Curriculum

Inpatient Clinical Nephrology Service

Clinical training in nephrology and hypertension is based primarily at the 766 bed Albany Medical Center and the Stratton Department of Veterans Affairs Medical Center (VAMC), which is located across the street. During the first year of clinical training, each fellow spends three months on the inpatient renal consultation service, three months on the inpatient nephrology service, and two months on the renal transplantation service. They will be involved in all aspects of inpatient care including critical care management of acute renal diseases in the intensive care unit setting. Inpatient clinical nephrology service performs approximately 600-700 new inpatient consults a year and oversees the delivery of approximately 100-150 inpatient dialysis during HD rotation.

While on the inpatient renal consultation service, fellows participate in the diagnosis and management of patients with fluid and electrolyte disturbances, acute and chronic renal failure, glomerulonephritis, interstitial nephritis, nephrolithiasis, complicated hypertension, intoxications, and related disorders. Fellows also gain experience with percutaneous renal biopsy under both CT and ultrasound guidance. Time spent on the ESRD service provides fellow training on all aspects of dialysis (hemodialysis and peritoneal dialysis), anemia management, treatment of renal osteodystrophy, evaluation and maintenance of vascular access for dialysis (AVFs, AVGs, and catheters).

On the renal transplantation service, fellows are part of an interdisciplinary team that provides acute perioperative and long-term care for patients receiving renal allografts. Clinical faculty of the Division of Nephrology serve as attending physicians and conduct daily teaching rounds which provide instruction in the scientific disciplines that underlie the clinical practice of nephrology as well as supervision in practical aspects of patient care. During this time fellows receive extensive training in acute renal replacement therapies including peritoneal dialysis, hemodialysis, and hemofiltration (CVVH, CVVHD, and SCUF).

Lines of Responsibilities

Fellows report to the attending nephrologist during this experience. If the attending nephrologist is unavailable, fellows report to the key faculty nephrologist on-call and ultimately to the program director. The attending will serve as a role model and evaluate the fellow in regard to these competencies (as well as the fellow evaluating the attending). It is expected that as patients are seen in the hospital, patient care is demonstrated as compassionate, appropriate, and effective for the treatment of health problems and promotion of health.

The appropriate medical care of patients requires medical knowledge that is established, up-to-date, includes an atmosphere of discovery initiated by both the fellow and attending. Given the complexity of medical care in a subspecialty in a tertiary care center, practice-based learning and improvement is paramount as fellows and attendings explore the literature to assimilate scientific evidence that will improve the care of all patients, nothing should seem routine. Patient management is a group effort, doctors, nurses, ancillary care, patients and families, thus interpersonal and communication skills as well as professionalism must be mentored and monitored by both parties.

Fellows are evaluated by their attending after each clinical service rotation. It is expected that the fellow incorporate this evaluation feedback into daily practice and that this will help the fellow identify strengths, deficiencies, and limits in one’s knowledge and expertise (“Practice-based learning and improvement”).

Goals
To learn the evaluation and management of the following areas of medical knowledge: Although much of this is taught during and through daily patient rounds, it is expected that the fellow make a habit of localizing and assimilating medical evidence from appropriate medical journals as well as other sources of information technology (“Practice-based learning and improvement”).

• Disorders of mineral metabolism, including nephrolithiasis and renal osteodystrophy
• Disorders of fluid, electrolyte, and acid-base regulation
• Acute renal failure
• Chronic renal failure and its management by conservative methods, including nutritional management of uremia
• End-stage renal disease
• Hypertensive disorders
• Renal disorders of pregnancy
• Urinary tract infections
• Tubulointerstitial renal diseases, including inherited diseases of transport, cystic diseases, and other congenital disorders
• Glomerular and vascular diseases, including the glomerulonephritides, diabetic nephropathy, and atheroembolic renal disease
• Disorders of drug metabolism and renal drug handling
• Genetic and inherited renal disorders
• Geriatric aspects of nephrology, including disorders of the aging kidney and urinary tract, including physiology and pathology of the aging kidney and drug dosing and renal toxicity in elderly patients.
• Indications for and interpretations of radiologic tests of the kidney and urinary tract

