University of Utah Nephrology Fellowship Program · 2020-01-27 · Curriculum Vitae and Personal Statement through ERAS Three letters of recommendation through ERAS International

Fellowship Program Guide

Division of Nephrology

University of Utah Health Sciences Center

2014-2015

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University of Utah Nephrology Fellowship Program

Table of Contents

1. Introduction/ Fellow Selection Policy/Process ……………………………………………..……… 2 2. Faculty Members………………………………………………………………………….…..……… 5 3. Training Sites…………………………………………………..…………….……………………….. 7 4. Training Schedule…………………………………………..………………………………….…….. 8 5. Clinical Curriculum – Overview and Objectives…………………………………………………… 11

6. Clinical Curriculum a. Renal Structure and Function………………………………….…..………………………….… 15 b. General Nephrology…………………………………………………………………………..….. 16 c. Renal Transplant…………………………………………………………………………………. 37 d. Dialysis and Extracorporeal Therapy…………………………………………………………... 57 e. Special Areas and Additional Evaluations…………………………………..…………….…... 80 7. Research Training Program……………………………………………………………..………….. 82 8. Fellow Performance/Work and Supervision Policies/Stipends and Benefits……………….…. 89 9. Faculty Research Interests...................................................................................................... 93 10. Faculty Publications ……………………………………………...................….…………………. 99 11. Current and Previous Fellows ………………………................................................................ 112

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1. Introduction (RETURN TO TABLE OF CONTENTS) The University of Utah Nephrology Fellowship Program is dedicated to providing the highest quality clinical and research training in the subspeciality of Nephrology. It is accredited by the Graduate Medical Education Committee of the University of Utah and by the Residency Review Committee of the ACGME. There are two programs: 1) The two-year clinical program is based at the University Hospital and the Salt Lake Veterans Affairs Medical Center. Upon completion, Fellows are board eligible in Nephrology. This program provides primarily clinical training, however, in addition to excellent clinical training, the University of Utah Nephrology Clinical Fellowship Program is designed to provide experience in clinical research. Fellows are placed into on-going faculty clinical research projects and given an opportunity to develop related research interests of their own. 2) The three-year research program. The program involves one year of clinical training and two years of basic or clinical research. The clinical year may be done at the beginning or the end of the fellowship and is structured identical to the clinical experience of a year in the two-year clinical fellowship. The two years of research are spent under the direction of a faculty member within the Division of Nephrology. This guide provides comprehensive information about all aspects of the Program, including:

Goals and objectives

Nature of sites where training is performed

Types of clinical encounters

Patient case-mix characteristics

Procedures and services

Educational activities and resources, including didactic training and conferences

Nature of supervision and evaluation of fellow’s performance

Faculty research activities

Fellow research opportunities and policies

On-call and vacation policies

Former Fellow information

Fellow selection policy

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2. Fellow Selection Policy/Process

1. To be eligible for a fellowship in the Division of Nephrology at the University of Utah School of Medicine, an applicant must:

Be a graduate of a U.S. or Canadian medical school accredited by the Liaison Committee on Medical Education (LCME) and have three years residency in an ACGME-approved program, OR

Be a graduate of a college of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA) and have three years residency in an ACGME-approved program, OR

Be a graduate of a medical school outside of the United States who meets one or more of the following qualifications:

1. Has a currently valid ECFMG certificate plus at least one year training in an ACGME approved program, OR

2. Has a full and unrestricted license to practice medicine in a US licensing jurisdiction plus at least one year training in an ACGME-approved program, OR

3. Is a graduate of a medical school outside the United States who has completed a Fifth Pathway program provided by an LCME-accredited medical school.

Be eligible for American Board of Internal Medicine prior to the time they begin training

2. The Division of Nephrology will send an applicant (upon request):

Introduction letter from the Division Chief and/or the Program Director

General information about the Salt Lake City area

Instructions on how to apply for the program through the Electronic Residency Application Service (ERAS)

A statement that “The University of Utah School of Medicine does not discriminate on the basis of sex, face, age, religion, color, national origin, disability, or veteran’s status”.

3. The Division of Nephrology requires the following documentation for application:

Completed fellowship application through ERAS

Curriculum Vitae and Personal Statement through ERAS

Three letters of recommendation through ERAS

International Medical Graduates must include the following in addition to the above: - Copy of green card, visa (J-1), or documentation of U.S. citizenship

- Valid ECFMG certificate with Clinical Skills Assessment certification - Evidence of previous training in the United States 4. Selection Criteria for Interviewing Applicants - The Nephrology faculty, in a joint meeting, reviews

applicants who meet the criteria. Based on the quality of the application and academic credentials, the applicant is subsequently invited for an interview. On the interview day, applicants receive an information packet and interview with members of the Division of Nephrology and the Nephrology fellows. At the conclusion of the interview, the interviewers complete a standard evaluation form for each applicant they interviewed. The results are tallied and form the basis of the preliminary rank order. The University of Utah Nephrology program participates in the National Residency Matching Program (NRMP, aka “the Match”) for all entering fellows.

5. The Guide to the Nephrology Fellowship Program is given to applicants on interview day and includes:

Examples of the fellow rotation schedule, the monthly call schedule, and the monthly conference schedule

Program curriculum, including goals, objectives and evaluation procedures

Work hours and supervision policy

Vacation/absence policy

Stipend information

Insurance coverage information

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Benefits summary

University policies pertinent to fellows with regard to sexual harassment 6. The University of Utah Graduate Medical Education Committee requires that fellows have a Utah

Medical License and ACLS certification. Fellows who are not currently certified in ACLS must become so within six months of commencing their training.

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3. Division of Nephrology Faculty Members (RETURN TO TABLE OF CONTENTS)

Name Research Interests Josephine Abraham, M.D. Clinical trials in glomerulonephritis and CKD Clinical Instructor Associate Training Program Director

Faris Ahmed, M.B.B.S. Clinical transplant nephrology Clinical Assistant Professor Srinivasan Beddhu, M.D. Randomized trials and epidemiology Professor of CKD and dialysis patients Terrence Bjordahl, M.D. Clinical care in Salt Lake City Clinical Assistant Professor Alfred K. Cheung, M.D. Randomized trials in CKD, dialysis and Division Chief and Professor hypertension; vascular access Epidemiology in CKD and dialysis Monique E. Cho, M.D. Metabolic cardiac complications of CKD Assistant Professor Scott Eppich, M.D. Clinical care in Provo County, UT Staff Physician Nasimul Ghani, M.D. Clinical care in Idaho Falls, ID Staff Physician Tom Greene, Ph.D. Proteinuria and CKD progression Professor Martin C. Gregory, M.D. Alport Syndrome Clinical Professor Training Program Director Arsalan Habib, M.D. Clinical care in Salt Lake City Clinical Assistant Professor Yufeng Huang, M.D., Ph.D. Pathogenesis of diabetic nephropathy Research Associate Professor and kidney fibrosis Zhanjun Jia, Ph.D. Prostaglandin synthesis in kidney physiology Instructor and pathophysiology Carl Kablitz, M.D. Clinical care in Cedar City Clinical Assistant Professor Sidhartha Kakani, M.D. Clinical care in Provo County, UT Staff Physician Bellamkonda Kishore, M.D., Ph.D. Purinergic regulation of renal function, Research Professor pathology and experimental therapies

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Donald E. Kohan, M.D., Ph.D. Hypertension and volume balance Professor Polycystic kidney disease Andrea Nelson, M.D. Clinical care in Salt Lake City Clinical Instructor Nirupama Ramkumar, M.D. Intrarenal renin angiotensin system Instructor Kalani Raphael, M.D. Chronic kidney disease outcomes Assistant Professor Acidosis and CKD progression

Abinash Roy, M.D. Clinical care in St. George, UT Clinical Associate Professor Fuad Shihab, M.D. Chronic cyclosporine nephropathy Clinical Professor Renal transplantation outcomes Biomarkers in kidney transplants Yan-Ting Shiu, Ph.D. Biophysics of vascular access stenosis Research Assistant Professor Ets-1 in vascular biology Christi Terry, Ph.D. Adipokines in the vasculature Research Assistant Professor Vascular access stenosis and development Alfred van Hoek, Ph.D. New innovations in renal imaging Research Assistant Professor Renal tubular signaling and function Christof Westenfelder, M.D. Stem cells in acute kidney injury Professor Renal actions of erythropoietin Chief, Renal Section, VA Salt Lake City Healthcare System Tianxin Yang, M.D., Ph.D. PPARgamma, obesity, clock genes Professor Collecting duct signaling Robert Yenchek, M.D. Clinical care in Salt Lake City Clinical Instructor

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4. Nephrology Fellowship Program Training Sites (RETURN TO TABLE OF CONTENTS) A. Inpatient sites (1) University Hospital (UH) - This is a tertiary care facility with 476 operating beds located on the

University of Utah Health Sciences Center Campus. It contains surgical, neurosurgical, burn, and medical intensive care units; a newly remodeled 3-station acute dialysis unit with support for hemodialysis, peritoneal dialysis, therapeutic apheresis and continuous renal replacement therapies; radiologic services with modern renal-related procedures and diagnostic vascular and radionucleotide imaging; electron microscopy for renal biopsy material; biochemical and serologic laboratories; a nutrition support service; and relevant social services. A close working relationship exists with other services including surgery, urology, obstetrics, gynecology, hematology, oncology, pediatrics and psychiatry.

(2) Salt Lake Veterans Affairs Medical Center (VAMC) – This is a tertiary care facility with 117 operating beds located adjacent to the University of Utah Lower Campus and approximately one-half mile from University Hospital. It contains surgical and medical intensive care units, a 10-station newly remodeled dialysis unit that performs acute and chronic hemodialysis and supports continuous renal replacement therapies and peritoneal dialysis, radiologic services with modern renal-related procedures and diagnostic vascular and radionucleotide imaging, electron microscopy for renal biopsy material, biochemical and serologic laboratories, a nutrition support service, and relevant social services. A close working relationship exists with other services including surgery, urology and psychiatry.

B. Outpatient sites (1) University Hospital Renal Clinic – Located on the A level of the University Hospital, this 11-room

clinic is the site for all general nephrology, nephrolithiasis, post-transplant and pre-transplant patients associated with the University of Utah.

(2) University of Utah Peritoneal Dialysis Clinic – Located in Rooms 113 and 114 in the Dumke Building at the University of Utah.

(3) VAMC General Nephrology Clinic – Located on the 4th floor of Building 1 (main hospital building) at the VAMC, this clinic is the site of ambulatory care for VA general nephrology, pre- and post-transplant patients.

(4) VAMC Dialysis Clinic – Located within the dialysis unit, this clinic is the site of outpatient follow-up of VA hemodialysis, peritoneal dialysis and post-transplant patients.

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5. Nephrology Training Program Schedule (RETURN TO TABLE OF CONTENTS) The two-year clinical fellowship and the one clinical year of the research fellowship are comprised of four major parts that cycle throughout the year. The following schedules are based on the Program’s current policy of having four fellows (A through D below) doing clinical service together. A. Yearly schedule for fellows on clinical service (only 1 year for research fellows) Year 1 (1 block = 4 weeks) U=University Hospital; VA=VA Hospital; OP=Outpatient; TP=Transplant

Block 1 2 3 4 5 6 7 8 9 10 11 12 13

U A B C D A B C D A B C D A

VA B C D A B C D A B C D A B

OP C D A B C D A B C D A B C

TP D A B C D A B C D A B C D

Year 2 (1 block = 4 weeks) U=University Hospital; VA=VA Hospital; OP=Outpatient; TP=Transplant

Block 1 2 3 4 5 6 7 8 9 10 11 12 13

U A B C D A B C D A B C D A

VA B C D A B C D A B C D A B

OP C D A B C D A B C D A B C

TP D A B C D A B C D A B C D

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University Hospital (3 months yearly)

Monday Tuesday Wednesday Thursday Friday

8 am

General Nephrology continuity clinic at U of U (Fellow Group A)

Ward duties (all day)


General Nephrology continuity clinic at U of U (Fellow Group B)


9 am

10 am

11 am Didactic Conference (11:30-12:30) Pathology Conference (12:30-1:30)

Noon

1 pm

2 pm Ward duties Ward duties

3 pm

4 pm Clinical conference

5 pm Research conference

VA Hospital (3 months yearly) Monday Tuesday Wednesday Thursday Friday

8 am Ward duties (all day)




9 am General Nephrology continuity clinic at U of U (Fellow Group A)

HD rounds or PD clinic – 1st and 3rd Tues of the month

HD rounds

10 am


Noon

1 pm HD rounds VA general nephrology

clinic (starts

at 12:30 pm)

HD rounds

2 pm

3 pm Ward duties

4 pm Ward duties

Clinical conference


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Outpatient nephrology and research (3 months yearly)

Monday Tuesday Wednesday Thursday Friday

8 am RESEARCH General Nephrology continuity clinic at U of U (Fellow Group B)

RESEARCH DAY 9 am General

Nephrology continuity clinic at U of U (Fellow Group A)

GN or Onconephrology clinic

10 am


Noon RESEARCH RESEARCH RESEARCH

1 pm

2 pm

3 pm



Transplant nephrology at University Hospital (3 months yearly) Monday Tuesday Wednesday Thursday Friday

8 am General Nephrology continuity clinic at U of U (Fellow Group A)

Post- transplant clinic

Pre-transplant clinic


Inpatient transplant (all day)

9 am

10 am


Noon

1 pm Inpatient transplant

Inpatient transplant



2 pm

3 pm



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6. Nephrology Clinical Training Program Curriculum – Overview (RETURN TO TABLE OF CONTENTS) A. Clinical Curriculum Introduction The Nephrology Fellowship Clinical Training Program is designed to provide individuals with the opportunity to achieve the fundamental knowledge, procedural skills, practical experience, and professional and ethical behavior necessary for the subspeciality of Nephrology. Fellows care for patients with the full spectrum of renal disorders at all stages of the disease process. Efforts are made at every point to emphasize the integration of fundamental medical knowledge, disease prevention, social, psychological, and economic issues. This section describes the clinical curriculum. The first part presents an outline of the Clinical Program goals and objectives. Subsequently, the full clinical curriculum is described, relating Clinical Program goals and objectives to the manner in which they are achieved. B. Overview of Clinical Program Goals and Objectives The Nephrology Fellowship Clinical Training Program is structured around goals and objectives derived from three major sources: 1) the ACGME Core Competencies; 2) the ACGME subspecialty requirements for Nephrology training programs; and 3) additional input derived from University of Utah Nephrology faculty. These various components are combined to achieve an integrated set of goals and objectives that cover all aspects of the training program. In this first section, an overview of the training program’s goals and objectives is presented, broken down by the six core competencies and then the specific Nephrology areas. This should be reviewed so that Fellows understand each of these components. The following section, devoted to the detailed curriculum, then combines the core competencies and specific nephrology issues into an integrated and comprehensive set of goals and objectives. Core competencies

(1) Patient care – Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to:

communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families

gather essential and accurate information about their patients

make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment

develop and carry out patient management plans

counsel and educate patients and their families

use information technology to support patient care decisions and patient education

perform competently all medical and invasive procedures considered essential for the area of practice

provide health care services aimed at preventing health problems or maintaining health

work with health care professionals, including those from other disciplines, to provide patient-focused care

(2) Medical knowledge - Fellows must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Fellows are expected to:

demonstrate an investigatory and analytic thinking approach to clinical situations

know and apply the basic and clinically supportive sciences which are appropriate to their discipline

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(3) Practice-based learning and improvement – Fellows must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Fellows are expected to:

analyze practice experience and perform practice-based improvement activities using a systematic methodology

locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems

obtain and use information about their own population of patients and the larger population from which their patients are drawn

apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness

use information technology to manage information, access on-line medical information; and support their own education

facilitate the learning of students and other health care professionals (4) Interpersonal and communication skills - Fellows must be able to demonstrate interpersonal

and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Fellows are expected to:

create and sustain a therapeutic and ethically sound relationship with patients

use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills

work effectively with others as a member or leader of a health care team or other professional group

(5) Professionalism - Fellows must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Fellows are expected to:

demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development

demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices

demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities (6) Systems-based practice - Fellows must demonstrate an awareness of and responsiveness to

the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Fellows are expected to:

understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice

know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources

practice cost-effective health care and resource allocation that does not compromise quality of care

advocate for quality patient care and assist patients in dealing with system complexities

know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

Specific renal competencies - Fellows will acquire expertise in: (1) An understanding of normal renal biology including: a. Renal anatomy and histology b. Renal physiology, including in the elderly c. Fluid, electrolyte and acid-base regulation d. Mineral metabolism

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e. Blood pressure regulation - normal and abnormal f. Renal drug metabolism and pharmacokinetics, including drug effects on renal function and

including in the elderly g. Renal function in pregnancy h. Basic immunologic principles, including mechanisms of disease and diagnostic laboratory

testing relevant to renal diseases i. Medical genetics (2) Prevention, evaluation, and management of general nephrologic disorders including: a. Acute renal failure b. Chronic renal failure c. End-stage renal disease d. Fluid, electrolyte, and acid-base disorders e. Disorders of mineral metabolism including nephrolithiasis and renal osteodystrophy (including

use of lithotripsy) f. Urinary tract infections g. Hypertensive disorders h. Renal disorders related to pregnancy i. Primary and secondary glomerulopathies including infection-related glomerulopathies. This

also entails a basic understanding of immunologic mechanisms of renal disease and the laboratory tests necessary for their diagnosis.

j. Diabetic nephropathy k. Tubulointerstitial nephritis including papillary necrosis l. Genetic and developmental renal diseases including renal cystic diseases, hereditary

glomerulopathies and interstitial nephritis, phakomatoses, systemic diseases with renal involvement, congenital malformations of the urinary tract, maternally inherited mitochondrial diseases, and renal cell carcinoma.

m. Vascular diseases including atheroembolic disease n. Disorders of drug metabolism and renal drug toxicity o. Renal disorders associated with the elderly including altered drug metabolism p. Renal cystic diseases without a recognized genetic basis q. Nutritional management of general nephrologic disorders (3) Pre- and post-renal transplant care including: a. Pre-transplant selection, evaluation and preparation of transplant recipients and donors b. Immunosuppressant drug effects and toxicity c. Immediate postoperative management of transplant recipients d. Immunologic principals of types and mechanisms of renal allograft rejection e. Clinical diagnosis of all forms of rejection including laboratory, histopathologic and imaging

techniques f. Prophylaxis and treatment of allograft rejection g. Recognition and medical management of nonrejection causes of allograft dysfunction

including urinary tract infections, acute renal failure, and others h. Understanding major causes of post-transplant morbidity and mortality i. Fluid, electrolyte, mineral and acid-base regulation in post-transplant patients j. Long-term follow-up of transplant recipients in the ambulatory setting including economic and psychosocial issues k. Principles of organ harvesting, preservation and sharing l. Renal disease in liver, heart and bone marrow transplant recipients (4) Dialysis and extracorporeal therapy including: a. Evaluation and selection of patients for acute hemodialysis or continuous renal replacement

therapies b. Evaluation of end-stage renal disease patients for various forms of therapy and their instruction regarding treatment options c. Drug dosage modification during dialysis and other extra-corporeal therapies

