Massachusetts General Hospital | Transplant Center

Overview

The overall objective of the Nephrology Fellowship Program at Massachusetts General Hospital is to provide vigorous and comprehensive clinical and research training in nephrology for physicians to become productive clinical and basic scientists, and leaders in academic nephrology. The program offers a one-year rotation on the clinical services at Massachusetts General Hospital and Brigham and Women's Hospital, and three or more years of training in full-time basic or clinical research at Massachusetts General Hospital. 

Curriculum

To achieve the Program's overall goals in providing quality training in patient care, teaching and research, several venues are utilized.

One-on-one teaching

This is traditionally the core of the learning process. It is carried out on a daily basis both in the clinical (in-patient and out-patient) and research settings.

Guided readings

These include the following standard texts of Nephrology as well as material assembled into syllabi by faculty.

1. "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 and "Renal Pathophysiology" by Rose and Rennke
2. 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
3. An extensive Dialysis Curriculum with reprints
4. Transplant and Transplant Immunology Curriculum with reprints
5. Dialysis Manual by Daugirdas and Ing (portions)
6. A Manual of Renal Transplantation by Allen and Chapman (portions)
7. Continuous Ambulatory Peritoneal Dialysis Curriculum & CAPD Policy and Procedure Manual
8. Sixty landmark articles in the field of nephrology selected by MKSAP
9. The MGH 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 Nephrology Division slide collection

Independent reading

Other texts and journals, as well as bibliographic search capabilities are available in the Nephrology Division library, the house staff library, the Mass General Treadwell library, and the Harvard Countway Library. Bibliographic searches are also available through the hospital's computer system.

Weekly Conferences

Mass General Renal Grand Rounds 
This is a weekly hour-long formal seminar held on Mondays at noon in Bigelow 10 Conference Room (Rm 1030). A wide range of mainly clinical topics are presented by Mass General and invited outside faculty.

Transplant Seminar

This is a joint seminar series with the Mass General Transplant service, held on Mondays at 5 pm in Sweet Room - Gray 4. Formal presentations are given by Mass General 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 Mass General and Brigham and Women's Hospital, 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 Mass General 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 Mass General Radiology Department 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 are held on Thursdays from 8:00 to 9:00 am in O'Keefe Auditorium, Blake 1st Floor.

Immunology Seminar series

This is held at Mass General on Thursdays at noon at Mass General East, Bldg. 149, 7th Floor Auditorium. Formal presentations are given by local as well as national and internationally-recognized immunologists. These one-hour 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 CPCs are held Thursdays, 12-1pm, in the O'Keefe Auditorium, Blake 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 Nephrology Division discuss 2 CPCs annually. These are held instead of the regular MGH-BWH Joint Renal Grand Rounds.

Dialysis Conference

This meeting is held from 1:00 to 2:00 p.m. on Thursdays in the Dialysis Unit, Bigelow 10, and attended by dialysis physicians, dialysis nurses, dietitians and surgeons. In this meeting, the progress of hemodialysis and peritoneal dialysis patients is reviewed.

Research Journal Club

This is held at CNY8 conference room on Thursdays from 10:00 to 11:00 with the purpose of reviewing 2 recent scientific publications of broad significance and/or application to renovascular research.

Renal Pathology Conference
This is held on Thursdays from 3:00 to 4:00 p.m. in the Pathology Department, Putschar Conference Room, Warren Basement. The goal 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

Clinical Fellows Conference

This is held at Mass General on Fridays from 1:00 to 2:00 p.m. at GRB1037 renal conference room from September to June of each year. This forum is used to present problem cases in a group meeting that includes the clinical Staff, listen to formal presentations given by the fellows addressing an in depth review of a topic or of recent journal articles. This conference is directed specifically to the first year fellows. Each of the renal fellows, with Mass General as their home base, will present two fellows' seminars at Mass General and one at Brigham and Women's. The fellows from Brigham will present two at Brigham and Women's and one at Mass General. The objective is to become proficient in clinical practice and up to date in the nephrology literature.

Transplant Conference

This is a weekly conference held on Fridays from 7:30 to 9:00 a.m. in Wellman 1 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 and in management of rejection and of infectious complications.

Nephrology Division Laboratory Meeting

This is held on Fridays from 1:00 to 2:00 pm at CNY8 renal conference room. Formal presentations by one to two research fellows of ongoing work are discussed by the research faculty.