Objectives:

• Evaluation and selection of patients for acute hemodialysis or continuous renal replacement therapies.
• Evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options. This skill encompasses a large percentage of the time a fellow interacts with patients on the inpatient consult service and needs to be undertaken with an awareness and responsiveness to the larger context of system health care, as well as an ability to effectively communicate with patients, families, and other health professionals. It assumes and requires the fellow working effectively within the health care system that provides these therapies and determines the appropriate modality of treatment for each patient. Specific patient needs must be taken in consideration including ambulation, socioeconomic factors, a patient’s self-confidence, a patient’s living situation, and family support. In addition there must be effective communication between the fellow and the ancillary services within and outside of the hospital, e.g. social workers, dietitians, access surgeons, discharge planners, and primary physicians. The fellow must show compassion for patients entering an ESRD program and respect patients’ autonomy and privacy while discussing ESRD options and sites of placement. Doing the above integrates the following competencies: patient care, systems-based practice, professionalism, and interpersonal and communication skills.
• Drug dosage modification during dialysis and other extracorporeal therapies.
• Evaluation and management of medical complications in patients during and between dialyses and other extracorporeal therapies, including dialysis access, and an understanding of the pathogenesis and prevention of such complications.
• Long-term follow-up of patients undergoing long-term dialysis, including their dialysis prescription and modification and assessment of adequacy of dialysis.
• 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.
• Understanding of the technology of peritoneal dialysis, including the use of automated cyclers.

In addition, the fellow will also learn the:

• Evaluation and selection of patients for acute hemodialysis or continuous renal replacement therapies.
• Writing of acute hemodialysis orders including decisions related to anticoagulation, potassium, calcium, sodium and bicarbonate dialysate concentrations as well as appropriate fluid removal with ultrafiltration.
• Evaluation and management of medical complications in patients during acute hemodialysis and other extracorporeal therapies including dialyzer reactions, air emboli, hemolytic reactions, and hemorrhage.
• Complications of vascular access and how to evaluate for recirculation.
• Evaluation and treatment of poor vascular access blood flow.
• Utilization of thrombolytics for poor access function.

The Kidney Transplant Program at Albany Medical Center has long enjoyed a robust relationship between the Divisions of Nephrology and Transplant Surgery. The renal transplant curriculum and rotation for the nephrology fellows is created with one main objective – to furnish graduating nephrology fellows with the comprehensive knowledge and experience necessary to provide transplant care to patients that is expected of general nephrologists today, and in the future. The rotation and curriculum is designed to cover all aspects of transplant nephrology, and provide the fellows experience in the longitudinal care of transplant patients. Some of the features of the program are:

• Albany Medical Center Transplant Program is recognized by the Organ Procurement and Transplant Network (OPTN) as the only 5-Star program in New York State
• Patient and transplant graft survival rates have been consistently recognized by the OPTN to be among the highest in the nation.
• Comprehensive program with social work, dietitians, pharmacists, and close working relationship with local area nephrologists and dialysis centers.
• Continuity of transplant care – fellows experience includes:
  • Pre-transplant clinics – initial and follow-up evaluations for transplant candidacy.
  • Multi-disciplinary transplant candidacy meetings.
  • In-patient perioperative medical management and induction immunosuppression.
  • Post-transplant clinics – assess and manage maintenance immunosuppression and complications in recent and remote transplant patients.
• Living donor assessment and follow-up clinics.
• Close academic and research relationship with original research opportunities for fellows. An example of a collaborative research project led by one of the nephrology fellows is a prospective study to accurately assess renal allograft function in the immediate post-transplant period.
• Prepare interested fellows for a renal transplant fellowship.

The Division of Transplant Surgery also works closely with the Division of Nephrology in the areas of dialysis access and surgical management of patients with secondary and tertiary hyperparathyroidism. As part of their rotation, nephrology fellows gain exposure to the surgical aspect of arteriovenous fistulas and grafts, peritoneal access evaluations, placement, complications, as well as assessment and post-operative management of patients undergoing parathyroidectomy.

