The intent of the Nephrology Fellowship Program, jointly held with Brigham and Women Hospital, is to train future leaders in academic nephrology. This is accomplished by providing our renal fellowship trainees with rigorous clinical training in nephrology and unparalleled resources for cutting-edge basic science and clinical research over a period of four years. The successful applicant will have strong evidence of superior clinical skills during internal medicine residency as well as exceptional ability and commitment to an academic research career.
The educational experience includes formal didactic talks, clinical renal practice, acquisition of expertise in a wide variety of renal, hypertensive and fluid-electrolyte disorders, extensive training in renal transplantation, dialysis, and extracorporeal therapy and versatility in performing a number of specialized procedures. Clinical learning and experience is largely acquired through one-on-one supervised patient care.
The clinical rotation comprises equal rotations on the dialysis, consult, ICU and transplant services. The clinical fellow spends roughly half the rotation time at MGH and BWH. A short rotation at the West Roxbury VA Hospital is also included. Each fellow will also have a half-day outpatient clinic supervised by a faculty member.
Several venues are utilized to achieve the program's overall goals in providing quality training in patient care, teaching, and research:
This is traditionally the core of the learning process. It is carried out on a daily basis both in the clinical (inpatient and outpatient) and research settings.
These include the following standard texts of Nephrology as well as material assembled into syllabi by faculty.
- "The Kidney" edited by B.M. Brenner.
- "Diseases of the Kidney" edited by Schrier and Gottschalk.
- "Clinical Physiology of Acid-Base and Electrolyte Disorders" by Rose.
- "Renal Pathophysiology" by Rose and Rennke.
- An extensive notebook of important articles in each area of general nephrology, emphasizing fluid and electrolyte and glomerular disease, has been organized by Mass General faculty.
- An extensive dialysis curriculum with reprints.
- Dialysis Manual by Daugirdas and Ing (portions).
- A Manual of Renal Transplantation by Allen and Chapman.
- Continuous Ambulatory Peritoneal Dialysis Curriculum & CAPD Policy and Procedure Manual.
- Sixty landmark articles in the field of nephrology selected by MKSAP
- The Mass General Nephrology Division Nephrology Case Collection. This collection includes some classic cases with pathological correlations and some paper cases for study when an actual patient with a particular condition is not available for observation. It is supplemented by the Division of Nephrology's slide collection.
Other tests and journals, as well as bibliographic search capabilities are available in the Division of Nephrology's Library, the Housestaff Library, MGH Treadwell Library, and the Harvard Countway Library. Bibliographic searches are also available through the hospital's computer system.
D. Weekly Conferences
- MGH Renal Grand Rounds: This is a weekly hour-long formal seminar held on Mondays at noon in the Renal Conference Room (GRB 1037). A wide range of mainly clinical topics are presented by the MGH and invited outside faculty.
- Transplant Seminar: This is a joint seminar series with the MGH Transplant service, held on Mondays at 5:00 pm. Formal presentations are given by MGH speakers from the Renal and Transplant Units, as well as by outside speakers. The subject matter addresses both basic and clinical aspects of transplantation immunology.
- MGH-BWH Joint Renal Grand Rounds: This is a joint teleconference between MGH and BWH held on Tuesday mornings in Potts Conference Room - Bigelow 856. Interesting case presentations are reviewed and discussed, alternating with formal presentations in areas of science relating to renal disease.
- Nephrology Division Seminars: These are held on Tuesdays at 4:00 pm at MGH East, Bldg. 149, 7th Floor Auditorium. Formal presentations are given by local as well as national and internationally recognized basic scientists. These one-hour seminars cover a wide range of basic topics in membrane biology, cell and structural biology and transplantation, and are designed to give the staff and trainees a broad and up to date exposure to major scientific progress.
- Radiology Rounds: These are held on Wednesdays at 4:00 pm in the MGH Department of Radiology in ACC-2. During these hour-long sessions, radiology reports on active renal patients are reviewed and the findings explained and discussed.
- Medical Grand Rounds: These one hour sessions are held on Thursdays at 8:00 am in the O'Keeffe Auditorium, Blake Building, 1st Floor.
- Immunology Seminar Series: This is held at MGH on Thursdays at noon at MGH East, Bldg. 149, 7th Floor Auditorium. Formal presentations are given by local as well as national and internationally recognized immunologists. These hour-long seminars cover a wide range of basic topics in humoral and cellular immunology and inflammation.