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d. Evaluation and management of medical complications in patients during and between dialyses and other extra-corporeal therapies, and an understanding of their pathogenesis and prevention

e. Long-term follow-up of patients undergoing chronic dialysis including their dialysis prescription modification and assessment of adequacy of dialysis

f. 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.

g. An understanding of the technology of peritoneal dialysis including the use of cyclers h. Assessment of peritoneal dialysis efficiency using peritoneal equilibration testing and the

principles of peritoneal biopsy i. An understanding of how to write a peritoneal dialysis prescription and how to assess

peritoneal dialysis adequacy j. The pharmacology of commonly used medications and their kinetic and dosage alteration

with peritoneal dialysis k. An understanding of the complications of peritoneal dialysis including peritonitis and its

treatment, exit site and tunnel infections and their management, hernias, plural effusions and other less common complications and their management

l. An understanding of the special nutritional requirements of the hemodialysis and peritoneal dialysis patient

m. An understanding of the psychosocial, economic and ethical issues of dialysis n. An understanding of dialysis water treatment, delivery systems and dialyzer reuse o. An understanding of end-of-life care and pain management in the care of patients undergoing

chronic dialysis. p. Evaluation, selection and management of patients for therapeutic plasma exchange (5) Personally conducting the following procedures: a. Urinalysis b. Percutaneous biopsy of native and transplanted kidneys c. Peritoneal dialysis d. Placement of temporary vascular access for hemodialysis and related procedures including

use of vascular ultrasound guidance e. Acute and chronic hemodialysis f. Continuous renal replacement therapies g. Therapeutic plasma exchange (6) Understanding indications, complications (if relevant), and interpretation of the following procedures: a. Placement of peritoneal catheters b. Renal imaging - ultrasound, CT, IVP, MRI, angiography, and nuclear medicine studies c. Therapeutic plasmapheresis d. Radiology, angioplasty and declotting of vascular access (7) Special areas in the management of patients of renal diseases including: a. Psychosocial and economic issues confronting patients with renal disease b. Ethical issues relevant to care of patients with renal disease c. Optimizing the relationship of the nephrologist with other health care providers d. Optimizing mechanisms towards achieving life-long learning as a nephrologist e. Quality assessment and improvement, patient safety, risk management, preventative

medicine, and physician impairment as it relates to the nephrologist Progressive objectives The objectives of the nephrology fellowship program are designed to reflect a progressive increase in learning. The learning principles are based on Bloom's taxonomy, describing progression through the six learning domains: knowledge, comprehension, application, analysis, synthesis and evaluation. In practice, the program's objectives change every 6 months of the 2-year training period. These four 6-

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month periods' progressively changing objectives are summarized in the sections addressing the three major rotations - general nephrology, dialysis and transplantation. These progressive objectives are reviewed with the fellows by the Program Director at the beginning of each 6-month rotation, i.e., each time the objectives change. 7. Full Clinical Curriculum - in this section, specific Clinical Program goals and objectives, as outlined

above, are related to the methods by which they are achieved. The methods of achieving the Clinical Program goals include:

Types and locations of clinical encounters

Patient characteristics including case-mix, population size, sex, age, and race

Relevant procedural training

Relevant educational training, including resources and teaching methods

Nature of supervision

Means of feedback and evaluation of Fellow’s performance A. Renal structure and function - Fellows will acquire expertise in understanding normal renal biology including renal anatomy and histology, renal physiology, fluid and electrolyte regulation, acid-base balance, mineral metabolism, blood pressure regulation, renal drug metabolism and pharmacokinetics, drug effects on renal function, renal function in pregnancy, renal functional changes with aging, and basic immunologic principles. 1) Educational training

a. Handouts - At the beginning of the Fellowship, Fellows are given several books for their personal use. The books include: Clinical Nephrology (Johnson and Feehally), Urinalysis (Sister Martine Graf), Handbook of Dialysis (Daugirdas and Ing), Handbook of Renal Transplantation (Danovitch), the AST Handbook of Transplant Infections (Kumar and Humar), and How the Immune System Works (Sompayrac). Fellows are also given access to UpToDate. While many of these sources primarily deal with renal disorders, they provide fundamental information on normal renal biology as well.

b. Didactic sessions - While normal renal biology is discussed during more informal sessions (attending rounds, renal clinics) it is recognized that a structured approach is necessary to guarantee coverage of the basics of normal renal biology. To accomplish this, a didactic conference is held each Friday from 11:30-12:30 PM for 2 years. During the session, a faculty member facilitates discussion of the assigned material. A one-hour session is devoted to each of the following normal renal biology topics: water handling, potassium balance, sodium and volume, acid-base balance, Ca/Mg/PO4 metabolism, renal immunology, blood pressure regulation, and renal function in pregnancy. Drug metabolism is discussed during several sessions dealing with antihypertensives, immunosuppressants, and other topics. Renal anatomy and histology are extensively discussed during several sessions on glomerular and interstitial diseases in which diseased kidneys are compared to normal kidneys.

c. Conferences - A renal pathology conference is held each Friday from 12:30-1:30 PM. Diseased kidneys are compared to normal kidneys throughout this conference. Fellows use a multi-headed microscope is for simultaneous viewing.

2) Nature of supervision - A faculty member facilitates discussion of the assigned material during the didactic sessions. A renal pathology attending supervises discussion of the cases during the pathology conference.

3) Means of Fellow evaluation - Faculty members give Fellows immediate feedback on their knowledge base during the didactic sessions. At the end of each year of didactic sessions, the Fellows take an in-house MKSAP test in Nephrology and Hypertension. Fellows are counseled on areas of weakness by the Program Director. Also, please see information on knowledge base assessment in the General Nephrology section – much of the information covered in basic renal structure and function overlaps with that required for General Nephrology.

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B. General Nephrology (RETURN TO TABLE OF CONTENTS) 1) Goal Fellows will become competent in caring for patients with general nephrology problems. 2) Objectives

Detailed objectives for general nephrology are described in the General Nephrology table. There are 4 separate tables that address objectives for each rotation on general nephrology. A rotation is defined as a 6-month period, so there are separate objectives for the 1st, 2nd, 3rd and 4th 6-month rotations. These objectives reflect a progressive increase in expectations for fellows' competency achievement. While these are discussed in detail in the table, the essence of the objectives for each 6-month rotation are as follows: 1. Months 1-6 - Fellows function at least a the level of accurate reporting of the history, physical and

other data, i.e., they correctly recall and state the relevant facts. Fellows begin to understand or comprehend this information, reviewing and reporting the relevant facts in an organized and efficient manner. Fellows begin to describe how to apply this information to make diagnostic and therapeutic decision.

2. Months 7-12 - Fellows are able to accurately interpret the history, physical examination and data. The information is analyzed and an accurate differential diagnosis is formulated. Fellows are able to perform urinalysis accurately. Fellows continue in their abilities to design a diagnostic plan and therapeutic interventions.

3. Months 13-18 - Fellows are able to correctly manage general nephrology patient care. This extends previous expectations to formulating a correct diagnostic plan, making the correct diagnosis. They should be beginning to critically analyze literature relevant to the care issues.

4. Months 19-24 - Fellows are competent in all six core competencies. They function as self-educators, reading and analyzing the literature, and adjusting their care based on this analysis. They also function as educators in a larger context, using their clinical experience and information they have obtained from the literature to teach their colleagues, staff and faculty.

3) Types of clinical encounters and supervision 1. Inpatient general nephrology encounters – Fellows spend 6 months/year on the inpatient general

nephrology service, 3 months at the UH and 3 months at the VAMC. The Fellows have direct patient care responsibilities for all Nephrology Service inpatients at the UH and VA, including transplant and dialysis patients. The Fellow is the first person from the Nephrology Service to evaluate a new inpatient, including a history, physical examination, and urinalysis (the latter faculty-supervised). The Fellow follows all nephrology inpatients with daily history and examinations and, after discussion with faculty, charts recommendations or writes orders. The Attending conducts didactic sessions each day on material relevant to the in-house cases. The Fellow is responsible for arranging outpatient renal follow-up and for providing a dictated discharge summary for use in renal clinic. The Attending is on-call with the Fellow 24 hours a day.

2. Outpatient encounters a. UH General Nephrology Clinic - Each Thursday or Monday morning (Fellows are assigned to

specific days for the duration of their training) from 8:30 AM - noon, all Fellows, regardless of rotation, attend a general nephrology clinic at the University covering all aspects of nephrology except transplantation and dialysis. Patients are assigned to Fellows and followed on a continuity basis throughout their fellowship (2 years for clinical fellows and three years for research fellows). The clinics are staffed by Drs. Kohan and Raphael on Mondays and by Drs. Gregory and Abraham on Thursdays who are there solely to supervise and train the Fellows. Each Fellow is given 1/2 hour for follow-up visits and 1 hour for new patients.

b. VA General Nephrology Clinic – Each Tuesday afternoon from 12:30-4:30 PM, the Fellow based at the VA and internal medicine resident assigned to the Nephrology services at UH attend a general nephrology clinic at the VA covering all aspects of nephrology except transplantation and dialysis. Typically, other residents or interns on VA outpatient rotations attend this clinic. The

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patients are followed on a non-continuity basis. All patients are presented to the VA Nephrology Attending who is in the clinic solely to supervise and teach.

4) Patient characteristics (number, demographics) 1. Inpatients - The average inpatient General Nephrology census is 15-25 patients at UH and 6-8

patients at the VA (these numbers include dialysis patients). Approximately 30% of inpatients are in the intensive care units at both hospitals. Ninety percent of VA patients are male (mean age – 58 years) and 10% are female (mean age – 49 years); the SLVAMC has the widest geographic referral area of any VA in the nation and sees a broad spectrum of general nephrology problems. Approximately 50% of UH patients are male; ages for both sexes range from 20-90 years. Because Salt Lake City is situated over 400 miles from any other city with a major medical center, it receives a wide variety of referrals with an extremely broad range of renal disorders covering all aspects of general nephrology. In addition, genetic diseases are prevalent in this region providing a tremendous learning opportunity..

2. Outpatients a. UH General Nephrology - Over the course of two years, each Fellow will follow a total of

approximately 150 general nephrology patients on a continuity basis. These patients come from Idaho, Utah, Nevada, Wyoming, Colorado, and Montana. All aspects of general nephrology are represented with equal numbers of male:female patients and ages ranging from 20-90 years. The majority of patients are Caucasian, however there are significant numbers of Hispanic, Native American, and South Pacific (Tonga and Samoa) patients. African American patients are seen although they represent the smallest minority. The General Nephrology clinic see about 6-7 patients per clinic.

b. VA General Nephrology Clinic – An average of 15 patients are seen in each clinic on a non-continuity basis. Demographics are similar to those for SLVAMC inpatients. A broad range of renal disorders are seen with particular emphasis on diabetes, hypertension, renal vascular disease, urinary tract obstruction, drug toxicity, primary glomerulopathies, and collagen vascular diseases.

5) Procedural training (see General Nephrology Table) 1. Percutaneous biopsy of native kidneys – Performed by the Fellow on inpatients on their inpatient

service at UH, outpatients they follow on a continuity basis, and VA outpatients when the Fellow is based at the VA. Fellows perform about 10-20 native renal biopsies yearly.

2. Urinalysis – Performed by the Fellow on most new inpatients and outpatients, and on follow-up evaluation as necessary.

3. Renal ultrasound – Fellows observe these during all renal biopsies. 4. Lithotripsy – Performed by the Urologists. Fellows are given didactic instruction in its use,

indications, complications and outcomes. 5. Therapeutic plasmapheresis – Fellows are trained in its indications, contraindications and

outcomes, and are supervised by Nephrology faculty. 6) Teaching methods (see General Nephrology Table) 1. Educational training

a. Handouts - At the beginning of the Fellowship, Fellows are given several books and access to UpToDate. The books include: Clinical Nephrology (Johnson and Feehally), NKF Primer on Kidney Diseases, and Urinalysis (Sister Laurine Graff). Recent articles may be provided at the beginning of the Fellowship on interpretation of urine electrolytes and osmolality, management of the nephrotic syndrome, diagnostic strategies in disorders of fluid, electrolyte and acid-base homeostasis, clinical disorders of water metabolism, nondialytic management of acute renal failure, hypokalemic and hyperkalemic states, clinical findings and therapy of glomerulonephritis, hyponatremia and hypernatremia, pathogenesis and treatment of kidney stones, prevention of progression in chronic renal disease, pathophysiology of chronic renal failure, diagnosis of acute glomerulonephritis, management of urinary tract infections in adults, and medical management of diabetic nephropathy, and other areas.

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2. Didactic sessions a. Weekly didactic conference – General nephrology issues are covered in detail in the didactic

conference held each Friday from 11:30-12:30 PM for 2 years. This conference is based on Clinical Nephrology (Johnson and Feehally) and other sources. The Fellows are responsible for reading the assigned material in advance - a yearly schedule is provided. During the session, a faculty member facilitates discussion of the assigned material. A total of 85-90 sessions are held covering dialysis, renal transplantation, renal physiology, fluid and electrolyte disorders, glomerulopathies, interstitial nephritis, renal diseases of pregnancy, congenital urinary tract malformations, acute and chronic renal failure, inherited renal diseases, primary and secondary hypertension, nephrolithiasis, radiologic imaging of the kidney, surgical and radiologic issues relevant to vascular access, ESRD economics, epidemiology, statistics, study design, informed consent, psychosocial aspects of ESRD, special issues of the elderly and others. In addition, fellows receive a series of 4 lectures on biostatistics. Finally, 4 sessions each year are devoted to NephSap review. Fellows and the assigned faculty review the questions in NephSAP (Nephrology Self-Assessment Program) distributed by the American Society of Nephrology. In advance of this meeting, the Fellows meet with a designated faculty who is expert in the particular topic to review the text (typically around 50 pages of NephSAP text on which the questions are based).

b. Primer Course: At the beginning of the Fellowship, a course (held over several days for a few hours each day) is given to provide trainees with a basic level of instruction regarding several issues in Nephrology. While it is geared primarily towards a basic level of instruction regarding topics in Nephrology that the fellow is unlikely to have covered during residency and will need to understand at the outset of their fellowship (mechanics of dialysis and transplant protocols), some general nephrology issues are discussed.

3. Conferences – Fellows must attend the following conferences: a. Nephrology Clinical Conference – held every other Wednesday from 4-5 PM. The conference is

divided into cycles of 4 weeks each: 1) Journal club (1 week out of the cycle) - This consists of a journal club in which fellows and

faculty briefly present an article of interest from the current literature. Fellows review assigned journals, identify and read important articles, and discuss these with faculty. All major nephrology journals are covered as well as some general research and clinical journals.

2) Case presentations (2 weeks out of the cycle) - Fellows and residents on the Nephrology Service prepare a 25 minute presentation including 5-10 minutes of case presentation followed by 15-20 minutes for review of relevant literature. Discussants pick the topic at least one week in advance and review their selection with their Attending. The discussant hands out one good review or original article, however their discussion should be based, at least in part, on review of original literature. The goal is to cover in-depth one, focused area pertinent to the case. In doing so, Fellows are closely critiqued and advised on interpretation of original articles, including study design, methods and data interpretation. Each Fellow presents once a month and keeps a log of cases they presented.

3) Board review/NephSap (every three months) – the latest American Society of Nephrology Nephrology self-assessment module is reviewed.

4) Transplant grand rounds (every other month) – Transplant cases are presented followed by a discussion by the transplant nephrologists.

5) Morbidity and Mortality conference (every three months) - Fellows and faculty present M&M cases that were encountered over the past 2 months. Correctable problems are identified and action plans initiated as appropriate. Fellows send potential M&M cases to the Training Program Director, Dr. Kohan, in advance of the meeting so that appropriate cases can be identified, including those that require more immediate attention. This conference is held every other month. Fellows keep a log of cases they presented.

b. 5 PM Nephrology Conference – held each Wednesday from 5-6 PM. About 70% of the conferences are based on local or visiting faculty research, while the remaining 30% are an in-depth review of clinical topics by the faculty.

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c. Renal Pathology Conference - held each Friday from 12:30-1:30 PM during the two years. All biopsies performed at University Hospital are reviewed as well as interesting historical cases. The conference is led by the Renal Pathologist using a multi-headed microscope and is attended by all Fellows. Renal biopsies performed at the VA are reviewed by the Fellow, Attending and VA Renal Pathologist independent of this conference.

4. Inpatient attending rounds – See under Types of Clinical Encounters above. 7) Assessment and evaluation of Fellows (see General Nephrology Table) 1. Clinical encounters – A variety of instruments are used to assess Fellow performance. The specific

evaluation utilized is indicated in the General Nephrology Table. These include: a. Checklist

1) Fellows are evaluated at the end of each 2-week block with a given attending. The attending uses a scale from 1-9 to assess patient care knowledge, skills, attitudes and behaviors. Fellows review these orally with the attending and both individuals sign the review form. If there is any significant issue, the attending immediately communicates this to the Program Director who meets with the attending and fellow to develop an action plan to address the issue. The Fellow’s performance in this area is then reassessed, by Checklist by the inpatient attendings, in one month and reviewed with the Program Director. During the first 6 months of fellowship, all scores must be "5" (satisfactory) or higher; scores under this will be reviewed with the Program Director, specific problem areas identified, and the appropriate corrective action taken. The problem areas are re-evaluated in one month. During the second 6 months (7-12 months of training), scores must average "6" or over; during the third 6 months (13-18 months of training), scores must average "7" or over; and during the fourth and final 6 months (19-24 months), scores must average "8" or above. If these ratings are not obtained, the same steps are taken as discussed above.