Outpatient Nephrology Continuity Clinic

The fellow’s continuity practice is an integral part of their training. Fellows have a three-half a day weekly continuity clinic for their entire fellowship. Fellows will have an outpatient general nephrology continuity clinic at Albany Medical Center's South Clinical Campus and at the Stratton VA Medical Center. These clinics see new outpatient consultations, and continue follow-up of established patients. The fellow-to-preceptor ratio is 1:1.

Lines of Responsibility

Fellows report to the attending nephrologist during this experience. If the attending nephrologist is unavailable, fellows report to the key faculty nephrologist on-call and ultimately to the program director. All patients assigned to the fellow are seen first by the fellow with the case then being presented to the attending and the case then subsequently discussed together. This team then sees the patient together and decides and relays further work-up and therapy. All aspects of acute and chronic renal disease may be seen in this clinic. The fellow dictates all letters and progress notes on their patients, which are reviewed with the attending. A fellow follows their patients throughout the 24-month period and sees an average of one new and three established patients/clinic day.

Goals and Objectives

The primary goal is to provide the fellows an opportunity to follow patients in a longitudinal fashion. This also provides a setting in which the fellows can experience, as close as possible, the outpatient general nephrology conditions they are likely to encounter in their future practice. It is also the goal to enhance the fellows’ clinical and time management skills.

To learn the evaluation and management of the following areas of medical knowledge: Although much of this is taught during the day as the fellow sees and presents patients to attending nephrologists, it is expected that the fellow make a habit of localizing and assimilating medical evidence from appropriate medical journals as well as other sources of information technology (“Practice-based learning and improvement”).

• The objectives are for the fellows to be able to effectively manage end stage renal disease on an outpatient basis.
• The aim of this outpatient clinic is for the fellows to be able to appropriately diagnose and manage renal causes of hypertension.
• A special emphasis is made on preparing patients for ESRD; considering nutritional, socioeconomic, and access concerns as well as requiring the patient to be an active participant in the ESRD modality choice.
• These skills need to be undertaken with an awareness and responsiveness to the larger context of system health care, as well as an ability to effectively communicate with patients, families, and other health professionals. It assumes and requires the fellow working effectively within the health care system that provides these therapies and determines the appropriate modality of treatment for each patient. There must be effective communication between the fellow and the patients, nurses and staff at the clinic. The fellow must show compassion for patients in an ESRD program being aware of how difficult it must be for a patient to have their access threatened. Doing the above integrates the following competencies: patient care, systems-based practice, professionalism, and interpersonal and communication skills.

Fellows will spend one month during their two-year fellowship in a pediatric nephrology rotation in the Department of Pediatrics. During that time they will become familiar with the differences between pediatric and adult ESRD replacement therapies, attend the pediatric nephrology clinics at Albany Medical Center, and learn to evaluate pediatric patients with proteinuria and hematuria, congenital electrolyte abnormalities. They may also see inpatient pediatric patients with an array of acute and chronic renal diseases. Dialysis of the newborn may also be observed.

Lines of Responsibility

Fellows report to the attending pediatric nephrologist during this experience. If the attending pediatric nephrologist is unavailable, fellows report to the attending pediatric nephrologist on-call and ultimately to the program director. The outpatient pediatric hemodialysis unit is located at the main Albany Medical Center campus.

Goals and Objectives

To learn the evaluation and management of the following areas of medical knowledge: Although much of this is taught during and through daily patient rounds, it is expected that the fellow make a habit of localizing and assimilating medical evidence from appropriate medical journals as well as other sources of information technology (“Practice-based learning and improvement”).

