Overview

The program is American Society of Transplant (AST) approved. Typically, there is one transplant nephrology fellow, one clinical nephrology fellow, one transplant surgical fellow and a fourth year surgical resident, a third year surgical resident and an intern on the service. The program is integrated between the surgery and the nephrology fellowship programs in order to benefit from the expertise of all its members. The program thrives from a true multidisciplinary effort.

Staff coverage and supervision in the transplant unit is provided by both a staff transplant surgeon as well as a staff transplant nephrologist at all times.

Transplant rounds are held daily with the transplant surgeon and transplant nephrologists, residents, fellows, and other support staff in attendance. Decisions regarding immunosuppression are made with reference to jointly established policy guidelines and protocols. Infectious disease consultants are present on morning rounds and available at all times. A transplant pharmacist is present at morning rounds.

There is a weekly transplantation conference, which again brings together members of the different departments working in transplantation-related fields. During these sessions, invited guests both national and international, present different areas in the field of transplantation. The fellow also has the opportunity to present research and clinical reviews at these conferences.

Requirements

Both the Division of Nephrology and Massachusetts General Hospital are equal opportunity employers. Before beginning the Transplant Fellowship Program in Nephrology, a candidate should have completed at least two (preferably three) years of training in internal medicine and be board-certified or board-eligible in nephrology.

Curriculum

The Transplant Fellow will attend a biweekly didactic conference which covers topics as outlined in the AST curriculum:

Transplant Immunology

    • Normal immune response
    • Response to allografts
    • Tolerance
    • Crossmatches, flow cytometry
    • Identification of anti-HLA antibodies/donor specific antibodies

Pharmacology/Immunosuppression

  • Available agents
  • Review mechanisms of the agents
  • Current pharmacotherapy
  • Investigational agents
  • Therapeutic drug monitoring of immunosuppressive therapies
  • Steroid avoidance and withdrawal
  • CNI elimination/minimization and withdrawal
  • Drug-drug interactions
  • Drug side effects

Medical Complications of Transplantation

        • Infections
          • Bacterial
          • Viral
          • Fungal
        • Hypertension
        • Atherosclerosis
        • Hyperlipidemia
        • Transplant-associated hyperglycemia
        • Transplant associated malignancy
          • Viral driven malignancy (PTLD, cervical CA, Kapos's sarcoma, nasopharyngeal CA)
          • Non-virally driven malignancy (renal cell, skin)
        • Hepatobiliary disease/HCV
        • Musculoskeletal and bone/mineral metabolism
        • Posttransplant erythrocytosis
        • Metabolic syndrome

Organ Allocation

  • Reviewing the new Kidney Allocation System (KAS)

Pretransplant Evaluation of the Recipient Pretransplant Evaluation of the Living Donor Graft Dysfunction

  • Rejection
  • Mechanical complications
  • Infection
  • Nephrotoxicity
  • Recurrent disease
  • De novo disease
  • Renal artery stenosis

Expected Outcomes/Risk Factors

  • LRD
  • Deceased donor organs
    • PHS high risk donors
    • KDPI>85%
    • DCD
    • Pediatric en bloc
  • LURD
  • Race
  • HLA matching
  • Original disease

Special issues in pediatric renal transplantation

Pregnancy and contraception

Ethics

Pancreas transplantation

Kidney transplantation in other solid organ transplant recipients (both after other organs, and the combined kidney/"other" organ)

Transplantation of ABO-incompatible and cross-match incompatible individuals

Paired kidney exchange programs

Business and Administrative Aspects of Transplantation

Transplant Pathology Series

  • Review of Banff Criteria
  • Acute and chronic rejection, subclinical rejection
  • Calcineurin inhibitor toxicity
  • Recurrent Disease
  • C4d staining
  • BK nephropathy
  • Thrombotic microangiopathy
  • Clinical management of pathologic findings
  • Protocol transplant biopsies

 

 The fellow will attend:
 

  • Transplant Center Conference (including monthly morbidity and mortality) - weekly
  • Renal Grand Rounds - weekly
  • Combined Renal Grand Rounds with Brigham and Women's Hospital – weekly
  • Daily Transplant Rounds (while rounding on the inpatient service)
  • Pathology Conference - weekly

Clinical Experience

The transplant nephrology fellow will develop expertise in the following areas of renal and pancreas transplantation through medical, surgical, and research experience and by satisfying the requirements of the American Transplant Society.

Pretransplant Renal Evaluation

(Work-up of at least 30 potential recipients)

 

Thorough participation in the already established multidisciplinary transplant recipient evaluation clinics, the fellow will understand the risks and benefits of dialysis versus renal transplant and will be involved with the counseling, evaluation, education, and selection of potential recipients for kidney transplantation, as well as kidney-pancreas transplants.