2) Fellows are evaluated by the Program Director every 6 months. First, the goals and objectives of the upcoming 6-month general nephrology rotation are reviewed. The Director uses a scale from 1-9 to evaluate the Fellow’s patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice as it pertains to general nephrology. Fellows review this with the Program Director. The evaluation is based on review of the attending checklists, 360 degree evaluations (see below), and any other pertinent information. If any significant issues exist, an action plan is developed and the fellow re-evaluated by the Program Director in 6 months using the same evaluation measurements as above. Importantly, this evaluation is also based on semi-annual discussions between all the clinical faculty and the Program Director. In addition, even if no significant issues are identified, goals are established for the fellow to work on over the next 6 months. These goals typically do not reflect needed attention to sub-par performance, but instead are intended to help the Fellow focus efforts. For example, faculty may note that the fellow did relatively few native kidney biopsies or that attending comments reflected a need to increased general nephrology knowledge base – appropriate recommendations to work on these areas would be made, and progress evaluated at the next semi-annual Program Director review.

b. Multi-source evaluation – this evaluation is completed by administrative assistants, secretaries, renal social workers, renal dieticians, nurses, pharmacists, technicians, nurse practitioners, physician assistants, and residents on the renal rotation in order to give a broad sense of how the Fellow delivers patient care and interacts with members of the general nephrology health care interdisciplinary team. It is completed every 6 months. Fellows review this with the Program Director. Problem areas (scores under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with particular attention to these problem areas.

c. Patient surveys – Over the course of the year, all patients in continuity clinic are asked to complete a form rating Fellow’s general nephrology clinic patient interaction. These are reviewed semi-annually with the Program Director. Areas in need of improvement (defined as greater than 5% of patients responding negatively) are identified and reassessed, by patient survey, within 3 months.

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d. Written exam – In the spring of first year, Fellows take the American Society of Nephrology In-Training Examination. Their performance is reviewed with the Program Director. General nephrology areas in need of improvement (defined as missing more than 2 questions in that area) are identified and an action plan is developed to address these. Fellow’s fund of knowledge in these areas is reassessed in 6 months by performance on the relevant NephSAP, if available, or by questioning by the Program Director.

e. Resident portfolio – This is partly intended to evaluate Fellow’s practice-based learning and improvement. Several approaches are utilized:

1) Faculty or fellow-initiated CQI project. The Fellow catalogues over time questions and issues that arose during patient care activities and identifies, with a faculty mentor, and issue to address. Once identified, an action plan is developed, the rationale expound (including identifying data sources used), actions taken, and the effect of such interventions assessed. This is reviewed every 6 months with the Program Director and the faculty mentor.

2) Morbidity and mortality conference. Identification of practice and/or system-based problems contributing to morbidity and mortality is an important aspect of meeting these core competencies. Fellows attendance at these conferences, and identification of the issues discussed and actions taken, is documented and included in the portfolio.

3) Case-based presentations. Each fellow does approximately 8 case-based presentations yearly. These presentations assist in improving the fellow's practice, detailing how they researched a topic and how such research impacted their care, or plan for subsequent care. The topics covered are listed in the portfolio and the presentation itself is added to the reference database in the web-based "Fellows Lounge" on the Nephrology Division website. This latter activity helps improve the practice of all fellows and faculty.

4) Journal club. Each fellow does approximately 8 journal club presentations yearly. The article that they presented is listed in the portfolio. This helps document the fellow's commitment to improving their analysis of the literature relevant to care of their patients.

5) Log of adverse events and actions taken. Fellows keep a computer log of this, independent of their M&M presentations.

6) Summative evaluations. All summative fellow evaluations are included in the portfolio to enable the fellow to review their progress and facilitate making any necessary changes. While this information can largely be obtained by each fellow using their unique logon access to the web-based evaluation system (MyEvaluations.com), having a written list facilitates discussion with, and review by, the Program Director.

7) Procedures. All procedures completed are listed here - see details in following section. 8) Self-evaluation. Fellows complete a self-assessment every 6 months that is reviewed with

them by the Program Director. f. Mini-clinical examination (Mini-CEX) – These are given about 4 times during the first year, in the

inpatient and outpatient setting, to provide formative input on the fellow’s progression towards obtaining clinical competence relevant to general nephrology patient care.

2. Procedures – Fellows are required to keep a log of all native kidney biopsies, indicating date, attending, patient identifier, indication and complications. Fellows are required to perform at least 5 native biopsies per year. These biopsies are always done in the presence of an attending, regardless of fellow competency and experience. Fellows are not required to keep a log of urinalyses, but must be certified as competent in these by the Program Director, based on faculty input, prior to being able to conduct these unsupervised.

3. Conferences – Fellows attendance at conferences is documented as described above. Participation in journal clubs, M&M, case-based presentations, and Landmark articles review, as they relate to general nephrology, is discussed with the Program Director during the 6-month evaluation.

4. Final (summative) evaluation - This evaluation includes a review of the Fellow’s performance during the final period of education, and verifies that the Fellow demonstrated sufficient professional ability to practice competently and independently

8) Assessment and evaluation of attendings by Fellows - discussed in section below devoted to this topic.

21

General Nephrology Table - Months 1-6

Competency category

Competency objectives General Nephrology objectives relevant to competency Teaching Methods Evaluation Methods

Acceptable Performance

Patient care

Exhibit caring and respectful behaviors

Exhibit caring and respectful behaviors towards general nephrology patients

Attending teaching Conferences Orientation Core lectures

Patient surveys 360 evaluation Checklist Mini-CEX

≤10% unacceptable

≥ 5

≥ 5

Formative

Gather essential and accurate information about their patients

Gather essential information about fellow’s general nephrology patient

Attending teaching Conferences Core lectures

Checklist 360 evaluation Mini-CEX

≥ 5

≥ 5

Formative

Make informed decisions about diagnostic and therapeutic interventions

Begin to understand the basics of making informed decisions about diagnostic and therapeutic interventions in general nephrology patients


Checklist

≥ 5

Develop and carry out patient management plans

Begin to develop general nephrology patient management plans


Checklist 360 evaluation

≥ 5

≥ 5

Counsel and educate patients and families

Counsel and educate, with direct attending supervision, general nephrology patients and families with regard to their disease, socioeconomics, support systems, diet, lifestyle, medications



≥ 5

≥ 5

Formative

Use information technology

Use information technology to assist caring for general nephrology patients, including UpToDate, NIH information and databases, NephSAP, electronic medical records, PubMed, and other sources

Attending teaching Orientation Conferences

Checklist ≥ 5

Perform: Physical exam

Examine the general nephrology patient, particularly with regard to the renal examination and organ systems affected by renal dysfunction


Checklist Mini-CEX

≥ 5

Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and understand the correct procedural techniques for: 1. Percutaneous native renal biopsy Understand interpretation and the correct technique for: 2. Urinalysis


Checklist ≥ 5

Provide preventative health care services

Understand preventative health care services relevant to general nephrology patients

Conferences Attending teaching

Checklist

≥ 5

Work within a team of health care professionals

Work within the general nephrology health care team, including attendings, nurses, dieticians, social workers, physician extenders, pharmacists and administrative assistants

Conferences Attending teaching Orientation


≥ 5

≥ 5

22

Medical knowledge

Demonstrate investigatory and analytic thinking about clinical situations

Begin to demonstrate investigatory and analytic thinking about clinical general nephrology situations

Attending teaching Core lectures Conferences Journal club Clinical meetings Orientation

Checklist Mini-CEX

≥ 5

Formative

Know and apply the basic and clinically supportive sciences

Fellows will gather the data and begin to develop the fund of knowledge necessary for prevention, evaluation, and management of general nephrologic disorders in: a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal

osteodystrophy (including use of lithotripsy) e. Urinary tract infections and pyelonephritis f. Hypertensive disorders g. Renal disorders related to pregnancy h. Primary and secondary glomerulopathies, including understanding of

immunologic mechanisms of renal disease and the laboratory tests necessary for their diagnosis

i. Diabetic nephropathy j. Tubulointerstitial nephritis including papillary necrosis k. Genetic and developmental renal diseases including renal cystic

diseases, hereditary glomerulopathies and interstitial nephritis, phakomatoses, systemic diseases with renal involvement, congenital malformations of the urinary tract, maternally inherited mitochondrial diseases, and renal cell carcinoma

l. Vascular diseases including atheroembolic disease m. Disorders of drug metabolism and renal drug toxicity, including in

geriatric patients n. Renal disorders associated with geriatric patients o. Renal cystic diseases without a recognized genetic basis Understand nutritional management of general nephrologic disorders Understand indications and interpretation of renal imaging, including

ultrasound, CT, IVP, MRI, angiography, nuclear medicine studies Understand indications, complications and outcomes in therapeutic

plasmapheresis


Checklist Mini-CEX

≥ 5

Formative

23

Practice-based learning and improvement

Analyze own practice and perform practice-based improvement using a systematic methodology

Fellow will hold up a mirror to themselves to document, assess, and improve their practice. This will involve: a. Monitoring their practice b. Reflecting on or analyzing their practice to identify learning

or improvement needs c. Begin a learning or improvement plan

Attending teaching Case-based presentations

on fellow’s own pts. Journal club Participation in CQI activities Exit rounds on patient

discharge M&M on fellow’s own

patients Conferences Log of significant events and

plan to address Assigned faculty mentor PIM

Resident portfolio (Fellow catalogues over time questions and issues that arose during patient care activities along with copies of the data sources used, and actions taken, to address the specific question or issue).

6 case-based talks* 6 journal clubs* 1 M&M*

≥ 5 on checklists

Log of 1 significant event and how addressed CQI project started *Conference performance evaluated by TPD

Use evidence from scientific studies related to patients’ health problems

Use evidence from scientific studies related to general nephrology patients’ health problems


on fellow’s own pts. Journal club

Checklist

≥ 5

Formative

Apply knowledge of study designs and statistical methods to appraising clinical studies and other information

Begin to understand study designs and statistical methods to appraising clinical studies and other information

Statistics and epidemiology course

Conferences Journal club Assigned faculty mentor

Checklist

≥ 5

Formative


Use information technology as itemized in Patient Care above Attending teaching Orientation Conferences

Checklist Resident portfolio

≥ 5

See “Analyze own practice…” above

Facilitate the learning of others

Facilitate the learning of others, including, residents, fellows, physician extenders, nurses and dialysis technicians. Initially, this is based on assigned literature review.

Role models Attending teaching Conferences


≥ 5

≥ 5

Interpersonal & communication skills

Maintain a therapeutic and ethical relationship with patients

Maintain a therapeutic and ethical relationship with general nephrology patients

Role models Attending teaching Conferences Core lectures

Checklist 360 evaluation Patient surveys

≥ 5

≥ 5

≤10% unacceptable

Demonstrate effective listening and writing skills

Demonstrate effective listening and writing skills Role models Attending teaching


≥ 5

≥ 5

Formative

24

Professionalism Demonstrate respect, compassion, and integrity

Demonstrate respect, compassion, and integrity Role models Attending teaching

Checklist 360 evaluation Patient surveys Mini-CEX

≥ 5

≥ 5

≤10% unacceptable Formative

Demonstrate an ethically sound practice

Demonstrate an ethically sound practice Role models Attending teaching Conferences


≥ 5

≥ 5

Demonstrate sensitivity to patients’ culture, age, gender, and disabilities




≥ 5

≥ 5


Systems-based practice

Understand interaction of their practices with the larger system

Begin to understand interaction between fellow’s practice and the hospital and clinic staff, administration, surgical service, radiology, and medical consult services


360 evaluation ≥ 5

Understand types of medical practice and delivery systems

Begin to understand how types of general nephrology practice and providers deliver care


Checklist ≥ 5

Practice cost-effective health care

Begin to understand how to practice cost-effective general nephrology patient care

Conferences Core lectures Attending teaching


≥ 5

≥ 5

Advocate for quality patient care

Begin to understand how to advocate for general nephrology patient quality care

Attending teaching Participation in CQI Conferences


≥ 5

≥ 5

25


Competency category



Patient care





≤10% unacceptable ≥ 6 ≥ 6 Formative





≥ 6 ≥ 6 Formative


Synthesize data to begin to make informed decisions about diagnostic and therapeutic interventions in general nephrology patients


Checklist

≥ 6 Formative


Develop general nephrology patient management plans. Understand how to carry out such plans.





Counsel and educate general nephrology patients and families with regard to their disease, socioeconomics, support systems, diet, lifestyle, medications






Attending teaching Conferences

Checklist ≥ 6




Checklist Mini-CEX

≥ 6 Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and demonstrate the correct procedural techniques for: 1. Percutaneous native renal biopsy Understand interpretation and demonstrate the correct technique for: 2. Urinalysis


Checklist ≥ 6 Perform at least 5 native renal biopsies by end of year 1


Provide preventative health care services relevant to general nephrology patients


Checklist

≥ 6 Formative





≥ 6 ≥ 6

26

Medical knowledge


Demonstrate investigatory and analytic thinking about clinical general nephrology situations

Attending teaching Core lectures Conferences Journal club Clinical meetings

Checklist ASN In-training

examination

≥ 6 Formative Formative


Fellows will continue to acquire the fund of knowledge necessary for prevention, evaluation, and management of the general nephrologic disorders below. They will begin to apply this information. a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis


Written exam Mini-CEX

≤4 incorrect in each general nephrology Area Formative

27




or improvement needs c. Engaging in a learning or plan improvement







12 case-base talks* 12 journal clubs* 2 M&M* ≥ 6 on checklists Log of 2 significant events and how addressed CQI project data analyzed and improvement plan developed *Conference performance evaluated by TPD





ASN In-training examination

Formative






Formative




≥ 6 See “Analyze own practice…” above


Facilitate the learning of others, including faculty, residents, fellows, physician extenders, nurses and dialysis technicians



≥ 6 ≥ 6






≥ 6

≥ 6 ≤10% unacceptable




≥ 6

≥ 6 Formative

28




≥ 6 ≥ 6 ≤10% unacceptable Formative




≥ 6 ≥ 6








Understand interaction between fellow’s practice and the hospital and clinic staff, administration, surgical service, radiology, and medical consult services




Understand how types of general nephrology practice and providers deliver care



Formative


Understand cost-effective general nephrology patient care and begin to apply these principles



≥ 6 ≥ 6


Advocate for general nephrology patient quality care by demonstrating proactive efforts towards general nephrology patient care



≥ 6 ≥ 6

29


Competency category



Patient care




Patient surveys 360 evaluation Checklist

≤10% unacceptable

≥ 7 ≥ 7





≥ 7 ≥ 7


Make informed decisions about diagnostic and therapeutic interventions in general nephrology patients


Checklist

≥ 7


Develop and carry out general nephrology patient management plans



≥ 7 ≥ 7





≥ 7 ≥ 7




Checklist ≥ 7




Checklist

≥ 7

Perform: Procedures



Checklist ≥ 7




Checklist

≥ 7





≥ 7

30

Medical knowledge




Checklist

≥ 7


Fellows will acquire the fund of knowledge necessary for prevention, evaluation, and management of general nephrologic disorders in: a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis


Checklist ≥ 7

31




or improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement







18 case-base talks* 18 journal clubs* 3 M&M*

≥ 7 on checklists

Log of 3 significant events and how addressed CQI project - intervention/begin data analysis *Conference performance evaluated by TPD





Checklist ≥ 7





Checklist

≥ 7









≥ 7

≥ 7






≥ 7 ≥ 7 ≤10% unacceptable




≥ 7 ≥ 7

32








≥ 7 ≥ 7














Checklist ≥ 7


Practice cost-effective general nephrology patient care Conferences Core lectures Attending teaching


≥ 7 ≥ 7


Advocate for general nephrology patient quality care by demonstrating proactive efforts towards dialysis CQI



≥ 7 ≥ 7

33


Competency category



Patient care





≤10% unacceptable ≥ 8 ≥ 8





≥ 8 ≥ 8


Make informed decisions about diagnostic and therapeutic interventions in general nephrology patients


Checklist

≥ 8


Develop and carry out general nephrology patient management plans



≥ 8 ≥ 8





≥ 8 ≥ 8




Checklist ≥ 8




Checklist

≥ 8

Perform: Procedures



Checklist ≥ 8 Perform at least 10

native renal biopsies by end of year 2




Checklist

≥ 8





≥ 8

34

Medical knowledge




Checklist

≥ 8


Fellows will acquire the fund of knowledge necessary for prevention, evaluation, and management of general nephrologic disorders in the areas below. They will serve as educators for other fellows, faculty and staff in these areas, whenever possible. a. Acute renal failure b. Chronic renal failure c. Fluid, electrolyte, and acid-base disorders d. Disorders of mineral metabolism including nephrolithiasis and renal








plasmapheresis


Checklist

≥ 8

35



Fellow will hold up a mirror to themselves to document, assess, and improve their practice. This will involve: a. Monitoring their practice b. Reflecting on or analyzing their practice to identify learning or

improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement e. Monitoring the impact of the learning or improvement







24 case-base talks* 24 journal clubs* 4 M&M* ≥ 8 on checklists Log of ≥4 significant events and how addressed CQI project - analysis & reporting *Conference performance evaluated by TPD





Checklist

≥ 8





Checklist

≥ 8


Use information technology as itemized in Patient Care above Attending teaching Conferences




Facilitate the learning of others, including faculty, residents, fellows, physician extenders, nurses and dialysis technicians. The degree of such education is one of the main differences from the preceding six months.



≥ 8 ≥ 8










≥ 8 ≥ 8

36








≥ 8 ≥ 8











≥ 8 ≥ 8




Checklist ≥ 8


Practice cost-effective general nephrology patient care Conferences Core lectures Attending teaching


≥ 8 ≥ 8


Advocate for general nephrology patient quality care by demonstrating proactive efforts towards dialysis CQI



≥ 8 ≥ 8

37

C. Transplant (RETURN TO TABLE OF CONTENTS) 1) Goal Fellows will become competent in caring for renal transplant patients and patients with renal

complications of non-renal transplants. 2) Objectives

Detailed objectives for transplant are described in the Transplant table. There are 4 separate tables that address objectives for each rotation on transplant nephrology. A rotation is defined as a 6-month period, so there are separate objectives for the 1st, 2nd, 3rd and 4th 6-month rotations. These objectives reflect a progressive increase in expectations for fellows' competency achievement. While these are discussed in detail in the table, the essence of the objectives for each 6-month rotation are as follows: 1. Months 1-6 - Fellows function at least a the level of accurate reporting of the history, physical and





3) Types of clinical encounters and supervision 1. Inpatient transplant encounters – Each Fellow spends 3 months/year on the UH Transplant (TP)

rotation. All UH patients admitted for surgical renal transplantation are admitted to the Transplant Surgery Service. These patients are followed by the Fellow on the UH rotation during the perioperative period. The Fellow discusses perioperative care with the Transplant Surgery Team each day. Subsequent admissions of renal transplant recipients are made to the Nephrology service (unless the problem is likely to require surgery); the Fellow sees these patients on a daily basis and helps oversee housestaff progress notes. Post-transplant patients are very infrequently admitted to the VA. The Attending sees the patients together with the Fellow after the Fellow has done the initial evaluation. The General Nephrology Attending is on-call with the Fellow 24 hours a day. A Transplant Nephrologist is on-call 24 hours each day for back-up of difficult transplant issues.

