ST. PAUL UNIVERSITY HOSPITAL RENAL CONSULT, ACUTE DIALYSIS, AND TRANSPLANT ROTATION
Service:
The St. Paul rotation consists of general nephrology consults, in patient dialysis, and kidney and kidney/pancreas transplants. The service consists of one attending and one fellow. The transplant service is still in its infancy having performed the first two transplants in January 2007. Over time the service is projected to grow to be the dominant transplant service within the University of Texas Southwestern Medical Center.
The trainee is exposed to all renal consults that are encountered in the hospital. These consults include evaluation of chronic and acute renal failure and all types of fluid and electrolyte disorders. The fellow manages dialysis treatments for all patients to include those with acute renal failure and those who require maintenance dialysis. Both hemodialysis and peritoneal dialysis are included in this group. The fellow also manages the continuous forms of dialysis required of patients in the ICU setting. Renal and allograft biopsies at St. Paul are performed by interventional radiology.
The fellow is the primary physician for both kidney and kidney-pancreas transplant patients. 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 involved in the pre-transplant work up and evaluation of patients referred for kidney and kidney/pancreas transplantation.
The clinical experience on this rotation and the expertise gained during this rotation are similar to what has been described on the Parkland Memorial Hospital consult, acute dialysis, and transplant rotations.
Responsibilities:
The clinical fellow typically is assigned to this rotation 3-4 months during the 2 years of clinical training. The Nephrology consult fellow is responsible for the initial evaluation and subsequent management of all hospitalized patients referred for consultation. The fellow will perform a history, physical examination, and review the relevant laboratory studies in each case consulted upon. The fellow will present the patient to an attending physician and, under their supervision, will formulate a diagnostic and treatment plan. This plan will also involve the implementation and management of renal replacement therapy (hemodialysis and peritoneal dialysis) when indicated. The fellow is not responsible for admitting or discharging the general nephrology consult patients. These patients are admitted to other services (medical or surgical) and the renal fellow acts in a consultant capacity only.
The transplant aspect of the rotation is a primary care service. The fellow will write admission notes and orders on all patients to include orders for immunosuppression from the time the patient is admitted to the hospital until discharge. All patients must have daily progress notes.
Expectations:
A. During this rotation the fellow should become familiar and develop and understanding of the following disease processes. In addition the fellow will be expected to learn the appropriate treatment and approach to these disorders. These issues will be accomplished from attending required teaching conferences, daily attending rounds, renal clinic, and evaluating patients as a consultant.
-Primary and secondary glomerular disease
-Diabetic nephropathy
-Tubulointerstitial renal disease
-Fluid and electrolyte disorders
-Acid-Base disorders to include metabolic and respiratory
-Management of hypertension
-Approach to patients with acute renal failure including those in the ICU
-Management of the patient with chronic renal failure
-Urinary tract infections
-Disorders of Divalent Cation and mineral metabolism
-Renal Disease in Pregnancy
-Tools used to assess renal function
During this rotation the fellow should also become familiar and develop and understanding of the following disease processes as it relates to the delivery of renal replacement therapy:
-Acute renal failure
-Hypertensive disorders
-Indications for initiation of renal replacement therapy, both elective and emergent
-Evaluation and selection of patients for acute dialysis or continuous renal replacement therapies (CVVHDF)
-End-state renal disease
-Evaluation of end-stage renal disease patients for various therapies and their instruction regarding treatment options
-Understanding of the indications, contraindications, and complications of placement of peritoneal catheters
-Evaluation and management of medical complications in patients during and between dialysis and other extracorporeal therapies, including dialysis access, and an understanding of their pathogenesis and prevention
-An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient
-Disorders of drug metabolism
-Drug dosage modification during dialysis and other extracorporeal therapies
-The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis
-Understanding of how to manage complications of chronic angioaccess, such as thrombosis
-Technical expertise: peritoneal dialysis
-Technical expertise: placement of temporary vascular access for hemodialysis and related procedures
-Technical expertise: acute hemodialysis
-Technical expertise: continuous veno-venous hemodialfiltration
During this rotation the fellow will also gain expertise in the areas listed below as part of the kidney and kidney/pancreas transplant experience:
-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. Additional expectations are those previously described in the PMH consult, acute dialysis, and transplant rotations.
General Competencies:
During this rotation, trainees are expected to acquire and master the core competencies that have been delineated in the PMH consult, dialysis, and transplant rotations discussed above, but can be summarized as follows:
A. Patient Care:
1. By demonstrating a compassionate, appropriate and effective care
2. By promoting health and general well being of the patients
3. By demonstrating satisfactory clinical competence in performing medical interviews, physical examinations, review of relevant data and procedural skills
4. By making diagnostic and therapeutic decisions based on available evidence, sound judgment and patient preferences
B. Medical Knowledge:
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
- By being highly resourceful in developing knowledge
C. Practice-Based Learning:
- By demonstrating improvement in patient care based on:
Evaluation of one’s own practice
Incorporation of feedback information into improvement activities
Appraisal and assimilation of scientific evidence
2. By demonstrating effective utilization of technology to manage information for patient care and self-improvement
D. Communication and Interpersonal Skills:
1. By demonstrating effective and humanistic information exchange with patients and their families and other health professionals
2. By demonstrating excellent listening, narrative and nonverbal skills
3. By demonstrating ability to educate and counsel patients, families and colleagues
E. Professionalism:
1. By demonstrating a commitment to carrying out professional responsibilities
- By adhering to ethical principles
- By exhibiting sensitivity to diverse patient population
4. By demonstrating respect, compassion, integrity and honesty
5. By consistently exhibiting role model and responsible behavior
- By willingly acknowledging errors
7. By consistently considering the needs of their patients, families and colleagues
F. Systems-Based Practice:
1. By demonstrating awareness of the larger context of health care systems.
- By demonstrating responsiveness to health care systems
3. By effectively utilizing system resources to provide care of optimal value
4. By effectively using systematic approaches to reduce errors and improve patient care
5. By enthusiastically assisting in developing systems’ improvement