- Clinicopathological Conferences (CPCs): The Cabot Clinicopathological Conferences (CPCs) are an old Boston medical tradition, published by the New England Journal of Medicine (NEJM) as case records of the Massachusetts General Hospital. The hour-long CPCs are held on Thursdays at 12:00 pm in the O'Keeffe Auditorium, Blake Building, 1st Floor. From a case abstract, an invited speaker (and the audience) must deduce the differential diagnosis for an anonymous MGH patient, arriving at the probable diagnostic procedure and its findings. Faculty from the Division of Nephrology discuss 2 CPCs annually. These are held instead of the regular MGH-BWH Joint Renal Grand Rounds.
- Dialysis Rounds: This meeting is held on Thursdays at 12:30 pm in the Nephrology Conference Room (GRB 1037) and attended by dialysis physicians, dialysis nurses and dieticians. In this meeting, the progress of hemodialysis and peritoneal dialysis patients are reviewed.
- Research Journal Club: This is an hour-long session held at the CNY-8 conference room on Thursdays at 10:00 am with the purpose of reviewing 2 recent scientific publications of broad significance and/or application to renovascular research.
- Renal Pathology Conference: This one hour session is held on Thursdays at 3:00 pm in the Department of Pathology's Putschar Conference Room located in the Warren Basement. The goal of this conference is to learn how to interpret renal biopsies and make correlations between the clinical and pathological findings. This conference also provides a useful forum to exchange innovative ideas.
- MGH-BWH Integrated Fellows Conference: This hour-long conference is held every Wednesday at 12:00 pm in the Renal Conference Room (GRB 1037).
- Transplant Conference: This is a weekly conference held on Wednesdays from 8:30 am - 9:30 am in the Blake 6 Conference Room, and attended by the Renal and Surgical Transplant visits in conjunction with the Infectious Disease visit and members of the Transplantation Biology Research Center. It reviews current cases to teach important elements in the immunology of transplantation, the management of rejection, and infectious complications.
- Nephrology Division Laboratory Meeting: This one hour session is held on Fridays at 1:00 pm in the CNY-8 renal conference room. Formal presentations by 1-2 research fellows of ongoing work are discussed by the research faculty.
In addition to the above listed formal conferences, a series of lectures are given at the beginning of the academic year on dialysis, transplantation and the care of renal emergencies.
Each fellow has the opportunity to attend one national nephrology meeting each year. Such meetings include the annual American Society of Nephrology Congress or the spring clinical meetings of the National Kidney Foundation. Research fellows may attend these meetings to present their abstracts in oral and/or poster formats. Fellows may also attend the annual nephrology postgraduate courses held at Harvard-Affiliated Hospitals.
Teaching is a very effective way of learning. As such, the fellows have ample opportunities to teach in this training program. In addition to the daily bedside teaching of medical students and residents attending renal rounds, fellows also prepare for case presentations during renal grand rounds, clinical case conferences, and give formal talks that are presented to the division's staff on three or more occasions each year. They also present their research findings in the weekly laboratory meetings. Many fellows also participate with the MGH/BWH faculty in teaching renal physiology and pathophysiology to first and second year medical students at Harvard Medical School.
Project Professionalism & Responsible Conduct of Research
- Project Professionalism: This program developed by the American Board of Internal Medicine offers a good forum for examining the various issues associated with caring for patients with end-stage renal disease.
- Responsible Conduct of Research: The promotion and maintenance of scientific integrity is a basic tenet in the conduct of research. All research trainees are required to participate in a course given annually to new fellows in the responsible conduct of research.
The Nephrology Handbook
This concise handbook provides some of the practical points and pearls of nephrology practice and a framework for further reading. It provides differential diagnoses and approaches to management of common renal diseases. It also lists specific rotations, daily seminars and useful hospital services phone numbers, and is distributed at the beginning of the fellowship.