2. Outpatient transplant encounters a. UH Post-Transplant Clinic - Each Tuesday morning, the Fellow on the TP rotation attends this

clinic. In all, Fellows attend 3 months/year of weekly UH Post-Transplant Clinic on a non-continuity basis. All patients are initially evaluated by the Fellow. Renal transplant coordinators are present to facilitate patient care. All patients are staffed with the Transplant attending.

b. UH Pre-Transplant Clinic – Fellows attend this clinic every Wednesday morning while on the TP rotation. In all, each Fellow attends this clinic for 3 months/year. The Fellow initially evaluates pre-transplant candidates. Renal transplant coordinators are present to facilitate this process. All patients are staffed with the Transplant attending.

4) Patient characteristics (number, demographics)

38

1. Inpatients - The average inpatient TP census is 4-8 patients. Approximately 95 patients received renal transplants at UH in 2013 of which about 30 were living-related donors. Patient demographics are similar to those for general nephrology patients. VA patients are transplanted at UH but admitted to the VA subsequently. About 3-5 VA patients are transplanted each year.

2. Outpatients – Over 600 patients are followed in the UH Post-Transplant Clinic. An average of 15-20 patients are seen in the weekly UH Post-Transplant Clinic. The UH Pre-Transplant Clinic evaluates up to four patients each week. Patient demographics are similar to those for general nephrology patients.

5) Procedural training (see Transplant Table) 1. Percutaneous biopsy of transplanted kidneys – performed by the Fellow on inpatients on their

service or outpatients they have seen in Post-Transplant Clinic. All renal transplant biopsies on inpatients are performed by the Fellow in the presence of the Attending. Each fellow performs about 15-20 renal transplant biopsies yearly.

6) Teaching methods (see Transplant Table) 1. Educational training

a. Handouts - At the beginning of the Fellowship, Fellows are given the Handbook of Renal Transplantation (Danovitch), the AST Handbook of Transplant Infections (Kumar and Humar), How the Immune System Works (Sompayrac), and access to UpToDate. Additionally, they are given the Handbook of Renal Transplant Protocols for the University of Utah.

2. Didactic sessions a. Weekly didactic conference – Renal transplant issues are covered in detail in the didactic

conference held each Friday from 11:30-12:30 PM. Sessions are devoted to recipient evaluation, mechanisms of allograft rejection, immunosuppressive drugs, prophylaxis and treatment of graft rejection, non-rejection causes of graft dysfunction, major causes of post-transplant morbidity and mortality, and renal disease associated with liver, heart and bone marrow transplantation.

b. Primer Course - At the beginning of the Fellowship, a multi-day course (a few hours each day) is given to provide a basic level of instruction regarding several issues in Nephrology. Those covered relevant to transplant include renal transplantation and UH Protocols, chronic immunosuppression, and approach to an elevated creatinine or fever in a transplant recipient.

3. Conferences – Fellows must attend the following conferences: a. 4 PM Nephrology Clinical Conference - See General Nephrology Section for details. General

nephrology, dialysis and transplant cases are discussed in the setting of case-based presentations, Landmark articles, M&M, and journal club.

b. 5 PM Nephrology Conference – See General Nephrology section for details. Several conferences are devoted to transplant yearly.

c. Renal Pathology Conference – The conference is held each Friday from 12:30-1:30 PM during the two years. All biopsies of transplanted kidneys performed at University Hospital are reviewed as well as interesting historical cases. The conference is led by the Renal Pathologist using a multi-headed microscope and is attended by all Fellows

4. Inpatient attending rounds – See under Types of Clinical Encounters above. 7) Assessment and evaluation of Fellows (see Transplant Table) 1. Clinical encounters – A variety of instruments are used to assess Fellow performance. The specific

evaluation utilized is indicated in the Transplant Table. These include: a. Checklist

1) Fellows are evaluated at the end of each 2-week block with a given attending. The attending uses a scale from 1-9 to assess patient care knowledge, skills, attitudes and behaviors. Fellows review these orally with the attending and both individuals sign the review form. If there is any significant issue, the attending immediately communicates this to the Program Director who meets with the attending and fellow to develop an action plan to address the issue. The Fellow’s performance in this area is then reassessed, by Checklist by the inpatient

39

attendings, in one month and reviewed with the Program Director. During the first 6 months of fellowship, all scores must be "5" (satisfactory) or higher; scores under this will be reviewed with the Program Director, specific problem areas identified, and the appropriate corrective action taken. The problem areas are re-evaluated in one month. During the second 6 months (7-12 months of training), scores must average "6" or over; during the third 6 months (13-18 months of training), scores must average "7" or over; and during the fourth and final 6 months (19-24 months), scores must average "8" or above. If these ratings are not obtained, the same steps are taken as discussed above.

2) Fellows are evaluated by Transplant Director (Dr. Shihab) and Program Director every 6 months. First, the goals and objectives of the upcoming 6-month transplant rotation are reviewed. The Transplant and Program Directors use a scale from 1-9 to evaluate the Fellow’s patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice as it pertains to transplant. Fellows review this with the Program and Transplant Directors. The evaluation is based on review of the attending checklists, 360 degree evaluations (see below), and any other pertinent information. Importantly, this evaluation is also based on semi-annual discussions between all clinical faculty and the Transplant and Program Directors. If any significant issues exist, an action plan is developed and the fellow re-evaluated by the Program and Transplant Directors in 6 months using the same evaluation measurements as above. In addition, even if no significant issues are identified, goals are established for the fellow to work on over the next 6 months. These goals typically do not reflect needed attention to sub-par performance, but instead are intended to help the Fellow focus efforts. For example, faculty may note that the fellow did relatively pre-transplant evaluations, did relatively few renal transplant biopsies, or that attending comments reflected a need to increased transplant knowledge base – appropriate recommendations to work on these areas would be made, and progress evaluated at the next semi-annual Program and Transplant Director review.

b. 360 evaluation – this evaluation is completed by transplant nurses, social workers, dieticians, pharmacists, and nurse practitioners in order to give a broad sense of how the Fellow delivers patient care and interacts with members of the transplant health care interdisciplinary team. It is completed every 6 months. Fellows review this with the Program Director. Problem areas (scores under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with particular attention to these problem areas.

c. Patient surveys – Over the course of the year, about 10 different patients are asked to complete a form rating transplant patient interaction. These are reviewed annually with the Transplant Director. Areas in need of improvement are identified and reassessed, by patient survey, within 6 months. These evaluations are not fellow-specific, since fellows do not follow transplant patients on a continuity basis. However, fellows are involved in discussion of the patient surveys and identification of areas for improvement.

d. Written exam – In the spring of the first year, Fellows take the American Society of Nephrology In-Training Examination. Their performance is reviewed with the Program Director. Transplant areas in need of improvement are identified (defined as missing more than 2 questions in that area) and an action plan is developed to address these. Fellow’s fund of knowledge in these areas is reassessed in three months by performance on the relevant NephSAP or by satisfactorily answering questions from the Transplant Director.

f. Resident portfolio – Please see details under General Nephrology section. A fellow's project may be in the transplant area, if deemed appropriate by the Transplant Director.

h. Mini-clinical examination (Mini-CEX) – These are given about four times in the first year in the inpatient and outpatient setting, to provide formative input on the fellow’s progression towards obtaining clinical competence relevant to transplant patient care.

2. Procedures – Fellows must keep a log of all transplant kidney biopsies indicating date, attending, patient identifier, indication and complications. Fellows must do at least 5 transplant kidney biopsies each year. However, at no time may a Fellow do a biopsy without attending supervision.

40

3. Conferences – Fellows attendance at conferences is documented. Participation in journal clubs, case-based presentations, and NephSAP review, as they relate to transplant, is discussed with the Program Director during the 6-month evaluation.



41

Transplant Table - Months 1-6

Competency category

Competency objectives

Transplant objectives relevant to competency Teaching Methods Evaluation Methods


Patient care


Exhibit caring and respectful behaviors towards transplant patients

Attending teaching Conferences Orientation Core lectures


≤10% unacceptable

≥ 5

≥ 5

Formative


Gather essential information about fellow’s transplant patient



≥ 5

≥ 5

Formative


Begin to understand the basics of making informed decisions about diagnostic and therapeutic interventions in transplant patients


Checklist

≥ 5


Begin to develop transplant patient management plans Attending teaching Conferences Core lectures


≥ 5

≥ 5


Counsel and educate transplant patients and families with regard to renal transplant types, socioeconomics, support systems, diet, lifestyle, medications



≥ 5

≥ 5

Formative


Use information technology to assist caring for transplant patients, including UpToDate, NIH information and databases, NephSAP, electronic medical records, PubMed, and other sources


Checklist ≥ 5


Examine the transplant patient, particularly with regard to transplant-related problems, including examination of the transplant site


Checklist Mini-CEX

≥ 5

Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and understand the correct procedural techniques for: 1. Renal transplant biopsy


Checklist ≥ 5


Understand preventative health care services relevant to transplant patients


Checklist

≥ 5


Work within the transplant health care team, including attendings, nurses, nurse coordinators, social workers, physician extenders, pharmacists, and administrative assistants



≥ 5

≥ 5

42

Medical knowledge


Begin to demonstrate investigatory and analytic thinking about clinical transplant situations


Checklist Mini-CEX

≥ 5

Formative


Fellows will gather the data and begin to develop the fund of knowledge necessary for: a. Pre-transplant selection, evaluation and preparation of

transplant recipients and donors b. Understanding of immunosuppressant drug effects and

toxicity c. Immediate postoperative management of transplant

recipients d. Understanding of immunologic principals of types and

mechanisms of renal allograft rejection e. Clinical diagnosis of all forms of rejection including

laboratory, histopathologic and imaging techniques f. Prophylaxis and treatment of allograft rejection g. Recognition and medical management of nonrejection

causes of allograft dysfunction, including urinary tract infections, acute renal failure, and others

h. Understanding major causes of post-transplant morbidity and mortality

i. Understanding of fluid, electrolyte, mineral and acid-base regulation in post-transplant patients

j. Long-term follow-up of transplant recipients in the ambulatory setting including economic and psychosocial issues

k. Understanding of principles of organ harvesting, preservation and sharing

l. Understanding of renal disease in liver, heart and bone marrow transplant recipients


Checklist Mini-CEX

≥ 5

Formative




or improvement needs c. Engaging in a learning or plan improvement While these objectives are relevant to transplant care, the

Fellow may do this PBLI project as part of another area (dialysis, general nephrology).

Attending teaching Case-based

presentations Journal club Participation in CQI Exit rounds on patient

discharge M&M on own patients Conferences Log of significant

events and plan to address

Assigned faculty mentor

Fellow portfolio (Catalogue of questions and issues that arose during patient care along with copies of the data sources used, and actions taken, to address the specific question or issue).

6 case-based talks* 6 journal clubs* 1 M&M*

≥ 5 on checklists

Log of 1 significant event and how addressed CQI project started *Conference performance evaluated by TPD

43


Use evidence from scientific studies related to transplant patients’ health problems


presentations on fellow’s own pts.

Journal club

Checklist

≥ 5





Checklist

≥ 5


Use information technology as itemized in Patient Care above



≥ 5



Facilitate the learning of others, including faculty, residents, fellows, physician extenders and nurses. Initially, this is based on assigned literature review.



≥ 5

≥ 5



Maintain a therapeutic and ethical relationship with transplant patients



≥ 5

≥ 5

≤10% unacceptable




≥ 5

≥ 5

Formative




≥ 5

≥ 5





≥ 5

≥ 5





≥ 5

≥ 5


44



Begin to understand interaction between fellow’s practice and the transplant staff, administration, surgical service, radiology, medical consult services, the clinic, and the hospital

Interdisciplinary rounds Conferences Attending teaching



Begin to understand how transplant programs are organized


Checklist ≥ 5


Begin to understand how to practice cost-effective transplant care



≥ 5

≥ 5


Begin to understand how to advocate for transplant patient quality care



≥ 5

≥ 5

45


Competency category




Patient care












Synthesize data and begin to make informed decisions about diagnostic and therapeutic interventions in transplant patients


Checklist

≥ 6


Develop transplant patient management plans. Understand how to carry out such plans.



≥ 6 ≥ 6









Checklist ≥ 6




Checklist Mini-CEX

≥ 6 Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and demonstrate the correct procedural techniques for: 1. Renal transplant biopsy



renal transplant biopsies by end of year 1


Provide preventative health care services relevant to transplant patients


Checklist

≥ 6





≥ 6 ≥ 6

46

Medical knowledge


Demonstrate investigatory and analytic thinking about clinical transplant situations



examination

≥ 6 Formative


Fellows will continue to acquire the fund of knowledge necessary for: a. Pre-transplant selection, evaluation and preparation of













ASN In-training examination Mini-CEX

Formative Formative




or improvement needs c. Engaging in a learning or plan improvement While these objectives are relevant to transplant care, the









47





Journal club


Formative






Formative







Facilitate the learning of others, including faculty, residents, fellows, physician extenders and nurses



≥ 6 ≥ 6






≥ 6





≥ 6

≥ 6 Formative








≥ 6 ≥ 6






48



Understand interaction between fellow’s practice and the transplant staff, administration, surgical service, radiology, medical consult services, the clinic, and the hospital


360 evaluation ≥ “5”


Understand how transplant programs are organized Conferences Attending teaching



Practice cost-effective transplant care Conferences Attending teaching


Formative


Advocate for transplant patient quality care by demonstrating proactive efforts towards transplant CQI



≥ 6 ≥ 6

49


Competency category




Patient care





≤10% unacceptable

≥ 7 ≥ 7





≥ 7 ≥ 7


Make informed decisions about diagnostic and therapeutic interventions in transplant patients


Checklist

≥ 7


Develop and carry out transplant patient management plans



≥ 7 ≥ 7



Attending teaching Conferences Core lectures Interdisciplinary rounds


≥ 7 ≥ 7




Checklist ≥ 7




Checklist

≥ 7

Perform: Procedures



Checklist ≥ 7




Checklist

≥ 7





≥ 7

50

Medical knowledge




Checklist

≥ 7


Fellows will acquire the fund of knowledge necessary for: a. Pre-transplant selection, evaluation and preparation of













Checklist ≥ 7




or improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement While these objectives are relevant to transplant care, the









≥ 7 on checklists


51




presentations Journal club

Checklist ≥ 7





Checklist

≥ 7







Facilitate the learning of others, including faculty, residents, fellows, physician extenders and nurses



≥ 7

≥ 7










≥ 7 ≥ 7








≥ 7 ≥ 7






52








Checklist ≥ 7


Practice cost-effective transplant care Conferences Core lectures Attending teaching


≥ 7 ≥ 7





≥ 7 ≥ 7

53


Competency category




Patient care










≥ 8 ≥ 8


Make informed decisions about diagnostic and therapeutic interventions in transplant patients


Checklist

≥ 8


Develop and carry out transplant patient management plans



≥ 8 ≥ 8



Attending teaching Conferences Core lectures Interdisciplinary rounds


≥ 8 ≥ 8




Checklist ≥ 8




Checklist

≥ 8

Perform: Procedures




renal transplant biopsies by end of year 2




Checklist

≥ 8





≥ 8

54

Medical knowledge




Checklist

≥ 8


Fellows will acquire the fund of knowledge necessary for: a. Pre-transplant selection, evaluation and preparation of













Checklist

≥ 8




or improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement e. Monitoring the impact of the learning or improvement While these objectives are relevant to transplant care, the









55




presentations Journal club

Checklist

≥ 8





Checklist

≥ 8







Facilitate the learning of others, including faculty, residents, fellows, physician extenders and nurses. The degree of such education is one of the main differences from the preceding six months.



≥ 8 ≥ 8










≥ 8 ≥ 8








≥ 8 ≥ 8






56






≥ 8 ≥ 8



Checklist ≥ 8


Practice cost-effective transplant care Conferences Core lectures Attending teaching


≥ 8 ≥ 8





≥ 8 ≥ 8

57

D. Dialysis (RETURN TO TABLE OF CONTENTS) 1) Goal Fellows will become competent in caring for patients requiring dialysis therapy. 2) Objectives

Detailed objectives for general nephrology are described in the Dialysis table. There are 4 separate tables that address objectives for each rotation on dialysis. A rotation is defined as a 6-month period, so there are separate objectives for the 1st, 2nd, 3rd and 4th 6-month rotations. These objectives reflect a progressive increase in expectations for fellows' competency achievement. While these are discussed in detail in the table, the essence of the objectives for each 6-month rotation are as follows: 1. Months 1-6 - Fellows function at least a the level of accurate reporting of the history, physical and





3) Types of clinical encounters and supervision 1. Inpatient dialysis encounters – Patients requiring acute dialysis are seen at the VA and UH during

the 6 months/year on-service by Fellows on the VA or UH rotations. Patients are acutely dialyzed at both hospitals in either the acute dialysis unit or any of the ICUs. Acute hemodialysis, hemofiltration, or CRRT modalities are available at both sites. The fellow is responsible for determining the optimal renal replacement modality and writing the relevant prescription. Fellows also follow chronic dialysis patients admitted with non-dialysis-related problems - the non-dialysis issues are primarily addressed by the resident on service. All acute and chronic dialysis inpatients are seen at the earliest availability and presented in full to the Attending on-service. The Attending sees the patients together with the fellow after the fellow has done the initial evaluation. The fellow then writes and is responsible for dialysis prescription and coordinating and/or performing access placement. The Attending is on-call with the Fellow 24 hours a day.

