PARKLAND MEMORIAL HOSPITAL (PMH) TRANSPLANT ROTATION
Service
The Renal Transplant Service at Parkland Memorial Hospital and UT Southwestern Medical Center is a joint effort of the divisions of Nephrology, Transplantation Surgery, and Urology. The In-Patient Transplant Service rounds twice/day with the participation of a Nephrology attending and a Transplant Surgery or Urology attending. Two Internal Medicine residents, one Renal fellow and one General Surgery resident make up the Transplant In-Patient team. Nursing staff, pharmacists, dieticians and social workers participate in rounds with the In-Patient Service daily. During this rotation, the trainee is exposed to kidney and kidney-pancreas transplants.
Fellows will participate in all of the clinical and academic activities of the Renal Transplant Service. The fellow becomes familiar with the pre-transplant workup of the patients. They will learn the principals of selection of candidates for transplantation, donor evaluation, management of patients on the list, management of patients in the perioperative period and long-term follow-up of kidney and kidney/pancreas transplant recipients in the outpatient clinic.
Responsibilities
The clinical fellow typically is assigned to this rotation 4 months during the 2 years of clinical training. Under direct faculty supervision, the trainee evaluates approximately 4-5 new transplant patients and 25-30 hospitalized transplant patients per month. The fellow will write admission notes and orders on all patients. All patients should also have daily progress notes. As the primary physician the fellow writes all orders for immunosuppression from the time the patient is admitted to the hospital and immediately post-operative. The fellow is also responsible for at least being familiar with the patients assigned to the two medical residents who rotate on the service. Occasionally some renal transplant patients will be under the care of one of the other services. This will occur most commonly when they are in one of the Intensive Care units. In this circumstance the fellow will continue to follow these patients regularly and will directly communicate to the ICU house staff the instructions regarding immunosuppression and management of the renal and/or pancreatic (if applicable) problems presented by the patients.
Outpatient Renal Transplant Clinic
The fellow will see patients in the PMH transplant clinics on Monday, Tuesday, and Friday, as well as cover walk in patients when on-call in rotation with the medical residents. The goal of the transplant clinic is to apply principles of clinical transplantation toward actual care of patients in the outpatient setting. Each patient is presented to the renal transplant attending who also sees every patient in clinic. A diagnostic and therapeutic plan is formulated after careful discussion.
In patients recently discharged from the hospital after having just received a transplant the objective of the clinic is to provide an educational experience in early post-transplant care. Expertise is gained in adjusting immunosuppression, evaluation of proteinuria, evaluation of renal dysfunction, management of hyperlipidemia, hypertension, follow-up for evaluating renal function, infectious complications, management of blood pressure, and other conditions specific for this time period post transplantation.
Patients who are farther removed from placement of the allograft are also evaluated. The objective of the clinic in these patients is to provide an educational experience in late transplant care that includes infectious complications, metabolic abnormalities, chronic allograft dysfunction, bone disease, malignancies and other conditions specific for this time period post transplantation.
Patients being evaluated for consideration for placement on the transplant list are also seen in the outpatient setting. The objective of these encounters is to educate the fellow on subjects that include (but not limited to): identification of cardiovascular risk factors for surgery, pre-transplant patient teaching, contraindications to transplantation, HLA crossmatching, preparing recipients for transplants in situations where the living donor is ABO incompatible or where the recipient has anti-HLA antibodies to the donor (high risk pretransplant evaluation and management).
Patients already on the transplant list are periodically evaluated in the outpatient setting. The objective of these encounters is to provide the fellow with specific educational experience from patients waiting for transplantation but receiving dialysis. Special complications are seen in this group of patients that relate to dialysis, vascular or peritoneal access, infections or cardiac problems that may have influence on transplantation and/or outcomes.
Expectations
A. During this rotation the fellow will gain expertise in the areas listed below. This expertise will be acquired from attending required teaching conferences, daily attending rounds, and transplant clinics
-Supervised involvement in the decision-making for patients during pre-and post-transplant care
-Evaluation and selection of transplant candidates
-Pre-operative evaluation and preparation of transplant recipients
-Immediate post-operative management of transplant recipients, including administration of immunosuppressant medications
-Clinical diagnosis of all forms of rejection, including laboratory, histopathologic, and imaging techniques
-Medical management of rejection, including use of immunosuppressant drugs and other agents
-Recognition and medical management of the surgical and nonsurgical complications of transplantations.