Each fellow will spend 3.5 months on the inpatient consultation service, 2 months at MGH, and 1.5 months at BWH. The consultation service at MGH also covers the Massachusetts Ear and Eye Infirmary. During this period, the fellow is expected to acquire experience in:
- Disorders of mineral metabolism, including nephrolithiasis, osteoporosis, and renal osteodystrophy
- Disorders of fluid, electrolyte, and acid-base balance
- Acute renal failure
- Chronic renal failure and its management by conservative, nutrition, and dialytic methods
- End-stage renal disease
- Hypertensive disorders
- Renal disorders of pregnancy
- Urinary tract infections
- Tubulointerstitial renal diseases, including inherited diseases of transport, cystic diseases, and other congenital disorders
- Glomerular and vascular diseases, including the glomerulonephritides, diabetic neuropathy, renovascular disease, and microvascular syndromes
- Disorders of drug metabolism and renal drug toxicity
The Fellow will see all requests for consultation called into the Renal Consultation service. After seeing the patient, the fellow discusses the problem with the visit for the Renal Consult service, writes an initial note after communication with the attending nephrologist, and follow-up notes as considered appropriate. Medical Residents rotating on the Renal Service may also take this role, and students are also involved in working up and following these patients. A fixed time is designated each day for the fellow (+/- student and resident) to meet with the attending nephrologist to discuss progress and plans. The fellow sees all of the Division of Nephrology patients admitted to the hospital, whatever the reason for admission is. If the patients are admitted to the Renal Visit on the private medical service, the fellow and the visit will act as the primary caretakers (in concert with the medical house staff) during hospitalization. When patients are admitted to the medical ward service or other non-medical services, the fellow acts as a consultant giving input as needed an appropriate. The fellow also manages any problems with peritoneal dialysis patients.
Dialysis and Extracorporeal Therapy
Each fellow will be exposed to dialysis and extracorporeal therapies during 3.5 months of the training, divided between MGH and BWH. During this rotation, the fellow evaluates all initial consults when hemodialysis is considered even if it is not imminent, supervised by the dialysis attending of the month. The clinical experience includes:
- Evaluation and selection of patients for acute hemodialysis or continuous renal replacement therapies.
- Evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options.
- Drug dosage modification during dialysis and other extracorporeal therapies.
- 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.
- Long-term follow-up of patients undergoing chronic dialysis, including their dialysis prescription, modification, and assessment of adequacy of dialysis.
- An understanding of the principles and practice of peritoneal dialysis, including the establishment of peritoneal access, the principles of dialysis catheters and how to choose appropriate catheters.
- An understand of the technology of peritoneal dialysis, including the use of cyclers.
- Assessment of peritoneal dialysis efficiency, using peritoneal equilibration testing and the indications and interpretation of peritoneal biopsy.
- An understanding of how to write a peritoneal dialysis prescription and how to assess peritoneal dialysis adequacy.
- The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis.
- An understanding of the complication of peritoneal dialysis, including peritonitis and its treatment, exit site and tunnel infections and their management, hernias, pleural effusions, and other less common complications and their management.
- An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient.
The activities on the Transplantation Service include the transplant donor and recipient evaluation, hospital admission of patients receiving transplants or those with transplants who are suffering from acute or chronic complications, as well as the outpatient management of patients post-transplant. Each fellow will have 3.5 months of experience on an active renal transplant service divided between MGH and BWH. The fellow is trained in the pre and post-transplant management and follow up of patients. During the rotation, the fellow attends two to three outpatient transplant clinics a week and participates in management decisions. This transplant experience includes the following:
- Evaluation and selection of transplant candidates.
- Preoperative evaluation and preparation of transplant recipients.
- Immediate postoperative management of transplant recipients including administration of immunosuppresive drugs.
- Clinical diagnosis and management of all forms of acute and chronic rejection including laboratory, histopathologic, and imaging techniques.
- Recognition and medical management of the surgical and non-surgical complications of transplantation.
- Long-term follow-up of transplant donors and recipients in the ambulatory setting.
Ambulatory Renal Service
The fellow will spend one-half day each week in the ambulatory practice setting, seeing the entire spectrum of outpatient nephrology. The fellow will evaluate the patients and formulate plans and will discuss the case with the attending physician. The fellow is responsible for communicating with referral physicians and for longitudinal follow-up of these patients when appropriate. The rotation will expose fellows to:
- Evaluation and management of patients with hematuria and proteinuria.
- Evaluation and management of the complicated hypertensive patients.
- Management of patients with chronic renal failure.
- Evaluation and management of patients with nephrolithiasis.
- Evaluation of patients for transplantation.
- Transplant donor evaluations.
- Management of patients following renal transplantation.