2. Outpatient dialysis encounters a. VA Hemodialysis Rounds - The VA Fellow attends weekly Outpatient Hemodialysis Rounds at

the VA. The rounds are for each of the 4 hemodialysis shifts; these typically occur at varying times during the week depending upon Fellow and Attending availability. A different Attending is permanently assigned to each shift; currently these Attendings are Drs. Beddhu, Cheung, Nelson and Westenfelder. Once a month, these rounds are more comprehensive and involve review of monthly labs and development of a detailed care plan. Patients are seen on dialysis and notes written by the Fellow. In this way, all chronic hemodialysis patients at the VA are seen on a formal basis. These rounds combine quality patient care with concomitant didactic teaching and are an important foundation for learning care of chronic hemodialysis patients. Rounds are made with the nurse, dietician, social worker, Attending and Fellow.

b. VA Peritoneal Dialysis Clinic - OP fellows attend this clinic on two Tuesday mornings each month, as the patient volume dictates. It is structured like the Hemodialysis Clinic and is

58

supervised by Drs. Gregory and Abraham. Like the Hemodialysis Clinic, didactic teaching is particularly emphasized. Patients are seen with the nurse, dietician, social worker, attending and fellow.

c. University Peritoneal Dialysis Clinic - Fellows see all University PD patients in a continuity manner in clinic on the 2nd and 4th Monday mornings of each month while on the outpatient rotation. About 8 PD patients are seen per clinic. The clinic is supervised by Drs. Gregory and Abraham. Like the Hemodialysis Clinic, didactic teaching is particularly emphasized.

4) Patient characteristics (number, demographics) 1. Inpatients - The average numbers of acute dialysis patients are 1-2 at the VA and 6-8 at UH. The

average numbers of chronic dialysis inpatients are 2-4 at the VA and 3-5 at UH. Patient demographics are similar to those for general nephrology patients discussed above.

2. Outpatients – Approximately 650 chronic dialysis patients, including about 65 peritoneal dialysis patients, are followed by the University of Utah Dialysis Program. These patients are dialyzed at ten different centers located in Salt Lake City, Provo, Ogden, Roosevelt, Price, Cedar City, St. George, Rexburg, Layton, and Idaho Falls. There are about 40 chronic hemodialysis patients at the VA. About 10 chronic hemodialysis VA patients attend each dialysis clinic or shift while about 2-3 patients per fellow attend each PD Clinic at the U or VA.

5) Procedural training (also see Dialysis Table) 1. Temporary vascular access – Fellows place internal jugular and femoral vein double lumen

catheters for dialysis access. Once fellow competence has been ascertained by the Attending, residents may also place vascular access on their patients. The Fellow will place over 20 temporary vascular access catheters during the Fellowship, however there is no required minimum for number of vascular access catheters placed. Rather, a fellow will be certified as competent in this area by the Program Director on the basis of attending evaluations.

2. Acute hemodialysis – Fellows are trained to perform hemodialysis. Outside of this training, fellows do not dialyze patients themselves; this is done by the dialysis staff.

3. CRRT – Fellows are taught the set-up, indications, contraindications and use of CVVH, CAVH, CVVHD and CAVHD. CVVH and CVVHD can be performed at the VA and UH. The University of Utah Dialysis Program owns 6 CRRT (Prisma) machines and the VA owns 2 machines. Currently, about 10 patients are placed on CRRT weekly at the UH and VA combined.

4. Peritoneal dialysis – Fellows are trained in performing peritoneal dialysis including CAPD and CCPD. Fellows do not perform PD themselves, rather they are trained in all aspects related to the performance of PD. The General Surgeons place Tenckhoff catheters at the VA and UH.

6) Teaching methods (also see Dialysis Table) 1. Educational training

a. Handouts - At the beginning of the Fellowship, fellows are given the Handbook of Dialysis (Daugirdas and Ing) and access to UpToDate.

2. Didactic sessions a. Weekly didactic conference – Dialysis issues are covered in detail in the didactic conference held

each Friday from 11:30-12:30 PM. Sessions are devoted to hemodialysis issues (including systemic disorders accompanying ESRD, dialysis access, dialyzers, technical aspects, kinetics, and complications), peritoneal dialysis (including indications, mechanics, adequacy, and complications), CRRT, and vascular access placement.

b. Primer Course - At the beginning of the Fellowship, a multi-day course (a few hours each day) is given to provide trainees with a basic level of instruction regarding several issues in Nephrology. Those covered relevant to dialysis are hemodialysis and CAPD prescription and acute and chronic complications of hemodialysis and CAPD and their management.

3. Conferences – Fellows must attend the following conferences: a. Nephrology Clinical Conference - See General Nephrology Section for details. General

nephrology, dialysis and transplant cases are discussed in the setting of case-based presentations, Landmark articles review, M&M, and journal club.

59

b. 5 PM Nephrology Conference – See General Nephrology section for details. About seven conferences are devoted to dialysis yearly.

4. Inpatient attending rounds – See under Types of Clinical Encounters above. 5. Outpatient hemodialysis and peritoneal dialysis rounds – See under Clinical Encounters above.

Note that interdisciplinary interactions are a key part of these clinics. 7) Assessment and evaluation of Fellows (also see Dialysis Table) 1. Clinical encounters – A variety of instruments are used to assess Fellow performance. The specific

evaluation utilized is indicated in the Dialysis Table. These include: a. Checklist

1) Fellows are evaluated at the end of each 2-week block with a given attending. The attending uses a scale from 1-9 to assess patient care knowledge, skills, attitudes and behaviors. Fellows review these orally with the attending and both individuals sign the review form. If there is any significant issue, the attending immediately communicates this to the Program Director who meets with the attending and fellow to develop an action plan to address the issue. The Fellow’s performance in this area is then reassessed, by Checklist by the inpatient attendings, in one month and reviewed with the Program Director. During the first 6 months of fellowship, all scores must be "5" (satisfactory) or higher; scores under this will be reviewed with the Program Director, specific problem areas identified, and the appropriate corrective action taken. The problem areas are re-evaluated in one month. During the second 6 months (7-12 months of training), scores must average "6" or over; during the third 6 months (13-18 months of training), scores must average "7" or over; and during the fourth and final 6 months (19-24 months), scores must average "8" or above. If these ratings are not obtained, the same steps are taken as discussed above..

2) Fellows are evaluated by the Program Director and the Dialysis Director (Dr. Beddhu) every 6 months. First, the goals and objectives are reviewed for the upcoming six months. These Directors use a scale from 1-9 to evaluate the Fellow’s patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice as it pertains to dialysis. Fellows review this with the Program Director. The evaluation is based on review of the attending checklists, 360 degree evaluations (see below), and any other pertinent information. Importantly, this evaluation is also based on semi-annual discussions between all the clinical faculty and the Program and Dialysis Directors. If any significant issues exist, an action plan is developed and the fellow re-evaluated by the Program and Dialysis Directors in 6 months using the same evaluation measurements as above. In addition, even if no significant issues are identified, goals are established for the fellow to work on over the next 6 months. These goals typically do not reflect needed attention to sub-par performance, but instead are intended to help the Fellow focus efforts. For example, faculty may note that the fellow did relatively few CRRTs, placed relatively few dialysis catheters, or that attending comments reflected a need to increased dialysis knowledge base – appropriate recommendations to work on these areas would be made, and progress evaluated at the next semi-annual Program and Dialysis Director review.

b. 360 evaluation – this evaluation is completed by dialysis technicians, dialysis nurses, social workers, dieticians, pharmacists, and nurse practitioners in order to give a broad sense of how the Fellow delivers patient care and interacts with members of the dialysis health care interdisciplinary team. It is completed every 6 months. Fellows review this with the Program Director. Problem areas (scores under "5") are identified and an action plan developed. Fellows are reassessed in 6 months with particular attention to these problem areas.

c. Patient surveys – Over the course of the year, 5-10 different patients are asked to complete a form rating dialysis patient interaction. These are reviewed annually with the Program Director. Areas in need of improvement are identified and reassessed, by patient survey, within 3 months. These evaluations are not fellow-specific, since fellows do not follow dialysis patients on a continuity basis (except for continuity physical examinations). However, fellows are involved in discussion of the patient surveys and identification of areas for improvement.

60

d. Written exam – In the spring of the first year, Fellows take the American Society of Nephrology In-Training Examination. Their performance is reviewed with the Program Director. Dialysis areas in need of improvement are identified (defined as missing more than 2 questions in that area) and an action plan is developed to address these. Fellow’s fund of knowledge in these areas is reassessed in three months by performance on the relevant NephSAP or by satisfactorily answering questions from the Dialysis Director.

e. Resident portfolio – Please see details under General Nephrology section. A fellow's project may be in the transplant area, if deemed appropriate by the Dialysis Director.

f. Mini-clinical examination (Mini-CEX) – These are given about four times in the first year, in the inpatient and outpatient setting, to provide formative input on the fellow’s progression towards obtaining clinical competence relevant to dialysis patient care.

2. Procedures – Fellows are required to keep a log of temporary vascular access procedures (for hemodialysis or CRRT). Competence is determined by supervising attendings; there is no minimum number of temporary vascular access procedures required. Once deemed competent, fellows may place temporary vascular access without direct attending supervision of the procedure. There is no defined minimum requirement for number of hemodialysis, PD or CRRT patients.

3. Conferences – Fellows attendance at conferences is documented. Participation in journal clubs, case-based presentations, and Landmark articles review, as they relate to dialysis, is discussed with the Program Director during the 6-month evaluation.



61

Dialysis Table - Months 1-6 Competency category


Dialysis objectives relevant to competency Teaching Methods Evaluation Methods Acceptable Performance

Patient care


Exhibit caring and respectful behaviors towards dialysis patients

Attending teaching Conferences Core lectures Orientation


≤10% unacceptable

≥ 5

≥ 5

Formative


Gather essential information about fellow’s dialysis patient Attending teaching Conferences Core lectures


≥ 5

≥ 5

Formative


Begin to understand the basics of making informed decisions about diagnostic and therapeutic interventions in dialysis patients


Checklist Mini-CEX

≥ 5


Begin to develop dialysis patient management plans Attending teaching Conferences Core lectures


≥ 5

≥ 5


Counsel and educate, with direct attending supervision, dialysis patients and families with regard to dialysis modalities, socioeconomics, support systems, dialysis withdrawal, diet, lifestyle, medications

Attending teaching Conferences Core lectures Interdisciplinary

rounds


≥ 5

≥ 5

Formative


Use information technology to assist caring for dialysis patients, including UpToDate, NIH information and databases, NephSAP, electronic medical records, PubMed, and other sources

Attending teaching Conferences Orientation

Checklist ≥ 5


Examine the dialysis patient, particularly with regard to dialysis-related problems, vascular access site identification and evaluation of access function and infection


Checklist Mini-CEX

≥ 5

Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and understand the correct procedural techniques for: 1. Temporary vascular access (competent in procedure also) 2. Hemodialysis, peritoneal dialysis, and CRRT


Checklist ≥ 5

≥ 5


Understand preventative health care services relevant to dialysis patients, including following DOQI guidelines for prevention of anemia, maintenance of accepted serum chemistries, and optimization of dialysis delivery

Interdisciplinary rounds


Checklist

≥ 5


Work within the dialysis health care team, including attendings, nurses, dieticians, social workers, physician extenders, pharmacists, technicians, administrators and administrative assistants




≥ 5

≥ 5

62

Medical knowledge


Begin to demonstrate investigatory and analytic thinking about clinical dialysis situations


Checklist Mini-CEX

≥ 5

Formative


Fellows will gather the data and begin to develop the fund of knowledge necessary for: a. Evaluation and selection of patients for acute hemodialysis

or CRRT b. Evaluation of ESRD patients for various forms of therapy c. Drug dosage modification during dialysis and other extra-

corporeal therapies d. Evaluation and management of medical complications in

patients during and between dialyses and other extra-corporeal therapies, and an understanding of their pathogenesis and prevention



g. An understanding of the technology of peritoneal dialysis including the use of cyclers

h. Assessment of peritoneal dialysis efficiency using peritoneal equilibration testing and the principles of peritoneal biopsy

i. An understanding of how to write a peritoneal dialysis prescription and how to assess peritoneal dialysis adequacy

j. The pharmacology of commonly used medications and their kinetic and dosage alteration with peritoneal dialysis

k. 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


m. An understanding of the psychosocial, economic and ethical issues of dialysis

n. An understanding of dialysis water treatment, delivery systems and dialyzer reuse

o. An understanding of end-of-life care and pain management in the care of patients undergoing chronic dialysis, including psychosocial, cultural, and religious issues related to death and dying


Checklist Mini-CEX

≥ 5

Formative

63

64

p. An understanding of the radiologic evaluation of dialysis access, including its indications, contraindications, complications and interpretations of results, as well as their cost-effectiveness and application to patient care

q. An understanding of balloon angioplasty of vascular access, including its indications, contraindications, complications and interpretations of results, as well as their cost-effectiveness and application to patient care


Checklist Mini-CEX

≥ 5

Formative







Journal club Participation in CQI

activities Exit rounds on patient


patients Conferences Log of significant



Fellow portfolio (Fellow catalogues over time questions and issues that arose during patient care activities along with copies of the data sources used, and actions taken, to address the specific question or issue).

Completed PIM 8 case-based talks 8 journal clubs 4 M&M ≥ “5”, Yr 2 avg. ≥ 7 on checklists Log of ≥2 significant events, how addressed, and results Fellow/faculty initiated project (PIM is an alternative)


Use evidence from scientific studies related to dialysis patients’ health problems



Journal club

Checklist

≥ 5




Conferences Journal club Assigned faculty

mentor

Checklist

≥ 5





≥ 5






≥ 5

≥ 5

65



Maintain a therapeutic and ethical relationship with dialysis patients



≥ 5

≥ 5

≤10% unacceptable




≥ 5

≥ 5

Formative




≥ 5

≥ 5





≥ 5

≥ 5





≥ 5

≥ 5




Begin to understand interaction between fellow’s practice and the dialysis unit staff, unit administration, surgical service, radiology, medical consult services, the clinic, and the hospital


Conferences Attending teaching Dialysis director &

administrator didactic teaching



Begin to understand how types of dialysis units and providers deliver dialysis care



Checklist ≥ 5


Begin to understand how to practice cost-effective dialysis care



≥ 5

≥ 5


Begin to understand how to advocate for dialysis patient quality care by demonstrating proactive efforts towards dialysis CQI



≥ 5

≥ 5

66




Patient care











Synthesize data to begin to make informed decisions about diagnostic and therapeutic interventions in dialysis patients


Checklist

≥ 6


Develop dialysis patient management plans. Understand how to carry out such plans.



≥ 6 ≥ 6


Counsel and educate dialysis patients and families with regard to dialysis modalities, socioeconomics, support systems, dialysis withdrawal, diet, lifestyle, medications


rounds






Checklist ≥ 6




Checklist Mini-CEX

≥ 6 Formative

Perform: Procedures

Understand the principles of informed consent, indications, contraindications, alternative procedures, and the risks and benefits, and demonstrate the correct procedural techniques for: 1. Temporary vascular access for hemodialysis 2. Hemodialysis, peritoneal dialysis, and CRRT


Checklist ≥ 6


Provide preventative health care services relevant to dialysis patients, including following DOQI guidelines for prevention of anemia, maintenance of accepted serum chemistries, and optimization of dialysis delivery



Checklist

≥ 6






≥ 6 ≥ 6

67

68

Medical knowledge


Demonstrate investigatory and analytic thinking about clinical dialysis situations



examination

≥ 6 Formative


Fellows will increase their fund of knowledge necessary for: a. Evaluation and selection of patients for acute hemodialysis
















ASN In-training examination Mini-CEX

Formative Formative

69





examination

≥ 6 Formative



















Journal club


Formative





mentor


Formative










≥ 6 ≥ 6

70






≥ 6





≥ 6

≥ 6 Formative








≥ 6 ≥ 6








Understand interaction between fellow’s practice and the dialysis unit staff, unit administration, surgical service, radiology, medical consult services, the clinic, and the hospital





≥ 6 ≥ 6


Understand how types of dialysis units and providers deliver dialysis care




Formative


Practice cost-effective dialysis care Conferences Core lectures Attending teaching


≥ 6 ≥ 6


Advocate for dialysis patient quality care by demonstrating proactive efforts towards dialysis CQI



≥ 6 ≥ 6

71




Patient care





≤10% unacceptable

≥ 7 ≥ 7




≥ 7 ≥ 7


Make informed decisions about diagnostic and therapeutic interventions in dialysis patients


Checklist

≥ 7


Develop and carry out dialysis patient management plans Attending teaching Conferences Core lectures


≥ 7 ≥ 7




rounds


≥ 7 ≥ 7




Checklist ≥ 7




Checklist

≥ 7

Perform: Procedures



Checklist ≥ 7





Checklist

≥ 7






≥ 7

72

73

Medical knowledge




Checklist

≥ 7


Fellows will acquire the fund of knowledge necessary for: a. Evaluation and selection of patients for acute hemodialysis
















Checklist

≥ 7

74




Checklist

≥ 7




or improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement











≥ 7 on checklists






Journal club

Checklist ≥ 7





mentor

Checklist

≥ 7










≥ 7

≥ 7

75










≥ 7 ≥ 7








≥ 7 ≥ 7













≥ 7 ≥ 7





Checklist ≥ 7




≥ 7 ≥ 7





≥ 7 ≥ 7

76




Patient care









≥ 8 ≥ 8


Make informed decisions about diagnostic and therapeutic interventions in dialysis patients


Checklist

≥ 8


Develop and carry out dialysis patient management plans Attending teaching Conferences Core lectures


≥ 8 ≥ 8




rounds


≥ 8 ≥ 8




Checklist ≥ 8




Checklist

≥ 8

Perform: Procedures



Checklist ≥ 8





Checklist

≥ 8






≥ 8

77

Medical knowledge




Checklist

≥ 8


Fellows will acquire the fund of knowledge necessary for: a. Evaluation and selection of patients for acute hemodialysis
















Checklist

≥ 8

78




Checklist

≥ 8




or improvement needs c. Engaging in a learning or plan improvement d. Applying the new learning or improvement e. Monitoring the impact of the learning or improvement















Journal club

Checklist

≥ 8





mentor

Checklist

≥ 8







Facilitate the learning of others, including faculty, residents, fellows, physician extenders, nurses and dialysis technicians. The degree of such education is one of the main differences from the preceding six months.