Lecture Series

In addition to the formal conferences listed above, a series of lectures is given at the beginning of the academic year on dialysis, transplantation and the care of renal emergencies.

Other Meetings

Each fellow has the opportunity to attend one national nephrology meeting such as the annual meeting of the American Society of Nephrology or the spring Clinical meetings of the National Kidney Foundation. Research fellows attend these meetings to present their abstracts in oral or poster formats. Fellows may also attend the annual nephrology postgraduate courses held at harvard-affiliated hospitals.

Teaching

Teaching is a very effective way of learning. As such, the fellows have ample opportunities of 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 and the Clinical case conferences, give formal talks that are presented to the Nephrology Division staff on three or more occasions each year, and present their research findings in the weekly laboratory meetings. Many fellows also participate with Mass General and Brigham and Women's faculty in teaching renal physiology and pathophysiology to first and second-year medical students at the Harvard Medical School.

Project Professionalism & Responsible Conduct of Research

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 Fellowship Handbook

This practical description of the Mass General Renal Fellowship is designed to acquaint new fellows with the program structure, environment and expectations. It provides comprehensive details of the specific rotations, responsibility for patient care, coverage and techniques, and is distributed at the beginning of the clinical rotation.

Clinical Experience

The clinical rotation is designed to help the fellow acquire the knowledge, management and technical skills, clinical judgment and attitudes essential to the practice of nephrology, as outlined in the ACGME Program Requirements for Residency Education in Nephrology.

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.

Rotation

The clinical rotation is comprised of three and a half months on the Dialysis service, three and a half months on the Renal Consultation service and three and a half months on the Transplant service. The fellow spends about half the time at each of the two major teaching hospitals (Mass General and Brigham and Women's). A two week to one month rotation as the renal consult at the West Roxbury VA Hospital is also included in the clinical rotation. Each fellow will have one half-day a week in an out-patient rotation with a faculty member, during which the fellow is exposed to the spectrum of patients with renal disease, and acquires the management skills needed to treat and follow this patient population. The clinical training experience encompasses therefore the following:

General Nephrology

Each fellow will spend three and a half months on the in-patient consultation service, two months at Mass General and one and a half months at Brigham. The consultation service at Mass General also covers the Massachusetts Eye and Ear Infirmary. During this period, the fellow is expected to acquire experience in:

1. Disorders of mineral metabolism, including nephrolithiasis, osteoporosis and renal osteodystrophy
2. Disorders of fluid, electrolyte, and acid-base balance
3. Acute renal failure
4. Chronic renal failure and its management by conservative, nutrition and dialytic methods
5. End-stage renal disease
6. Hypertensive disorders
7. Renal disorders of pregnancy
8. Urinary tract infections
9. Tubulointerstitial renal diseases, including inherited diseases of transport, cystic diseases, and other congenital disorders
10. Glomerular and vascular diseases, including the glomerulonephritides, diabetic nephropathy, renovascular disease and microvascular syndromes
11. Disorders of drug metabolism and renal drug toxicity

The Fellow will see all requests for consultation called in to 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 to meet with the attending nephrologist to discuss progress and plans. The fellow sees all the Nephrology Division patients admitted to the hospital, whatever the reason for admission is. If 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 and 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 a three and a half months of the training, divided between Mass General and Brigham and Women's. 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:

1. Evaluation and selection of patients for acute hemodialysis or continuous renal replacement therapies
2. Evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options
3. Drug dosage modification during dialysis and other extracorporeal therapies
4. 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
5. Long-term follow-up of patients undergoing chronic dialysis, including their dialysis prescription and modification and assessment of adequacy of dialysis
6. 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
7. An understanding of the technology of peritoneal dialysis, including the use of cyclers
8. Assessment of peritoneal dialysis efficiency, using peritoneal equilibration testing and the indications and interpretation of peritoneal biopsy
9. An understanding of how to write a peritoneal dialysis prescription and how to assess peritoneal dialysis adequacy
10. The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis
11. An understanding of the complications 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
12. An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient.

