Fellows in the Nephrology Fellowship Program at Lankenau Hospital

Inpatient Consultation Service and Nephrology Service
The major portion of this Fellowship is devoted to clinical nephrology. There are two categories of acute and chronic patients that the trainee has responsibilities for: nephrology consultations and nephrology service patients.

When performing nephrology consultations the Fellow sees all consultations first, does the work-up and outlines the management and treatment plan. He or she is responsible for reviewing the lab work, radiology studies, urine, etc., and writes up the consult. The patient (and write-up) is then reviewed by the assigned attending on teaching rounds and the Fellow communicates the final recommendations to the medical house staff assigned to the patient who, in turn, calls his own attending physician (the patient's primary physician). The Fellow then has the responsibility, working through the medical resident, to be certain that the recommendations are implemented and that the management of the case moves forward in a timely fashion.

In many acute cases involving intensive care unit problems, because of the acuity of the problem, the fellow will, with appropriate supervision, institute emergency procedures such as insertion of Shaldon catheters into the femoral vessels or MedComp catheters into femoral vessels for immediate dialysis access routes. The fellow will also start acute peritoneal dialysis in an emergency situation. Procedures should be logged in the Procedure Booklet and supervised as indicated by the level of experience and expertise of the individual fellow.

Later in the fellowship, the fellow may also communicate the nephrologis's recommendations directly to the attending physician. In assuming this role of communicator, the Fellow matures as a consultant. The fellow's ongoing recommendations are reviewed and confirmed or revised on a daily basis by the teaching-team attending nephrologist during the morning patient management rounds, at which time the fellow writes the daily progress notes countersigned by the attending physician. The teaching attending will interview patient and write his/her own confirmatory note as indicated.

The fellow also has responsibilities for acute and chronic nephrology service patients (a patient admitted to the private service of one of the staff Nephrologists). When a patient is admitted by the attending nephrologist, a call is made to the fellow assigned to the appropriate teaching team to describe the case. In the case of acute care problems on nephrology service patients, the fellow then sees the patient and data base and then reviews the patient with the house staff and recommends management plans subject to the approval of the attending nephrologist. In the case of nephrology service patients, the day-to-day care and management is more actively controlled by the fellow since he or she, in effect, is the representative of the attending nephrologist.

The fellow may initiate diagnostic procedures (lab work, clearances and x-rays) in conjunction with the medical house staff. All of the fellow's actions on these nephrology service patients are reviewed daily by an attending nephrologist during the morning patient management rounds. The fellow makes every attempt in managing the nephrology service patients to work through the medical resident. Whether or not he or she writes the orders, the fellow assumes the responsibility that all orders are ultimately implemented.

Other responsibilities of the trainee for acute and chronic inpatients include all procedures relative to the care of the renal patients, such as intravenous access cannulations, peritoneal dialysis catheter insertions and revisions, and renal biopsies.

Renal Hypertension Continuity Clinic
Patients seen in Renal Hypertension Clinic (which is open every Wednesday morning from 10:30 to 12:30) are referred from the Medical Clinic, or as follow-up appointments on patients discharged from the hospital who have been followed by Nephrology Consultative Service, from the Emergency Room or long-term Nephrology Clinic patients. These patients should be followed also in Medical Clinic or by a private practitioner for their non-nephrology management. A Nephrology Attending is assigned to supervise the trainee during the clinic session. Approximately three to four clinic patients are seen per clinic session. This typically includes no more than two new patients and two to three follow-up patients. The Nephrology Fellow attends this continuity based clinic throughout the entire two-year period except when on rotation at the Hospital of the University of Pennsylvania or at St. Christopher's Hospital, both in Philadelphia.

Fellows are required to notify the clinic in advance of any vacation or conferences that will conflict with clinic schedules and to work out coverage with other Nephrology Fellows. In addition, nephrology fellows are encouraged to be actively involved in the Ob/Gyn Lankenau clinic for cases involving pre-eclampsia, eclampsia, HELLP syndrome, hypertension and proteinuria. Follow-up is preferably on a continuity basis.

Ambulatory Rotation
Fellows are assigned to an attending private physician's office for one or more office session per week. This is readily accomplished since the private offices are part of the hospital complex and run by the teaching attending faculty. The Fellow sees and examines the patient and then discusses the diagnoses and management with the attending. Additional discussion occurs at the end of the office session to clarify and emphasize salient points. In the average three-hour session, the trainee sees four to six outpatients, with not more than one of these being a new patient per session.

There are two months per year specifically dedicated to the ambulatory private physician office rotations. Unlike the Renal Hypertension Continuity Clinic, the follow-up by the fellow, in the private offices, is less continuous unless the patient goes on to dialysis, in which case the fellow continues follow-up care in the dialysis unit.

By the end of these rotations, the fellow should be familiar with common outpatient/ambulatory problems (and management of same) of CKD patients. Most common among such clinical problems are the diagnosis and management of renal insufficiency, hypertension, anemia, edema, electrolyte abnormalities and educational preparation of the patient for dialysis and erythropoietic agents. During the Ambulatory Rotation, the Fellow will also cover the ER (for non-inpatient team Nephrology patients) and spend time with the Nephrology Nurse Educator. To the extent that there is free time during Ambulatory Rotations, spare time should be directed toward the fellow's research project.