≥ 8 ≥ 8

79










≥ 8 ≥ 8








≥ 8 ≥ 8













≥ 8 ≥ 8





Checklist ≥ 8




≥ 8 ≥ 8





≥ 8 ≥ 8

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E. Special areas - (RETURN TO TABLE OF CONTENTS) It is critical to emphasize the importance of

psychosocial and economic issues confronting patients with renal disease, ethical issues relevant to care of patients with renal disease, optimizing the relationship of the nephrologist with other health care providers, and optimizing mechanisms towards achieving life-long learning as a nephrologist. These issues are covered in detail in the above curriculum, however, they are not always clearly identified in the curriculum’s goals as being of paramount significance. In addition, formal courses on statistics and epidemiology, geriatric evaluation, nursing home care, and dialysis discontinuation/end-of-life issues are offered. These special aspects of the curriculum are discussed below: a. Dialysis initiation, discontinuation and end-of-life issues – Fellows are given lectures by the division

faculty on dialysis discontinuation and end-of-life issues. In addition, the issues surrounding dialysis initiation are discussed. These issues are also addressed on the inpatient service and in the clinics. The RPA/ASN Clinical Practice Guidelines for Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis form part of the discussion basis.

b. Geriatric assessment – Fellows are given didatic lectures by the renal division faculty devoted to the physiology and pathology of the aging kidney, altered drug metabolism with aging, and drug toxicity in the elderly. In addition, fellows read the American Society of Nephrology on-line geriatric nephrology curriculum and review this with the faculty.

c. Medical ethics – Fellows attend conferences during the course of their fellowship devoted to renal-related ethical issues. These focus on dialysis initiation and withdrawal, dialysis funding, renal transplant donor and recipient selection, kidney transplant availability, and other renal-related issues. The social and economic impact of their decisions and the need to be the patient’s advocate are discussed.

d. Health care policy and legal medicine – In addition to health policy issues related to end-of-life care, fellows attend lectures on health care policy and legal medicine, focusing on dialysis and renal transplant.

e. Physician impairment, risk management, patient safety – At the time of initial hire, all fellows spend a full day in the GME office. During this time, they are given instruction in physician impairment, OSHA, infection control, risk management, and HIPAA compliance.

f. Quality assessment and quality improvement - These processes are addressed by relevant projects as described in each section (General Nephrology, Transplant and Dialysis) above.

g. Medical genetics – Fellows are given several lectures focusing on renal-related medical genetics issues, including discussion of relevant techniques, single gene mutations, and polygenic disorders.

h. Pain control – This issue is discussed with fellows in the sessions on pharmacology in dialysis and CKD patients.

i. Division of Nephrology Clinical Research course – Fellows attend 8 one-hour sessions over the course of their clinical training devoted to understanding basics of clinical research. The course is run by Dr. Beddhu. It is based in part on the JAMA publications devoted to these areas, as well as other sources. Clinical epidemiology issues are discussed. The topics of the 8 lectures are:

1. Introduction to hypothesis testing- power and limitations of p value 2. Analysis of continuous variables - T-test, ANOVA, linear regression 3. Analysis of categorical variables - Chi-square. logistic regression 4. Survival analysis 5. Interpreting studies on therapeutic benefit 6. Interpreting studies on harm 7. Interpreting studies on diagnostic tests 8. Interpreting studies on cost-effectiveness

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F. Assessment and evaluation of attendings by Fellows 1. Annual evaluation of faculty and training program – Fellows complete a written form annually that

confidentially evaluates the faculty and training program. They evaluate the effectiveness of the program in achieving of the goals and objectives identified in the curriculum above. The evaluation includes utilization of the resources, contribution of each institution, the financial and administrative support, the volume and variety of patients, effectiveness of inpatient and ambulatory teaching, the performance of all faculty members, and the quality of supervision. Fellows meet with the Program Director and any changes in the program that are made as a result of the review are documented. These evaluations are also reviewed with each attending (keeping the Fellow’s name unknown) and documented in writing.

2. Semi-annual program evaluation by Fellowship Executive Committee – All clinical fellows, together with the Program Director, the Dialysis Director (Dr. Beddhu), the Transplant Director (Dr. Shihab), Dr. Kohan and Dr. Abraham formally meet to discuss how well the training program is meeting the goals and objectives of the curriculum. In addition, the curriculum itself is critically evaluated, along with all other issues raised during the Fellow and faculty evaluation of the program. Problems or areas of improvement are identified, a plan of action established, and the issues revisited, along with any new matters, at the next semi-annual meeting. Written minutes of these meetings are made and are available to all faculty. Any changes in the curriculum are presented to the entire clinical nephrology faculty for their approval. In practice, this committee meets as often as is felt necessary (typically every 3 months), but no less than every 6 months.

G. Self-evaluation by Fellows – The process of self-evaluation is important in the Fellow’s development into a competent nephrologist and is intended to help establish a life-long pattern of self-assessment and self-improvement. Consequently, Fellows complete a self-evaluation semi-annually that they review with the Program Director. The goal is for the Program Director and Fellow to develop goals, and related action plans, based on this self-evaluation, so that the Fellow can continue to improve. This self-evaluation is not used to critique fellow performance, but only as a tool to help focus the Fellow’s development.

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8. Nephrology Research Training Program (RETURN TO TABLE OF CONTENTS) A. Clinical research curriculum as part of 2-year clinical fellowship (1) Research Sites – Clinical research is conducted primarily when the Fellows are on the OP

rotation. The OP service, which comprises three months each year, allows a substantial amount of time for research, without having inpatient responsibilities. Additionally, several opportunities exist for Fellows to become involved in ongoing multicenter collaborations.

(2) Research Schedule - Within the first month of Fellowship, Fellows meet with all clinical research faculty to discuss possible clinical research projects and mentorship. Basic research projects are not realistic during the two years of Fellowship. Fellows are expected to become involved in projects already in progress and not to be responsible for designing a new project. Fellows are not expected to obtain independent funding to support their salary or research activities. After identifying a mentor and project, Fellows are actively involved in the faculty-directed clinical research project while on each OP rotation.

(3) Goals and Objectives of Research Program a. Understand fundamentals of clinical research including basics of research design, data

analysis (biostatistics), public policy, economics, health education, designing trials, recruiting subjects, responsible use of informed consent, standards of ethical conduct of research, clinical epidemiology, and outcomes analysis.

b. Gain hands-on experience with conducting a clinical research project including research design (where feasible), data analysis, subject recruitment, data collection, and manuscript preparation.

c. Understand principles of grant writing. d. Provide sufficient exposure to clinical research to allow Fellows to make an informed

decision about pursuing a career involving clinical research. e. Provide sufficient exposure to clinical research to allow Fellows to critically assess clinical

research literature and to be competent in using available medical informatics systems. Bibliographic retrieval and critical appraisal skills are of paramount importance.

f. Become a co-author on a published manuscript or abstract, or present research at a national meeting.

(4) Educational Training a. Didactic courses

1. CRC course - Fellows interested in clinical research attend a 2-day general clinical research course given in August of their first year by the Clinical Research Center at the University of Utah. Topics covered include basics of research design, ethical conduct of research, responsible used of informed consent, data analysis (biostatistics), public policy, economics, health education, designing trials, recruiting subjects and other epidemiology issues, and outcomes analysis.

2. Division of Nephrology Clinical Research course – Fellows attend 8 one-hour sessions over the course of each year devoted to understanding clinical research. The course is taught by Dr. Beddhu. Details are discussed in Section 7E above.

b. The research mentor-Fellow relationship is the primary means by which Fellows will achieve training in clinical research.

(5) Nature of Supervision - Fellows should select a project and mentor by September 1 of the first year of Fellowship and inform the Nephrology Fellowship Program Director of their selection. For the next 22 months, the Fellow’s clinical research activities will be guided by the Mentor. This involves frequent meetings (at least every two weeks during the OP rotation and every two months during other rotations) between the Fellow and mentor during which all aspects of conducting the clinical research projects are addressed.

(6) Means of Fellow Evaluation – The mentor provides the Fellow with ongoing informal feedback. In addition, the mentor meets with the Nephrology Training Program Director semiannually to report on the Fellow’s progress. The Training Program Director also discusses the research progress with the Fellow during their semi-annual meetings. Evidence of successful completion of the Fellow research requirement includes presenting an abstract at a national or regional

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meeting, publishing an abstract or manuscript, and/or presentation of the research to the Division of Nephrology for the one hour research conference.

B. Research fellowship curriculum for fellows on 3-year research fellowship (1) Research Sites – Basic or clinical research are conducted at the VA or at University Hospital,

depending upon the location of the mentor. (2) Research Schedule - Research fellows identify a mentor within the first month of their fellowship.

Depending upon the fellow's preference and the number of clinical fellows, the research fellow will do their clinical year either at the beginning or the end of their fellowship. Once the fellow starts in the laboratory, they will do this exclusively for two years with the exception that they will maintain a ½-day general nephrology continuity clinic throughout their entire fellowship.

(3) Goals and Objectives of Research Program a. Understand fundamentals of basic or clinical research. For both clinical and basic research,

this includes research design and data analysis (biostatistics). For clinical research, this also includes public policy, economics, health education, designing trials, recruiting subjects and other epidemiology issues, and outcomes analysis.

b. Gain hands-on experience with conducting a basic or clinical research project including research design (where feasible), conducting the study, data analysis, and manuscript preparation. It is expected that the fellow will generate at least one peer-reviewed original research publication from this work, although this is not a requirement for graduation from the program.

c. Understand principles of grant writing. d. Provide sufficient experience in basic or clinical research to allow Fellows to make an

informed decision about their academic career choices. e. Provide sufficient exposure to basic or clinical research to allow Fellows to interpret basic

and clinical research literature. (4) Educational Training

a. Didactic courses 1. Clinical Research Training Track for Physician-Scientists. All fellows engaging in clinical

research are given the option to enroll in the Masters of Science in Clinical Investigation (MSCI) at the University of Utah. The MSCI is a two-year post-graduate experience that emphasizes epidemiology, clinical outcomes, clinical trials and health services research. The MSCI is funded by a Clinical and Translational Scientist Award (CTSA) of the NIH. Additional funding to support the program is provided by the Vice President for Health Sciences. The program is composed of formal didactic coursework, a longitudinal seminar series, and a mentored clinical research project. Fellows who successfully complete the program are eligible for a Master’s Degree awarded by the School of Medicine. Fellows successfully completing the program are awarded a Master’s Degree in Clinical Investigation. This degree is offered by the General Clinical Research Center, which has been designated as a degree-granting academic department within the SOM. The academic year for the TPCI program begins the second week of July and runs through the last week in May.

The curriculum during Year 1 of the MSCI program begins with a six-week intensive block of didactic course work and workshops (Schedule A). Fellows take a set of core courses in epidemiology, data management, bioethics, biostatistics and the research seminar series. Workshops in grant writing and the preparation of clinical research protocols are also offered. The curriculum focuses on community intervention studies, an epidemiology seminar and a computer practicum. During the six-week intensive block, the renal fellow will design and initiate their research project in conjunction with their preceptor.

Advanced, didactic coursework is continued through the fall and spring semesters (Schedule A). Courses are given two afternoons each week or in brief blocks over Thursday, Friday and Saturday morning. The mentor-based clinical research project continues. During the second year effort is focused on the clinical research project.

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However, during the fall semester of the second year, all fellows are required to take a weekly one-hour course entitled "Scientific Integrity & Ethics of Scientific Research". This course meets federal requirements for training grants and is described below.

During the late fall semester or early spring semester of the second year of the MSCI program, fellows will prepare (with the aid of his/her mentor) an application for a career development award through the NIH, the Department of Veterans Affairs, or an appropriate professional society. At the conclusion of the second year, a master’s thesis is submitted which can also serve as a research paper of publishable quality. Throughout the two-year program, fellows are required to attend a longitudinal research seminar series, given on two Friday afternoons per month. This series covers a wide variety of subjects of interest to students and also provides an opportunity for camaraderie amongst all MSCI participants, not just those in the Nephrology Training Program. All enrollees to date have ample time during the two years to complete their clinical research projects and to be highly competitive for NIH funding.

Fellows will be expected to participate by presenting their research at these research conferences as described above. Fellows will attend the annual American Society of Nephrology meeting each of these two years and will be expected to present their research at this meeting during the third year. Fellows also will be encouraged to present their research at the annual National Kidney Foundation meeting as well as any relevant regional conferences.

Schedule A. Training program in clinical research curriculum

INITIAL BLOCK (6 weeks)

MDCRC 6010 Introduction to Epidemiology. Covers the basics of epidemiology including: measures of disease frequency, measures of effect, basic study designs, confounding bias, stratification, and causal reasoning. This course is presented in two-hour sessions, two days a week for the first three weeks of the block. MDCRC 6020 Data Management. Covers managing databases for research, including problems and solutions for data management, database design, table linkage, confidentiality issues and data security. The course is presented in six two-hour sessions. MDCRC 6430 Bioethical Issues in Clinical Research. Ethical issues and standards for scientific investigation are covered in depth. Course- work emphasizes the history and evolution of research norms and practices, institutional expectations and standards, and the process of review and oversight for experimental protocols. Additional material covers ethical issues and public policy linked to genetic research. Case-based problem solving is used to cover interactions with the Institutional Review Board. This course is presented in two hour blocks, once weekly. MDCRC 6000 Introduction to Biostatistics. Basic statistics with emphasis on medical and epidemiologic research problems, including description of data, theoretical distribution, experimental design, hypothesis testing, comparison of groups, correlation, confidence intervals and sample size estimation. This course is presented in two-hour blocks, once weekly. MDCRC 6410 Research Seminar Series. This course is presented during the intensive introductory course and throughout the fall and spring. The course is presented for two hours on every Friday afternoon throughout the intensive introductory course and on the second and fourth Fridays of the fall and spring semester. Each seminar begins with the presentation of a clinical issue related to health care delivery or epidemiology. Discussions follow based on the methods used for defining epidemiologic and other health care issues. The seminars are designed to illustrate the process of scientific discovery in clinical investigation, provide examples of how innovative approaches and methods were applied and to discuss obstacles that impede progress. Visiting faculty from other universities participate in the seminar series. MDCRC 6100 Epidemiology Seminar. Key papers describing epidemiological methods are discussed followed by critical reviews of representative studies illustrating the application of these methods. This course is presented in two two-hour blocks each week

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for the first three weeks. MDCRC 6030 Computer Practicum. This course is designed to afford hands-on practice with statistical software (e.g. Stata). Students learn to merge databases, analyze data, scientific graphing, Monte Carlo simulation, and sensitivity analysis. This course is offered in two-hour blocks twice weekly during the last three weeks.

FALL SEMESTER YEAR ONE

MDCRC 6040 Design and Implementation of Clinical Trials. This course defines clinical trials and reviews drug registration trials, phase I, II and III trials, clinical endpoints, surrogate endpoints, pharmacokinetics, drug-drug interactions, data and safety monitoring, criteria for closure and single versus multi-institutional trials. Case-based sessions covering clinical trials in occlusive heart disease, arthritis, asthma and oncology provide informative examples of trial design and potential pitfalls. This course is presented in a weekly two- hour block.

MDCRC 6240 Community Intervention Studies. Strategies are presented for designing and implementing field intervention trials. Methods of analysis are covered, including cluster randomization and time series analysis. This course is presented as a one day intensive experience totaling 8 hours of lectures and tutorials. MDCRC 6230 Health Services Research. This course focuses on measurement of clinical outcomes and includes scale development, reliability and validity, study design, misclassification bias, co-morbidity, severity of illness scores, organizational structure and quality of life measurements. The course is taught as 3 intensive 1- day blocks every 2 months.

MDCRC 6130 Introduction to Decision Analysis. This course serves as an introduction to the subject of decision analysis related to health care and includes concepts, creation and evaluation of decision trees, Markov chains, sensitivity analysis and incorporation of patient preferences with utility analysis. This course is presented as a two and one-half day intensive experience totaling sixteen hours of lectures and tutorials.

MDCRC 6120 Cost Effectiveness Analysis. The material presented covers concepts used in the economic evaluation of health care programs, foundations of cost effectiveness analysis, interpreting and critiquing the literature of cost-effective analysis, and constructing these analyses. This course is presented as a two and one-half day intensive experience totaling sixteen hours of lectures and tutorials. OPTIONAL MDCRC 6110 Intermediate Epidemiology. Students enrolling in this course must have completed MDCRC 6010, Introduction to Epidemiology. Intermediate Epidemiology covers research design and conduct of epidemiologic studies, including assessing effect modification, stratification, matching, sampling and reasoning with causal diagrams. This course is presented in a weekly two- hour block during the second six weeks. OPTIONAL

SPRING SEMESTER YEAR ONE

MDCRC 6140 Intermediate Decision Analysis. Students enrolling in this class are required to have completed MDCRC 6130, Introduction to Decision Analysis. The intermediate decision analysis course is a practicum in designing and constructing a decision analysis model to solve an actual health care problem. A problem is provided and students are instructed in methods to solve the problem utilizing decision analysis. This course meets in two one-day blocks, each eight hours in duration. In the first block the problem is presented; in the second block students present their solution to the problem. MDCRC 6200 Meta Analysis. This focuses on the meta-analysis approach combining quantitative data. Subjects covered include statistical methods, eligibility criteria of studies, tests of homogeneity, summary measures, sources of variation and sensitivity analysis. This course is presented in a weekly two-hour block throughout the last six weeks. OPTIONAL MDCRC 6210 Regression Models. Students enrolling in this course must have completed MDCRC 6000, Introduction to Biostatistics and MDCRC 6010, Introduction to Epidemiology. The course in regression models covers linear regression, logistic

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regression, Poisson regression, Cox regression, and includes methods for correlated data (generalized estimating equations and mixed models), testing model assumptions, and assessment of model fit. This course is presented in a weekly two-hour block. MDCRC 6220 Survey Methods. Students must have completed MDCRC 6210. The course on survey methods covers the design and analysis of surveys, including questionnaire development, sample designs, stratification, clustering, multi-stage sampling, and the analysis of data generated from these complex designs. This course is presented as a two and one-half day experience totaling sixteen hours of lectures and tutorials. OPTIONAL

FALL SEMESTER YEAR TWO

INT MD 7570 Scientific Integrity & Ethics of Scientific Research. The course meets federal ethics requirements for training grants. The series covers topics of general interest in ethics and science. Topics include the norms of scientific inquiry and the nature of scientific misconduct; conflicts of interest (including the university policy); intellectual property and technology transfer; responsible authorship and editorial policies; and protection of research subjects and research with animals. Sessions are panel discussions featuring responsible administrators, scientists and physicians from a wide range of disciplines, and faculty in philosophy and law. The course meets 12 times during the fall semester and each meeting lasts for 1 hour. Course coordinator is Leslie Francis, Professor of Philosophy and Law.

2. Division of Nephrology Statistics course – Fellows attend 10 two-hour sessions held on

Thursdays from 4:30-6:30 PM dedicates to understanding medical statistics. The course is taught by members of the nephrology division as well as University of Utah statisticians.