• Congenital and acquired disorders of fluid, electrolyte, and acid-base regulation.
• Acute renal failure in the neonate, infant, and adolescent.
• End-stage renal disease management in the pediatric population and the use of growth hormone.
• Secondary hypertensive disorders seen in the pediatric population.
• Urinary tract infections and reflux nephropathy.
• Tubulointerstitial renal diseases, including inherited diseases of transport, cystic diseases, and other congenital disorders.
• Glomerular diseases common to the pediatric population.
• Drug dosing in pediatric patients.
• Continuous renal replacement therapy in neonates, infants, and adolescents.
• Acute and long-term hemodialysis in infants and adolescents.
  • This skill is especially challenging given the age of the patient population and the need to include parents in all patient decisions that involve a pediatric patient. Thus, this skill needs to be undertaken with an awareness and responsiveness to the larger context of system health care, as well as an ability to effectively communicate with patients, their parents or guardians, and other health professionals. It assumes and requires the fellow working effectively within the health care system that provides these therapies and determines the appropriate modality of treatment for each patient. Specific patient needs must be taken into consideration, including patient age, size, ambulation, socioeconomic factors, a patient’s living situation, and family support. In addition there must be effective communication between the fellow and the ancillary services within and outside of the hospital, e.g. social workers, dieticians, access surgeons, discharge planners, and primary physicians. The fellow must show compassion for patients (and their families) entering an ESRD program and respect patients’ autonomy and privacy while discussing ESRD options and sites of placement. Doing the above integrates the following competencies: patient care, systems-based practice, professionalism, and interpersonal and communication skills.

Fellows spend one month their first year on the renal pathology rotation. During that month they learn the fundamentals of renal histopathology through a combination of one-on-one teaching and slide review that the fellow performs on their own.

Lines of Responsibility

Fellows report to the attending renal pathologist during this experience. If the attending renal pathologist is unavailable, fellows report to the renal pathologist on-call and ultimately to the program director. Training in interpretation of renal biopsies is provided through weekly Pathology conference. A joint conference between the Section of Nephrology and the Department of Pathology that takes place in the conference room of the Department of Pathology. Several cases are presented each week.

All cases, in which a biopsy of a native kidney was performed at Albany Medical Center, in addition to selected cases of transplant biopsies, are written up as a protocol by the fellow involved in the case. This protocol is handed out to conference participants and is orally presented by that fellow. Both attendings and fellows then discuss the case as they are called upon by a conference mediator. After a differential diagnosis has been generated, the pathology is presented onto a screen. A fellow is randomly chosen to read these slides (first year fellows do not read cases in this conference until they have completed their pathology rotation). When the slide review has been completed, the fellow is asked to give a histologic diagnosis. The treatment is then discussed by attendings and fellows as they are called upon. The active process of reading biopsies in an intellectually stimulating and supportive setting is the most effective teaching tool. Fellows are encouraged to perform as many renal biopsies as they can that are medically indicated during their fellowship. Biopsies may be done on native kidneys as well as on renal transplants.

Goals and Objectives

To learn the evaluation and management of the following areas of medical knowledge: Although much of this is taught during and through a daily session at the microscope, it is expected that the fellow know:

• Normal renal histology including the recognition of different normal and abnormal cells within the glomerulus and interstitium.
• The handling and processing of renal biopsy specimens.
• The normal staining characteristics of the trichrome, PAS, H&E, and silver stains.
• A systematic approach to reading renal histopathologic slides.
• A systematic approach to reading renal immunofluorescence slides.
• A systematic approach to reading renal electron micrographs.
• The renal histopathologic features of the major nephrotic, nephritic, microvascular, and tubulointerstitial diseases including an understanding of the criteria of acute rejection in the renal transplant.
• Fellows are evaluated after the rotation. It is expected that the fellow incorporate this evaluation feedback into daily practice and that this will help the fellow identify strengths, deficiencies, and limits in one’s knowledge and expertise, make a habit of localizing and assimilating medical evidence from appropriate medical journals as well as other sources of information technology.

The Vascular Access Interventional Training Program at Albany Medical College is a program that is jointly operated between the Division of Nephrology in the Department of Medicine and the Division of Interventional Radiology in the Department of Radiology. This program has been established by Drs. Gary Siskin and Loay Salman.

Dr. Siskin is the chair of Radiology and service chief of Interventional Radiology and has extensive experience in interventional procedures, including dialysis access interventional procedures. Dr. Salman is an interventional nephrologist and was the chief of Interventional Nephrology at the University of Miami Miller School of Medicine for five years before joining Albany Medical College as the division chief of Nephrology and Hypertension.