A number of electives, usually 2-4 weeks, are available for the renal fellows. They include:
- Pediatrics: This rotation may take place in the second or third year. The fellow will participate fully in the outpatient pediatric clinics at MGH, the inpatient consult services, and conferences.
- Radiology: This elective is structured with the MGH Department of Rediology. During this elective, the fellow will attend the various renal-focused procedures and the interpretation sessions.
- Pathology: This rotation involves supervised training in the preparation and processing of renal tissues, and the interpretation of the material by light or electron microscopy. During the elective, the fellow presents the pathology findings during the weekly pathology conference.
Technical and Other Skills
Fellows will receive hands-on training, including the indications, contraindications, complications, and interpretation of results of the following procedures:
- Urinalysis and uroscopy
- Percutaneous biopsy of native and transplanted kidneys
- Peritoneal dialysis
- Placement of temporary vascular access (subclavian, femoral, or internal jugular) for hemodialysis and related procedures
- Acute and chronic hemodialysis
- Placement of peritoneal catheters
- Renal ultrasound (use and interpretation)
- Continous hemofiltration, arteriovenous and/or venovenous
- Placement of temporary peritoneal catheters
Fellows are encouraged to acquire the knowledge base (that includes cost-effectiveness) and expertise in the following procedures:
- Radiology of vascular access
- Balloon angioplasty of vascular access
- Therapeutic plasmapheresis
- Interpretation of renal biopsies
- Bone biopsy
- Placement of permanent peritoneal catheters
Please click here for more information on the MGH guidelines for research fellows.
The main elements of the Mass General research training program are:
Basic and clinical research activities involve several NIH-supported initiatives directed by the Mass General Division of Nephrology staff. These include
- Program in Membrane Biology
- Program in Leukocyte Biology & Inflammation
- Program in Renovascular Development and Cystogenesis
- Program in Dialysis & Transplantation
- Program in Clinical Outcomes and Epidemiology Research
- Program in Structural Biology
In addition, research on the induction of tolerance across concordant and discordant species is carried out in the Transplantation Biology Research Center on the 9th floor of Building 149 in the Navy Yard, one floor above the Renal Unit's research laboratories. Fellows joining ongoing research projects in any of the above programs will receive intensive training in a multidisciplinary environment and be closely supervised by senior and junior faculty preceptors. There are ample opportunities for training in diverse disciplines of membrane biology, biophysics, immunology, cell adhesion, development, biochemistry, biophysics, cell signaling, structural biology and outcomes, and epidemiology research. This provides a multi-disciplinary approach in the study of one of the most heterogenous organs in the mammilian organism - the kidney. These approaches are applied in many cases to clinically relevant diseases such as nephritis, acute renal failure, electrolyte disorders, polycystic kidney disease, bioincompatibility, allograft rejection, and vasculitis.
Acquisition of new research tools is most effectively accomplished through the daily interaction of the fellow with an assigned person who already has the required methodological skills, and is able to transmit this knowledge in a friendly and comprehensive manner. Formal lectures are also offered that introduce the fellow to laboratory or to clinical investigation. In addition, Mass General has established "The Society of Fellows." Among the activities of this society is a formal introduction of fellows to the residents and staff, a lecture series on grant writing, bioethics, conflict resolution, job hunting, and time management in two career families. At Mass General, several such summer/fall programs specifically designed for new post-doctoral fellows are offered. Examples include "Current Techniques in Molecular Biology," a one month intensive course offered in July of each year, and covers the theory and practice of major molecular biology techniques including Bioinformatics. This course is followed by "Introduction to Laboratory Techniques in Molecular Biology," a more specialized two week intensive course offered by the Department of Molecular Biology at Mass General. The third course "Issues in Physiologic Investigation" reviews specific principles, tools, and methodologies for investigating physiologic questions, paying particular attention to the relative strengths and weaknesses of various methodologies. In addition to the formal course content, participants are exposed to a cadre of physiologic investigators, providing opportunities for faculty interaction and networking. "Design and Conduct of Clinical Trials," surveys the theory and practice of clinical trials, reviews design and conduct of clinical research, and enables participants to conceive, plan, propose, and develop effective clinical trials. Content essential to the design and conduct of clinical trials are covered including the components of phase I - IV studies, the design and writing of study protocols, issues regarding patient recruitment and selection, human subjects, the informed consent process and regulatory issues. For additional course lists, see the MGHCRnet. Opportunities are available to further supplement the didactic programs described above. There are a number of opportunities for fellows to enrich their fundamental scientific knowledge with courses at Harvard College, Harvard Medical School, Harvard School of Public Health, and Massachusetts Institute of Technology (MIT). A wide choice of relevant courses provides flexibility in structuring the overall fellowship program. In addition to these formal courses, a weekly lecture series, combined with clinical and research journal clubs, weekly laboratory meetings, and daily contacts with the mentor and the Program Director provide the other important venues for enhancing intellectual growth and development of the fellow in clinical investigation and basic research.