-Management of post-transplant complications – including rejection, chronic allograft dysfunction, post-transplant malignancies, infections, cardiovascular diseases, hypertension, and fluid/ electrolyte problems
-Technical expertise: percutaneous biopsy of allograft kidneys
-Principles of tissue typing
B. The fellow will become familiar with the indications for percutaneous renal allograft biopsy. The fellow will become skilled in this procedure at PMH and be familiar with the risks and complications of the procedure. Allograft biopsies at St. Paul are performed by interventional radiology.
C. The fellow will be responsible for all dialysis treatments of post-transplant patients up to 6 months after reinitiation of dialysis should the transplant fail. He/she will also manage dialysis for patients admitted specifically for pre-transplant workup.
D. The fellow will admit and cover transplant in-patients at PMH, and ZLU in rotation with two medical residents.
E. The fellow will see patients in the PMH transplant clinics on Monday, Tuesday, and Friday, as well as cover walk in patients when on-call in rotation with the medical residents.
F. The fellow will see pre and post-transplant patients in the St Paul transplant clinic.
General competencies
A. Patient Care:
By the end of this rotation, first year fellows are expected to develop and demonstrate the following skills:
1. Communicate effectively and demonstrate respectful behavior when interacting with patients referred for transplant evaluation.
2. Gather essential and accurate information about their patients
3. Make informed decisions about diagnostic and therapeutic interventions based on medical knowledge, patient preferences and judgment
4. Understand out management plans, such as treatment of rejection, adjustment of immunosuppressive medications and diagnostic procedures
5. Use information technology to educate patients about transplantation and donation
6. Perform transplant renal biopsies under supervision.
7. Provide health maintenance and preventive health care, specifically aimed at preventing complications of renal transplantation including toxicity of drugs, opportunistic infection, malignancy, cardiovascular disease
8. Work with members of the transplant team, including surgeons, other consultants, social workers, nurse practitioners, members of the organ procurement organization and UNOS
9. Demonstrate competency in performing transplant renal biopsies
10. Independently formulate a diagnostic and treatment plan for complications of renal transplantation
B. Medical Knowledge:
Fellows are expected to develop competency in transplant as described in detail above:
1. By demonstrating knowledge in established and evolving biomedical, clinical, epidemiological and social-behavioral sciences (as listed above)
2. By demonstrating the ability of applying this knowledge to patient care and understanding complex mechanisms of diseases
3. By being highly resourceful in developing knowledge
C. Practice based learning:
By the end of this rotation, first and second year fellows are expected to develop and demonstrate the following skills:
1. Understand the resources involved in procuring and allocating organs for transplantation: the role of UNOS, organ procurement organizations, donor networks, tissue typing laboratories
2. Understand the cost-effectiveness of renal transplantation (deceased donor vs. living donor) as well as the cost-effectiveness of various immunosuppressive regimens
3. Assist patients with chronic kidney disease in obtaining access to evaluation for transplantation
4. Work with members of the transplant team to improve and consolidate cost-effective health care delivery
D. Communication and interpersonal skills
By the end of this rotation, first year fellows are expected to develop and demonstrate the following skills:
1. Establish rapport with patients from different backgrounds
2. Provide appropriate counseling to patients and their families regarding their therapeutic options: risks and benefits of renal transplantation, both from deceased and living donors
3. Communicate effectively with all members of the transplant team
4. Interact with other physicians, nurses, and therapists caring for the patient
5. Interact with the staff of the transplant unit to promote cooperative care
6. Provide teaching to residents and medical students
7. Work with pertinent hospital personnel to arrange transplant biopsies
8. Communicate results of biopsies to nephrologists and transplant team
E. Professionalism:
By the end of this rotation, first and second year fellows are expected to develop and demonstrate the following skills:
1. Demonstrate a commitment to ethical principles particularly as pertains obtaining organs for transplantation and allocating them equitably
2. Demonstrate compassion and integrity by being responsive to patients’ needs regardless of culture, age, gender, ability to pay
3. Interact professionally with other members of the health care team, colleagues and students
F. Systems-Based Practice:
By the end of this rotation, first and second year fellows are expected to develop and demonstrate the following skills:
1. Understand the resources involved in procuring and allocating organs for transplantation: the role of UNOS, organ procurement organizations, donor networks, tissue typing laboratories
2. Understand the cost-effectiveness of renal transplantation (deceased donor vs. living donor) as well as the cost-effectiveness of various immunosuppressive regimens
3. Assist patients with chronic kidney disease in obtaining access to evaluation for transplantation
4. Work with members of the transplant team to improve and consolidate cost-effective health care delivery
