Fellowships, Residencies & CME

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Transplant Nephrology Fellowship Program

This one-year program is accredited by the American Transplant Society and endorsed by the American Society of Nephrology. After completion of the fellowship, graduates are UNOS (United Organ Sharing) certified transplant nephrologists and qualified to head UNOS approved transplant nephrology programs.

Overview

The Transplant Nephrology Fellowship at Massachusetts General Hospital is accredited by the American Society of Transplantation (AST) and integrates components of surgical and nephrology fellowship programs. This multidisciplinary approach provides fellows the opportunity to participate in a comprehensive, patient-centered program and learn from faculty who are experts in all areas of transplantation.

The service is made up of a:

  • Transplant nephrology fellow
  • Clinical nephrology fellow
  • Transplant surgical fellow
  • Third year surgical resident
  • Fourth year surgical resident
  • Surgical intern

Staff coverage and supervision in the Transplant Unit is provided at all times by both a staff transplant surgeon and a staff transplant nephrologist.

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 for guidance at all times. A transplant pharmacist is present at morning rounds.

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

Both the Division of Nephrology and Massachusetts General Hospital are equal opportunity employers. Before beginning the Transplant Nephrology Fellowship Program, 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.

Education

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

  1. Transplant Immunology
    1. Normal immune response
    2. Response to allografts
    3. Tolerance
    4. Crossmatches, flow cytometry
    5. Identification of anti-HLA antibodies/donor specific antibodies
  2. Pharmacology/Immunosuppression
    1. Available agents
    2. Review mechanisms of the agents
    3. Current pharmacotherapy
    4. Investigational agents
    5. Therapeutic drug monitoring of immunosuppressive therapies
    6. Steroid avoidance and withdrawal
    7. CNI elimination/minimization and withdrawal
    8. Drug-drug interactions
    9. Drug side effects
  3. Medical Complications of Transplantation
    1. Infections
      1. Bacterial
      2. Viral
      3. Fungal
    2. Hypertension
    3. Atherosclerosis
    4. Hyperlipidemia
    5. Transplant-associated hyperglycemia
    6. Transplant associated malignancy
      1. Viral driven malignancy (PTLD, cervical CA, Kapos's sarcoma, nasopharyngeal CA)
      2. Non-virally driven malignancy (renal cell, skin)
    7. Hepatobiliary disease/HCV
    8. Musculoskeletal and bone/mineral metabolism
    9. Posttransplant erythrocytosis
    10. Metabolic syndrome
  4. Organ Allocation
    1. Reviewing the new Kidney Allocation System (KAS)
  5. Pretransplant Evaluation of the Recipient
  6. Pretransplant Evaluation of the Living Donor
  7. Graft Dysfunction
    1. Rejection
    2. Mechanical complications
    3. Infection
    4. Nephrotoxicity
    5. Recurrent disease
    6. De novo disease
    7. Renal artery stenosis
  8. Expected Outcomes/Risk Factors
    1. LRD
    2. Deceased donor organs
      1. PHS high risk donors
      2. KDPI>85%
      3. DCD
      4. Pediatric en bloc
    3. LURD
    4. Race
    5. HLA matching
    6. Original disease
  9. Special issues in pediatric renal transplantation
  10. Pregnancy and contraception
  11. Ethics
  12. Pancreas transplantation
  13. Kidney transplantation in other solid organ transplant recipients (both after other organs, and the combined kidney/"other" organ)
  14. Transplantation of ABO-incompatible and cross-match incompatible individuals
  15. Paired kidney exchange programs
  16. Business and administrative Aspects of Transplantation

Transplant Pathology Series

  1. Review of Banff Criteria
  2. Acute and chronic rejection, subclinical rejection
  3. Calcineurin inhibitor toxicity
  4. Recurrent Disease
  5. C4d staining
  6. BK nephropathy
  7. Thrombotic microangiopathy
  8. Clinical management of pathologic findings
  9. Protocol transplant biopsies

Expanded Learning Opportunities

In addition to followining the above curriculum, The fellow will attend weekly:

  • Transplant Center conferences, including monthly morbidity and mortality conferences
  • Renal Grand Rounds
  • Combined Renal Grand Rounds with Brigham and Women's Hospital
  • Daily Transplant Rounds while rounding on the inpatient service
  • Pathology conferences

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:

  1. 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.
  2. 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.
  3. Deceased donor
    The transplant nephrology fellow will be involved in at least three multi-organ retrievals, and be involved with the:
    1. Principles of organ preservation
    2. Identification and evaluation of a deceased donor organ
    3. Surgical aspects of renal, liver, heart, and pancreas procurement from the a deceased donor
    4. Procedure for procuring non-heart-beating donors
  4. Renal Transplantation
    It is the expectation that the transplant nephrology fellow will:
    1. Obtain a detailed knowledge immunology of transplantation, including the normal immune response, immune and inflammatory responses to the allograft, immunogenetics, and tissue typing
    2. 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
    3. 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
    4. 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
    5. 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
    6. 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
    7. 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
    8. Gain an understanding of the special considerations for pancreas-after-renal transplantation as well as simultaneous pancreas and renal transplantation
    9. Consider issues of pregnancy in renal transplant recipients.
    10. Pediatric Renal Transplantation
  5. 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.
  6. 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 conferences.