This program will be available for nephrology fellows to rotate through and acquire the necessary knowledge and skills in the following areas:

• Hemodialysis access physical examination
• Hemodialysis access surveillance
• Arteriovenous fistulas and grafts angiograms and angioplasties
• Arteriovenous fistulas and grafts thrombectomy procedures
• Arteriovenous fistulas and grafts stent placement
• Arteriovenous fistulas coil placement
• Tunneled hemodialysis catheter insertion, exchange, and removal
• Kidney biopsies
• Vessel mapping

Hemodialysis and Continuous Renal Replacement therapies (CRRT)

Training in hemodialysis and CRRT is centered in both the inpatient at Albany Medical Center and the Stratton VA Medical Center (VAMC) and outpatient at Albany Regional Kidney Center (ARKC), Albany Dialysis Center (ADC), Dialysis Center, Inc. (DCI) settings.

Lines of Responsibility

Fellows report to the attending nephrologist during this experience. If the attending nephrologist is unavailable, fellows report to the key faculty nephrologist on-call and ultimately to the program director. Fellows learn inpatient hemodialysis while on the clinical services at both Albany Medical Center and VAMC. The fellows learn to write orders for inpatients requiring hemodialysis, determine the proper dialysate bath, anticoagulation protocol, fluid removal amount, time on hemodialysis, blood flow rate, and the need for sodium modeling. These orders are written under the supervision of the attending physician. Fellows will spend two one-month blocks during their PGY-4 year and one one-month block during their PGY-5 year on the outpatient hemodialysis rotation managing hemodialysis patients at ARKC, ADC, and DCI. All outpatient hemodialysis activities are supervised by nephrology attending physicians assigned to patients by shifts. Except for conferences and lectures, the fellow will be present at the HD unit from approximately 8:30 a.m. to 5 p.m., five days a week.

Fellow responsibilities include writing and updating hemodialysis orders, evaluation and management of patients’ hemodialysis accesses, dry weights, blood pressures and extracellular fluid balances, hemodialysis prescriptions, nutritional status, osteodystrophy status, and anemia status; fellows also review monthly and other non-routine labs and cultures. The fellow will also address and triage patient medical complaints. These issues are identified and dealt with through daily rounds. Rounds may be made with or without the attending present. Fellows on outpatient HD will also attend the monthly patient-care conferences. These are multidisciplinary conferences attended by the head HD nurse, the on-site social worker, and the on-site dietitian. An attending physician runs the meeting. The purpose of this conference is to review all medical, social, and dietary issues that pertain to a patient on chronic hemodialysis.

Goals and Objectives

The fellows are expected to learn how to determine and how to deliver a patient’s clearance needs, the net ultrafiltration fluid removal and the role of different replacement fluid electrolyte concentrations. They are expected to learn how to write acute hemodialysis orders including decisions related to anticoagulation, potassium, calcium, sodium and bicarbonate dialysate concentrations as well as appropriate fluid removal with ultrafiltration. They are also expected to manage all hemodialysis related problems that develop while a patient receives hemodialysis and other extracorporeal therapies. These include hemodynamic instability, poor access function, dialyzer reactions, air emboli, hemolytic reactions, and hemorrhage. Doing the above integrates the following competencies: patient care, systems-based practice, professionalism, and interpersonal and communication skills.

For first year fellows

• Learn history and physical examination of vascular access
• Learn basic differential diagnosis of vascular access pathology
• Learn details of the acute dialysis prescription and management of the dialysis patient in an acute setting
• Learn communication with referring physicians
• Learn the risks, benefits, and indications for the various forms of interventional procedures
• All fellows must present all patients to an attending faculty physician at each visit. The attending will see the patient and either observe the fellow with the patient or repeat critical components of the history and physical. This occurs weekly throughout the academic year.

For second year fellows

In addition to skills learned in the first year:

• Refine the history and physical for vascular access
• Refine the differential diagnosis of vascular access problems to be more Complete

All fellows must present all patients to an attending faculty physician at each visit. The attending will see the patient and either observe the fellows with the patient or repeat critical components of the history and physical. This occurs weekly throughout the academic year.

Peritoneal Dialysis

Training in peritoneal dialysis is centered in both the inpatient and outpatient settings.

