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Fellows participate in all clinical activities of the Division of Nephrology at Tufts Medical Center and St. Elizabeth's Medical Center (SEMC). First- and second-year clinical fellows share responsibilities on five rotations: 1) the Consult Service, 2) the Transplant Service, 3) the Dialysis Service, 4) the SEMC Rotation, and 5) the Independent Study Block. In addition, fellows participate in longitudinal continuity clinics in the Kidney and Blood Pressure Center and care for a cohort of outpatient dialysis patients at Dialysis Clinic, Inc.
Consult Service
The Consult Service is based at Tufts Medical Center and designed to provide educational exposure to kidney disease consultations in an active tertiary-care medical center. Fellows spend three to five months on this rotation during their fellowship, with increasing responsibilities throughout their training.
The kidney disease consult team includes a staff physician, a fellow, occasional Internal Medicine residents, and one or more fourth-year medical students. In general, one to three requests for consultation are received daily regarding acute kidney injury, acid-base and electrolyte disturbances, hypertension, and medical care for patients with chronic kidney disease. Fellows are trained to place internal jugular and femoral venous access catheters, and supervise acute hemodialysis and continuous veno-venous hemofiltration. In addition, fellows perform between 5 and 20 percutaneous kidney biopsies each year.
Transplant Service
The Transplant Service is based at Tufts Medical Center and designed to provide educational exposure to the special medical needs of patients undergoing kidney transplantation or kidney donation, or requiring immunosuppressive therapy. Fellows spend three to five months on this rotation during their fellowship, with increasing responsibilities throughout their training.
Approximately fifty living-donor and deceased-donor kidney transplants are performed annually at Tufts. Fellows participate in all phases of patient care, including pre-transplant evaluation and selection of recipients and living-donors, peri- and post-operative care, and treatment of rejection and other complications. Following discharge, transplant recipients receive primary medical care in the Kidney and Blood Pressure Center. The transplant fellow and attending staff are responsible for the care of all hospitalized kidney transplant recipients and living-donors. In addition, the transplant fellow performs consults and dialysis on inpatient liver, heart, lung, and bone marrow transplant recipients as requested. The fellow interacts daily with members of the Transplant Surgery team, which includes three staff surgeons. Multi-disciplinary work rounds are held weekly with the Transplant Surgery service, at which time prospective recipients and donors are discussed, the progress of both inpatients and outpatients are reviewed, and treatment plans are formulated.
Dialysis Service
The Dialysis Service is based at Tufts Medical Center and designed to provide educational exposure to patients with end-stage kidney disease on hemodialysis or peritoneal dialysis who are admitted to the hospital. The fellow on this service acts as a liaison between the outpatient dialysis unit and the outpatient nephrologist, and the inpatient dialysis unit and the inpatient care team. Fellows spend two to four months on this rotation during their fellowship, with increasing responsibilities throughout their training.
St. Elizabeth's Medical Center Rotation
Fellows spend three consecutive months during their training at SEMC. SEMC is a 350-bed teaching hospital located a few miles from Tufts. It is one of the major teaching resources of Tufts University School of Medicine, providing training each year to 100 housestaff, a third of the Tufts medical students, and fellows in many clinical areas. The hospital serves as both a tertiary referral center and a community resource, and offers a full range of clinical services including cardiac surgery and the largest hospital-based dialysis program in Boston. This experience is designed to provide a broad exposure to Nephrology in an academic/community hospital setting. Fellows are expected to manage an inpatient Nephrology service, a Nephrology consult service, an outpatient hemodialysis population, and see outpatients in a weekly clinic. Fellows also play a role in teaching medical students and housestaff. Fellows are responsible for preparing one to two case presentations during their three-month rotation at SEMC for the research/clinical Nephrology conference. Fellows are responsible for organizing, ordering, and coordinating all dialysis procedures including CVVH, acute hemodialysis, and peritoneal dialysis.
Independent Study Block
For fellows participating in the two-year Clinical Track, the independent study block is four to six consecutive months that are designated for supervised learning. Fellows must identify a mentor three to four months prior to starting their block so appropriate preparation and organization can take place. During this time, fellows can work on mentored research projects or quality improvement projects, prepare review articles, case reports, or book chapters for publication, or self-arrange electives. These electives can be in pediatric nephrology, ICU nephrology, kidney pathology, transplantation, tissue-typing, or other topics. The fellow is expected to report regularly to their mentor to update progress.
Kidney and Blood Pressure Center
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 area. Patients are seen in one of seven weekly nephrology clinics located on the 4th floor of 35 Kneeland Street. There are approximately 4000 active patients in the clinic, with 300 new referrals and 5000 return visits each year. The outpatient practice includes consultation on patients referred for a wide variety of kidney and hypertensive disorders, as well as the longitudinal care of patients with chronic kidney disease, metabolic disturbances, or end-stage renal disease on home-hemodialysis or peritoneal dialysis. Additionally, evaluation of living kidney donors, pre-transplant candidacy assessment, and follow-up care of patients after transplantation takes place in the clinic. A specialty Kidney Stone Clinic emphasizes the metabolic evaluation, preventive therapy, dietary management, and early detection of recurrent stones. Other specialty clinics focus on hereditary kidney disease, chronic kidney disease education, and an inter-disciplinary approach to kidney transplantation.
Fellows develop their own panel of 200-500 nephrology patients in two or three weekly clinic sessions where they are supervised by Division members. Except in unusual circumstances, they will always see the same patients with the same attending during the same time slot. There is no interchange of patients between the two to threedifferent clinic sessions that a single fellow attends. Fellows provide continuity of care for the duration of their training. To allow fellows to concentrate on the issues at hand, coverage of inpatient emergencies is provided during clinic sessions. Support services include two transplant coordinators, a Physician Assistant, a full-time nurse, and a medical assistant/phlebotomist.
Dialysis Clinic, Inc.
The Division’s outpatient dialysis facility is operated by Dialysis Clinic, Inc., a national nonprofit corporation. The facility currently serves about 100 hemodialysis patients. These include high-functioning dialysis patients who live in the neighboring community, patients undergoing evaluation for home-hemodialysis and transplantation, and others with complex medical and social needs requiring access to a tertiary care setting.
Tufts’ peritoneal dialysis program was the first in Boston. Currently, over twenty patients perform home peritoneal dialysis. A peritoneal dialysis nurse trains patients in collaboration with fellows and the attending staff. After training is complete, patients are seen monthly for follow-up visits in the Kidney and Blood Pressure Center as well as monthly in Somerville for visits with the peritoneal dialysis nurse.
Fellows are assigned a cohort of hemodialysis outpatients on a common shift. For a year, they serve as each patient’s primary nephrologist, with supervision from staff nephrologists. Vascular and peritoneal access surgery is performed by Transplant Surgery, and vascular access maintenance is provided by both Transplant Surgery and Interventional Radiology.
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