  7. 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.

  8. 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.

  9. 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

Clinical Responsibilities of the Transplant Nephrology FellowInpatient Responsibilities

The transplant nephrology fellow will spend at least six months on the inpatient clinical service. The fellow will participate in the daily multidisciplinary transplant rounds and follow the patients with the attending physician. The fellow will also see consults for patients with other organ transplants (lung, liver, heart and bone marrow) who have developed renal issues such as acute kidney injury. The fellow will be on call with the attending physician one weekend per month.

Outpatient Responsibilities

The transplant nephrology fellow will participate (for 12 months) in the longitudinal follow-up of renal and pancreas post-transplant patients. The fellow will attend three clinics weekly while on the inpatient service and four clinics weekly while on the outpatient service. In addition, the fellow will be expected to attend (for a period of three months) a multidisciplinary transplant recipient and living donor clinic. Patients will be reviewed by the staff physician prior to discharge from the clinic. 

Educational Resources

Tissue Typing Coordinators

The transplant fellow will spend a two-week rotation in the Tissue Typing Lab in order to become familiar with the methodology, utility and reliability of various tissue typing, cross match and immune surveillance technology. Dr. Susan Saidman is the director of the Tissue Typing Laboratory at Mass General.

Renal Pathology Coordinators

The transplant fellow will learn the art of renal biopsy, under the auspices of Winfred Williams, MDKassem Safa, MD, and David Wojciechowski, DO, who will supervise the performance of the biopsies at Mass General. The interpretation of transplant biopsies will be coordinated with Robert Colvin, MD, and Neal Smith, MD, PhD, renal pathologists at Mass General. The fellow will gain experience with the interpretation of these biopsies, the knowledge of Banff criteria and a translation of clinical issues.

There is a weekly renal pathology conference at Mass General at which these biopsies are reviewed.

Weekly Transplant Conference

Each week, topics in transplantation are presented by members of the nephrology, immunology and transplant community in areas of basic science research as well as in clinical care. These conferences are attended by members of both divisions and attendance by the fellow would be required. This weekly conference is coordinated by Francis Delmonico, MD, surgeon in the Division of Transplant Surgery and director of New England Organ Bank.

Morbidity and Mortality Rounds

These mothly rounds review all medical and surgical complications and are prepared in coordination with the clinical fellow. These rounds are coordinated by Nahel Elias, MD, surgical director of Kidney Transplantation.

The clinical research program in Transplant Nephrology at Massachusetts General Hospital is a robust program supervised by Dr. David Wojciechowski. In the last six months, nine new clinical trials in various stages of development and initiation have begun. These trials focus on novel immunosuppression regimens and agents as well as immune monitoring and treatment and prevention of opportunistic infections post-transplant. The program has an emphasis on clinical trials in BKV and CMV, which builds on Mass General's traditional strength in transplant infectious disease.  Most of these trials are suited to have a fellow co-investigator. Additionally, a research database is being developed to enhance and facilitate retrospective studies that can be completed by a fellow with a limited timeframe. 

The program has a strong basic science component through the Center for Transplantation Sciences (CTS). Fellows can develop basic and translational research projects under the guidance of Larry Turka, MD, co-director for the CTS. The CTS focuses on the following three areas:

  • Understanding the mechanisms underlying the immune response
  • Developing novel means of inducing immune tolerance
  • Finding creative ways of increasing the supply of donor organs. 

In addition to the research performed within the CTS laboratories, Mass General is one of the three major institutional partners supporting research performed under the auspices of the Immune Tolerance Network (ITN).

Interested applicants should submit a copy of their CV and three letters of recommendation to Wendy De Mille (at WDeMille@partners.org) between May 1st and September 15th, 2016 for positions beginning July 1, 2017. The information will then be reviewed and invitations to interview will be sent out after August 1st, 2016. Outstanding candidates will be invited for a one-day interview process in September through October 2016.

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: wdemille@partners.org

 

 

Fellowship Training Program

55 Fruit Street
GRB 1003
Boston, MA 02114

Phone: 617-726-3706
Fax: 617-726-2288
Email: wdemille@partners.org

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