Inpatient and Outpatient Experiences

The Kidney Consult Service is designed to provide educational exposure to kidney disease in an active quaternary-care medical center. The team includes a staff physician and 2 fellows, with frequent involvement of rotating Internal Medicine residents and 4th-year medical students. In general, 2–5 requests for consultation are received daily for a range of conditions. Fellows are trained to perform a microscopic evaluation of the urine sediment, place internal jugular and femoral hemodialysis catheters under real-time ultrasound guidance, have the opportunity to use ultrasound to evaluate the kidneys and other point-of-care techniques (shared with a critical-care curriculum), perform percutaneous native and transplant kidney biopsies and supervise acute hemodialysis and continuous veno-venous hemodialysis treatments.

Fellows also manage most patients with end-stage kidney disease treated with hemodialysis or peritoneal dialysis who are admitted to the hospital, though some are cared for by a ward attending directly. The fellows develop skill in treating the complications of hemodialysis and peritoneal dialysis, as well as diet, medication dosing, and other unique aspects of medical care for this population.

The Transplant Service is designed to train fellows on the special medical needs of patients undergoing kidney transplantation and kidney donation or requiring immunosuppressive therapy. Between 30–60 live- and deceased- donor kidney transplants are performed annually at Tufts MC. Fellows participate in all phases of patient care, including pre-transplant evaluation in clinic, selection of recipients and living donors, peri- and post-operative care, treatment of rejection and other complications. Following discharge, transplant recipients are seen immediately by fellows in the Kidney and Blood Pressure Center. The fellows on transplant service and attending physician are responsible for the care of all hospitalized kidney transplant recipients and live donors, as well as consults and dialysis on inpatient liver, heart, lung, and bone marrow transplant recipients as requested. The fellows interact daily with members of the transplant surgery team, which includes 2 surgeons, 3 transplant coordinators, a transplant pharmacist, a transplant social worker and a transplant nutritionist. Multi-disciplinary work rounds are held weekly, when prospective recipients and donors are discussed, the progress of both inpatients and outpatients is reviewed, and treatment plans are formulated. In addition, fellows perform between 5–15 percutaneous transplant kidney biopsies each year.

The Division of Nephrology recognizes that ambulatory care is a significant element of nephrology practice which is often underrepresented during training. We have developed a comprehensive exposure for fellows in these areas, and graduating fellows report feeling particularly well-prepared for this aspect of practice.

The Kidney and Blood Pressure Center at Tufts MC has provided consultations since 1950 and now has one of the busiest outpatient nephrology practices in the region in addition to multiple general nephrology clinics for the patients referred for a wide variety of kidney and hypertensive disorders and the transplant clinics. There are specialty clinics with a focus on complex hypertension, glomerulonephritis and an interdisciplinary approach to polycystic kidney disease.

First-year fellows are assigned to 2 weekly clinic sessions where they build their own panel of nephrology patients under the supervision of division members. Second-year fellows have 1 weekly clinic. A full-time nurse coordinates clinic activities, and 3 transplant coordinators and 4 physician assistants participate in patient care. An administrative coordinator of the clinic and 3 patient care coordinators who oversee scheduling, flow, paperwork and phone calls. A full-time medical assistant/phlebotomist is available to dip and spin urine, draw blood and perform EKGs when necessary.

The division’s outpatient dialysis facility, which is located in the same building as the clinic and division offices, is operated by the non-profit Dialysis Clinic, Inc. (DCI) and serves approximately 115 hemodialysis patients.

Second-year fellows are assigned a cohort of 20-25 hemodialysis outpatients on a single dialysis shift. They serve as the primary nephrologist and round weekly with supervision provided by a single faculty member. Transplant Surgery performs vascular and peritoneal access surgery, and both Transplant Surgery and Interventional Radiology provide vascular access maintenance.

Tufts MC's peritoneal dialysis program was the first in Boston and is now the largest in the region. Over 60 patients perform home peritoneal dialysis and home hemodialysis, representing an extraordinary >35% of our total dialysis population served. Six home dialysis nurses educate and train patients in collaboration with fellows and staff physicians. After training is complete, patients are seen monthly for follow-up visits at the DCI unit in Somerville, MA, by a fellow, a staff physician and the home dialysis team.

The home dialysis patient population is divided into 4 shifts, each managed by 1 fellow and 1 supervising attending for an entire academic year. The fellow and supervising attending travel to the home dialysis clinic in Somerville, MA, 1 morning each month to see their patient panel. The inpatient responsibilities of the fellow going to Somerville are covered for that day. Fellows also participate in home visits to observe the set-up, initiation and performance of a home hemodialysis treatment.

The PKD Clinic is held on Friday mornings with Drs. Ron Perrone, Dana Miskulin and Craig Gordon, who are world-renowned PKD experts. Comprehensive, multi-disciplinary care is provided to these patients with the help of Transplant Surgery, Neurosurgery and Interventional Radiology. Patients diagnosed with PKD are referred from across the country and worldwide to undergo comprehensive evaluation at our recognized Center of Excellence. Each fellow rotates through the PKD Clinic several times per year.

The division views ultrasound as an important advancement in the field and is actively moving to make this a part of the educational experience. Through didactic sessions, technique development in the Simulation Center, and supervised practice sessions, as well as a dedicated division ultrasound, fellows will be trained to assess normal and abnormal kidney anatomy in coordination with our pulmonary/critical care division. Fellows will also be exposed to other ultrasound techniques.

Each clinical fellow is expected to select an area of quality improvement within their area of focused study, implement a plan to gather data, develop an initiative to improve outcomes and assess the response to the change. The results of this project are presented at division conferences and are strongly encouraged to be published as a manuscript or abstract.

Fellows perform non-tunneled hemodialysis catheter placements under ultrasound guidance and native and transplant kidney biopsies. Our on-site staff renal pathologist reviews all biopsy specimens with the nephrology team.

Urine microscopy is an essential part of the evaluation of kidney disease. Fellows receive dedicated teaching on urine microscopic evaluation from the faculty. Facilities to perform the urinalysis are located conveniently in both inpatient and outpatient areas.