3. Division of Nephrology Clinical Research course – Fellows interested in clinical research, but not enrolled in the CTSA program, attend a one-hour session each month devoted to understanding basics of research design, data analysis (biostatistics), public policy, economics, health education, designing trials, recruiting subjects and other epidemiology issues, and outcomes analysis. The course is run by Dr. Beddhu and is largely based on the JAMA publications devoted to these areas.

4. Fellows engaging in basic research will be required to take the Basic Research in Nephrology Curriculum. This curriculum involves required core and elective courses. Core courses are taken during the first year and involve training in biostatistics (MDCRC 6000) (Schedule A), scientific integrity and ethics of scientific research (INT MD 7570) (Schedule A), and basic research techniques. Since every basic research laboratory utilizes some degree of physiologic, cell biologic, and molecular biologic techniques, fellows will be given the option to take core courses in these areas (Schedule B). In addition, they may take a course on scientific lecturing and writing (Schedule B). Depending upon the nature of the basic research project, fellows will be offered courses on an elective basis. While multiple courses exist, given the Nephrology Training Program research activities, it is anticipated that they will most likely take one or more of the courses described in Schedule C. These courses are intended to supplement learning that occurs in the laboratory due to interactions with the preceptor, collaborators, and laboratory members.

During the fall and spring semesters of year 2 of research training (depending on the application due date), trainees will apply for mentored research grants, such as an NIH K08, an American Heart Association Scientist Development Grant, or similar funding.

Schedule B. Basic research core courses.

FALL SEMESTER YEAR ONE

BLCHM 6400 Genetic Engineering. This course covers essential techniques used in genetic engineering. Topics include the use of restriction endonucleases, amplification of DNA sequences using PCR, Southern and Northern blotting, properties of cloning vectors and their use in constructing genomic and cDNA libraries, DNA sequencing and sequence analysis, creating and detecting mutations in DNA and introducing these mutations into a genome (transgenic and knockout models), and expression of proteins. Held in 2-hour weekly sessions.

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FALL AND SPRING SEMESTER YEAR ONE

PHYS 7910 Practicum in Physiology. A laboratory-oriented practicum emphasizing the practice of physiological technique as it pertains to specific research problems. Course covers membrane models, ion selectivity, intracellular pH and Ca2+ regulation. Recording surface potentials, ionic currents, nerve discharge and documentation of nervous activity with antibody markers are taught. The second half of the practicum emphasizes assays involving antibodies including receptor binding, and radio immunoassays. Microfluorometric analysis, confocal microscopy, in-vivo drug assay and genetic markers in disease are given practical consideration. Held in three hour sessions once a month. ANAT 7790 Fluorescence Microscopy and Digital Imaging. Laboratory and lecture course of basic and advanced microscopic techniques. Phase contrast, fluorescence, and confocal microscopy. Digital image-processing, quantitative analysis, and production of publication-quality images. Held in 1-hour sessions once a month.

FALL SEMESTER YEAR TWO

ANAT 7690 Scientific Lecturing and Writing. Course teaches guidelines for writing clear scientific papers and delivering good lectures. Lectures, discussion, homework assignments and submission of a new original scientific paper in an area chosen by each student. Held in hourly sessions once a month.

Schedule C. Selected highly relevant basic research courses

Physiology PHYS 6010 Systemic Physiology II. Must have had basic physiology. Emphasizes physiological principles of major organ systems. Three hours weekly in fall semester.

Molecular Biology

MBIOL 6420 Genetics and Genome. The Genetics and Genomes course covers the basic principles of genetics in both prokaryotes and eukaryotes, and the basic mechanisms of genome structure and replication. Mechanisms governing the transmission of genetic information are covered in bacteria, fungi, flies, worms, and vertebrates, including mutagenesis, transposons, suppression, epistasis, recombination, mosaics, gene knockouts, and two hybrid analysis. The genomes section of the course covers the organization of genes on chromosomes, chromatin structure, DNA replication and repair, gene silencing, chromosome inactivation, imprinting, and genome evolution. Three hours weekly in fall semester. MBIOL 6440 Gene Expression. This course covers transcriptional and post-transcriptional mechanisms of gene regulation. Lectures cover recent advances in these fields with material based on the primary literature. The transcriptional regulation section of the course covers, basic mechanisms of gene activation and repression, chromatin remodeling machines, regulation of transcription activation by signal transduction cascades. The post-transcriptional section covers mechanisms regulating RNA processing (splicing, editing, and transport), translation and mRNA stability. Three hours weekly in spring semester.

Cell Biology

MBIOL 6480-2 Cell Biology II. Must have had basic cell biology. The course covers: 1. cell structure/function and intracellular trafficking. 2. Signal transduction, cell cycle and apoptosis. 3. Cell-cell communication, differentiation and tissue maintenance. Each section consists of a series of lectures that explore the basic concepts associated with the various topics. Each section has an in class exam and a writing assignment in the form of a mini grant proposal that encourages the identification of important scientific problems and the formation of a testable hypothesis, the creation of a research plan to test the hypothesis and the presentation of this material in an acceptable and persuasive format. 3 hr weekly in fall semester.

b. The research mentor-Fellow relationship is the primary means by which Fellows will achieve

training in basic or clinical research. (5) Nature of Supervision - Fellows should select a project and mentor by September 1 of the first

year of Fellowship and inform the Nephrology Fellowship Program Director of their selection. For the next 23 months, the Fellow’s research activities will be guided by the Mentor. This involves frequent meetings (at least bi-weekly during the two years of research).

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(6) Means of Fellow Evaluation – The mentor provides the Fellow with ongoing informal feedback. In addition, the mentor meets with the Nephrology Training Program Director semiannually to report on the Fellow’s progress. The Training Program Director also discusses the research progress with the Fellow during quarterly meetings between the Research Fellow and the Training Program Director. Fellows are expected to be a first author on at least one publication in a peer-reviewed journal. In addition, they are expected to present their research at least once annually at national meetings.

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9. Dealing with unsatisfactory Fellow performance – (RETURN TO TABLE OF CONTENTS) This information is provided in the unlikely event that a serious problem is encountered with a Fellow; fortunately, this has never occurred in the Nephrology Division. In the event of a repeated unsatisfactory rating (failure to improve despite counseling and supervision), the Fellow meets with the Program Director and/or the faculty member involved to discuss his/her deficiencies. Written documentation is made of these meetings. If the Program Director and the faculty involved deem the Fellow’s deficiencies severe enough, because of clinical incompetence or inability to exhibit professional attitudes, then the Fellow will be placed on probation. Short of probation, the Program Director may, in certain cases, require counseling for that Fellow. The Fellow will be advised of specific steps required to correct the stated deficiencies. One month later, the Fellow will be re-evaluated by the Program Director and the Attending(s) involved and written documentation made. If correction is not seen at this point, the Program Director will meet with all Nephrology faculty to make a decision whether to refuse to renew a Fellow's contract at the end of the year or to refuse to sign off on the Fellow's training. At any time a Fellow may express a grievance in writing either by requesting to meet all full-time faculty or entering the appeal process of the University via the Chairman of the Department of Internal Medicine or via the Dean of the Medical School.

10. Guidelines for Promotion and Graduation A. Clinical Track – 2-year clinical fellowship (1) Promotion from 1st to 2nd year – The criteria for promotion are listed in the General Nephrology,

Dialysis, and Transplant tables. All of these criteria must be met in order to be promoted. They must have been met within the last month of the 1st year of fellowship. Failure to meet all criteria will result in review by all Clinical Faculty with whom the Fellow has had contact in the past year, and placement on probation. The Fellows must demonstrate satisfactory performance over the next 1 month of clinical activities, as determined by the criteria for performance during year 1, in order to be allowed to continue in their training. Any exceptions will be determined on an individual basis by the entire Clinical Faculty, and will be based on all circumstances surrounding the Fellow’s activities.

(2) Graduation – The criteria for graduation are listed in the General Nephrology, Dialysis, and Transplant tables (labeled as 2nd year performance). All of these criteria must have been met over the last 3 months of fellowship in order to graduate. Failure to meet all criteria will result in review by all Clinical Faculty with whom the Fellow has had contact in the past year, and a decision made on a necessary course of action. Such action may include, but is not limited to, requirement for additional clinical activities, counseling, or other actions.

B. Research Track – 1-year clinical fellowship. The criteria for graduation are listed in the General

Nephrology, Dialysis, and Transplant tables (labeled as 2nd year performance). Note that these criteria are labeled 2nd year since they pertain to the 2nd year clinical fellows, but they apply to fellows doing only 1 year of clinical fellowship. These criteria must have been met over the last 3 months of fellowship. All of these criteria must be met in order to graduate. Failure to meet all criteria will result in review by all Clinical Faculty with whom the Fellow has had contact in the past year, and a decision made on a necessary course of action. Such action may include, but is not limited to, requirement for additional clinical activities, counseling, or other actions.

11. Nephrology Fellowship Work, Duty Hours, Moonlighting and On-Call Policy A. Work and duty hours

(1) ACGME requires that Fellows not work more than 80 hours per week averaged over a 4-week period. Our program requires than Fellows will work no more than 70 hours per week when averaged over a four week period. In reality, Fellows rarely work more than 60 hours per week.

(2) Fellows are required by ACGME to be free of all work obligations for one day out of seven over a 4-week period. The Division strictly adheres to this policy. In reality, over the course of the

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Fellowship, Fellows are free of all work obligations for substantially more than the ACGME-required minimum.

(3) The ACGME requires that adequate time for rest and personal activities is provided by a 10-hour time period between all daily duty periods and after in-house call. There is no in-house call (see C. below). Fellows rarely have to return at night to the hospital from home while on call.

B. The Division of Nephrology recognizes that fellow moonlighting can be complementary to the

fellowship training experience. However, any fellow choosing to moonlight must do so with the clear understanding that fellowship training is their first priority and any actions interfering with the fellowship training program are strictly prohibited. Each moonlighting activity must be approved in advance by the program director using the moonlighting authorization form. This form must be signed by the program director before any moonlighting can begin. The following restrictions apply to fellow moonlighting:

The fellow must be performing satisfactorily in the program.

If a fellow chooses to “moonlight,” he or she is responsible for their own liability coverage. Even if this activity is being performed at the University, or an affiliated hospital, and/or additional compensation is being provided to the fellow, it is outside the scope of a fellow’s duties as a house officer. As per the GME office, the fellow should not wear a University lab coat or nametag while moonlighting.

If the fellowship director feels that the fellow’s “good standing” is at risk by the time spent moonlighting, he or she can prohibit such moonlighting even without placing the fellow on probation. This action and an explanation for it must be transmitted to the fellow both in person and in writing and to the fellow’s file.

As per GME regulations, fellows should not work more than 80 hours a week, when averaged over a four week period. Hours worked include training program hours and moonlighting hours.

Fellows may not moonlight while on-call. C. Fellows will be on-call about one out of four days. All call is from home – there is no in-house call.

Fellows average one weekend in four on call (5 PM Friday to 8 AM Monday) and one weekday (Monday-Thursday) in four on call. The Outpatient (OP) Fellow (3 months/year) is never on call. The Transplant (TP) Fellow is on call 1 weekday/week and 2 weekends/month. The VA Fellow is on call 2 weekdays/week and no weekends. The University Hospital (UH) Fellow is on call 1 weekday/week and 2 weekends/month. The on-call UH Fellow covers the UH General Nephrology and Transplant Services, answering all phone calls, seeing and writing notes on all established inpatients (weekends) and new admissions (nights and weekends), writing necessary dialysis orders and following patients on dialysis, and any other business relevant to covering the Nephrology and Transplant Services. The VA Attending takes weekend call when the UH Fellow is on weekend call. When the residents are on-call, they cover only University Hospital General Nephrology Service. The TP Fellow takes call when the residents do on the weekends, but covers only the UH Transplant Service and the VA. Attending and clinic physicians are responsible for supervising all care provided to inpatients and outpatients, respectively. The Attending physician is on-call 24 hours a day, provided backup to the Fellow as needed. When residents are on call, the VA Fellow sees only VA acute dialysis patients only on Saturday morning, with VA Attending coverage.

D. Fellows receive three weeks of paid vacation each year. All applications for leave, or special

requests with respect to the call schedule, must be submitted at least eight weeks preceding the intended absence.

E. An example of a monthly call schedule is as follows. Note that the OP Fellow is not included. On the

weekends where the resident and TP Fellow are on together, the resident covers University Hospital and the TP Fellow covers the transplant service at the University Hospital and all inpatients at the VA Hospital.

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Sun. Mon. Tues. Wed. Thurs. Fri. Sat.

1 VA Fellow

2 TP Fellow

3 UH Fellow

4 VA Fellow

5 UH Fellow

6 UH Fellow

7 UH Fellow

8 VA Fellow

9 TP Fellow

10 UH Fellow

11 VA Fellow

12 Residents/TP fellow



15 VA Fellow

16 TP Fellow

17 UH Fellow

18 VA Fellow

19 UH Fellow

20 UH Fellow

21 UH Fellow

22 VA Fellow

23 TP Fellow

24 UH Fellow

25 VA Fellow




29 VA Fellow

30 TP Fellow

31 UH Fellow

F. Policies regarding medical leave, family leave, maternity leave, leave for examinations, educational

leave, sexual harassment, physician impairment and disability, jury duty, counseling services, and grievance procedures can be found in the University of Utah Housestaff Policies and Procedures Manual. This manual is distributed to all new Fellows at orientation during first week of Fellowship. Information can be obtained prior to then by contacting the Fellowship Director (Dr. Gregory) or by contacting the Graduate Medical Education Office at 801-581-2401 or [email protected].

G. There is no liability insurance by the University of Utah for clinical activities outside the State of Utah

or outside the country. Fellows will, therefore, perform all clinical activities in the State of Utah. 12. Nephrology Fellow Stipend and Benefits A. Fellows are paid PGY4, PGY5 or PGY6 salaries according to University of Utah School of Medicine

policy (Job Class 0253). For 2014-15, this is $58,663 for PGY4, $60,608 for PGY5, and $62,794 for PGY6.

B. Benefits include Hospital and Medical insurance (premium costs shared between UH and the Fellow),

dental insurance (nominal monthly charge), group life insurance up to salary amount but not to exceed $25,000 at no charge (additional life insurance may be purchased), 24-hour accident insurance, malpractice insurance, long-term disability insurance, and parking. Other benefits, such as reduced tuition, bookstore discount and others are offered to all University employees. More details can be found in the University of Utah Housestaff Policies and Procedures Manual.

C. Fellows are provided with the following: (1) Pager (2) Offices at VA and UH (shared with other fellows) (3) Texts and handouts (see Curriculum) (4) One trip to the American Society of Nephrology Annual Meeting, including registration, airfare, meals, and hotel expenses. (5) A computer at the VA and UH (shared with other fellows). (6) Access to UpToDate 13. Policy on Fellow Teaching and Supervision of Residents – Fellows interact with residents on the inpatient wards, during VA clinics, and in division conferences. Fellows are expected to behave in a professional manner towards residents. This includes answering resident questions to the best of the fellow’s ability, directing the resident towards known appropriate learning resources, and notifying residents of the timing of attending rounds each day (since the time may change from day to day). Fellows may teach residents as they are able, but the burden of resident teaching, as it relates to the

mailto:[email protected]

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nephrology rotation goals and objectives, falls on the attending. Fellows may assign inpatients to residents, but attendings have the final approval for all assignments. Fellows may supervise temporary dialysis vascular access placement by residents only after the fellow has demonstrated mastery of this skill and such mastery is documented in their record. Fellows and residents may not render decisions about nephrology patient care (including general nephrology, dialysis and transplant), either written or verbally, without the attending’s verbal or written approval. Hence, fellows may not direct residents to advise primary providers, or their assistants (e.g., nurses, technicians, residents) on medical matters without the direct guidance on such matters by the attending.

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14. Faculty Research Interests (RETURN TO TABLE OF CONTENTS) The research interests of faculty in the Nephrology Division are listed below. This information, combined with the list of faculty publications in the subsequent section, as intended to help Fellows identify a faculty mentor and research project. Josephine Abraham, M.D., Assistant Professor of Medicine. We are conducting clinical trials that involve treatment of glomerular diseases such as focal and segmental glomerulosclerosis (FSGS), lupus nephritis and diabetic nephropathy. Srinivasan Beddhu, M.D., Professor of Medicine. My research focus is on obesity, malnutrition and cardiovascular disease in CKD and dialysis patients. I conduct epidemiological studies of large national databases, smaller but more detailed observational studies, translational studies as well as clinical trials to address questions in the areas of my research interest. I currently serve as the Co-Director of the NHLBI Systolic Pressure Intervention Trial (SPRINT) Utah Clinical Center Network and the PI of the SPRINT Utah clinical site. I was a member of the KDOQI Hemodialysis Cardiovascular Guidelines Committee and had the honor of serving on several NIH review panels, NKF and ASN committees. My team consists of statisticians, study coordinators, clinical study assistants as well as graduate and doctoral research assistants. My mentees have been successful in obtaining meritorious national career development awards and fellowship grants. Alfred Cheung, M.D., Professor of Medicine. Dr. Alfred Cheung’s research has four major areas of focus. These include:

1) Hemodialysis vascular access: Our lab focuses on native arteriovenous fistula maturation failure and synthetic arteriovenous graft stenosis. The approaches that we approach span the gamut of cell culture, in vivo and ex vivo models and clinical studies. We have collaborated closely and extensively with the laboratories of Dr. Christi Terry and Dr. Yan-Ting Shiu (both in the Division of Nephrology & Hypertension), Department of Radiology, Department of Pharmaceutics & Pharmaceutical Chemistry, Department of Pharmacology & Toxicology, and Department of Bioengineering at the University of Utah to develop local pharmacotherapy for the prevention of vascular stenosis. We also participate as one of seven Clinical Centers in the Hemodialysis Fistula Maturation Consortium sponsored by the NIDDK (http://healthcare.utah.edu/clinicaltrials/trial.php?id=FP00000016) with the primary goal of understanding the factors in various domains that contribute to fistula maturation failure. In conjunction with the University of Florida (Dr. Scott Berceli) and the University of Cincinnati (Dr. Prabir Roy-Chaudhury), we are examining the association of mechanical shear stress along the fistula wall and subsequent vascular luminal development, using MRI and computational fluid dynamics modeling. These projects are supported by U01DK82222 (Cheung, PI) and R01DK088777 (Cheung, Berceli and Roy-Chaudhury, Multiple PIs).