Lines of Responsibility

Fellows report to the attending nephrologist during this experience. If the attending nephrologist is unavailable, fellows report to the key faculty nephrologist on-call and ultimately to the program director. While on the clinical service, the fellow, in conjunction with the attending on the clinical service, will manage all peritoneal dialysis in the hospital. The issues related to the management of these patients may or may not be similar to those seen in the outpatient setting. This fellow/attending team will make daily decisions that are required to manage these patients’ dialysis prescriptions, as well as manage infectious and mechanical complications of the therapy.

Fellows will spend one-month blocks each year on the peritoneal dialysis rotation managing peritoneal dialysis patients at ARKC. This is done through formal peritoneal dialysis clinics, in which peritoneal dialysis patients make outpatient visits on a monthly basis. Patients are initially seen and examined by the fellow, who reports to an attending physician and the case is discussed. Both the fellow and the attending physician then see the patients and appropriate changes are made in dialysis prescription to affect ultrafiltration or clearance. The patient’s anemia and osteodystrophy management are reviewed and the treatment of a patient’s peritonitis or exit site infection if applicable are reviewed.

When new patients start peritoneal dialysis, the fellow will, in conjunction with the attending, write orders for the patient that will be tailored to a patient’s medical and lifestyle requirements The fellows on this service will observe peritoneal dialysis staff-based patient training for both CAPD and CCPD, and will become well versed in “connectology.” They will also learn about the diagnosis and outpatient treatment of peritonitis, the outpatient evaluation of peritoneal transport, and peritoneal dialysis adequacy. They will review all labs and cultures.

Goals and Objectives

The fellow will learn or develop an expertise in the following areas of medical knowledge for peritoneal dialysis: Although much of this is taught during Peritoneal Dialysis Clinic and in reviewing the fellows’ notes with the attending, it is expected that the fellow make a habit of localizing and assimilating medical evidence from appropriate medical journals as well as other sources of information technology.

• 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.
• Understanding of the technology of peritoneal dialysis, including the use of automated cyclers.
• Assessment of peritoneal dialysis efficiency, using peritoneal equilibration testing and the principles of peritoneal biopsy.
• Understanding of how to write a peritoneal dialysis orders.
• Understanding of the complications of peritoneal dialysis, including peritonitis and its treatment, exit site and tunnel infections and their management, hernias, plural effusions, sclerosing encapsulating peritonitis, leaks, and other less common complications and their management.
• Understanding of the special nutritional requirements of patient’s peritoneal dialysis.
• Understanding of the special social services requirements of patients peritoneal dialysis.
• The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis.
• Long-term follow-up of patients undergoing long-term peritoneal dialysis, including their dialysis prescription and modification and assessment of adequacy of dialysis, management of anemia, osteodystrophy, and blood pressure.

The above skills need to be undertaken with an awareness and responsiveness to the larger context of system health care, as well as an ability to effectively communicate with patients, families, and other health professionals. It assumes and requires the fellow working effectively within the health care system that provides these therapies and determines the appropriate modality of treatment for each patient. Specific patient needs must be taken into consideration, including ambulation, socioeconomic factors, a patient’s living situation and family support, and ability to pay for medications that may be medically indicated. In addition there must be effective communication between the fellow and the ancillary services associated with PD clinic including, nurses, dietitians, and social workers. The fellow must show compassion for patients within an ESRD program and respect patients’ autonomy and privacy. Doing the above integrates the following competencies: patient care, systems-based practice, professionalism, and interpersonal and communication skills.

For first year fellows

• Learn history and physical examination of vascular access
• Learn basic differential diagnosis of vascular access pathology
• Learn details of the acute dialysis prescription and management of the dialysis patient in an acute setting
• Learn communication with referring physicians
• Learn the risks, benefits and indications for the various forms of interventional procedures
• All fellows must present all patients to an attending faculty physician at each visit. The attending will see the patient and either observe the fellow with the patient or repeat critical components of the history and physical. This occurs weekly throughout the academic year.

For second year fellows

In addition to skills learned in the first year:

• Refine the history and physical for vascular access
• Refine the differential diagnosis of vascular access problems to be more complete