative ≤4 incorrect each transplant area






Formative ≤4 incorrect each transplant area







Facilitate the learning of others, including faculty, residents, fellows, physician extenders and nurses



≥ 6 ≥ 6


















≥ 6 ≥ 6






46



Understand interaction between fellow’s practice and the transplant staff, administration, surgical service, radiology, medical consult services, the clinic, and the hospital


360 evaluation ≥ “5”


Understand how transplant programs are organized Conferences Attending teaching



Practice cost-effective transplant care Conferences Attending teaching

Written exam ≤4 incorrect each transplant area


Advocate for transplant patient quality care by demonstrating proactive efforts towards transplant CQI



≥ 6 ≥ 6

47





Patient care










≥ 7 ≥ 7


Make informed decisions about diagnostic and therapeutic interventions in transplant patients


Checklist

≥ 7


Develop and carry out transplant patient management plans



≥ 7 ≥ 7



Attending teaching Conferences Core lectures Interdisciplinary rounds


≥ 7 ≥ 7




Checklist ≥ 7




Checklist

≥ 7

Perform: Procedures



Checklist ≥ 7




Checklist

≥ 7





≥ 7

48

Medical knowledge




Checklist

≥ 7


Fellows will acquire the fund of knowledge necessary for: a. Pre-transplant selection, evaluation and preparation of













Checklist ≥ 7




or improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement While these objectives are relevant to transplant care, the









49

Use evidence from




presentations Journal club

Checklist ≥ 7





Checklist

≥ 7







Facilitate the learning of others, including faculty, residents, fellows, physician extenders and nurses



≥ 7 ≥ 7










≥ 7 ≥ 7








≥ 7 ≥ 7






50








Checklist ≥ 7


Practice cost-effective transplant care Conferences Core lectures Attending teaching


≥ 7 ≥ 7





≥ 7 ≥ 7

51





Patient care










≥ 8 ≥ 8


Make informed decisions about diagnostic and therapeutic interventions in transplant patients



recall

≥ 8 Formative


Develop and carry out transplant patient management plans



recall




Attending teaching Conferences Core lectures Interdisciplinary rounds


≥ 8 ≥ 8




Checklist ≥ 8




Checklist

≥ 8

Perform: Procedures



Checklist ≥ 8





recall

≥ 8 Formative





≥ 8

52

Medical knowledge





recall

≥ 8 Formative


Fellows will acquire the fund of knowledge necessary for: a. Pre-transplant selection, evaluation and preparation of














≥ 8 Formative




or improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement e. Monitoring the impact of the learning or improvement While these objectives are relevant to transplant care, the









53

Use evidence from




presentations Journal club


Formative






Formative







Facilitate the learning of others, including faculty, residents, fellows, physician extenders and nurses. The degree of such education is one of the main differences from the preceding six months.



≥ 8 ≥ 8










≥ 8 ≥ 8








≥ 8 ≥ 8






54






≥ 8 ≥ 8



Checklist ≥ 8


Practice cost-effective transplant care Conferences Core lectures Attending teaching


≥ 8 ≥ 8





≥ 8 ≥ 8

55 D. Dialysis 1) Goal Fellows will become competent in caring for patients requiring dialysis therapy. 2) Objectives

Detailed objectives for general nephrology are described in the Dialysis table. There are 4 separate tables that address objectives for each rotation on dialysis. A rotation is defined as a 6-month period, so there are separate objectives for the 1st, 2nd, 3rd and 4th 6-month rotations. These objectives reflect a progressive increase in expectations for fellows' competency achievement. While these are discussed in detail in the table, the essence of the objectives for each 6-month rotation are as follows: 1. Months 1-6 - Fellows function at least a the level of accurate reporting of the history, physical and





3) Types of clinical encounters and supervision 1. Inpatient dialysis encounters – Patients requiring acute dialysis are seen at the VA and UH during

the 8 months/year on-service by Fellows on the VA or UH rotations. Patients are acutely dialyzed at both hospitals in either the acute dialysis unit or any of the ICUs. Acute hemodialysis, hemofiltration, or CRRT modalities are available at both sites. The fellow is responsible for determining the optimal renal replacement modality and writing the relevant prescription. Fellows also follow chronic dialysis patients admitted with non-dialysis-related problems - the non-dialysis issues are primarily addressed by the resident on service. All acute and chronic dialysis inpatients are seen at the earliest availability and presented in full to the Attending on-service. The Attending sees the patients together with the fellow after the fellow has done the initial evaluation. The fellow then writes and is responsible for dialysis prescription and coordinating and/or performing access placement. The Attending is on-call with the Fellow 24 hours a day.

2. Outpatient dialysis encounters a. VA Hemodialysis Clinic - The VA Fellow attends Outpatient Hemodialysis Clinic at the VA with

Dr. Beddhu, the Director of the VA Dialysis Program, on Monday and Thursday mornings. Patients are seen on dialysis, weekly and monthly laboratories reviewed, and detailed notes written by the Fellow. In this way, all chronic hemodialysis patients at the VA are seen on a formal basis. These rounds combine quality patient care with concomitant didactic teaching and are an important foundation for learning care of chronic hemodialysis patients. Rounds are made with the nurse, dietician, social worker, attending and Fellow.

b. VA Hemodialysis Continuity Exams – The Fellows are assigned dialysis shifts which they follow on a continuity basis for two years. This involves performing complete physical examinations while the patient is off dialysis. The physical examinations are performed as close to the patient’s birthday as possible and while the fellow is on the ESRD service. Patients are staffed with Dr. Beddhu.

56

c. VA Peritoneal Dialysis Clinic - OP fellows attend this clinic on 1-2 Thursday mornings each month, as the patient volume dictates. It is structured like the Hemodialysis Clinic and is supervised by Dr. Beddhu.Like the Hemodialysis Clinic, didactic teaching is particularly emphasized. Patients are seen with the nurse, dietician, social worker, attending and fellow.

e. University Peritoneal Dialysis Clinic - Fellows see all University PD patients in a continuity manner in clinic on all Monday mornings. Approximately 1-2 patients are seen per clinic. The clinic is supervised by Dr. Gregory. Like the Hemodialysis Clinic, didactic teaching is particularly emphasized.

f. University Peritoneal Dialysis Multidisciplinary Meeting - All fellows meet with Dr. Kablitz, the PD nurses, the dietician and the social worker to discuss all PD patients. Recent events and testing results are discussed and action plans formulated. Fellows are taught extensively about interpreting peritoneal function tests, urea kinetics, and many other aspects of PD patient care. This meeting is held on the first Thursday of each month from 3-4 PM.

g. Vascular rounds – Fellows round with the dialysis attending and the vascular surgeons on VA dialysis patients while fellows are on the VA rotation. Vascular access for each patient is evaluated and any need and plans for evaluation and/or intervention with their vascular access are discussed and developed. These rounds are held on the 1st and 3rd Wednesdays of each month at 11:30 AM.

4) Patient characteristics (number, demographics) 1. Inpatients - The average numbers of acute dialysis patients are 1-2 at the VA and 3-4 at UH. The

average numbers of chronic dialysis inpatients are 2-4 at the VA and 3-5 at UH. Patient demographics are similar to those for general nephrology patients discussed above.

2. Outpatients – Approximately 650 chronic dialysis patients, including about 65 peritoneal dialysis patients, are followed by the University of Utah Dialysis Program. These patients are dialyzed at ten different centers located in Salt Lake City, Provo, Ogden, Roosevelt, Price, Cedar City, St. George, Rexburg, Layton, and Idaho Falls. There are about 40 chronic hemodialysis patients at the VA. About 10 chronic hemodialysis VA patients attend each dialysis clinic or shift while about 1-2 patients per fellow attend each PD Clinic at the U or VA.

5) Procedural training (also see Dialysis Table) 1. Temporary vascular access – Fellows place internal jugular, subclavian, and femoral vein double

lumen catheters for dialysis access. Once fellow competence has been ascertained by the Attending, residents may also place vascular access on their patients. The Fellow will place over 20 temporary vascular access catheters during the Fellowship, however there is no required minimum for number of vascular access catheters placed. Rather, a fellow will be certified as competent in this area by the Program Director on the basis of attending evaluations.

2. Acute hemodialysis – Fellows are trained to perform hemodialysis themselves including preparing the dialysis machine and placing on, following during, and removing from dialysis. Outside of this training, fellows do not dialyze patients themselves; this is done by the dialysis staff.

3. CRRT – Fellows are taught the set-up, indications, contraindications and use of CVVH, CAVH, CVVHD and CAVHD. CVVH and CVVHD can be performed at the VA and UH. The University of Utah Dialysis Program owns two CRRT (Prisma) machines and the VA owns one machine. Currently, about 10 patients are placed on CRRT monthly at the UH and VA combined.

4. Peritoneal dialysis – Fellows are trained in performing peritoneal dialysis including CAPD and CCPD. Fellows do not perform PD themselves, rather they are trained in all aspects related to the performance of PD. The General Surgeons place Tenckhoff catheters at the VA and UH.

6) Teaching methods (also see Dialysis Table) 1. Educational training

a. Handouts - At the beginning of the Fellowship, fellows are given the Handbook of Dialysis (Daugirdas and Ing) and access to UpToDate.

2. Didactic sessions

57

a. Weekly didactic conference – Dialysis issues are covered in detail in the didactic conference held each Wednesday from 3-4 PM. Sessions are devoted to hemodialysis issues (including systemic disorders accompanying ESRD, dialysis access, dialyzers, technical aspects, kinetics, and complications), peritoneal dialysis (including indications, mechanics, adequacy, and complications), CRRT, and vascular access placement.

b. Primer Course - At the beginning of the Fellowship, a two day course is given to provide trainees with a basic level of instruction regarding several issues in Nephrology. Those covered relevant to dialysis are hemodialysis and CAPD prescription and acute and chronic complications of hemodialysis and CAPD and their management.


nephrology, dialysis and transplant cases are discussed in the setting of case-based presentations, Landmark articles review, M&M, and journal club.

b. 5 PM Nephrology Conference – See General Nephrology section for details. About seven conferences are devoted to dialysis yearly.

4. Inpatient attending rounds – See under Types of Clinical Encounters above. 5. Outpatient hemodialysis and peritoneal dialysis rounds – See under Clinical Encounters above.

Note that interdisciplinary interactions are a key part of these clinics. 7) Assessment and evaluation of Fellows (also see Dialysis Table) 1. Clinical encounters – A variety of instruments are used to assess Fellow performance. The specific

evaluation utilized is indicated in the Dialysis Table. These include: a. Checklist

1) Fellows are evaluated at the end of each 2-week block with a given attending. The attending uses a scale from 1-9 to assess patient care knowledge, skills, attitudes and behaviors. Fellows review these orally with the attending and both individuals sign the review form. If there is any significant issue, the attending immediately communicates this to the Program Director who meets with the attending and fellow to develop an action plan to address the issue. The Fellow’s performance in this area is then reassessed, by Checklist by the inpatient attendings, in one month and reviewed with the Program Director. During the first 6 months of fellowship, all scores must be "5" (satisfactory) or higher; scores under this will be reviewed with the Program Director, specific problem areas identified, and the appropriate corrective action taken. The problem areas are re-evaluated in one month. During the second 6 months (7-12 months of training), scores must average "6" or over; during the third 6 months (13-18 months of training), scores must average "7" or over; and during the fourth and final 6 months (19-24 months), scores must average "8" or above. If these ratings are not obtained, the same steps are taken as discussed above..

2) Fellows are evaluated by the Program Director and the Dialysis Director (Dr. Beddhu) every 6 months. First, the goals and objectives are reviewed for the upcoming six months. These Directors use a scale from 1-9 to evaluate the Fellow’s patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice as it pertains to dialysis. Fellows review this with the Program Director. The evaluation is based on review of the attending checklists, 360 degree evaluations (see below), and any other pertinent information. Importantly, this evaluation is also based on semi-annual discussions between all the clinical faculty and the Program and Dialysis Directors. If any significant issues exist, an action plan is developed and the fellow re-evaluated by the Program and Dialysis Directors in 6 months using the same evaluation measurements as above. In addition, even if no significant issues are identified, goals are established for the fellow to work on over the next 6 months. These goals typically do not reflect needed attention to sub-par performance, but instead are intended to help the Fellow focus efforts. For example, faculty may note that the fellow did relatively few CRRTs, placed relatively few dialysis catheters, or that attending comments reflected a need to increased dialysis knowledge base – appropriate recommendations to work on these areas

58

would be made, and progress evaluated at the next semi-annual Program and Dialysis Director review.

b. 360 evaluation – this evaluation is completed by dialysis technicians, dialysis nurses, social workers, dieticians, pharmacists, and nurse practitioners in order to give a broad sense of how the Fellow delivers patient care and interacts with members of the dialysis health care interdisciplinary team. It is completed every 6 months. Fellows review this with the Program Director. Problem areas (scores under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with particular attention to these problem areas.

c. Patient surveys – Over the course of the year, 5-10 different patients are asked to complete a form rating dialysis patient interaction. These are reviewed annually with the Program Director. Areas in need of improvement are identified and reassessed, by patient survey, within 3 months. These evaluations are not fellow-specific, since fellows do not follow dialysis patients on a continuity basis (except for continuity physical examinations). However, fellows are involved in discussion of the patient surveys and identification of areas for improvement.

d. Written exam – At the end of the first year, Fellow’s are given the MKSAP written examination (multiple choice style). Their performance is reviewed with the Program Director. Dialysis areas in need of improvement are identified (defined as missing more than 2 questions in that area) and an action plan is developed to address these. Fellow’s fund of knowledge in these areas is reassessed in three months by performance on the relevant NephSAP or by satisfactorily answering questions from the Dialysis Director.

e. Chart-stimulated recall – At the end of the first year, Fellow’s review up to 8-12 cases with the combined clinical faculty, lasting no longer than 2 hr. This session is not exclusively devoted to dialysis, but contains at least 2 cases pertinent to dialysis. The questions are not standardized, but each faculty member asks questions that are designed to evaluate the Fellow’s analytic, investigative and patient care skills, knowledge and attitudes. Areas in need of improvement are identified (defined as incorrectly answering any questions about major concepts in that area) and an action plan formulated with the Dialysis Director. Fellow’s fund of knowledge in these areas is reassessed in 6 months by performance on the relevant NephSAP, if available, or by questioning by the Dialysis Director. These evaluations are intended to be formative, not summative.

f. Resident portfolio – Please see details under General Nephrology section. A fellow's project may be in the transplant area, if deemed appropriate by the Dialysis Director.


h. Mini-clinical examination (Mini-CEX) – These are given about four times in the first year, in the inpatient and outpatient setting, to provide formative input on the fellow’s progression towards obtaining clinical competence relevant to dialysis patient care.

2. Procedures – Fellows are required to keep a log of all CRRT, indicating date, attending, patient identifier, indication and complications. Fellows are required to be involved in the care of least 5 patients per year getting CRRT and 10 patients per year getting PD. At no time may a fellow conduct PD or CRRT without attending supervision. There is no defined minimum requirement for number of hemodialysis patients seen since fellows always care for a large number of these types of patients.

3. Conferences – Fellows attendance at conferences is documented. Participation in journal clubs, case-based presentations, and Landmark articles review, as they relate to dialysis, is discussed with the Program Director during the 6-month evaluation.



