Inpatient + 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 two fellows, with frequent involvement of rotating Internal Medicine residents and fourth-year medical students. In general, two to five requests for consultation are received daily for a range of conditions. Fellows are trained to perform microscopic evaluation of the urine sediment, have the opportunity to place internal jugular and femoral hemodialysis catheters under real-time ultrasound guidance, use ultrasound to evaluate the kidneys and volume status, perform percutaneous native and transplant kidney biopsies, and supervise acute hemodialysis and continuous veno-venous hemodialysis treatments.

Fellows also manage patients with end-stage kidney disease treated with hemodialysis or peritoneal dialysis who are admitted to the hospital, though many of these patients are managed by an attending service. 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 fifty and sixty 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, and treatment of rejection and other complications. Following discharge, transplant recipients are seen immediately by fellows in the Kidney and Blood Pressure Center. The fellow on Transplant Service and the supervising physician are responsible for the care of 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 round daily with members of the transplant surgery team, which includes two surgeons, three transplant coordinators, a transplant pharmacist, a transplant social worker, and a transplant nutritionist. Multi-disciplinary transplant conference is held weekly at which time 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 and 15 percutaneous transplant kidney biopsies under ultrasound guidance 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 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 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 inter-disciplinary approach to polycystic kidney disease.

First year fellows are assigned to two weekly clinic sessions where they build their own panel of nephrology patients under the supervision of Division members.  Second year fellows have one weekly clinic.  A full-time nurse coordinates clinic activities, and four physician assistants participate in patient care.  There is an administrative coordinator of the clinic, and three 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 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 where they serve as the primary nephrologist and round weekly with supervision provided by a single faculty member.  Vascular and peritoneal access surgery is performed by Vascular and Transplant Surgery, and vascular access maintenance is provided by both Vascular Surgery and Interventional Radiology.

Tufts MC's peritoneal dialysis program was the first in Boston, and is now the largest in the region. Currently, over 60 patients perform home peritoneal dialysis and home hemodialysis, representing an extraordinary 35% of our total dialysis population. 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 5 shifts, with each shift managed by one fellow and one supervising attending for an entire academic year. The fellow and supervising attending travel to the home dialysis clinic in Somerville, MA one morning each month to see their patient panel, while the inpatient responsibilities of the fellow 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, world-renowned PKD experts.  Comprehensive, multi-disciplinary care in provided to these patients with the help of Transplant Surgery, Neurosurgery, Hepatology, and Interventional Radiology.  Patients with the diagnosis of PKD are referred from across the country and around the world to undergo comprehensive evaluation at our recognized Center of Excellence.  Each fellow rotates through the PKD Clinic several times per year.

Kidney imaging

The Division views ultrasound as an important tool in the assessment of kidney disease and as incorporated this into the educational experience. Through didactic sessions, technique development in the Simulation Center, and supervised practice sessions, as well as a dedicated Division ultrasound machine, fellows are trained to assess kidney anatomy and volume status.

Quality assessment and practice improvement

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.

Procedures

Fellows have the opportunity to 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.