Kidney Donors

(Evaluation of at least 20 potential donors, and observe  the surgical procedures of a  live donor nephrectomy)

The trainee will be educated in the pros and cons of using living donors; the short- and long-term risks and follow-up of the live kidney donor; the evaluation, education and counseling of the living-related and unrelated kidney donor; and the differences between the open procedure and laparoscopic procedure.

Deceased donor

The transplant nephrology fellow will be involved in at least 3 multi-organ retrievals, and be involved with the:

      • Principles of organ preservation
      • Identification and evaluation of a deceased donor organ
      • Surgical aspects of renal, liver, heart, and pancreas procurement from the a deceased donor
      • Procedure for procuring non-heart-beating donors

Renal Transplantation

      It is the expectation that the transplant nephrology fellow will:

 

      • Obtain a detailed knowledge immunology of transplantation, including the normal immune response, immune and inflammatory responses to the allograft, immunogenetics, and tissue typing
      • Gain an in-depth knowledge of induction and maintenance immunosuppressive therapy, including the mechanism of action and pharmacology of drug interactions, safety, side effect profile, and efficacy of immunosuppressive therapy, including new investigational therapies, e.g., tolerance protocols
      • Obtain knowledge about prophylactic therapy with antiviral agents to prevent cytomegalovirus infection, HSV, Pneumocystis jiroveci, as well as urinary tract infections. Will understand the pharmacology, drug interactions, pharmacokinetics, safety, and side effect profiles
      • Gain expertise in the post renal transplant care of in patients as well as outpatients and knowledge of the expected clinical outcomes and analysis of risk factors
      • Obtain knowledge of the management of the diagnosis and management of acute rejection, as well as the evaluation and treatment of nonimmunologic causes of acute kidney transplant dysfunction
      • Gain knowledge about the evaluation and treatment of surgical complications of renal transplant, as well as the evaluation, prevention, and treatment of medical complications including cardiovascular disease, opportunistic infection, bone disease, and malignancy. The transplant fellow will observe 3 kidney transplants
      • Be involved with the management of chronic allograft dysfunction, including chronic rejection, both cellular and humoral, recurrent disease within the allograft as well as de novo disease
      • Gain an understanding of the special considerations for pancreas-after-renal transplantation as well as simultaneous pancreas and renal transplantation
      • Consider issues of pregnancy in renal transplant recipients
      • Pediatric Renal Transplantation
        • The transplant fellow will be exposed to pediatric renal transplantation, and the special consideration involved in evaluating a donor and selection of immunosuppression, as well as issues related to growth and development with renal transplant

        Tissue Typing

        The renal transplant fellow will be required to spend at least 2 weeks in the Histocompatability Lab, learning the principles, methodology, and interpretation of tissue typing and crossmatching for renal transplantation, including various lymphocytotoxic assays, ELISA, and flow crossmatch.

        Renal Pathology

        The fellow will perform at least 10 transplant biopsies and will review the biopsies with renal pathologists according to the Banff criteria. The fellow will attend the weekly renal pathology conference and present patients at monthly morbidity and mortality conference.

        Family Meetings

        The fellow will be involved with family meetings, to discuss the risks and benefits of transplant with the patient, family, psychiatrist, nephrologists, surgeon, transplant coordinator, and social worker, and will learn about the ethics of organ donation.

        Waiting List

        The transplant nephrology fellow will be involved with creating and managing the renal transplant waiting list, and will attend the weekly interdisciplinary transplant conference to determine candidacy.

        Organ Procurement

        The fellow will obtain knowledge of other procurement and transplant systems, including UNOS, as well as the economics of transplantation. The fellow will be involved with organ awareness programs.

Research Experience

There are ample opportunities for the transplant fellow’s participation in clinical and/or basic science research. Clinical and animal studies in tolerance, ABO incompatibility and desensitization are ongoing.

How to Apply

Interested applicants should submit a copy of their CV and three (3) letters of recommendation to Wendy De Milleby emailbetween May 1 and September 15, 2014, for positions beginning July 1, 2015. The information will then be reviewed and invitations to interview will be sent out after August 1, 2014. Out-standing candidates will be invited for a one-day interview process in September through October 2014.

For additional information, please contact:

Wendy De Mille, Manager, Nephrology Academic Affairs and Dialysis Services

Division of Nephrology
Massachusetts General Hospital
55 Fruit Street, GRB 1003K
Boston, MA 02114
Phone: 617-726-3706
Fax: 617-726-2288
Email

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Fellowship Training Program

GRB 100355 Fruit Street Boston, MA 02114
  • Phone: 617-726-3706
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