59 Dialysis Table - Months 1-6 Competency category


Dialysis objectives relevant to competency Teaching Methods Evaluation Methods Acceptable Performance

Patient care


Exhibit caring and respectful behaviors towards dialysis patients

Attending teaching Conferences Core lectures Orientation




Gather essential information about fellow’s dialysis patient Attending teaching Conferences Core lectures




Begin to understand the basics of making informed decisions about diagnostic and therapeutic interventions in dialysis patients



recall Mini-CEX

Checklist


Begin to develop dialysis patient management plans Attending teaching Conferences Core lectures


recall



Counsel and educate, with direct attending supervision, dialysis patients and families with regard to dialysis modalities, socioeconomics, support systems, dialysis withdrawal, diet, lifestyle, medications

Attending teaching Conferences Core lectures Interdisciplinary

rounds




Use information technology to assist caring for dialysis patients, including UpToDate, NIH information and databases, NephSAP, electronic medical records, PubMed, and other sources

Attending teaching Conferences Orientation

Checklist Checklist


Examine the dialysis patient, particularly with regard to dialysis-related problems, vascular access site identification and evaluation of access function and infection


Checklist Mini-CEX

Checklist Mini-CEX

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and understand the correct procedural techniques for: 1. Temporary vascular access for hemodialysis 2. Hemodialysis, peritoneal dialysis, and CRRT


Checklist Checklist


Understand preventative health care services relevant to dialysis patients, including following DOQI guidelines for prevention of anemia, maintenance of accepted serum chemistries, and optimization of dialysis delivery

Interdisciplinary rounds



recall


recall


Work within the dialysis health care team, including attendings, nurses, dieticians, social workers, physician extenders, pharmacists, technicians, administrators and administrative assistants





60

Medical knowledge


Begin to demonstrate investigatory and analytic thinking about clinical dialysis situations


Checklist Mini-CEX

≥ 5 Formative


Fellows will gather the data and begin to develop the fund of knowledge necessary for: a. Evaluation and selection of patients for acute hemodialysis

or CRRT b. Evaluation of ESRD patients for various forms of therapy c. Drug dosage modification during dialysis and other extra-

corporeal therapies d. Evaluation and management of medical complications in

patients during and between dialyses and other extra-corporeal therapies, and an understanding of their pathogenesis and prevention



g. An understanding of the technology of peritoneal dialysis including the use of cyclers

h. Assessment of peritoneal dialysis efficiency using peritoneal equilibration testing and the principles of peritoneal biopsy

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

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

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


m. An understanding of the psychosocial, economic and ethical issues of dialysis

n. An understanding of dialysis water treatment, delivery systems and dialyzer reuse

o. An understanding of end-of-life care and pain management in the care of patients undergoing chronic dialysis, including psychosocial, cultural, and religious issues related to death and dying


Checklist Mini-CEX

≥ 5 Formative

61

p. An understanding of the radiologic evaluation of dialysis

access, including its indications, contraindications, complications and interpretations of results, as well as their cost-effectiveness and application to patient care

q. An understanding of balloon angioplasty of vascular access, including its indications, contraindications, complications and interpretations of results, as well as their cost-effectiveness and application to patient care


Checklist Mini-CEX

≥ 5 Formative







Journal club Participation in CQI

activities Exit rounds on patient


patients Conferences Log of significant



Fellow portfolio (Fellow catalogues over time questions and issues that arose during patient care activities along with copies of the data sources used, and actions taken, to address the specific question or issue).

Completed PIM 8 case-based talks 8 journal clubs 4 M&M ≥ “5”, Yr 2 avg. ≥ 7 on checklists Log of ≥2 significant events, how addressed, and results Fellow/faculty initiated project (PIM is an alternative)


Use evidence from scientific studies related to dialysis patients’ health problems



Journal club


≥ 5 Formative




Conferences Journal club Assigned faculty

mentor


≥ 5 Formative










≥ 5 ≥ 5

62



Maintain a therapeutic and ethical relationship with dialysis patients















≥ 5 ≥ 5








Begin to understand interaction between fellow’s practice and the dialysis unit staff, unit administration, surgical service, radiology, medical consult services, the clinic, and the hospital


Conferences Attending teaching Dialysis director &

administrator didactic teaching



Begin to understand how types of dialysis units and providers deliver dialysis care



Checklist ≥ 5


Begin to understand how to practice cost-effective dialysis care



≥ 5 ≥ 5


Begin to understand how to advocate for dialysis patient quality care by demonstrating proactive efforts towards dialysis CQI



≥ 5 ≥ 5

63 Dialysis Table - Months 7-12 Competency category



Patient care











Synthesize data to begin to make informed decisions about diagnostic and therapeutic interventions in dialysis patients



recall

≥ 6 Formative


Develop dialysis patient management plans. Understand how to carry out such plans.



recall



Counsel and educate dialysis patients and families with regard to dialysis modalities, socioeconomics, support systems, dialysis withdrawal, diet, lifestyle, medications


rounds






Checklist ≥ 6




Checklist Mini-CEX

≥ 6 Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and demonstrate the correct procedural techniques for: 1. Temporary vascular access for hemodialysis 2. Hemodialysis, peritoneal dialysis, and CRRT


Checklist ≥ 6


Provide preventative health care services relevant to dialysis patients, including following DOQI guidelines for prevention of anemia, maintenance of accepted serum chemistries, and optimization of dialysis delivery




recall

≥ 6 Formative






≥ 6 ≥ 6

64

Medical knowledge


Demonstrate investigatory and analytic thinking about clinical dialysis situations



recall Written exam

≥ 6 Formative ≤4 incorrect each dialysis area


Fellows will increase their fund of knowledge necessary for: a. Evaluation and selection of patients for acute hemodialysis

















≤4 incorrect each dialysis area Formative Formative

65






recall Written exam

≥ 6 Formative ≤4 incorrect each dialysis area



















Journal club







mentor












≥ 6 ≥ 6

66


















≥ 6 ≥ 6








Understand interaction between fellow’s practice and the dialysis unit staff, unit administration, surgical service, radiology, medical consult services, the clinic, and the hospital





≥ 6 ≥ 6


Understand how types of dialysis units and providers deliver dialysis care





Practice cost-effective dialysis care Conferences Core lectures Attending teaching


≥ 6 ≥ 6


Advocate for dialysis patient quality care by demonstrating proactive efforts towards dialysis CQI



≥ 6 ≥ 6

67

Dialysis Table - Months 13-18 Competency category



Patient care









≥ 7 ≥ 7


Make informed decisions about diagnostic and therapeutic interventions in dialysis patients


Checklist

≥ 7


Develop and carry out dialysis patient management plans Attending teaching Conferences Core lectures


≥ 7 ≥ 7




rounds


≥ 7 ≥ 7




Checklist ≥ 7




Checklist

≥ 7

Perform: Procedures



Checklist ≥ 7





Checklist

≥ 7






≥ 7

68

Medical knowledge




Checklist

≥ 7


Fellows will acquire the fund of knowledge necessary for: a. Evaluation and selection of patients for acute hemodialysis
















Checklist

≥ 7

69





Checklist

≥ 7



















Journal club

Checklist ≥ 7





mentor

Checklist

≥ 7










≥ 7 ≥ 7

70










≥ 7 ≥ 7








≥ 7 ≥ 7













≥ 7 ≥ 7





Checklist ≥ 7




≥ 7 ≥ 7





≥ 7 ≥ 7

71

Dialysis Table - Months 19-24 Competency category



Patient care









≥ 8 ≥ 8


Make informed decisions about diagnostic and therapeutic interventions in dialysis patients



recall

≥ 8 Formative


Develop and carry out dialysis patient management plans Attending teaching Conferences Core lectures


recall





rounds


≥ 8 ≥ 8




Checklist ≥ 8




Checklist

≥ 8

Perform: Procedures



Checklist ≥ 8






recall

≥ 8 Formative






≥ 8

72

Medical knowledge





recall

≥ 8 Formative


Fellows will acquire the fund of knowledge necessary for: a. Evaluation and selection of patients for acute hemodialysis

















recall

≥ 8 Formative

73






recall

≥ 8 Formative




or improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement e. Monitoring the impact of the learning or improvement















Journal club


Formative





mentor


Formative










≥ 8 ≥ 8

74










≥ 8 ≥ 8








≥ 8 ≥ 8













≥ 8 ≥ 8





Checklist ≥ 8




≥ 8 ≥ 8





≥ 8 ≥ 8

75 E. Special areas - It is critical to emphasize the importance of psychosocial and economic issues

confronting patients with renal disease, ethical issues relevant to care of patients with renal disease, optimizing the relationship of the nephrologist with other health care providers, and optimizing mechanisms towards achieving life-long learning as a nephrologist. These issues are covered in detail in the above curriculum, however, they are not always clearly identified in the curriculum’s goals as being of paramount significance. In addition, formal courses on statistics and epidemiology, geriatric evaluation, nursing home care, and dialysis discontinuation/end-of-life issues are offered. These special aspects of the curriculum are discussed below: a. Dialysis initiation, discontinuation and end-of-life issues – Fellows are given 2 one-hour lectures by

the division faculty on dialysis discontinuation and end-of-life issues. In addition, the issues surrounding dialysis initiation are discussed. These issues are also addressed on the inpatient service and in the clinics. The RPA/ASN Clinical Practice Guidelines for Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis form part of the discussion basis.

b. Geriatric assessment – Fellows are given 2 hours of didatic lectures by the renal division faculty devoted to the physiology and pathology of the aging kidney, altered drug metabolism with aging, and drug toxicity in the elderly.

c. Medical ethics – Fellows attend 4 one-hour conferences during the course of their fellowship devoted to renal-related ethical issues. These focus on dialysis initiation and withdrawal, dialysis funding, renal transplant donor and recipient selection, kidney transplant availability, and other renal-related issues. The social and economic impact of their decisions and the need to be the patient’s advocate are discussed.

d. Health care policy and legal medicine – In addition to health policy issues related to end-of-life care, fellows attend two one-hour lectures on health care policy and legal medicine, focusing on dialysis and renal transplant.

e. Physician impairment, risk management, patient safety – At the time of initial hire, all fellows spend a full day in the GME office. During this time, they are given instruction in physician impairment, OSHA, infection control, risk management, and HIPAA compliance.

f. Quality assessment and quality improvement - These processes are addressed by relevant projects as described in each section (General Nephrology, Transplant and Dialysis) above. In addition, at the beginning of each academic year, new Fellows are given either: 1) a 2-hour lecture by Mo Mulligan, JD, BSN, RN, the Director of Performance Monitoring and Improvement for University Health Care Hospital and Clinics, University of Utah that describes what constitutes continuous quality improvement, how it is conducted, and how Fellows can perform these activities; or 2) a similar lecture by a Department of Medicine faculty member that is jointed attended with the internal medicine housestaff.

g. Medical genetics – Fellows are given several lectures focusing on renal-related medical genetics issues, including discussion of relevant techniques, single gene mutations, and polygenic disorders.

h. Pain control – This issue has only recently been addressed (2006) in dialysis and CKD patients. This issue is discussed with fellows in the sessions on pharmacology in dialysis and CKD patients.

i. Division of Nephrology Clinical Research course – Fellows attend 8 one-hour sessions over the course of their clinical training devoted to understanding basics of clinical research. The course is run by Dr. Beddhu. It is based in part on the JAMA publications devoted to these areas, as well as other sources. Clinical epidemiology issues are discussed. The topics of the 8 lectures are:

1. Introduction to hypothesis testing- power and limitations of p value 2. Analysis of continuous variables - T-test, ANOVA, linear regression 3. Analysis of categorical variables - Chi-square. logistic regression 4. Survival analysis 5. Interpreting studies on therapeutic benefit 6. Interpreting studies on harm 7. Interpreting studies on diagnostic tests 8. Interpreting studies on cost-effectiveness

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F. Assessment and evaluation of attendings by Fellows

1. Annual evaluation of faculty and training program – Fellows complete a written form annually that confidentially evaluates the faculty and training program. They evaluate the effectiveness of the program in achieving of the goals and objectives identified in the curriculum above. The evaluation includes utilization of the resources, contribution of each institution, the financial and administrative support, the volume and variety of patients, effectiveness of inpatient and ambulatory teaching, the performance of all faculty members, and the quality of supervision. Fellows meet with the Program Director and any changes in the program that are made as a result of the review are documented. These evaluations are also reviewed with each attending (keeping the Fellow’s name unknown) and documented in writing.

2. Semi-annual program evaluation by Fellowship Executive Committee – All clinical fellows, together with the Program Director, the Dialysis Director (Dr. Beddhu), the Transplant Director (Dr. Shihab), and Dr. Gregory formally meet to discuss how well the training program is meeting the goals and objectives of the curriculum. In addition, the curriculum itself is critically evaluated, along with all other issues raised during the Fellow and faculty evaluation of the program. Problems or areas of improvement are identified, a plan of action established, and the issues revisited, along with any new matters, at the next semi-annual meeting. Written minutes of these meetings are made and are available to all faculty. Any changes in the curriculum are presented to the entire clinical nephrology faculty for their approval. In practice, this committee meets as often as is felt necessary (typically every 3 months), but no less than every 6 months.

G. Self-evaluation by Fellows – The process of self-evaluation is important in the Fellow’s development into a competent nephrologist and is intended to help establish a life-long pattern of self-assessment and self-improvement. Consequently, Fellows complete a self-evaluation semi-annually that they review with the Program Director. The goal is for the Program Director and Fellow to develop goals, and related action plans, based on this self-evaluation, so that the Fellow can continue to improve. This self-evaluation is not used to critique fellow performance, but only as a tool to help focus the Fellow’s development. 8. Nephrology Research Training Program A. Clinical research curriculum as part of 2-year clinical fellowship (1) Research Sites – Clinical research is conducted primarily when the Fellows are on the OP

rotation. The OP service, which comprises four months each year, allows a substantial amount of time for research, without having inpatient responsibilities. Additionally, several opportunities exist for Fellows to become involved in ongoing multicenter collaborations.

(2) Research Schedule - Within the first month of Fellowship, Fellows meet with all clinical research faculty to discuss possible clinical research projects and mentorship. Basic research projects are not realistic during the two years of Fellowship, but such projects can be considered subsequently. Fellows are expected to become involved in projects already in progress and not to be responsible for completely designing a new project. Fellows are not expected to obtain independent funding to support their salary or research activities. After identifying a mentor and project, Fellows are actively involved in the faculty-directed clinical research project while on each OP rotation - every Thursday and Friday of this rotation is reserved, with the exception of a one hour Pathology conference on Friday, for research. Thus, during the two years of fellowship, each Fellow spends 48 week days devoted to research, the equivalent of 9-10 work weeks.

(3) Goals and Objectives of Research Program a. Understand fundamentals of clinical research including basics of research design, data

analysis (biostatistics), public policy, economics, health education, designing trials, recruiting

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subjects, responsible use of informed consent, standards of ethical conduct of research, clinical epidemiology, and outcomes analysis.

b. Gain hands-on experience with conducting a clinical research project including research design (where feasible), data analysis, subject recruitment, data collection, and manuscript preparation.

c. Understand principles of grant writing. d. Provide sufficient exposure to clinical research to allow Fellows to make an informed

decision about pursuing a career involving clinical research. e. Provide sufficient exposure to clinical research to allow Fellows to critically assess clinical

research literature and to be competent in using available medical informatics systems. Bibliographic retrieval and critical appraisal skills are of paramount importance.

f. Become a co-author on a published manuscript or abstract, or present research at a national meeting.

(4) Educational Training a. Didactic courses

1. CRC course - Fellows interested in clinical research attend a two day general clinical research course given in August of their first year by the Clinical Research Center at the University of Utah. Topics covered include basics of research design, ethical conduct of research, responsible used of informed consent, data analysis (biostatistics), public policy, economics, health education, designing trials, recruiting subjects and other epidemiology issues, and outcomes analysis.