Choice of Preceptor and Research Project
Trainees generally choose a mentor prior to beginning the fellowship. During the interview process, they also have the opportunity to learn about the work being done in various laboratories, to consider specific research projects, and to discuss training and the research environment with current fellows. Clinical fellows with no previous laboratory experience are encouraged to work closely with their chosen mentor to develop a plan for the research years. If, however, such trainees are not able to identify a specific mentor and project area, the decision can be deferred until after initiation of the clinical year of training. To aid in this effort, the Division of Nephrology has devised a seminar series during the summer and fall sessions of every year during which preceptors present their respective research. The trainees are then encouraged to meet with all of their potential preceptors in the training program to further discuss their career development plans. In addition, first year clinical fellows are encouraged to discuss their goals with more senior fellows, both for general advice and for more detail about the overall research directions previously chosen by other fellows. In this manner, the trainees enter the research training program already familiar with the skills and interests of the entire faculty as well as personal knowledge of potential mentors. This process provides a smooth transition into the research arena, and presents the appropriate environment where enthusiasm among faculty and colleagues can be readily displayed to the young trainees in helping them choose such a career. Fellows are also encouraged to write a brief research grant proposal under the guidance of the mentor, a process that helps crystallize the candidate's research plans, and provides a training forum in grant writing.
Guidance and Evaluation
During the research years, direct guidance of the trainee is the immediate responsibility of the individual preceptor. Fellows are however encouraged to interact with the other principal investigators and their personnel in the program, a process that will increase their overall knowledge base, and expose them to new fields and techniques that could be invaluable in their pursuit of independent scientific careers. The clinical fellows serving at Mass General will meet with Dr. Amin Arnaout and Dr. Hasan Bazari both formally and informally. During these sessions, any issues related to the program are discussed, and any necessary refinements/improvements in the program are implemented as a result. At Mass General, the research fellows will also have formal or informal (bimonthly) meetings with Dr. Arnaout, during which any issues regarding their research training, environment and progress are reviewed and discussed. The fellows are also given adequate exposure to other faculty through several forums such as the visit of the month rotation, the formal year-round lecture series given by various principal investigators, the weekly presentation of clinical cases at the joint MGH/BWH Renal Grand Rounds, the weekly dialysis, transplantation, pathology and radiology conferences through participation in regularly scheduled journal clubs, and the weekly intra- and inter group presentations. The fellowship program is overseen by a supervisory committee made up of two staff members from each hospital. The committee meets quarterly to monitor progress of the fellows. Evaluations are communicated to each of the clinical fellows to provide them with opportunities for improvement and to help them refine their clinical and technical skills. Feedback to the research fellows is provided on a quarterly basis, after consultation with their preceptors and research colleagues. Each trainee meets several times a year with the Supervisory Committee to evaluate his/her progress and to make any necessary modifications in the program.
Both the Division of Nephrology and Massachusetts General Hospital are equal opportunity employers. Before beginning the MGH/BWH Joint Fellowship Program in Nephrology, a candidate should have completed at least two (preferably three) years of training in internal medicine. Interested applicants should submit their application through ERAS between July 1 and March 1 for positions beginning July 1. We strongly recommend that applicants complete the ERAS application process before December 1 as this will facilitate timely interview dates since fellowship programs can access applications on December 1st. We will then invite outstanding candidates for a two-day interview process to be scheduled from December through March. We do sponsor visas for exceptional renal fellowship candidates. We will be participating in the Nephrology Fellowship Match using the NRMP system and their listed dates.
For additional information, please contact:
Wendy De Mille, Nephrology Academic Coordinator and ESRD Program Manager
Division of Nephrology
Massachusetts General Hospital
55 Fruit Street, GRB 1003K
Boston, MA 02114
Fellowship Training Program