Outpatient Dialysis Rotation
The Out-Patient Chronic Dialysis Rotation consists of two major parts: peritoneal dialysis and hemo dialysis.

Peritoneal dialysis (PD) further consists of Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated or Cycler Assisted Peritoneal Dialysis (APD). The fellow is expected to become familiar with both of these PD modalities. The fellow is assigned specific PD patients who the fellow, along with the primary attending nephrologist and PD Nurse Coordinator, follows on a longitudinal continuity of care basis. Patients are typically seen in the PD Clinic. The fellow should become familiar with the orientation to and initiation of the PD technique, as instructed by the PD Nurse Coordinator, Nephrology Attending, reading materials, didactic PD conferences and literature. The fellow is also expected to attend the insertion of chronic PD catheter placement by the access surgeon and to be familiar with possible complications of access care and complications including management of exit site-related problems. The diagnosis and management of peritonitis, adequacy of PD dose prescription, fluid management, poor infusion or drainage, exit site infection, hydro thorax, herniation and other relevant PD-related complications should be mastered through this approach. PD patients are typically seen on a monthly basis, but may be seen more frequently if conditions warrant.

The chronic hemo dialysis (HD) rotation takes place concurrently with the PD experience. Although PD patients, being fewer in number, may need to be seen during other rotations as part of a continuity approach, chronic HD out-patient experience is gained largely during the seven monthly rotations of the two year fellowship. The fellow is expected to become thoroughly familiar with and competent in the management of ESRD and HD issues and technology including all types of access placement (catheter, graft, fistula) and should be present during the insertion of each of these types of access with the vascular access surgeon in the operating room. The complications of access, including thrombosis, bleeding and infection, should also be followed by the fellow, whether it be in the operating room or radiology department.

The fellow shall become familiar with the setting-up of the dialysis machinery, lines and needles, as well as the comprehensive dialysis prescription routine. The management of complications during the HD (hypotension, cramping, seizures, blood loss, dialyzer reaction and infection) should all be incorporated into the experience of the rotation. The diagnosis and management of ESRD-related complications, including anemia, iron deficiency, osteodystrophy, neuropathy, psycho-social adjustment, sleep disorders, fluid overload, hyperkalemia and hypertension, should all be mastered by the fellow as a result of these rotations, as well as the reviewing of literature and Division of Nephrology lecture series.

The fellow will round regularly with the assigned attending Nephrologist for the particular shift of dialysis. It is expected that the fellow will be an integrated part of the multi-disciplinary team including the nurses, social worker, dietician and dialysis technician. The fellow will actively participate in the bi-weekly dialysis multi-discipline team meetings. In addition, the fellow should become knowledgeable about the water treatment equipment and related aspects for water delivery within the dialysis unit rotation. Comprehensive monthly blood work notes as well as annual history and physicals shall be performed by and become a routine part of the out-patient dialysis rotation by the Nephrology Fellows. Routine day-to-day ESRD-related issues for the chronic out patient dialysis population is also an integral part of this series of rotations.

Outpatient Renal Transplantation Clinic
The Continuity Transplant Clinic experience at Lankenau Hospital takes place weekly for each senior fellow at The Hospital of the University of Pennsylvania. Each fellow sees approximately 10-15 patients per week over four weeks, or approximately 60 patients at The Hospital of the University of Pennsylvania.

The fellow is responsible for filling out an evaluation of his or her transplant rotation experience at the University of Pennsylvania and submitting the evaluation form to the Lankenau Fellowship Program Coordinator. In addition, the fellow should see 3-4 patients per week at the Lankenau Renal Transplant Clinic throughout his or her 2nd year of fellowship. At the completion of the fellow's training, he or she is expected to be competent in the diagnosis, physiologic understanding and therapeutic management of renal transplantation, acute and chronic rejection, evaluation of living related donors, surgical complications of donation and implantation of kidney allografts including bleeding, infection and immunosuppression as well as vascular and genitourinary complications. A comprehensive understanding of immunosuppressive therapy and its rationale for use as well as complications of specific commonly used anti-rejection medications is expected.

Outpatient Pediatric Nephrology
Fellows will rotate for four weeks at St. Christopher Hospital for Children in Philadelphia. St. Christopher's Hospital has a Department of Pediatric Nephrology. Fellows will be under the direct supervision of Dr. Susan Conley, Section Chief of Pediatric Nephrology.

The fellow is responsible for filling out an evaluation of his or her pediatric nephrology rotation experience at St. Christopher's Hospital for Children and submitting the evaluation form to the Lankenau Fellowship Program Coordinator. Upon the completion of the rotation, the fellow should have an appreciation for common, as well as uncommon, pediatric nephrologic conditions and their complications including glomerulonephritis, reflux uropathy, obstructive uropathy, dialytic issues unique to pediatric patients and metabolic/nutritional aspects of the pediatric nephrology population. An understanding of genetic and congenital related renal disease is especially pertinent as a comprehensive part of this rotation.