2. Division of Nephrology Clinical Research course – Fellows attend 8-10 one-hour sessions over the course of each year devoted to understanding clinical research. The course is taught by Dr. Beddhu. Details are discussed in Section 7E above.

b. The research mentor-Fellow relationship is the primary means by which Fellows will achieve training in clinical research.

(5) Nature of Supervision - Fellows should select a project and mentor by September 1 of the first year of Fellowship and inform the Nephrology Fellowship Program Director of their selection. For the next 22 months, the Fellow’s clinical research activities will be guided by the Mentor. This involves frequent meetings (at least every two weeks during the OP rotation and every two months during other rotations) between the Fellow and mentor during which all aspects of conducting the clinical research projects are addressed.

(6) Means of Fellow Evaluation – The mentor provides the Fellow with ongoing informal feedback. In addition, the mentor meets with the Nephrology Training Program Director semiannually to report on the Fellow’s progress. The Training Program Director also discusses the research progress with the Fellow during their semi-annual meetings. Evidence of successful completion of the Fellow research requirement includes presenting an abstract at a national meeting, publishing an abstract or manuscript, and/or presentation of the research to the Division of Nephrology for the one hour research conference.

B. Research fellowship curriculum for fellows on three year research fellowship (1) Research Sites – Basic or clinical research are conducted at the VA or at University Hospital,

depending upon the location of the mentor. (2) Research Schedule - Research fellows identify a mentor within the first month of their fellowship.

Depending upon the fellow's preference and the number of clinical fellows, the research fellow will do their clinical year either at the beginning or the end of their fellowship. Once the fellow starts in the laboratory, they will do this exclusively for two years with the exception that they will maintain a 1/2 day general nephrology continuity clinic throughout their entire fellowship.

(3) Goals and Objectives of Research Program a. Understand fundamentals of basic or clinical research. For both clinical and basic research,

this includes research design and data analysis (biostatistics). For clinical research, this also includes public policy, economics, health education, designing trials, recruiting subjects and other epidemiology issues, and outcomes analysis.

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b. Gain hands-on experience with conducting a basic or clinical research project including research design (where feasible), conducting the study, data analysis, and manuscript preparation. It is expected that the fellow will generate at least one peer-reviewed original research publication from this work, although this is not a requirement for graduation from the program.

c. Understand principles of grant writing. d. Provide sufficient experience in basic or clinical research to allow Fellows to make an

informed decision about their academic career choices. e. Provide sufficient exposure to basic or clinical research to allow Fellows to interpret basic

and clinical research literature. (4) Educational Training

a. Didactic courses 1. CRC course - Fellows interested in clinical research attend a two day general clinical

research course given in August of their first year by the Clinical Research Center at the University of Utah. Topics covered include basics of research design, ethical conduct of research, responsible used of informed consent, data analysis (biostatistics), public policy, economics, health education, designing trials, recruiting subjects and other epidemiology issues, and outcomes analysis.

2. Division of Nephrology Statistics course – Fellows attend 10 two-hour sessions held on Thursdays from 4:30-6:30 PM dedicates to understanding medical statistics. The course is taught by members of the nephrology division as well as University of Utah statisticians.

3. Division of Nephrology Clinical Research course – Fellows interested in clinical research attend a one-hour session each month devoted to understanding basics of research design, data analysis (biostatistics), public policy, economics, health education, designing trials, recruiting subjects and other epidemiology issues, and outcomes analysis. The course is run by Dr. Beddhu and is largely based on the JAMA publications devoted to these areas.

b. The research mentor-Fellow relationship is the primary means by which Fellows will achieve training in basic or clinical research.

(5) Nature of Supervision - Fellows should select a project and mentor by September 1 of the first year of Fellowship and inform the Nephrology Fellowship Program Director of their selection. For the next 23 months, the Fellow’s research activities will be guided by the Mentor. This involves frequent meetings (at least bi-weekly during the two years of research).

(6) Means of Fellow Evaluation – The mentor provides the Fellow with ongoing informal feedback. In addition, the mentor meets with the Nephrology Training Program Director semiannually to report on the Fellow’s progress. The Training Program Director also discusses the research progress with the Fellow during quarterly meetings between the Research Fellow and the Training Program Director. Fellows are expected to be a first author on at least one publication in a peer-reviewed journal. In addition, they are expected to present their research at least once annually at national meetings.

9. Dealing with unsatisfactory Fellow performance – This information is provided in the unlikely event

that a serious problem is encountered with a Fellow; fortunately, this has never occurred in the Nephrology Division. In the event of a repeated unsatisfactory rating (failure to improve despite counseling and supervision), the Fellow meets with the Program Director and/or the faculty member involved to discuss his/her deficiencies. Written documentation is made of these meetings. If the Program Director and the faculty involved deems the Fellow’s deficiencies severe enough, because of clinical incompetence or inability to exhibit professional attitudes, then the Fellow will be placed on probation. Short of probation, the Program Director may, in certain cases, require counseling for that Fellow. The Fellow will be advised of specific steps required to correct the stated deficiencies. One month later, the Fellow will be re-evaluated by the Program Director and the Attending(s) involved and written documentation made. If correction is not seen at this point, the Program Director will meet with all Nephrology faculty to make a decision whether to refuse to renew a Fellow's contract at the end of the year or to refuse to sign off on the Fellow's training. At any time a Fellow may express a grievance

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in writing either by requesting to meet all full-time faculty or entering the appeal process of the University via the Chairman of the Department of Internal Medicine or via the Dean of the Medical School.

10. Guidelines for Promotion and Graduation A. Clinical Track – 2 year clinical fellowship (1) Promotion from 1st to 2nd year – The criteria for promotion are listed in the General Nephrology,

Dialysis, and Transplant tables. All of these criteria must be met in order to be promoted. They must have been met within the last month of the 1st year of fellowship. Failure to meet all criteria will result in review by all Clinical Faculty with whom the Fellow has had contact in the past year, and placement on probation. The Fellows must demonstrate satisfactory performance over the next 1 month of clinical activities, as determined by the criteria for performance during year 1, in order to be allowed to continue in their training. Any exceptions will be determined on an individual basis by the entire Clinical Faculty, and will be based on all circumstances surrounding the Fellow’s activities.

(2) Graduation – The criteria for graduation are listed in the General Nephrology, Dialysis, and Transplant tables (labeled as 2nd year performance). All of these criteria must have been met over the last 3 months of fellowship in order to graduate. Failure to meet all criteria will result in review by all Clinical Faculty with whom the Fellow has had contact in the past year, and a decision made on a necessary course of action. Such action may include, but is not limited to, requirement for additional clinical activities, counseling, or other actions.

B. Research Track – 1 year clinical fellowship. The criteria for graduation are listed in the General

Nephrology, Dialysis, and Transplant tables (labeled as 2nd year performance). Note that these criteria are labeled 2nd year since they pertain to the 2nd year clinical fellows, but they apply to fellows doing only 1 year of clinical fellowship. These criteria must have been met over the last 3 months of fellowship. All of these criteria must be met in order to graduate. Failure to meet all criteria will result in review by all Clinical Faculty with whom the Fellow has had contact in the past year, and a decision made on a necessary course of action. Such action may include, but is not limited to, requirement for additional clinical activities, counseling, or other actions.

11. Nephrology Fellowship Work, Duty Hours, Moonlighting and On-Call Policy A. Work and duty hours

(1) ACGME requires that Fellows not work more than 80 hours per week averaged over a 4-week period. Our program requires than Fellows will work no more than 70 hours per week when averaged over a four week period. In reality, Fellows rarely work more than 60 hours per week.

(2) Fellows are required by ACGME to be free of all work obligations for one day out of seven over a 4-week period. The Division strictly adheres to this policy. In reality, over the course of the Fellowship, Fellows are free of all work obligations for substantially more than the ACGME-required minimum.

(3) The ACGME requires that adequate time for rest and personal activities is provided by a 10-hour time period between all daily duty periods and after in-house call. There is no in-house call (see C. below). Fellows rarely have to return at night to the hospital from home while on call.

B. The Division of Nephrology recognizes that fellow moonlighting can be complementary to the

fellowship training experience. However, any fellow choosing to moonlight must do so with the clear understanding that fellowship training is their first priority and any actions interfering with the fellowship training program are strictly prohibited. Each moonlighting activity must be approved in advance by the program director using the moonlighting authorization form. This form must be signed by the program director before any moonlighting can begin. The following restrictions apply to fellow moonlighting: • The fellow must be performing satisfactorily in the program.

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• If a fellow chooses to “moonlight,” he or she is responsible for their own liability coverage. Even if this activity is being performed at the University, or an affiliated hospital, and/or additional compensation is being provided to the fellow, it is outside the scope of a fellow’s duties as a house officer. As per the GME office, the fellow should not wear a University lab coat or nametag while moonlighting.

• If the fellowship director feels that the fellow’s “good standing” is at risk by the time spent moonlighting, he or she can prohibit such moonlighting even without placing the fellow on probation. This action and an explanation for it must be transmitted to the fellow both in person and in writing and to the fellow’s file.

• As per GME regulations, fellows should not work more than 80 hours a week, when averaged over a four week period. Hours worked include training program hours and moonlighting hours.

• Fellows may not moonlight while on-call. C. Fellows will be on-call about one out of five days. All call is from home – there is no in-house call.

Fellows average one weekend in six on call (5 PM Friday to 8 AM Monday) – 4 months of the year have 1/2 weekends on call and 8 months of the year (VA and OP service) have no weekend call. Weekday call is from 6 PM until 8 AM the next morning – 8 months of the year have 1/3 weekdays on call and 4 months of the year (OP service) have no weekday call. The On-call Fellow covers both the VA and UH, answering all phone calls, seeing and writing notes on all established inpatients (weekends) and new admissions (nights and weekends), writing necessary dialysis orders and following patients on dialysis, and any other business relevant to covering the Nephrology and Transplant Services. Two residents are typically on Nephrology Service at any one time for 2-4 week blocks, one at the VA and one at UH. When the residents are on-call, they cover only their hospital. Attending and clinic physicians are responsible for supervising all care provided to inpatients and outpatients, respectively. The Attending physician is on-call 24 hours a day, provided back-up to the Fellow as needed. When residents are on call, the VA Fellow sees only VA acute dialysis patients only on Saturday morning, with University Attending coverage.

D. Fellows receive three weeks of paid vacation each year. All applications for leave, or special

requests with respect to the call schedule, must be submitted at least eight weeks preceding the intended absence.

E. An example of a monthly call schedule is as follows. Note that the OP Fellow is not included. Sun. Mon. Tues. Wed. Thurs. Fri. Sat. 1

VA Fellow 2 Residents

3 UH Fellow

4 VA Fellow

5 UH Fellow

6 UH Fellow

7 UH Fellow

8 VA Fellow

9 Residents

10 UH Fellow

11 VA Fellow

12 Residents

13 Residents

14 Residents

15 VA Fellow

16 Residents

17 UH Fellow

18 VA Fellow

19 UH Fellow

20 UH Fellow

21 UH Fellow

22 VA Fellow

23 Residents

24 UH Fellow

25 VA Fellow

26 Residents

27 Residents

28 Residents

29 VA Fellow

30 Residents

31 UH Fellow

F. Policies regarding medical leave, family leave, maternity leave, leave for examinations, educational

leave, sexual harassment, physician impairment and disability, jury duty, counseling services, and grievance procedures can be found in the University of Utah Housestaff Policies and Procedures Manual. This manual is distributed to all new Fellows at orientation during first week of Fellowship. Information can be obtained prior to then by contacting the Fellowship Director (Dr. Kohan) or by contacting the Graduate Medical Education Office at 801-581-2401 or [email protected].

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G. There is no liability insurance by the University of Utah for clinical activities outside the State of Utah or outside the country. Fellows will, therefore, perform all clinical activities in the State of Utah.

12. Nephrology Fellow Stipend and Benefits A. Fellows are paid PGY4 and PGY5 salaries according to University of Utah School of Medicine policy.

For 2007-08, this was $50,625 for PGY4 and $52,475 for PGY5. B. Benefits include Hospital and Medical insurance (premium costs shared between UH and the Fellow),

dental insurance (nominal monthly charge), group life insurance, 24-hour accident insurance, malpractice insurance, long term disability insurance, and parking. More details can be found in the University of Utah Housestaff Policies and Procedures Manual.

C. Fellows are provided with the following: (1) Pager (2) Cell phone (3) Offices at VA and UH (shared with other fellows) (4) Texts and handouts (see Curriculum) (5) One trip to the American Society of Nephrology Annual Meeting, including registration, airfare, meals, and hotel expenses. (6) A computer at the VA and UH (shared with other fellows). (7) Access to UpToDate 13. Policy on Fellow Teaching and Supervision of Residents – Fellows interact with residents on the inpatient wards, during VA clinics, and in division conferences. Fellows are expected to behave in a professional manner towards residents. This includes answering resident questions to the best of the fellow’s ability, directing the resident towards known appropriate learning resources, and notifying residents of the timing of attending rounds each day (since the time may change from day to day). Fellows may teach residents as they are able, but the burden of resident teaching, as it relates to the nephrology rotation goals and objectives, falls on the attending. Fellows may assign inpatients to residents, but attendings have the final approval for all assignments. Fellows may supervise temporary dialysis vascular access placement by residents only after the fellow has demonstrated mastery of this skill and such mastery is documented in their record. Fellows and residents may not render decisions about nephrology patient care (including general nephrology, dialysis and transplant), either written or verbally, without the attending’s verbal or written approval. Hence, fellows may not direct residents to advise primary providers, or their assistants (e.g., nurses, technicians, residents) on medical matters without the direct guidance on such matters by the attending. 14. Faculty Research Interests The research interests of faculty in the Nephrology Division, as well as research faculty with the Pediatric Nephrology Division, are listed below. This information, combined with the list of faculty publications in the subsequent section, as intended to help Fellows identify a faculty mentor and research project. Srinivasan Beddhu, M.D., Associate Professor of Medicine. Dr. Beddhu’s research focuses on nutrition and atherosclerotic disease in CKD. He is a member of the NKF K/DOQI guidelines on cardiovascular disease on dialysis patients. He has extensively used the USRDS and NHLBI pubic access databases. He is moving into interventional and translational studies of dialysis patients to address the same questions in more detail. His has studied the independent association of kidney disease with the hazard of myocardial infarction and the associations of obesity, malnutrition, serum albumin and inflammation with atherosclerosis in CKD as well as the association of obesity with inflammation in CKD. Drs. Samore and Cheung are co-investigators on studies on protein intake and dialysis outcomes, while Drs. Anderson, Greene, McClain and Cheung are co-investigators on studies on adipokine association with cardiovascular outcomes.