Renal Transplantation

The activities on the Transplantation service include 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 three and a half months of experience on an active renal transplant service divided between Mass General and Brigham. 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 out-patient transplant clinics a week and participates in management decisions. This transplant experience includes the following:

1. Evaluation and selection of transplant candidates
2. Preoperative evaluation and preparation of transplant recipients
3. Immediate postoperative management of transplant recipients including administration of immunosuppressive drugs
4. Clinical diagnosis and management of all forms of acute and chronic rejection including laboratory, histopathologic and imaging techniques
5. Recognition and medical management of the surgical and non surgical complications of transplantation
6. 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 out-patient 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.This rotation will expose fellows to:

1. Evaluation and management of patients with hematuria and proteinuria
2. Evaluation and management of the complicated hypertensive patients
3. Management of patients with chronic renal failure
4. Evaluation and management of patients with nephrolithiasis
5. Evaluation of patients for transplantation
6. Transplant donor evaluations
7. Management of patients following renal transplantation

Electives

A number of electives, usually two to four weeks, are available for the renal fellows. These are listed below.

1. Pediatrics - This rotation may take place in the second or third year. The fellow will participate fully in the out-patient Pediatric Clinics at Mass General, the in-patient consult service and conferences
2. Radiology - This elective is structured with the Mass General Department of Radiology. During this elective, the fellow will attend the various renal-focused procedures and the interpretation sessions
3. Pathology This rotation involves supervised training in the preparation and processing of renal tissues, and in 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:

1. Urinalysis and uroscopy
2. Percutaneous biopsy of native and transplanted kidneys
3. Peritoneal dialysis
4. Placement of temporary vascular access (subclavian, femoral or internal jugular) for hemodialysis and related procedures
5. Acute and chronic hemodialysis
6. Placement of peritoneal catheters
7. Renal ultrasound (use and interpretation)
8. Continuous hemofiltration, arteriovenous and/or venovenous
9. Hemoperfusion
10. Placement of temporary peritoneal catheters

Fellows are encouraged to acquire the knowledge base (that includes cost-effectiveness) and expertise in the following procedures:

1. Radiology of vascular access
2. Balloon angioplasty of vascular access
3. Therapeutic plasmapheresis
4. Interpretation of renal biopsies
5. Bone biopsy
6. Placement of permanent peritoneal catheters

Research Experience

The goal of this three-year program at Mass General Hospital is to develop highly committed MDs and/or PhDs into mature, broadly educated and independent scientists who will continue in nephrologic research. The program offers ample basic or clinical research opportunities, and an excellent environment towards achieving this goal. The main elements of the research training program at Mass General are as follows:
Research opportunitiesBasic and clinical research activities involve several NIH-supported initiatives directed by the Staff of the Mass General Nephrology Division.

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 Mass General 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 multidisciplinary approach in the study of one of the most heterogeneous organs in the mammalian 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.
Didactic TrainingAcquisition of new research tools is most efficiently 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.

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 ProjectTrainees 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 the 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 Nephrology Division has devised a seminar series during the summer and fall seasons 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 EvaluationDuring 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 the Massachusetts General Hospital will meeting with Drs. Arnaout or Bazar formally or informally. During these sessions, any issues relating to the clinical program are discussed, and any necessary refinements/improvements in the program implemented as a result. At Mass General, the research fellows also have informal or formal (bimonthly) meeting with Dr. Arnaout, during which any issues relating 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 Mass General/Brigham Renal Grand Rounds, the weekly dialysis, transplantation, pathology and radiology conferences, through participation in the regularly scheduled journal clubs, and the weekly intra- and inter group presentations.

The clinical 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 or her progress and to make any necessary modifications in the program.

How to Apply

Clinical/Research Training Program in Nephrology

Before beginning the clinical/research training program in Nephrology, a candidate should have completed at least two, and preferably three years of training in internal medicine. The Nephrology Division and the Massachusetts General Hospital are equal opportunity employers. Interested applicants should submit their application through ERAS between July 1 and January 15 for positions beginning July 1, 2009. We strongly recommend that applicants complete the ERAS application process before December 1 as this will facilitate timely interview dates.

Fellowship programs can access applications on December 1. We will invite outstanding candidates for a two-day interview process to be scheduled in December or January. We do sponsor visas for exceptional trainees. We will also adhere to the recommendations of the American Society of Nephrology in that all applicants offered a position will not be required to make a final decision before February 1, 2009.

Begin your application through ERAS.

Division of Nephrology

Phone: 617-726-5050
Fax: 617-724-1122

Public Transportation Access: yes
Disabled Access: yes