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Wayne Border, M.D., Professor of Medicine. Drs. Border and Noble are interested in basic research focused on the molecular pathogenesis of progressive kidney disease. They have produced a large body of work showing that the cytokine transforming growth factor-ß (TGF–ß) is a major cause of tissue fibrosis in numerous experimental and human disorders. Their laboratory was the first to implicate TGF-ß in the pathogenesis of fibrosis in both glomerulonephritis and diabetic nephropathy. They were also the first to show the therapeutic effect of inhibiting TGF–ß in vivo with an antibody and the human protein decorin. They have also demonstrated that gene therapy could be used in a novel way to block fibrosis in a model of glomerulonephritis. Finally, they have recently shown the therapeutic benefit in blocking the in vivo actions of PAI-1 in a model of glomerulonephritis. Drs. Border and Noble are the major investigators in the Renal Fibrosis Institute. Alfred Cheung, M.D., Professor of Medicine. Dr. Alfred Cheung’s research has two primary foci. The first is laboratory research where the efforts are directed towards the development of strategies to prevent hemodialysis vascular access stenosis using local drug delivery systems. The main strategy of this project is to employ drug delivery platforms that are thermosensitive (thus injectable), nontoxic, biodegradable (thus obviate surgical removal), and allow delayed release (thus allowing for wound healing after arteriovenous graft placement) and sustained release. One goal is to examine the efficacy and specificity of anti-proliferative drugs on both arterial and venous smooth muscle cells. The mechanism of actions of some of these drugs is also explored in cell culture models. A second goal is to develop polymers with characteristics that fulfill the specific requirements for the local delivery. A third goal to examine the pharmacokinetics of the perivascularly delivered drugs across native blood vessels and synthetic grafts in vitro, ex vivo and in vivo. A final goal is to examine the safety and efficacy of these strategies in experimental animal models of vascular access stenosis. This project utilizes many research techniques, including tissue culture, gel electrophoresis, high-performance liquid chromatography, PCR, autoradiography, immunoblotting and immunoassays, microarray, proteomics, polymer chemistry, in vitro vascular tissue models for pharmacokinetic studies, animal surgery, various histology techniques, 3-dimensional image reconstruction, vascular sonography, magnetic resonance imaging, mathematical modeling, statistical analysis and relational database. The second research focus of Dr. Cheung is clinical investigation related to chronic kidney disease and dialysis. Some of the ongoing projects are secondary analyses of the multicenter Hemodialysis trial (HEMO Study) sponsored by the NIDDK in which Dr. Cheung served as the P.I. of the Utah Clinical Center, analysis of the preserved plasma samples and data from an ancillary project of the HEMO Study examining lipids and lipoproteins which was initiated and organized by Dr. Cheung, and epidemiologic studies of cardiovascular risk factors in dialysis patients. Dr. Cheung has also organized and chairs a Kidney Disease Research Consortium, with the primary objective of conducting multicenter observational and interventional studies related to chronic kidney disease and dialysis. This consortium is currently comprised of 29 clinical centers which are mostly academic centers. Several projects are currently being planned with the consortium members. These clinical projects are fertile training opportunities for the clinical research fellows who are interested in epidemiology research involving large national databases, in-depth single-center or multi-center observational studies, and interventional trials. Tom Greene, Ph.D., Professor of Medicine. Dr. Greene is the lead statistician on NIH-sponsored multi-centered trials and is very activity involved with study design. He works with Drs. Cheung and Leypoldt on follow-up analysis of the HEMO trial. He also works with Dr. Beddhu on analysis of the influence of dietary protein on outcomes in dialysis patients as well as the association of adipokines in dialysis patients with cardiovascular morbidity and mortality. Yufeng Huang, M.D., Ph.D., Research Assistant Professor. Dr. Huang studies plasminogen activator inhibitor-1 (PAI-1) involvement in glomerular disease. In particular, she investigates the role of PAI-1 in progression of diabetic nephropathy. She also studies the profibrotic actions of renin in kidney disease. Bellamkonda Kishore, M.D., Ph.D., Research Associate Professor of Medicine. Dr. Kishore has more than 20 years of research experience in renal physiology, pathophysiology and drug toxicity. In

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renal physiology, his research interests are cellular and molecular mechanisms of vasopressin-independent regulation of renal medullary collecting duct water transport, with particular emphasis on the role of purinergic mechanisms, and the interaction of purinergic and prostanoid systems in medullary collecting duct. The second area of research interest of Dr. Kishore is the study of cellular and molecular mechanisms of vasopressin-resistant polyuria of acute renal failure, with particular emphasis on biology of medullary collecting duct. The third area of research interest of Dr. Kishore is the study of cellular and molecular mechanisms of tubulointerstitial reactions associated with certain forms of acute lysosomal storage conditions of proximal tubular cells, with particular emphasis on the induction of proliferation of erythropoietin-producing peritubular cells in the kidney. In addition, Dr. Kishore brings to the program the capability to study ion and water transport in isolated perfused tubules. Donald E. Kohan, M.D., Ph.D., Professor of Medicine. Dr. Kohan's laboratory studies two major areas. The first area is understanding the role of collecting duct-derived endothelin and nitric oxide in regulating systemic blood pressure and renal sodium and water excretion in health and disease. They have pioneered cell-specific gene targeting in the kidney using the Cre-loxP system and have used this technique to knockout components of the endothelin system selectively in principal cells of the collecting duct. Collecting duct endothelin-1 knockout mice are hypertensive and have impaired ability to excrete a sodium or water load. They have ongoing efforts to optimize cell specific knockout, including development of inducible knockouts (using Cre coupled to the ligand-binding domain of the estrogen receptor or the tetracycline transactivator) as well as improved integration site independent transgene expression. The technique of cell-specific gene targeting has recently been adapted by Dr. Kohan's laboratory to developing a mouse model of polycystic kidney disease. The other area of research in Dr. Kohan's laboratory involves understanding the mechanisms of cell injury in post-diarrheal hemolytic uremic syndrome. They have determined that renal tubular cells are highly susceptible to shigatoxin cytotoxicity, while endothelial cell sensitivity requires exposure to inflammatory cytokines. They have examined the molecular mechanisms controlling globotriaosylceramide (Gb3) expression (the major cognate shigatoxin receptor) and have determined that Gb3 synthase is a control site of Gb3 expression. They are now examining the signaling systems involved in controlling Gb3 synthase activity. Ken Leypoldt, Ph.D., Research Professor of Medicine. Dr. Leypoldt's research explores new approaches for improving renal replacement therapies when treating end stage renal disease patients. The research encompasses several laboratory and clinical projects and includes the modalities of hemodialysis, hemofiltration and peritoneal dialysis. A major focus of his research examines the molecular kinetics and removal capacities of the different treatment modalities. Another major project in his laboratory examines the effect of peritoneal inflammation on the transport characteristics of the peritoneal membrane in animal models. This project aims to understand the relationship between peritonitis and permanent changes in peritoneal membrane structure and function. Teri Jo Mauch, M.D., Ph.D., Associate Professor of Pediatrics, Division of Pediatric Nephrology. Dr. Mauch's laboratory investigates the roles of the vasculature and vasoactive peptides in embryonic kidney development. The first project investigates branching morphogenesis in cultured mouse metanephroi from the GFP-kidney mouse, (GFP is expressed under the control of the Hox b7 promoter) illuminating the ureteric bud and its derivatives, thereby facilitating real-time analysis of branching morphogenesis. Fetal kidneys cultured in vitro under conditions that either suppressed or drove AT2 mediated angiotensin II signaling showed that AT2 is important in patterning the ureteric bud. Current studies compare wild type with AT2-null mice, using microarray, quantitative PCR and in situ hybridization to identify downstream effectors of AT2 mediated angiotensin II signaling. The second project combines the avian model with the genetic power of mutant mice to define the molecular relationships between blood vessel formation, somitogenesis and pronephros induction. Dr. Mauch hypothesizes that molecules secreted by resident angioblasts regulate pronephros induction by the paraxial mesoderm. Studies include fate mapping to determine the relationship of angioblasts to paraxial and intermediate mesoderm precursors during gastrulation and tests to determine if angioblasts and vascular signals are necessary and sufficient for pronephros induction. Chemical manipulation

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(inhibitors of vasculogenesis and angiogenesis) and cut and paste tissue recombination experiments combining tissues isolated from knockout mice that lack blood vessels with chick intermediate mesoderm will determine if blood vessel precursors are required for pronephros induction by PM. To determine if the vasculature is sufficient to induce the pronephros, intermediate mesoderm will be co-cultured with arteries, vascular inducers. Lance Miller, Ph.D., Research Assistant Professor of Medicine, Divisions of Adult and Pediatric Nephrology. Dr. Miller studies collecting duct salt and water transport as well as renal development. He investigates the regulation of amiloride-sensitive current by endothelin-1 in MPKccd14 and A6 cells using patch-clamp, open circuit analysis and immunoblotting. These experiments are to be extended to the isolated perfused collecting ducts from mice with the collecting duct-specific knockout of endothelin-1. Dr. Miller also collaborates with Dr. Raoul Nelson on the identification of collecting duct-specific transcription factors. He and Dr. Nelson developed transgenic mice which express GFP in either intercalated or principal cells. Using these mice, they have recently developed a technique for the automated isolation of large quantities of pure collecting duct for genomic, proteomic, functional analysis and establishing primary cell cultures. They are now developing a method to obtain pure intercalated and principal cells using fluorescence activated cell sorting and mice expressing DsRed fluorescent protein in principal cells and GFP in intercalated cells. Raoul D. Nelson, M.D., Ph.D., Associate Professor of Pediatrics, Division of Pediatric Nephrology. Dr. Nelson studies regulation of gene expression within principal and intercalated cells of the collecting duct. Aquaporin-2 and the V-ATPase B1 subunit promoters have been coupled to GFP in transgenic mice to achieve principal and intercalated cell, respectively, -specific expression in vivo. Studies are underway to define the promoter elements and transcription factors responsible for cell specific gene expression. Fluorescent assisted microdissection and FACS are used to isolate collecting ducts, principal cells or intercalated cells from transgenic kidneys expressing GFP. In addition, transgenic kidneys expressing GFP are being used to develop cell culture systems. Dr. Nelson has identified candidate collecting duct specific transcription factor gene families. The epithelial Ets factors are the first group of collecting duct transcription factors under investigation. Real-time RT-PCR, in situ hybridization and immunocytochemistry are being used to define the expression of these factors in the adult and developing kidney. In addition, the reporter gene assays and chromatin immunoprecipitation assays are being used to examine the role of these factors in the regulation of collecting duct transporters such as aquaporin-2, epithelial sodium channel and V-ATPase. The epithelial Ets factors may be important in the differentiation and maturation of the collecting duct, and also potentially in diseases of the collecting duct. Knowledge about collecting duct specific gene expression is being used to develop principal and intercalated cell specific gene targeting systems. The aquaporin-2 promoter has already been used to drive expression of Cre recombinase in transgenic mice. These transgenic mice are being used to constitutively delete genes in principal cells. One such application that is currently underway is to delete PKD1 in principal cells of the collecting duct in attempts to develop a non-lethal mouse model of polycystic kidney disease. The V-ATPase B1 subunit promoter is currently being employed to drive the expression of Cre recombinase or rtTA intercalated cells of transgenic mice. These transgenic mice will be used to achieve constitutive and temporal regulated deletion of genes in the intercalated cells. One such application of this system will be to delete the V-ATPase in intercalated cells. Nancy Noble, Ph.D., Research Professor of Medicine. Drs. Border and Noble are interested in basic research focused on the molecular pathogenesis of progressive kidney disease. They have produced a large body of work showing that the cytokine transforming growth factor-ß (TGF–ß) is a major cause of tissue fibrosis in numerous experimental and human disorders. Their laboratory was the first to implicate TGF-ß in the pathogenesis of fibrosis in both glomerulonephritis and diabetic nephropathy. They were also the first to show the therapeutic effect of inhibiting TGF–ß in vivo with an antibody and the human protein decorin. They have also demonstrated that gene therapy could be used in a novel way to block fibrosis in a model of glomerulonephritis. Finally, they have recently shown the therapeutic benefit in blocking the in vivo actions of PAI-1 in a model of glomerulonephritis. Drs. Border and Noble are the major investigators in the Renal Fibrosis Institute.

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Fuad Shihab, M.D., Professor of Medicine. Dr. Shihab's laboratory studies mechanisms of fibrosis in nephrotoxicity of immunosuppressive drugs in transplantation. Animals models of chronic calcineurin inhibitors nephrotoxicity have been established. The involvement of vascular endothelial growth factor, connective tissue growth factor, and fibrogenic cytokines such as TGF-ß and plasminogen activator inhibitor-1 are investigated in these models. In addition, the composition of the extracellular matrix and the role of apoptosis in these disease entities are studied. The effect of angiotensin converting enzyme inhibitors, angiotensin receptor blockers and anti-fibrotic molecules such as pirfenidone on fibrosis are examined. The interactions of cyclosporine with other newer immunosuppressive drugs such as mycophenolate mofetil and sirolimus and the resultant effect on fibrosis and on the expression of fibrogenic cytokines and matrix proteins is also being investigated. Finally, applications of these findings are being carried to the clinical arena by studying the effect of different immunosuppressive strategies, such as corticosteroid withdrawal, on the expression of transforming growth factor as a means of predicting long-term renal allograft function. Kevin Strait, Ph.D., Research Assistant Professor of Medicine. Dr Strait collaborates with Dr. Donald Kohan in studies of renal collecting duct salt and water transport as they relate to changes in signaling systems that are modulated by endothelin-1, adenylate cyclase and/or nitric oxide. Dr Strait also collaborates with Dr. Lance Miller on identifying the biochemical pathways involved in endothelin-1 regulation of ENaC channels in MPKccd14 cells, and in isolated perfused collecting ducts. Florian Toegel, M.D., Ph.D. Research Assistant Professor of Medicine. Dr. Toegel’s current research interests include: 1) treatment of ischemic acute kidney injury (AKI) with novel cell based treatment approaches; 2) mechanism of action of mesenchymal stem cells in AKI; 3) role of the chemokine SDF-1 in the kidney after AKI; 4) homing mechanisms of stem cells in AKI; 5) clinical scale expansion systems for mesenchymal stem cells; 6) in vivo tracking of administered stem cell populations; and 7) influence of uremic environment on growth and differentiation properties of mesenchymal stem cells. He works closely with Dr. Westenfelder. Christof Westenfelder, M.D., Professor of Medicine. The overall research focus of Dr. Westenfelder's research is on the pathophysiology and treatment of acute renal failure. There is a particular emphasis on the role of erythropoietin (EPO) in acute renal failure, which has been identified by Dr. Westenfelder as a renotropic cytokine. In addition, his group has found that EPO has additional importance in kidney cancer, polycystic kidney disease, acquired cystic kidney disease, and uremic encephalopathy. Besides the role of EPO in acute renal failure, Dr. Westenfelder has demonstrated that bone marrow-derived stem cells possess kidney specific plasticity (are able to differentiate into renal cells), and when administered to rats with acute renal failure, act renoprotectively (appear to function as kidney precursor cells. He closely collaborates with Dr. Toegel on the stem cell studies. Co-investigations with Dr. Kishore on the “Novel Induction of Erythropoietin-Producing Cells in the Kidney” are based on their discovery that a small polypeptide, poly-D-glutamic acid, when administered to a rat, results in a proximal tubular, noncytotoxic lysosomal storage condition that triggers a robust proliferative response of erythropoietin-producing peritubular fibroblasts. In addition, there are collaborations with Dr. Teri Jo Mauch investigating the expression of developmental genes in the acute renal failure kidney as well as in bone marrow-derived stem cells (e.g. Pax 2 and Pax 8). Tianxin Yang, M.D., Ph.D., Research Associate Professor of Medicine. Dr. Yang’s long term interests are the role of arachidonic acid metabolites and other lipid-derived products in regulation of renal function, related to sodium balance and blood pressure regulation. The current emphasis is on characterizing renal function of cyclooxygenase-2 (COX-2) and peroxisome proliferator-activated receptor γ (PPARγ) and thus there are two lines research: 1) Renal function of COX-2. COX-2 is expressed in distinct cell types in the kidney involved in regulation of a wide spectrum of renal functions. Macula densa COX-2 is induced by low salt and involved in regulation of renin secretion and vascular tone while renal medullary COX-2 is induced by high salt and possibly involved in promoting salt excretion and stabilizing blood pressure. Therefore, two series of studies are being pursued: a)

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Elucidation of the role and mechanism of COX-2 in regulation of renin secretion. This will be achieved by examining the interaction of COX-2 and nNOS in the macula densa cells. The interaction between the two pathways is examined in vivo using nNOS -/- and COX-2 -/- mice and in vitro using a mouse macula densa derived cell line; b) Investigation of the role and mechanism of high salt-induced renal medullary COX-2 expression in regulation of sodium balance and blood pressure. Chronic intramedullary infusion techniques are currently used to examine whether site-specific COX-2 inhibition in renal medulla produces salt sensitive hypertension. Interactions between renal medullary COX-2 with other local factors, such as nitric oxide and endothelins, are also being examined. 2) Renal and vascular functions of PPARγ. PPARγ is a novel nuclear receptor, controlling expression of a range of target genes through interaction with PPAR responsive elements. PPARγ ligands (thiazolidinediones) cause edema due to with fluid retention, yet the mechanism is not fully known. Knockout of PPARγ in the collecting duct abrogates the fluid retention; these knockout mice are being used explore the molecular mechanisms of PPARγ in regulation of sodium balance and blood pressure.

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15. Publications by Nephrology Faculty 2001-2006 2006 1. Kohan DE. The renal medullary endothelin system in control of sodium and water excretion and systemic blood pressure. Current Opinion Nephrol Hypertens 15:34-40, 2006 2. Battistini B, Berthiaume N, Kelland NF, Webb DJ, Kohan DE. Profile of past and current clinical trials involving endothelin receptor antagonists: the novel "-sentan" class of drug. Exp Biol Med 231:653-695, 2006. 3. Ye W, Zhang H, Hillas E, Kohan DE, Miller RL, Nelson RD, Honeggar M, Yang T. Expression and

function of COX isoforms in the renal medulla: evidence for regulation of salt sensitivity and blood pressure. Am J Physiol 290:F542-F549, 2006.

4. Hughes AK, Kohan DE. Mechanism of vasopressin-induced contraction of renal medullary interstitial cells. Nephron Physiol 103:119-124, 2006.

5. Hughes AK, Stricklett PK, Kishore BK, Kohan DE. Adenosine triphosphate inhibits endothelin-1 production in rat inner medullary collecting duct. Exp Biol Med 231:1009-1009, 2006.

6. Hughes AK, Stricklett PK, Strait KA, Kohan DE. Endothelin-1 stimulates NO production and inhibits cAMP accumulation in rat inner medullary collecting duct through independent pathways. Am J Physiol 290:F1315-F1319, 2006.

7. Ge Y, Bagnall A, Stricklett PK, Strait K, Webb D, Kotelevtsev Y, Kohan DE. Collecting duct-specific knockout of the endothelin B receptor causes hypertension and sodium retention. Am J Physiol 291:F1274-F1280, 2006.

8. Kwan BC, Beddhu S, Kronenberg F, Cheung AK. Does statin therapy improve cardiovascular outcomes in patients with type 2 diabetes receiving hemodialysis? Nat Clin Pract Nephrol. 2006 Feb;2(2):76-7.

9. Ching-Ha Kwan B, Beddhu S. Metabolic syndrome and chronic kidney disease. Minerva Urol Nefrol. 2006 Mar;58(1):1-12.

10. Ng YH, Meyer KB, Kusek JW, Yan G, Rocco MV, Kimmel PL, Benz RL, Beddhu S, Dwyer JT, Toto RD, Eknoyan G, Unruh ML. Hemodialysis timing, survival, and cardiovascular outcomes in the Hemodialysis (HEMO) Study. Am J Kidney Dis. 2006 Apr;47(4):614-24.

11. Beddhu S. If fat is good, muscle is better. Am J Kidney Dis. 2006 Jan;47(1):193. 12. Delmez JA, Yan G, Bailey J, Beck GJ, Beddhu S, Cheung AK, Kaysen GA, Levey AS, Sarnak MJ,

Schwab SJ; Hemodialysis (HEMO) Study Group. Cerebrovascular disease in maintenance hemodialysis patients: results of the HEMO Study. Am J Kidney Dis. 2006 Jan;47(1):131-8.

13. Huang Y, Border WA, Lawrence DA, Noble NA. Noninhibitory PAI-1 enhances plasmin-mediated matrix degradation both in vitro and in experimental nephritis. Kidney Int. 2006 Aug;70(3):515-22.

14. Huang Y, Border WA, Noble NA. Perspectives on blockade of TGFbeta overexpression. Kidney Int. 2006 May;69(10):1713-4.

15. Chonchol M, Goldenberg I, Moss AJ, McNitt S, Cheung AK. Risk Factors for Sudden Cardiac Death in Patients with Chronic Renal Insufficiency and Left Ventricular Dysfunction. Am J Nephrol. 2007 Jan 5;27(1):7-14

16. Zhuplatov SB, Masaki T, Blumenthal DK, Cheung AK. Mechanism of dipyridamole's action in inhibition of venous and arterial smooth muscle cell proliferation. Basic Clin Pharmacol Toxicol. 2006 Dec;99(6):431-9.

17. Terry CM, Blumenthal DK, Sikharam S, Li L, Kuji T, Kern SE, Cheung AK. Evaluation of histological techniques for quantifying haemodialysis arteriovenous (AV) graft hyperplasia. Nephrol Dial Transplant. 2006 Nov;21(11):3172-9.

18. Zhu W, Masaki T, Cheung AK, Kern SE. Cellular pharmacokinetics and pharmacodynamics of dipyridamole in vascular smooth muscle cells. Biochem Pharmacol. 2006 Oct 16;72(8):956-64.

19. Kwan BC, Beddhu S, Kronenberg F, Cheung AK. Does statin therapy improve cardiovascular outcomes in patients with type 2 diabetes receiving hemodialysis? Nat Clin Pract Nephrol. 2006 Feb;2(2):76-7.

20. Thekkedath UR, Chirananthavat T, Leypoldt JK, Cheung AK, Mohammad SF. Elevated fibrinogen fragment levels in uremic plasma inhibit platelet function and expression of glycoprotein IIb-IIIa. Am

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J Hematol. 2006 Dec;81(12):915-26. 21. Li L, Blumenthal DK, Masaki T, Terry CM, Cheung AK. Differential effects of imatinib on PDGF-

induced proliferation and PDGF receptor signaling in human arterial and venous smooth muscle cells. J Cell Biochem. 2006 Dec 15;99(6):1553-63.

22. Habib AN, Baird BC, Leypoldt JK, Cheung AK, Goldfarb-Rumyantzev AS. The association of lipid levels with mortality in patients on chronic peritoneal dialysis. Nephrol Dial Transplant. 2006 Oct;21(10):2881-92.

23. Lee RM, Masaki T, Yang HS, Liu J, Chen J, Li L, Blumenthal DK, Cheung AK. Different signaling responses to anti-proliferative agents in human aortic and venous smooth muscle cells. J Cell Biochem. 2006 Oct 15;99(3):835-44.

24. Kuji T, Masaki T, Goteti K, Li L, Zhuplatov S, Terry CM, Zhu W, Leypoldt JK, Rathi R, Blumenthal DK, Kern SE, Cheung AK. Efficacy of local dipyridamole therapy in a porcine model of arteriovenous graft stenosis. Kidney Int. 2006 Jun;69(12):2179-85.

25. Roy-Chaudhury P, Sukhatme VP, Cheung AK. Hemodialysis vascular access dysfunction: a cellular and molecular viewpoint. J Am Soc Nephrol. 2006 Apr;17(4):1112-27.

26. Goldfarb-Rumyantzev AS, Cheung AK, Habib AN, Wang BJ, Lin SJ, Baird BC, Naiman N, Cannon-Albright L. A population-based assessment of the familial component of chronic kidney disease mortality. Am J Nephrol. 2006;26(2):142-8.

27. Goteti K, Masaki T, Kuji T, Leypoldt JK, Cheung AK, Kern SE. Perivascular tissue pharmacokinetics of dipyridamole. Pharm Res. 2006 Apr;23(4):718-28.

28. Leypoldt JK, Cheung AK. Revisiting the hemodialysis dose. Semin Dial. 2006 Mar-Apr;19(2):96-101. 29. Goldfarb-Rumyantzev AS, Hurdle JF, Baird BC, Stoddard G, Wang Z, Scandling JD, Barenbaum LL,

Cheung AK. The role of pre-emptive re-transplant in graft and recipient outcome. Nephrol Dial Transplant. 2006 May;21(5):1355-64.

30. Cheung AK, Rocco MV, Yan G, Leypoldt JK, Levin NW, Greene T, Agodoa L, Bailey J, Beck GJ, Clark W, Levey AS, Ornt DB, Schulman G, Schwab S, Teehan B, Eknoyan G. Serum beta-2 microglobulin levels predict mortality in dialysis patients: results of the HEMO study. J Am Soc Nephrol. 2006 Feb;17(2):546-55.

31. Delmez JA, Yan G, Bailey J, Beck GJ, Beddhu S, Cheung AK, Kaysen GA, Levey AS, Sarnak MJ, Schwab SJ; Hemodialysis (HEMO) Study Group. Cerebrovascular disease in maintenance hemodialysis patients: results of the HEMO Study. Am J Kidney Dis. 2006 Jan;47(1):131-8.

32. Gueye AS, Chelamcharla M, Baird BC, Nguyen C, Tang H, Barenbaum AL, Koford JK, Shihab F, Goldfarb-Rumyantzev AS. The association between recipient alcohol dependency and long-term graft and recipient survival. Nephrol Dial Transplant. 2006 Dec 15 (in press)

33. Lin SJ, Koford JK, Baird BC, Habib AN, Reznik I, Chelamcharla M, Shihab FS, Goldfarb-Rumyantzev AS. The association between length of post-kidney transplant hospitalization and long-term graft and recipient survival. Clin Transplant. 2006 Mar-Apr;20(2):245-52.

34. Suri RS, Garg AX, Chertow GM, Levin NW, Rocco MV, Greene T, Beck GJ, GassmanJJ, Eggers PW, Star RA, Ornt DB, Kliger AS. Frequent Hemodialysis Network (FHN) randomized trials: Study design. Kidney Int. 2006 Dec 13 in press)

35. Levey AS, Greene T, Sarnak MJ, Wang X, Beck GJ, Kusek JW, Collins AJ, Kopple JD. Effect of dietary protein restriction on the progression of kidney disease: long-term follow-up of the Modification of Diet in Renal Disease (MDRD) Study. Am J Kidney Dis. 2006 Dec;48(6):879-88.

36. Norris K, Bourgoigne J, Gassman J, Hebert L, Middleton J, Phillips RA, Randall O, Rostand S, Sherer S, Toto RD, Wright JT Jr, Wang X, Greene T, Appel LJ, Lewis J; AASK Study Group. Cardiovascular outcomes in the African American Study of Kidney Disease and Hypertension (AASK) Trial. Am J Kidney Dis. 2006 Nov;48(5):739-51.

37. Wang X, Lewis J, Appel L, Cheek D, Contreras G, Faulkner M, Feldman H, Gassman J, Lea J, Kopple J, Sika M, Toto R, Greene T. Validation of creatinine-based estimates of GFR when evaluating risk factors in longitudinal studies of kidney disease. J Am Soc Nephrol. 2006 Oct;17(10):2900-9.

38. Norris KC, Greene T, Kopple J, Lea J, Lewis J, Lipkowitz M, Miller P, Richardson A, Rostand S, Wang X, Appel LJ. Baseline predictors of renal disease progression in the African American Study of Hypertension and Kidney Disease. J Am Soc Nephrol. 2006 Oct;17(10):2928-36.

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39. Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, Kusek JW, Van Lente F; Chronic Kidney Disease Epidemiology Collaboration. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006 Aug 15;145(4):247-54.

40. Menon V, Li L, Wang X, Greene T, Balakrishnan V, Madero M, Pereira AA, Beck GJ, Kusek JW, Collins AJ, Levey AS, Sarnak MJ. Adiponectin and mortality in patients with chronic kidney disease. J Am Soc Nephrol. 2006 Sep;17(9):2599-606.

41. Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function--measured and estimated glomerular filtration rate. N Engl J Med. 2006 Jun 8;354(23):2473-83.

42. Lash JP, Wang X, Greene T, Gadegbeku CA, Hall Y, Jones K, Kusek JW, Sika M, Unruh M; African American Study of Kidney Disease and Hypertension Trial Study Group. Quality of life in the African American Study of Kidney Disease and Hypertension: effects of blood pressure management. Am J Kidney Dis. 2006 Jun;47(6):956-64.

43. Myers GL, Miller WG, Coresh J, Fleming J, Greenberg N, Greene T, Hostetter T, Levey AS, Panteghini M, Welch M, Eckfeldt JH. Recommendations for Improving Serum Creatinine Measurement: A Report from the Laboratory Working Group of the National Kidney Disease Education Program. Clin Chem. 2006 Mar 23 (in press)

44. Menon V, Sarnak MJ, Greene T, Wang X, Pereira AA, Beck GJ, Kusek JW, SelhubJ, Collins AJ, Levey AS, Shlipak MG. Relationship between homocysteine and mortality in chronic kidney disease. Circulation. 2006 Mar 28;113(12):1572-7.

45. Allon M, Daugirdas J, Depner TA, Greene T, Ornt D, Schwab SJ. Effect of change in vascular access on patient mortality in hemodialysis patients. Am J Kidney Dis. 2006 Mar;47(3):469-77.

46. Myers GL, Miller WG, Coresh J, Fleming J, Greenberg N, Greene T, Hostetter T, Levey AS, Panteghini M, Welch M, Eckfeldt JH; National Kidney Disease Education Program Laboratory Working Group. Recommendations for improving serum creatinine measurement: a report from the Laboratory Working Group of the National Kidney Disease Education Program. Clin Chem. 2006 Jan;52(1):5-18.

47. Alverson DC, Saiki SM Jr, Caudell TP, Goldsmith T, Stevens S, Saland L, Colleran K, Brandt J, Danielson L, Cerilli L, Harris A, Gregory MC, Stewart R, Norenberg J, Shuster G, Panaoitis, Holten J 3rd, Vergera VM, Sherstyuk A, Kihmm K, Lui J, Wang KL. Reification of abstract concepts to improve comprehension using interactive virtual environments and a knowledge-based design: a renal physiology model. Stud Health Technol Inform. 2006;119:13-8.

48. Kishore BK, Isaac J, Westenfelder C. Administration of Poly-D-Glutamic Acid Induces the Proliferation of Erythropoietin-producing Peritubular Cells in Rat Kidney. Am J Physiol Renal Physiol. 2006 Oct 3 (in press)

49. Leypoldt JK, Jaber BL, Lysaght MJ, McCarthy JT, Moran J. Kinetics and dosing predictions for daily haemofiltration. Nephrol Dial Transplant. 2003 Apr;18(4):769-76.

50. Shihab FS, Bennett WM, Yi H, Andoh TF. Effect of cyclosporine and sirolimus on the expression of connective tissue growth factor in rat experimental chronic nephrotoxicity. Am J Nephrol. 2006;26(4):400-7.

51. Coleman TR, Westenfelder C, Togel FE, Yang Y, Hu Z, Swenson L, Leuvenink HG, Ploeg RJ, d'Uscio LV, Katusic ZS, Ghezzi P, Zanetti A, Kaushansky K, Fox NE, Cerami A, Brines M. Cytoprotective doses of erythropoietin or carbamylated erythropoietin have markedly different procoagulant and vasoactive activities. Proc Natl Acad Sci U S A. 2006 Apr 11;103(15):5965-70.

52. Zhang A, Dong Z, Yang T. Prostaglandin D2 inhibits TGF-beta1-induced epithelial-to-mesenchymal transition in MDCK cells. Am J Physiol Renal Physiol. 2006 Dec;291(6):F1332-42.

53. Zhang A, Wang MH, Dong Z, Yang T. Prostaglandin E2 is a potent inhibitor of epithelial-to-mesenchymal transition: interaction with hepatocyte growth factor. Am J Physiol Renal Physiol. 2006 Dec;291(6):F1323-31.

54. Yang T. Kidney-specific gene targeting: insight into thiazolidinedione-induced fluid retention. Nephrology (Carlton). 2006 Jun;11(3):201-6.

55. Guo X, Yang T. Endothelin B receptor antagonism in the rat renal medulla reduces urine flow rate and sodium excretion. Exp Biol Med (Maywood). 2006 Jun;231(6):1001-5.

56. Yang T, Zhang A, Pasumarthy A, Zhang L, Warnock Z, Schnermann JB. Nitric oxide stimulates

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3. Zhang H, Zhang A, Kohan DE, Gonzalez FJ, Nelson RD, Ye W, Yang T. Collecting duct-specific deletion of PPARgamma blocks thiazolidinedione-induced fluid retention. Proc Natl Acad Sci 102:9406-9411, 2005.

4. Guan Y, Hao R, Cha DR, Rao R, Lu W, Kohan DE, Magnuson M, Redha R, Zhang Y, Breyer MD. Thiazolidinediones expand body fluid volume by activating PPARgamma stimulation of ENaC-mediated renal salt absorption. Nature Medicine 11:861-866, 2005.

5. Ge Y, Stricklett PK, Hughes AK, Yang T, Yanagisawa M, Kohan DE. Collecting duct-specific knockout of the endothelin A receptor alters renal vasopressin responsiveness, but not sodium excretion or blood pressure. Am J Physiol 289:F692-F698, 2005.

6. Clayton F, Pysher TJ, Lou R, Kohan DE, Denkers ND, Tesh VL, Taylor FB, Siegler RL. Lipopolysaccharide upregulates renal Shiga toxin receptors in a primate model of hemolytic uremic syndrome. Am J Nephrol 25:536-540, 2005.

7. McDevitt LM, Smith LD, Somerville KT, Corbett JL, Shihab FS. A retrospective assessment of pre-treatment variables on the response to darbepoetin alfa after renal transplantation. Am J Transplant. 2005 Aug;5(8):1948-56.

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9. Lange C, Togel F, Ittrich H, Clayton F, Nolte-Ernsting C, Zander AR, Westenfelder C. Administered mesenchymal stem cells enhance recovery from ischemia/reperfusion-induced acute renal failure in rats. Kidney Int. 2005 Oct;68(4):1613-

10. Togel F, Isaac J, Hu Z, Weiss K, Westenfelder C. Renal SDF-1 signals mobilization and homing of CXCR4-positive cells to the kidney after ischemic injury. Kidney Int. 2005 May;67(5):1772-84.

11. Togel F, Hu Z, Weiss K, Isaac J, Lange C, Westenfelder C. Administered mesenchymal stem cells protect against ischemic acute renal failure through differentiation-independent mechanisms. Am J Physiol Renal Physiol. 2005 Jul;289(1):F31-42.

12. Lin SJ, Koford JK, Baird BC, Hurdle JF, Krikov S, Habib AN, Goldfarb-Rumyantzev AS. Effect of Donors' Intravenous Drug Use, Cigarette Smoking, and Alcohol Dependence on Kidney Transplant Outcome. Transplantation. 2005 Aug 27;80(4):482-486.

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14. Beddhu S, Ramkumar N, Pappas LM. Normalization of protein intake by body weight and the associations of protein intake with nutritional status and survival, J Ren Nutr. 2005 Oct;15(4):387-97.

15. Ramkumar N, Pappas LM, Beddhu S. Effect of body size and body composition on survival in peritoneal dialysis patients. Perit Dial Int. 2005 Sep-Oct;25(5):461-9.

16. Morris D, Samore MH, Pappas LM, Ramkumar N, Beddhu S. Nutrition and racial differences in cardiovascular events and survival in elderly dialysis patients. Am J Med. 2005 Jun;118(6):671-5.

17. Logar CM, Pappas LM, Ramkumar N, Beddhu S. Surgical revascularization versus amputation for peripheral vascular disease in dialysis patients: a cohort study. BMC Nephrol. 2005 Mar 21;6(1):3.

18. Allon M, Radeva M, Bailey J, Beddhu S, Butterly D, Coyne DW, Depner TA, Gassman JJ, Kaufman AM, Kaysen GA, Lewis JA, Schwab SJ; HEMO Study Group. The spectrum of infection-related morbidity in hospitalized haemodialysis patients. Nephrol Dial Transplant. 2005 Jun;20(6):1180-6.

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20. Gregory MC. The clinical features of thin basement membrane nephropathy. Semin Nephrol. 2005 May;25(3):140-5.

21. Sun R, Miller RL, Hemmert AC, Zhang P, Shi H, Nelson RD, Kishore BK. Chronic dDAVP infusion in rats decreases the expression of P2Y2 receptor in inner medulla and P2Y2 receptor-mediated PGE2 release by IMCD. Am J Physiol Renal Physiol. 2005 Oct;289(4):F768-76.

22. Sun R, Carlson NG, Hemmert AC, Kishore BK. P2Y2 receptor-mediated release of prostaglandin E2 by IMCD is altered in hydrated and dehydrated rats: relevance to AVP-independent regulation of IMCD function. Am J Physiol Renal Physiol. 2005 Sep;289(3):F585-92.

23. Kishore BK, Krane CM, Miller RL, Shi H, Zhang P, Hemmert A, Sun R, Nelson RD. P2Y2 receptor mRNA and protein expression is altered in inner medullas of hydrated and dehydrated rats: relevance to AVP-independent regulation of IMCD function. Am J Physiol Renal Physiol. 2005 Jun;288(6):F1164-72.

24. Kishore BK, Isaac J, Fausther M, Tripp SR, Shi H, Gill PS, Braun N, Zimmermann H, Sevigny J, Robson SC. Expression of NTPDase1 and NTPDase2 in murine kidney: relevance to regulation of P2 receptor signaling. Am J Physiol Renal Physiol. 2005 May;288(5):F1032-43.

25. Piret J, Schanck A, Delfosse S, Van Bambeke F, Kishore BK, Tulkens PM, Mingeot-Leclercq MP. Modulation of the in vitro activity of lysosomal phospholipase A1 by membrane lipids. Chem Phys Lipids. 2005 Jan;133(1):1-15.

26. Strait KA, Warnick CT, Ford CD, Dabbas B, Hammond EH, Ilstrup SJ. Histone deacetylase inhibitors induce G2-checkpoint arrest and apoptosis in cisplatinum-resistant ovarian cancer cells associated with overexpression of the Bcl-2-related protein Bad. Mol Cancer Ther. 2005 Apr;4(4):603-11.

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29. Yang T, Zhang A, Honeggar M, Kohan DE, Mizel D, Sanders K, Hoidal JR, Briggs JP, Schnermann JB. Hypertonic induction of COX-2 in collecting duct cells by reactive oxygen species of mitochondrial origin. J Biol Chem 25:536-540, 2005.

30. Ramkumar N, Beddhu S, Eggers P, Pappas LM, Cheung AK. Patient preferences for in-center intense hemodialysis. Hemodial Int. 2005 Jul;9(3):281-95.

31. Beddhu S, Kimmel PL, Ramkumar N, Cheung AK. Associations of metabolic syndrome with inflammation in CKD: results From the Third National Health and Nutrition Examination Survey (NHANES III). Am J Kidney Dis. 2005 Oct;46(4):577-86.

32. Goldfarb-Rumyantzev AS, Hurdle JF, Scandling JD, Baird BC, Cheung AK. The role of pretransplantation renal replacement therapy modality in kidney allograft and recipient survival. Am J Kidney Dis. 2005 Sep;46(3):537-49.

33. Kim SJ, Masaki T, Rowley R, Leypoldt JK, Mohammad SF, Cheung AK. Different responses by cultured aortic and venous smooth muscle cells to gamma radiation. Kidney Int. 2005 Jul;68(1):371-7.

34. Goldfarb-Rumyantzev AS, Baird BC, Leypoldt JK, Cheung AK. The association between BP and mortality in patients on chronic peritoneal dialysis. Nephrol Dial Transplant. 2005 Aug;20(8):1693-701.

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39. Zehnder AF, Adams JC, Santi PA, Kristiansen AG, Wacharasindhu C, Mann S, Kalluri R, Gregory MC, Kashtan CE, Merchant SN. Distribution of type IV collagen in the cochlea in Alport syndrome. Arch Otolaryngol Head Neck Surg. 2005 Nov;131(11):1007-13.

2004 1. Herron MD, Kohan DE, Hansen CD: Minimal change nephropathy associated with pemphigus

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3. Crompton JA, Alexander D, Somerville T, Shihab FS. Lipid-based amphotericin in pulmonary zygomycosis: safety and efficacy of high exposure in a renal allograft recipient. Transpl Infect Dis. 2004 Dec;6(4):183-7.

4. Shihab FS, Bennett WM, Yi H, Choi SO, Andoh TF. Sirolimus increases transforming growth factor-beta1 expression and potentiates chronic cyclosporine nephrotoxicity. Kidney Int. 2004 Apr;65(4):1262-71.

5. Shihab FS, Bennett WM, Yi H, Choi SO, Andoh TF. Combination therapy with sirolimus and mycophenolate mofetil: effects on the kidney and on transforming growth factor-beta1. Transplantation. 2004 Mar 15;77(5):683-6.

6. Togel F, Isaac J, Westenfelder C. Hematopoietic stem cell mobilization-associated granulocytosis severely worsens acute renal failure. J Am Soc Nephrol. 2004 May;15(5):1261-7.

7. Unruh M, Benz R, Greene T, Yan G, Beddhu S, DeVita M, Dwyer JT, Kimmel PL, Kusek JW, Martin A, Rehm-McGillicuddy J, Teehan BP, Meyer KB; HEMO Study Group. Effects of hemodialysis dose and membrane flux on health-related quality of life in the HEMO Study. Kidney Int. 2004 Jul;66(1):355-66.

8. Beddhu S. The body mass index paradox and an obesity, inflammation, and atherosclerosis syndrome in chronic kidney disease. Semin Dial. 2004 May-Jun;17(3):229-32.

9. Beddhu S, Pappas LM, Ramkumar N, Samore MH. Malnutrition and atherosclerosis in dialysis patients. J Am Soc Nephrol. 2004 Mar;15(3):733-42.

10. Yu L, Border WA, Anderson I, McCourt M, Huang Y, Noble NA. Combining TGF-beta inhibition and angiotensin II blockade results in enhanced antifibrotic effect. Kidney Int. 2004 Nov;66(5):1774-84.

11. Gaedeke J, Noble NA, Border WA. Curcumin blocks multiple sites of the TGF-beta signaling cascade in renal cells. Kidney Int. 2004 Jul;66(1):112-20.

12. Merchant SN, Burgess BJ, Adams JC, Kashtan CE, Gregory MC, Santi PA, Colvin R, Collins B, Nadol JB Jr. Temporal bone histopathology in alport syndrome. Laryngoscope. 2004 Sep;114(9):1609-18.

13. Parr CJ, Miller FJ, Gregory MC, Yoon HC. SIR 2004 film panel case: Primary hyperoxaluria type I mimicking arterial vasculitis--a lethal disease. J Vasc Interv Radiol. 2004 Sep;15(9):1017-20.

14. Gregory MC. Alport syndrome and thin basement membrane nephropathy: unraveling the tangled strands of type IV collagen. Kidney Int. 2004 Mar;65(3):1109-10.

15. Sheikh-Hamad D, Cacini W, Buckley AR, Isaac J, Truong LD, Tsao CC, Kishore BK. Cellular and molecular studies on cisplatin-induced apoptotic cell death in rat kidney. Arch Toxicol. 2004 Mar;78(3):147-55.

16. Jaber BL, Zimmerman DL, Teehan GS, Swedko P, Burns K, Meyer KB, Leypoldt JK. Daily hemofiltration for end-stage renal disease: a feasibility and efficacy trial. Blood Purif. 2004;22(6):481-9

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19. Paliege A, Mizel D, Pasumarthy A, Huang YG, Bachmann S, Briggs J, Schnermann J, and Yang T. Distinct interaction between COX-2 and nNOS in macula densa: inhibition of nNOS expression by PGE2. Am J Physiol Renal. 287:F152-9, 2004

20. Kobayashi H, Kawamoto S, Brechbiel MW, Jo SK, Hu X, Yang T, Diwan BA, Waldmann TA, Schnermann J, Choyke PL, Star RA. Micro-MRI methods to detect renal cysts in mice. Kid Int 65:1511-1516, 2004

21. Hansen PB, Yang T, Huang Y, Mizel D, Briggs J, Schnermann J. Plasma renin in mice with one or two renin genes. Acta Physiol Scan 181:431-437, 2004.

22. Terry CM, Kling SJ, Cheang KI, Hoidal JR, Rodgers GM. Polymorphisms in the 5'-UTR of the tissue factor gene are associated with altered expression in human endothelial cells. Journal of Thrombosis and Haemostasis 2:1351-1358, 2004.

23. Masaki T, Rathi R, Zentner G, Leypoldt JK, Mohammad SF, Burns GL, Li L, Zhuplatov S, Chirananthavat T, Kim SJ, Kern S, Holman J, Kim SW, Cheung AK. Inhibition of neointimal hyperplasia in vascular grafts by sustained perivascular delivery of paclitaxel. Kidney Int. 2004 Nov;66(5):2061-9.

24. Ramkumar N, Cheung AK, Pappas LM, Roberts WL, Beddhu S. Association of obesity with inflammation in chronic kidney disease: a cross-sectional study. J Ren Nutr. 2004 14:201-7.

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26. Leypoldt JK, Cheung AK, Deeter RB, Goldfarb-Rumyantzev A, Greene T, Depner TA, Kusek J. Kinetics of urea and beta-microglobulin during and after short hemodialysis treatments. Kidney Int. 2004 Oct;66(4):1669-76.

27. Kim SJ, Masaki T, Leypoldt JK, Kamerath CD, Mohammad SF, Cheung AK. Arterial and venous smooth-muscle cells differ in their responses to antiproliferative drugs. J Lab Clin Med. 2004 Sep;144(3):156-62.

28. Masaki T, Kamerath CD, Kim SJ, Leypoldt JK, Mohammad SF, Cheung AK. In vitro pharmacological inhibition of human vascular smooth muscle cell proliferation for the prevention of hemodialysis vascular access stenosis. Blood Purif. 2004;22(3):307-12.

29. Cheung AK, Sarnak MJ, Yan G, Berkoben M, Heyka R, Kaufman A, Lewis J, Rocco M, Toto R, Windus D, Ornt D, Levey AS; HEMO Study Group. Cardiac diseases in maintenance hemodialysis patients: results of the HEMO Study. Kidney Int. 2004 Jun;65(6):2380-9.

30. Depner TA, Greene T, Daugirdas JT, Cheung AK, Gotch FA, Leypoldt JK. Dialyzer performance in the HEMO Study: in vivo K0A and true blood flow determined from a model of cross-dialyzer urea extraction. ASAIO J. 2004 Jan-Feb;50(1):85-93.

2003 1. Shihab FS, Bennett WM, Yi H, Choi SO, Andoh TF. Mycophenolate mofetil ameliorates

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2. Crompton JA, Somerville T, Smith L, Corbett J, Nelson E, Holman J, Shihab FS. Lack of economic benefit with basiliximab induction in living related donor adult renal transplant recipients. Pharmacotherapy. 2003 Apr;23(4):443-50.

3. Shihab FS, Bennett WM, Isaac J, Yi H, Andoh TF. Nitric oxide modulates vascular endothelial growth factor and receptors in chronic cyclosporine nephrotoxicity. Kidney Int. 2003 Feb;63(2):522-33.

4. Ergonal Z, Hughes AK, Kohan DE: Stx-1 induces apoptosis of human brain microvascular endothelial cells. J Infect Dis 187:154-158, 2003.

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6. Sticklett PK, Taylor D, Nelson RD, Kohan DE: Thick ascending limb-specific expression of Cre recombinase. Am J Physiol 285:F33-F39, 2003.

7. Sorokin A, Kohan DE: Physiology and pathology of endothelin-1 in renal mesangium. Am J Physiol 285:F579-F589, 2003.

8. Goldfarb-Rumyantzev AS, Scandling JD, Pappas L, Smout RJ, Horn S. Prediction of 3-yr cadaveric graft survival based on pre-transplant variables in a large national dataset. Clin Transplant. 2003 Dec;17(6):485-97.

9. Goldfarb-Rumyantzev A, Schwenk MH, Liu S, Charytan C, Spinowitz BS. Prediction of single-pool Kt/v based on clinical and hemodialysis variables using multilinear regression, tree-based modeling, and artificial neural networks. Artif Organs. 2003 Jun;27(6):544-54.

10. Beddhu S, Pappas LM, Ramkumar N, Samore M. Effects of body size and body composition on survival in hemodialysis patients. J Am Soc Nephrol. 2003 Sep;14(9):2366-72.

11. Beddhu S. Say "no" and comorbidity. Am J Kidney Dis. 2003 Aug;42(2):429-30. 12. Allon M, Depner TA, Radeva M, Bailey J, Beddhu S, Butterly D, Coyne DW, Gassman JJ,

Kaufman AM, Kaysen GA, Lewis JA, Schwab SJ; HEMO Study Group. Impact of dialysis dose and membrane on infection-related hospitalization and death: results of the HEMO Study. J Am Soc Nephrol. 2003 Jul;14(7):1863-70.

13. Logar CM, Herzog CA, Beddhu S. Diagnosis and therapy of coronary artery disease in renal failure, end-stage renal disease, and renal transplant populations. Am J Med Sci. 2003 Apr;325(4):214-27.

14. Aben JA, Hoogervorst DA, Paul LC, Borrias MC, Noble NA, Border WA, Bruijn JA, de Heer E. Genes expressed by the kidney, but not by bone marrow-derived cells, underlie the genetic predisposition to progressive glomerulosclerosis after mesangial injury. J Am Soc Nephrol. 2003 Sep;14(9):2264-70.

15. Yu L, Border WA, Huang Y, Noble NA. TGF-beta isoforms in renal fibrogenesis. Kidney Int. 2003 Sep;64(3):844-56.

16. Huang Y, Haraguchi M, Lawrence DA, Border WA, Yu L, Noble NA. A mutant, noninhibitory plasminogen activator inhibitor type 1 decreases matrix accumulation in experimental glomerulonephritis. J Clin Invest. 2003 Aug;112(3):379-88.

17. Peters H, Border WA, Ruckert M, Kramer S, Neumayer HH, Noble NA. L-arginine supplementation accelerates renal fibrosis and shortens life span in experimental lupus nephritis. Kidney Int. 2003 Apr;63(4):1382-92.

18. Welch BD, Carlson NG, Shi H, Myatt L, Kishore BK. 2Y2 receptor-stimulated release of prostaglandin E2 by rat inner medullary collecting duct preparations. Am J Physiol Renal Physiol. 2003 Oct;285(4):F711-21.

19. Hill WG, Kaetzel MA, Kishore BK, Dedman JR, Zeidel ML. Annexin A4 reduces water and proton permeability of model membranes but does not alter aquaporin 2-mediated water transport in isolated endosomes. J Gen Physiol. 2003 May;121(5):413-25.

20. Warnick CT, Dabbas B, Ilstrup SJ, Ford CD, Strait KA. Cell type-dependent regulation of hMLH1 promoter activity is influenced by the presence of multiple redundant elements. Mol Cancer Res. 2003 Jun;1(8):610-8.

21. McCarthy JT, Moran J, Posen G, Leypoldt JK, Hull AR, Jaber BL, Correa-Rotter R. A time for rediscovery: chronic hemofiltration for end-stage renal disease. Semin Dial. 2003 May-Jun;16(3):199-207.

22. Leypoldt JK, Jaber BL, Lysaght MJ, McCarthy JT, Moran J. Kinetics and dosing predictions for daily haemofiltration. Nephrol Dial Transplant. 2003 Apr;18(4):769-76.

23. Cheung AK, Levin NW, Greene T, Agodoa L, Bailey J, Beck G, Clark W, Levey AS, Leypoldt JK, Ornt DB, Rocco MV, Schulman G, Schwab S, Teehan B, Eknoyan G. Effects of high-flux hemodialysis on clinical outcomes: results of the HEMO study. J Am Soc Nephrol. 2003 Dec;14(12):3251-63.

24. Beddhu S, Samore MH, Roberts MS, Stoddard GJ, Ramkumar N, Pappas LM, Cheung AK. Impact of timing of initiation of dialysis on mortality. J Am Soc Nephrol. 2003 Sep;14(9):2305-12.

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2002 1. Gill PS, Krueger GG, Kohan DE: Doxycycline-inducible retroviral expression of green fluorescent

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4. Stricklett PK, Hughes AK, Ergonul Z, Kohan DE: Molecular basis for inflammatory cytokine upregulation of Stx-1 cytotoxicity and globotriaosylceramide expression. J Infect Dis 186:976-982, 2002.

5. Zharkikh L, Zhu X, Stricklett PK, Kohan DE, Chipman G, Breton S, Brown D, Nelson RD: Renal principal cell specific expression of green fluorescent protein in transgenic mice. Am J Physiol 283:F1351-F1364, 2002.

6. Isaac J, Shihab FS. Recurrent lupus nephritis in the second allograft of a patient with systemic lupus erythematosus. Nephron. 2002 Dec;92(4):947-9.

7. Isaac J, Shihab FS. De novo C1q nephropathy in the renal allograft of a kidney pancreas transplant recipient: BK virus-induced nephropathy? Nephron. 2002 Oct;92(2):431-6.

8. Shihab FS, Bennett WM, Isaac J, Yi H, Andoh TF. Angiotensin II regulation of vascular endothelial growth factor and receptors Flt-1 and KDR/Flk-1 in cyclosporine nephrotoxicity. Kidney Int. 2002 Aug;62(2):422-33.

9. Shihab FS, Bennett WM, Yi H, Andoh TF. Pirfenidone treatment decreases transforming growth factor-beta1 and matrix proteins and ameliorates fibrosis in chronic cyclosporine nephrotoxicity. Am J Transplant. 2002 Feb;2(2):111-9.

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14. Gaedeke J, Noble NA, Border WA. Angiotensin II and progressive renal insufficiency. Curr Hypertens Rep. 2002 Oct;4(5):403-7.

15. Yu L, Noble NA, Border WA. Therapeutic strategies to halt renal fibrosis. Curr Opin Pharmacol. 2002 Apr;2(2):177-81.

16. Strait KA, Dabbas B, Hammond EH, Warnick CT, Iistrup SJ, Ford CD. Cell cycle blockade and differentiation of ovarian cancer cells by the histone deacetylase inhibitor trichostatin A are associated with changes in p21, Rb, and Id proteins. Mol Cancer Ther. 2002 Nov;1(13):1181-90.

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19. Leypoldt JK. Diagnostic methods for vascular access: access flow measurements. Contrib Nephrol. 2002;(137):31-7.

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22. Yang T, Forrest S, Stine S, Endo Y, Pasumarthy A, Aller S, Forrest JN, Schnermann J, Briggs J. cDNA cloning of a cyclooxygenase gene and effect of cyclooxygenase inhibition on chloride secretion in rectal gland of the Dogfish shark, Aqualus Acanthias. Am J Physiol 283:R631-687, 2002

23, Eknoyan G, Beck GJ, Cheung AK, Daugirdas JT, Greene T, Kusek JW, Allon M, Bailey J, Delmez JA, Depner TA, Dwyer JT, Levey AS, Levin NW, Milford E, Ornt DB, Rocco MV, Schulman G, Schwab SJ, Teehan BP, Toto R; Hemodialysis (HEMO) Study Group. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med. 2002 Dec 19;347(25):2010-9.

24. Goldfarb-Rumyantzev AS, Cheung AK, Leypoldt JK. Computer simulation of small-solute and middle-molecule removal during short daily and long thrice-weekly hemodialysis. Am J Kidney Dis. 2002 Dec;40(6):1211-8.

25. Beddhu S, Allen-Brady K, Cheung AK, Horne BD, Bair T, Muhlestein JB, Anderson JL. Impact of renal failure on the risk of myocardial infarction and death. Kidney Int. 2002 Nov;62(5):1776-83.

26. Beddhu S, Kaysen GA, Yan G, Sarnak M, Agodoa L, Ornt D, Cheung AK; HEMO Study Group. Association of serum albumin and atherosclerosis in chronic hemodialysis patients. Am J Kidney Dis. 2002 Oct;40(4):721-7.

27. Cheung AK, Yan G, Greene T, Daugirdas JT, Dwyer JT, Levin NW, Ornt DB, Schulman G, Eknoyan G; Hemodialysis Study Group. Seasonal variations in clinical and laboratory variables among chronic hemodialysis patients. J Am Soc Nephrol. 2002 Sep;13(9):2345-52.

28. Leypoldt JK, Cheung AK. Optimal use of hemodialyzers. Contrib Nephrol. 2002;(137):129-37. 29. Bergstrom J, Lysaght M, Cheung AK. The career of Lee W. Henderson. J Am Soc Nephrol. 2002

Jan;13 Suppl 1:S1-2. 30. Leypoldt JK, Cheung AK, Delmez JA, Gassman JJ, Levin NW, Lewis JA, Lewis JL, Rocco MV.

Relationship between volume status and blood pressure during chronic hemodialysis. Kidney Int. 2002 Jan;61(1):266-75.

2001 1. Hughes AK, Stricklett PK, Kohan DE: Effect of Shiga toxin-1 on cytokine production by human

glomerular epithelial cells. Nephron 88:14-23, 2001. 2. Schmid DA, Kohan DE: Shiga toxin-1 modulation of vasoactive factor production by human

glomerular epithelial cells. Kidney Int 60:1026-1036, 2001. 3. Kohan DE: Endothelin. In: Clinical Physiology of Acid-Base and Electrolyte Disorders. Rose BD

and Post TW, editors. McGraw-Hill, New York. pp. 213-215, 2001. 4. Isaac J, Herrera GA, Shihab FS: De novo fibrillary glomerulopathy in the renal allograft of a

patient with systemic lupus erythematosus. Nephron 87:365-368, 2001. 5. Shihab FS, Yi H, Bennett WM, Andoh TF: Expression of vascular endothelial growth factor and its

receptors Flt-1 and KDR/Flk-1 in chronic cyclosporine nephrotoxicity. Transplantation 72:164-168, 2001.

6. Shihab FS: Renin-angiotensin system in chronic renal allograft dysfunction. Contrib Nephrol 135:222-234, 2001

7. Haas LJ, Gregory MC. Teaching behavior change skills to first-year medical students: a small group experiential approach. Educ Health (Abingdon). 2000;13(3):337-45.

8. Border WA, Noble N: Maximizing hemodynamic-independent effects of angiotensin II antagonists in fibrotic diseases. Semin Nephrol. 21:563-72, 2001

9. Gaedeke J, Peters H, Noble NA, Border WA: Angiotensin II, TGF-beta and renal fibrosis. Contrib Nephrol. 135:153-60, 2001

10. Haraguchi M, Border WA, Huang Y, Noble NA: t-PA promotes glomerular plasmin generation and matrix degradation in experimental glomerulonephritis. Kidney Int 59:2146-55, 2001

11. Heath KE, Campos-Barros A, Toren A, Rozenfeld-Granot G, Carlsson LE, Savige J, Denison JC, Gregory MC, White JG, Barker DF, Greinacher A, Epstein CJ, Glucksman MJ, Martignetti JA:

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Nonmuscle myosin heavy chain IIA mutations define a spectrum of autosomal dominant macrothrombocytopenias: May-Hegglin anomaly and Fechtner, Sebastian, Epstein, and Alport-like syndromes. Am J Hum Genet 69:1033-45, 2001

12. Florell SR, Egan CA, Gregory MC, Zone JJ, Petersen MJ: Eosinophilic fasciitis occurring four weeks after the onset of dialysis in a renal failure patient. J Cutan Med Surg 5:33-6, 2001

13. Barker DF, Denison JC, Atkin CL, Gregory MC: Efficient detection of Alport syndrome COL4A5 mutations with multiplex genomic PCR-SSCP. Am J Med Genet 98:148-60, 2001

14. Schwiebert EM, Kishore BK: Extracellular nucleotide signaling along the renal epithelium. Am J Physiol 280:F945-F963, 2001

15. Ecelbarger CA, Sands JM, Doran JJ, Cacini W, Kishore BK: Expression of salt and urea transporters in rat kidney during cisplatin-induced polyuria. Kidney Int 60:2274-2282, 2001

16. Warnick CT, Dabbas B, Ford CD, Strait KA. Identification of a p53 response element in the promoter region of the hMSH2 gene required for expression in A2780 ovarian cancer cells. J Biol Chem. 2001 Jul 20;276(29):27363-70.

17. Peng H, Cheung AK, Reimer LG, Kamerath CD, Leypoldt JK: Effect of indomethacin on peritoneal protein loss in a rabbit model of peritonitis. Kidney Int 59:44-51, 2001

18. Steuer RR, Miller DR, Zhang, S, Bell DA, Leypoldt JK: Noninvasive transcutaneous determination of access blood flow rate. Kidney Int 60:284-291, 2001

19. Leypoldt JK, Cheung AK: Increases in mass transfer-area coefficients and urea Kt/V with increasing dialysate flow rate are greater for high-flux hemodialyzers. Am J Kidney Dis 38:575-579, 2001

20. Ward RA, Leypoldt JK, Clark WR, Ronco C, Mishkin GJ, Paganini EP: What clinically important advances in understanding and improving dialyzer function have occurred recently? Semin Dial 14:160-174, 2001

21. Rocco MV, Yan G, Heyka RJ, Benz R, Cheung AK: Risk factors for hypertension in chronic hemodialysis patients: baseline data from the HEMO study. Am J Nephrol 21:280-8, 2001

22. Henderson LW, Clark WR, Cheung AK: Quantification of middle molecular weight solute removal in dialysis. Semin Dial 14:294-9, 2001

23. Sun D, Samuelson LC, Yang T, Huang Y, Paliege A, Saunders T, Briggs J, Schnermann J. Mediation of tubuloglomerular feedback by adenosine: evidence from mice lacking adenosine 1 receptors. Proc Natl Acad Sci 98:9983-9988, 2001

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16. Nephrology Fellows previous ten years Name Years in Program Board Certified in Nephrology Mazen Nemeh, M.D. 1997-99 yes Division of Nephrology University of South Dakota Muhammad Uwais Qarni, M.D. 1997-99 yes Division of Nephrology & Immunology University of Alberta Mary Vierthaler, M.D. 1999-2001 yes Private practice in Denver, CO David Tien, M.D. 1999-2001 yes Private practice in Salt Lake City, UT Adhish Agarwal, M.D. 2001-03 yes Private practice in Ogden, UT Scot Born, M.D. 2001-03 yes Private practice in Kallispell, MT Donald Morris, M.D. 2002-04 yes Private practice in Salt Lake City, UT Matthew Cyphers, M.D. 2003-05 yes Private practice in Grand Junction, CO Shital Shah, M.D. 2003-05 yes Private practice in Salt Lake City, UT Josephine Abraham, M.D. 2004-06 yes Private practice in Salt Lake City, UT Arsalan Habib, M.D. 2004-07 pending Division of Nephrology University of Utah Madhukar Chelamcharla, M.D. 2004-07 pending Private practice in Atlanta, GA Terrence Bjordahl, M.D. 2005-07 pending Division of Nephrology University of Utah Jay Reddy Kaluvapalle, M.D. 2005-08 Current fellow - research Kalani Raphael, M.D. 2006-09 Current fellow – research Duncan McGregor 2007-09 Current fellow Christopher Rich 2007-09 Current fellow

19 General Nephrology Table - Months 1-6 Competency category



Patient care












Begin to understand the basics of making informed decisions about diagnostic and therapeutic interventions in general nephrology patients


Checklist

≥ 5


Begin to develop general nephrology patient management plans



≥ 5 ≥ 5


Counsel and educate, with direct attending supervision, general nephrology patients and families with regard to their disease, socioeconomics, support systems, diet, lifestyle, medications







Checklist ≥ 5




Checklist Mini-CEX

≥ 5 Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and understand the correct procedural techniques for: 1. Percutaneous native renal biopsy Understand interpretation and the correct technique for: 1. Urinalysis


Checklist ≥ 5


Understand preventative health care services relevant to general nephrology patients


Checklist

≥ 5





≥ 5 ≥ 5

20

Medical knowledge


Begin to demonstrate investigatory and analytic thinking about clinical general nephrology situations


Checklist Mini-CEX

≥ 5 Formative


Fellows will gather the data and begin to develop the fund of knowledge necessary for prevention, evaluation, and management of general nephrologic disorders in: a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis


Checklist Mini-CEX

≥ 5 Formative

21




or improvement needs c. Begin a learning or improvement plan













≥ 5 Formative






≥ 5 Formative






Facilitate the learning of others, including, residents, fellows, physician extenders, nurses and dialysis technicians. Initially, this is based on assigned literature review.



≥ 5 ≥ 5











22








≥ 5 ≥ 5








Begin to understand interaction between fellow’s practice and the hospital and clinic staff, administration, surgical service, radiology, and medical consult services




Begin to understand how types of general nephrology practice and providers deliver care


Checklist ≥ 5


Begin to understand how to practice cost-effective general nephrology patient care



≥ 5 ≥ 5


Begin to understand how to advocate for general nephrology patient quality care



≥ 5 ≥ 5

23




Patient care












Synthesize data to begin to make informed decisions about diagnostic and therapeutic interventions in general nephrology patients



recall

≥ 6 Formative


Develop general nephrology patient management plans. Understand how to carry out such plans.



recall










Checklist ≥ 6




Checklist Mini-CEX

≥ 6 Formative

Perform: Procedures



Checklist ≥ 6





recall

≥ 6 Formative





≥ 6 ≥ 6

24

Medical knowledge





recall Written exam

≥ 6 Formative ≤4 incorrect in each general nephrology area


Fellows will continue to acquire the fund of knowledge necessary for prevention, evaluation, and management of the general nephrologic disorders below. They will begin to apply this information. a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis



≤4 incorrect in each general nephrology Area Formative Formative

25























Formative ≤4 incorrect each general nephrology area









≥ 6 ≥ 6











26








≥ 6 ≥ 6
















Understand cost-effective general nephrology patient care and begin to apply these principles



≥ 6 ≥ 6


Advocate for general nephrology patient quality care by demonstrating proactive efforts towards general nephrology patient care



≥ 6 ≥ 6

27




Patient care










≥ 7 ≥ 7




Checklist

≥ 7





≥ 7 ≥ 7





≥ 7 ≥ 7




Checklist ≥ 7




Checklist

≥ 7

Perform: Procedures



Checklist ≥ 7




Checklist

≥ 7





≥ 7

28

Medical knowledge




Checklist

≥ 7


Fellows will acquire the fund of knowledge necessary for prevention, evaluation, and management of general nephrologic disorders in: a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis


Checklist ≥ 7

29
















Checklist ≥ 7





Checklist

≥ 7









≥ 7 ≥ 7










≥ 7 ≥ 7

30








≥ 7 ≥ 7














Checklist ≥ 7




≥ 7 ≥ 7





≥ 7 ≥ 7

31




Patient care










≥ 8 ≥ 8





recall

≥ 8 Formative





recall






≥ 8 ≥ 8




Checklist ≥ 8




Checklist

≥ 8

Perform: Procedures



Checklist ≥ 8





recall

≥ 8 Formative





≥ 8

32

Medical knowledge





recall

≥ 8 Formative


Fellows will acquire the fund of knowledge necessary for prevention, evaluation, and management of general nephrologic disorders in the areas below. They will serve as educators for other fellows, faculty and staff in these areas, whenever possible. a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis



≥ 8 Formative

33



Fellow will hold up a mirror to themselves to document, assess, and improve their practice. This will involve: a. Monitoring their practice b. Reflecting on or analyzing their practice to identify learning or

improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement e. Monitoring the impact of the learning or improvement













Formative






Formative


Use information technology as itemized in Patient Care above Attending teaching Conferences







≥ 8 ≥ 8










≥ 8 ≥ 8

34








≥ 8 ≥ 8











≥ 8 ≥ 8




Checklist ≥ 8




≥ 8 ≥ 8





≥ 8 ≥ 8

35 C. Transplant 1) Goal Fellows will become competent in caring for renal transplant patients and patients with renal

complications of non-renal transplants. 2) Objectives

Detailed objectives for transplant are described in the Transplant table. There are 4 separate tables that address objectives for each rotation on transplant nephrology. A rotation is defined as a 6-month period, so there are separate objectives for the 1st, 2nd, 3rd and 4th 6-month rotations. These objectives reflect a progressive increase in expectations for fellows' competency achievement. While these are discussed in detail in the table, the essence of the objectives for each 6-month rotation are as follows: 1. Months 1-6 - Fellows function at least a the level of accurate reporting of the history, physical and





3) Types of clinical encounters and supervision 1. Inpatient transplant encounters – Each Fellow spends 4 months/year on the UH rotation. It is during

the UH rotation that the Fellow has inpatient transplant encounters. All UH patients admitted for surgical renal transplantation are admitted to the Transplant Surgery Service. These patients are followed by the Fellow on the UH rotation during the perioperative period. The Fellow discusses perioperative care with the Transplant Surgery Team each day. Subsequent admissions of renal transplant recipients are made to the Nephrology service (unless the problem is likely to require surgery); the Fellow is the primary provider for these patients, seeing them and writing notes on a daily basis. The Fellow makes sit-down interdisciplinary rounds with the renal transplant team on Mondays and Thursdays from 1-2 PM in which the patient’s current status and care plan are discussed. Post-transplant patients are very infrequently admitted to the VA. The Attending sees the patients together with the Fellow after the Fellow has done the initial evaluation. The Attending is on-call with the Fellow 24 hours a day. A Transplant Nephrologist is on-call 24 hours each day for back-up of difficult transplant issues.

2. Outpatient transplant encounters a. UH Post-Transplant Clinic - Each Tuesday morning, the Fellow on the outpatient nephrology

(OP) rotation attends this clinic. In all, Fellows attend 4 months/year of weekly UH Post-Transplant Clinic on a non-continuity basis. All patients are initially evaluated by the Fellow or residents. Renal transplant coordinators are present to facilitate patient care. All patients are staffed with the Transplant attending.

b. UH Pre-Transplant Clinic – Fellows attend this clinic every Wednesday morning while on the OP rotation. In all, each Fellow attends this clinic for 4 months/year. The Fellow initially evaluates pre-transplant candidates. Renal transplant coordinators are present to facilitate this process. All patients are staffed with the Transplant attending.

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4) Patient characteristics (number, demographics) 1. Inpatients - The average inpatient renal transplant census is 2-6 patients at UH and very

infrequently at the VAMC. Approximately 80 patients received renal transplants at UH in 2005 of which about 25 were living-related donors. Patient demographics are similar to those for general nephrology patients. VA patients are transplanted at UH but admitted to the VA subsequently. About 3-5 VA patients are transplanted each year.

2. Outpatients – Over 600 patients are followed in the UH Post-Transplant Clinic. An average of 15-20 patients are seen in the weekly UH Post-Transplant Clinic. The UH Pre-Transplant Clinic evaluates up to four patients each week. Patient demographics are similar to those for general nephrology patients.

5) Procedural training (see Transplant Table) 1. Percutaneous biopsy of transplanted kidneys – performed by the Fellow on inpatients on their

service or outpatients they have seen in Post-Transplant Clinic. All renal transplant biopsies on inpatients are performed by the Fellow in the presence of the Attending. Each fellow performs about 15-20 renal transplant biopsies yearly.

6) Teaching methods (see Transplant Table) 1. Educational training

a. Handouts - At the beginning of the Fellowship, Fellows are given the Handbook of Renal Transplantation (Danovitch) and access to UpToDate. Additionally, they are given the Handbook of Renal Transplant Protocols for the University of Utah.

2. Didactic sessions a. Weekly didactic conference – Renal transplant issues are covered in detail in the didactic

conference held each Wednesday from 3-4 PM. Sessions are devoted to recipient evaluation, mechanisms of allograft rejection, immunosuppressive drugs, prophylaxis and treatment of graft rejection, non-rejection causes of graft dysfunction, major causes of post-transplant morbidity and mortality, and renal disease associated with liver, heart and bone marrow transplantation.

b. Primer Course - At the beginning of the Fellowship, a 2 day course is given to provide a basic level of instruction regarding several issues in Nephrology. Those covered relevant to transplant include renal transplantation and UH Protocols, chronic immunosuppression, and approach to an elevated creatinine or fever in a transplant recipient.


nephrology, dialysis and transplant cases are discussed in the setting of case-based presentations, Landmark articles, M&M, and journal club.

b. 5 PM Nephrology Conference – See General Nephrology section for details. Several conferences are devoted to transplant yearly.

c. Renal Pathology Conference – The conference is held each Friday from 1-2 PM during the two years. All biopsies of transplanted kidneys performed at University Hospital are reviewed as well as interesting historical cases. The conference is led by the Renal Pathologist using a multi-headed microscope and is attended by all Fellows

4. Inpatient attending rounds – See under Types of Clinical Encounters above. 7) Assessment and evaluation of Fellows (see Transplant Table) 1. Clinical encounters – A variety of instruments are used to assess Fellow performance. The specific

evaluation utilized is indicated in the Transplant Table. These include: a. Checklist

1) Fellows are evaluated at the end of each 2-week block with a given attending. The attending uses a scale from 1-9 to assess patient care knowledge, skills, attitudes and behaviors. Fellows review these orally with the attending and both individuals sign the review form. If there is any significant issue, the attending immediately communicates this to the Program Director who meets with the attending and fellow to develop an action plan to address the

37

issue. The Fellow’s performance in this area is then reassessed, by Checklist by the inpatient attendings, in one month and reviewed with the Program Director. During the first 6 months of fellowship, all scores must be "5" (satisfactory) or higher; scores under this will be reviewed with the Program Director, specific problem areas identified, and the appropriate corrective action taken. The problem areas are re-evaluated in one month. During the second 6 months (7-12 months of training), scores must average "6" or over; during the third 6 months (13-18 months of training), scores must average "7" or over; and during the fourth and final 6 months (19-24 months), scores must average "8" or above. If these ratings are not obtained, the same steps are taken as discussed above.

2) Fellows are evaluated by Transplant Director (Dr. Shihab) and Program Director every 6 months. First, the goals and objectives of the upcoming 6 month transplant rotation are reviewed. The Transplant and Program Directors use a scale from 1-9 to evaluate the Fellow’s patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice as it pertains to transplant. Fellows review this with the Program and Transplant Directors. The evaluation is based on review of the attending checklists, 360 degree evaluations (see below), and any other pertinent information. Importantly, this evaluation is also based on semi-annual discussions between all clinical faculty and the Transplant and Program Directors. If any significant issues exist, an action plan is developed and the fellow re-evaluated by the Program and Transplant Directors in 6 months using the same evaluation measurements as above. In addition, even if no significant issues are identified, goals are established for the fellow to work on over the next 6 months. These goals typically do not reflect needed attention to sub-par performance, but instead are intended to help the Fellow focus efforts. For example, faculty may note that the fellow did relatively pre-transplant evaluations, did relatively few renal transplant biopsies, or that attending comments reflected a need to increased transplant knowledge base – appropriate recommendations to work on these areas would be made, and progress evaluated at the next semi-annual Program and Transplant Director review.

b. 360 evaluation – this evaluation is completed by transplant nurses, social workers, dieticians, pharmacists, and nurse practitioners in order to give a broad sense of how the Fellow delivers patient care and interacts with members of the transplant health care interdisciplinary team. It is completed every 6 months. Fellows review this with the Program Director. Problem areas (scores under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with particular attention to these problem areas.

c. Patient surveys – Over the course of the year, about 10 different patients are asked to complete a form rating transplant patient interaction. These are reviewed annually with the Transplant Director. Areas in need of improvement are identified and reassessed, by patient survey, within 6 months. These evaluations are not fellow-specific, since fellows do not follow transplant patients on a continuity basis. However, fellows are involved in discussion of the patient surveys and identification of areas for improvement.

d. Written exam – At the end of the first year, Fellow’s are given the MKSAP written examination (multiple choice style). Their performance is reviewed with the Program Director. Transplant areas in need of improvement are identified (defined as missing more than 2 questions in that area) and an action plan is developed to address these. Fellow’s fund of knowledge in these areas is reassessed in three months by performance on the relevant NephSAP or by satisfactorily answering questions from the Transplant Director.

e. Chart-stimulated recall – At the end of the first year, Fellow’s review up to 8-12 cases with the combined clinical faculty, lasting no longer than 2 hours. This session is not exclusively devoted to transplant, but contains at least 2 cases pertinent to transplant. The questions are not standardized, but each faculty member asks questions that are designed to evaluate the Fellow’s analytic, investigative and patient care skills, knowledge and attitudes. Areas in need of improvement are identified (defined as incorrectly answering any questions about major concepts in that area) and an action plan formulated with the Transplant Director. Fellow’s fund of knowledge in these areas is reassessed in 6 months by performance on the relevant

38

NephSAP, if available, or by questioning by the Transplant Director. These evaluations are intended to be formative, not summative.

f. Resident portfolio – Please see details under General Nephrology section. A fellow's project may be in the transplant area, if deemed appropriate by the Transplant Director.


h. Mini-clinical examination (Mini-CEX) – These are given about four times in the first year in the inpatient and outpatient setting, to provide formative input on the fellow’s progression towards obtaining clinical competence relevant to transplant patient care.

2. Procedures – Fellows must keep a log of all transplant kidney biopsies indicating date, attending, patient identifier, indication and complications. Fellows must do at least 5 transplant kidney biopsies each year. However, at no time may a Fellow do a biopsy without attending supervision.

3. Conferences – Fellows attendance at conferences is documented. Participation in journal clubs, case-based presentations, and NephSAP review, as they relate to transplant, is discussed with the Program Director during the 6-month evaluation.



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