2) Randomized blood pressure trial: Dr. Cheung is the Principal Investigator of one the five Clinical Center Network, the Utah Clinical Center Network , in the Systolic Blood Pressure Intervention Trial (SPRINT) (www.sprinttrial.org; http://clinicaltrials.gov/ct2/show/NCT01206062). SPRINT is multicenter randomized trial that examined, in over 9,000 people age over 50 years with hypertension, if management of blood pressure with a systolic target of <120 mm Hg would decrease the risks for cardiovascular events than management with the usual systolic target of <140 mm Hg. Of particular interest are the CKD subgroup and the subgroup of people age >75 years. CKD progression and cognitive function decline are important secondary outcomes in this trial. Our network is currently comprised of 17 academic centers in the U.S., 15 of which are Nephrology Divisions, 1 is a Cardiology Division and 1 is a Geriatric Division. These investigators worked not only collaboratively to conduct the trial, but also creatively to initiate manuscripts and ancillary studies, exploiting the unique infrastructure of SPRINT. The Utah Clinical Center Network in SPRINT in supported by a contract from the NHLBI (HHSN268200900046C

3) Pathogenic role of prorenin: Renin and its precursor prorenin bind to the cell surface (pro)renin receptor and initiate pro-proliferative and pro-fibrotic cellular events, independent of the proteolytic action of renin and are therefore not blocked by clinically used angiotensin converting enzyme inhibitors or

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angiotensin receptor blockers. Dr. Cheung and his collaborators in Utah, Dr. Yufeng Huang, Dr. Tom Greene and Dr. Carol Sweeney are collaborating with Dr. Harold Feldman and his colleagues at the University of Pennsylvania to perform a longitudinal observational study that examines the association between serum prorenin and renin levels with kidney, cardiovascular and retinal outcomes. To achieve this goal, we utilize the serum samples collected by the NIDDK-sponsored Chronic Renal Insufficiency Cohort (CRIC). In addition, we exploit the rich CRIC database that include serial eGFR, repeat echocardiograms and retinal examination as well as clinical events. We will examine the association of serum prorenin and renin levels with CKD progression, cardiac function and clinical cardiac events and retinopathy. This study is expected to develop novel insights into the pathogenic roles of prorenin and renin and may pave the way to develop new strategies for the treatment of multi-systemic organ damage related to diabetes non non-diabetic conditions. This work is supported by R01DK099098 (Cheung, PI)

4) Chronic Kidney Disease Pilot (CKDP) Consortium (http://grants.nih.gov/grants/guide/rfa-files/RFA-DK-12-016.html): Effective therapies for the prevention of progression and complication of CKD are limited. The NIDDK has formed a CKDP Consortium in 2013 to initiate, design and conduct pilot studies that will hopefully translate into large definitive randomized trials for the treatment of CKD. There are 4 Clinical Centers in this Consortium, one of which is the Utah Clinical Center with Dr. Cheung and Dr. Kalani Raphael (also in the Division of Nephrology & Hypertension) are Multiple PIs. The Utah Clinical Center is also supported by Dr. Donald Wesson at the Scott & White and Dr. Tom Hostetter at Case Western University. The pilot study that has been proposed by the Utah Clinical Center and is being developed by the Consortium aims at preventing CKD progression using chronic oral sodium bicarbonate therapy. The Utah Clinical Center will also work collaboratively with other Clinical Centers in the Consortium to develop and conduct other pilot studies. The Utah Clinical Center in the CKDP Consortium is supported by U01DK099933 from the NIDDK. Monique E. Cho, M.D., Assistant Professor of Medicine. Chronic kidney disease (CKD) is associated with the development of a variety of metabolic derangements, including dysfunctional iron and adipose tissue metabolism and insulin resistance (IR). Iron overload, whether it is due to chronic inflammatory conditions such as CKD or dietary iron overload, is strongly associated with development of IR and diabetic risk. Recent studies have shown that iron metabolism is important for adipocyte regulation and function, including maintenance of energy and glucose homeostasis. IR, a highly prevalent feature in CKD patients, plays a central pathomechanistic role in increased cardiac mortality risk in CKD. At the myocardial level, IR leads to inefficient energy metabolism through increased dependence on the free fatty acid metabolism for energy, with downstream effects of lipotoxicity-induced mitochondrial injury, increased oxidative stress burden, and induction of pro-fibrotic pathways. Dr. Cho’s research focuses on evaluating for the possible role dysfunctional iron metabolism and its associated IR in the development of uremic cardiomyopathy in pre-dialysis CKD patients. Tom Greene, Ph.D., Professor of Medicine. Dr. Greene is the lead statistician on NIH-sponsored multi-centered trials and is very activity involved with study design. He works closely with Drs. Cheung, Beddhu and Raphael on a number of clinical trials. Martin Gregory, M.D., Professor of Medicine. The University of Utah has been working on the genetics of Alport syndrome since 1949. This culminated in the discovery of mutations in the COL4A5 gene with workers from Oulu, Finland in 1990. Work has continued on genotype-phenotype correlations and, together with Paul Bernstein and collaborators in the Moran Eye Center, on ophthalmologic manifestations of Alport syndrome. We are also co-investigators in ASTOR, the Alport Syndrome Treatment and Outcomes Registry. Yufeng Huang, M.D., Ph.D., Research Associate Professor. The Huang Research Laboratory studies the pathophysiological role of renin-angiotensin-aldosterone system (RASS), transforming growth factor beta (TGFß) and plasminogen activator inhibitor (PAI-1) in the development and progression of renal fibrosis and potential novel strategies for treatment.

One of our major areas of focus is the receptor-mediated prorenin/renin’s action in renal fibrosis. Although pharmacological blockers of the renin-angiotensin system are clearly effective in many renal

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and cardiovascular diseases, their effectiveness is limited, and exciting novel therapeutic avenues are likely to open through research on receptor-mediated renin and prorenin actions. We have demonstrated the receptor-binding site of renin is distinct from the enzymatic active site on the surface of renin and renin has receptor-mediated profibrotic effects independent of AngII’s generation and action. We keep our effort to further identify the receptor-binding site on the human renin structure and to elucidate the molecular basis of renin’s dual pathophysiological actions that are both AngII-dependent and Ang II-independent, as a prerequisite of the development of therapeutic agents blocking renin activity and binding in patients.

The role of prorenin in disease is also an exciting new area for us. Elevated plasma prorenin levels are commonly found in diabetic patients and it has been known for more than 20 years that prorenin levels correlate with microvascular disease including diabetic nephropathy. Neither the cause for elevated prorenin levels nor their role in disease, if any, is known. The work on receptor-mediated activation and profibrotic action of prorenin is potentially important line of investigation, particularly in the development of diabetic nephropathy. We generated an inducible prorenin transgenic rat model and demonstrated that high levels of circulating prorenin cause hypertension and renal and cardiac fibrosis. We keep our effort to generate non-cleavable prorenin and enzymatic site-mutant prorenin transgenic rat models to further explore the potential roles and mechanisms of elevated prorenin in the development of hypertension, cardiovascular and kidney disease. We investigate the role of PAI-1 in renal fibrosis. These studies revealed that PAI-1’s ability to inhibit plasmin-dependent extracellular matrix turnover, stimulate infiltration of macrophages and myofibroblasts and signal directly to regulate TGFß expression and injury podocyte, provides possible mechanistic pathways involved in the progression of chronic kidney disease. Our laboratory also studies the non-viral strategies for cell-specific delivery of pathway-interactors and molecular probes to diseased kidney. These studies involve combining siRNA or miRNA with nanobiotechnology to develop a self-assembled nanovector system for gene delivery specifically to glomerular cells. Bellamkonda Kishore, M.D., Ph.D., Research Associate Professor of Medicine. The major focus of Kishore Research Laboratory is the role of purinergic signaling in renal physiology, pathophysiology and experimental therapeutics. Purinergic signaling mediated by extracellular nucleotides, nucleosides and nucleobases is a relatively new area with a vast potential for developing a new class of drugs. Besides uncovering many new phenomena, the Kishore Lab identified P2Y receptors (P2Y2 and P2Y12, specifically) as potential targets from the development of innovative drugs to treat water balance disorders, such as acquired nephrogenic diabetes insipidus (NDI) and diet-induced obesity and insulin resistance. This work is being performed in collaboration with Drs. Donald E. Kohan, Raoul D. Nelson and Noel G. Carlson at the University of Utah, Dr. Carolyn M. Ecelbarger at the Georgetown University, Washington DC, and Prof. Christa Müller at the University of Bonn, Bonn, Germany. The work done in Kishore Lab in collaboration with Dr. Simon Robson at the Beth Israel Deaconess Medical Center & Harvard University, Boston, MA and Dr. Karen Dwyer at the Univ. of Victoria, Australia, uncovered the role of CD39 (NTPDase1) in the regulation of water and sodium handling by the kidney. Furthermore, in collaboration with Dr. Christof Westenfelder at the VA Medical Center and University of Utah, the Kishore Lab developed a novel method for the induction of proliferation of erythropoietin-producing cells in the kidney, with potential therapeutic applications in anemia of chronic kidney disease.

Donald E. Kohan, M.D., Ph.D., Professor of Medicine. Dr. Kohan's laboratory studies three major areas. The first area is understanding the role of collecting duct-derived endothelin and nitric oxide in regulating systemic blood pressure and renal sodium and water excretion in health and disease. They have pioneered cell-specific gene targeting in the kidney using the Cre-loxP system and have used this technique to knockout components of the endothelin system selectively in principal cells of the collecting duct. Collecting duct endothelin-1 knockout mice are hypertensive and have impaired ability to excrete a sodium or water load. They have ongoing efforts to optimize cell specific knockout, including development of inducible knockouts (using Cre coupled to the ligand-binding domain of the estrogen receptor or the tetracycline transactivator) as well as improved integration site independent transgene expression. The technique of cell-specific gene targeting has recently been adapted by Dr. Kohan's laboratory to developing a mouse model of polycystic kidney disease. The other areas of interest include

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the role of the distal nephron renin system and distal nephron adenylyl cyclases in control of renal salt and water excretion and blood pressure during health and in hypertension. Kalani Raphael, M.D., Assistant Professor of Medicine. Most chronic kidney disease (CKD) patients with acidosis are treated with sodium bicarbonate to counteract the negative effects of acidosis on a variety of organ systems. However, CKD patients without acidosis may also benefit from sodium bicarbonate, in particular, by reducing kidney injury and delaying kidney failure. The Raphael Research team conducts observational research studies related to acid-base regulation in CKD and interventional studies testing the effect of sodium bicarbonate treatment on renal injury markers among CKD patients with normal serum bicarbonate. If sodium bicarbonate reduces kidney damage in CKD patients with normal serum bicarbonate, it would create a major paradigm shift in CKD care and provide a cost effective therapy to delay kidney failure. Fuad Shihab, M.D., Professor of Medicine. Dr. Shihab has a research interest in mechanisms of fibrosis in the field of kidney transplantation. One area of interest has focused on the pathogenesis of nephrotoxicity of immunosuppressive drugs. He has moved that interest at the present time to the translational phase by developing specific biomarkers that would be utilized to detect fibrosis. New investigational drugs are currently being studied to try to slow down or reverse fibrosis. Dr. Shihab also conducts a number of clinical studies testing new immunosuppressive drugs safety and efficacy in the different phases of development. Another major area of interest is outcome studies with a specific interest on the living kidney donor.

Yan-Ting Shiu, Ph.D., Research Assistant Professor. The Shiu Research Laboratory is devoted to laboratory and clinical research related to hemodialysis vascular access and the mechanobiology of vascular cells in health and in disease. We have substantial experience in (1) investigating cell responses to mechanical stimulation using in vitro and ex vivo models where cells are exposed to mechanical loading that closely approximates in vivo conditions; (2) using image-based modeling to characterize mechanical environments in vivo; (3) exploring how vascular cells sense and react to altered blood flow rate/pressure and how hemodynamic stress contributes to vascular wall remodeling. Our laboratory is fully equipped for research projects in these areas, and our methods are state-of-the art techniques.

One of our major areas of focus is the investigation of the pathophysiology of hemodialysis vascular access failure, as well as strategies to inhibit vascular access stenosis. We aim to identify new intracellular mechanotransduction pathways responsible for neointimal hyperplasia formation in arteriovenous grafts and for maturation failure of arteriovenous fistulas. We also aim to understand the role of extracellular matrices in hemodialysis vascular access failure. The results have the potential for broad applications in other vascular pathological conditions.

Another major area of focus is the investigation of the biomechanics of hemodialysis vascular access. In arteriovenous grafts and fistulas, shunting of arterial blood flow directly into the vein alters the hemodynamics in the vein. We believe that these hemodynamic changes are major contributors to graft stenosis and/or fistula non-maturation. Detailed hemodynamic changes in the arteriovenous conduits are not yet fully understood, partly because of the technical challenges, especially those that are required to assess the deformation of the thin venous wall. We have made significant progress in establishing these techniques in recent years. (1) Together with Dr. Alfred Cheung and Dr. Christi Terry in the Division of Nephrology, we have developed a magnetic resonance imaging (MRI)-based computational fluid dynamics (CFD) protocol to characterize the complex blood flow patterns and fluid shear stress in human and porcine arteriovenous accesses. (2) Together with Dr. Edward Hsu in the Department of Bioengineering, we have already developed a micro computed tomography (microCT)-based finite element analysis (FEA) to measure the deformation of thin venous wall under arterial pressure at high resolution and calculate the wall stress. We are currently developing elastography for in vivo measurement of vein mechanics. These state-of-the-art techniques have broad applications in the biomechanics fields. Christi Terry, Ph.D., Research Assistant Professor. The Terry research laboratory studies the

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pathophysiology of hemodialysis vascular access failure. Dr. Terry is a pharmacologist with expertise in localized drug delivery and utilizes these skills to develop novel approaches to increase vascular access longevity and function. Hemodialysis vascular access pathology-Synthetic arteriovenous hemodialysis grafts are created when a plastic tubing is surgically inserted between an artery and a vein so that arterial blood flow is diverted into the vein. The vein has less resistance than the artery so much higher volumetric blood flows are possible than what would normally occur in the body. These high blood flow rates allow for shorter hemodialysis times when the graft is needled for hemodialysis. Unfortunately the synthetic grafts suffer from high rates of failure due to thrombosis triggered by vascular stenosis. A native fistula is formed when a vein is surgically anastomosed to the side of an artery. The arterial blood is subsequently shunted into the vein whereupon the vein can be punctured with dialysis needles to access the blood. The fistula is the preferred vascular access for hemodialysis because it has fewer complications once it has matured to a functioning access. However, a very large number of fistula never mature.

The major areas or research are: (1) Localized drug delivery to inhibit vascular access stenosis and thrombosis. Her laboratory is investigating the use of autologous adipose tissue transplants for the localized delivery of the anti-diabetic glitazone drugs (pioglitazone, rosiglitazone) and the induction and delivery of endogenous adiponectin protein to inhibit stenosis, inflammation and thrombosis in synthetic arteriovenous grafts used for hemodialysis. The glitazones inhibit smooth muscle cell proliferation and inflammation and promote endothelial cell function and also induce adiponectin, a protein produced by fat that has anti-inflammatory and anti-proliferative effects. She also is investigating the localized application of novel protein-based anti-thrombotic drugs that target anti-coagulant effects specifically to areas of vascular injury. The advantage to localized anti-coagulant approaches are decreased risks of systemic bleeding events. (2) Investigation of the interplay of hemodynamic forces on the blood vessels of native arteriovenous fistulas with existing vessel wall properties and arteriovenous fistula maturation. Her laboratory, in collaboration with the Cheung and Shiu laboratories, is using magnetic resonance imaging to collect blood vessel lumen and blood flow data over time in newly created native arteriovenous fistulas of patients in order to determine the blood flow forces that correlate with positive and negative fistula outcomes.

Alfred Van Hoek, Ph.D., Research Assistant Professor. Dr. Van Hoek’s major research is focused on electrolyte and water homeostasis and how this is affecting cardiovascular and renal physiology. There are major unanswered questions with respect to the effects of osmosis; often it is taken for granted that water permeation is a diffusional process secondary to electrolyte redistribution. Novel insight in this area is important, because a disease can be manifested by spatial variations owing to changes in (sub) cellular structure and/or in extra cellular spaces, leading to edema states. Recognition of morphological patterns together with development of probes reporting a local cellular osmolality may be considered a staging ground to advance diagnostic methods as is the use of microscopes that can image at the sub micron level. High resolution imaging of tissue, cell and nuclear envelope can be accomplished using a novel microscopic technique that can image at the nanometer level. The helium-ion microscope (HIM) has a nominal 0.5 nm resolution and provides superb depth of field, high contrast, without the requirement of a metal coat of the sample; this allows use of immunogold to for labeling purposes. The technique has an enormous potential to discover novel structures enabling studies mapping the topology and architecture of luminal spaces in the kidney. Christof Westenfelder, M.D., Professor of Medicine. The research of the Westenfelder laboratory is focused on: 1) The translation of pre-clinical, stem cell-based therapies for the treatment of Acute Kidney Injury (AKI), Chronic Kidney Disease (CKD) and Type I Diabetes mellitus. Based on extensive pre-clinical studies, a successful Phase I Clinical Trial (NCT00733876) was completed in 2013, showing that the administration of allogeneic, bone marrow-derived mesenchymal Stem Cells (MSCs) to on-pump cardiac surgery patients at high risk for post-operative AKI (due to underlying CKD, diabetes mellitus, age > 60 yrs, hypertension, congestive heart failure and on-pump times > 2 hr) was safe and feasible, prevented the post-operative development of AKI (vs. historical controls), shortened the length of hospital stay, reduced the post discharge readmission rates, and importantly, prevented the development and progression of CKD vs. well matched historical controls. A Phase II Efficacy Trial

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(double blind, randomized, controlled) of this patented technology is currently enrolling study subjects, having received fast track approval from the FDA, at 34 study sites in the US and Canada. This laboratory collaborates closely with stem cell investigators at the University of Hamburg, Germany. 2) The full development of a novel, stem cell-based and patented technology that shows that Type I Diabetes mellitus can be cured in experimental animal. 3) The non-hematopoietic roles of erythropoietin (EPO) in the protection of the acutely and chronically injured kidney and on a novel oral therapy that allows oxygen- and hematocrit-independent up-regulation in the kidney, patented technologies.

Tianxin Yang, M.D., Ph.D., Professor of Medicine. My long-term research interests are the roles of prostaglandins and other lipid-derived products in regulation of fluid metabolism and blood pressure. Our early work revealed an important relationship between dietary salt intake and regulation of COX-2 expression in macula densa and renal medulla with low salt increasing COX-2 expression in cortex but high salt increasing it in renal medulla. We isolated and characterized a macula densa cell line from renal cortex of SV-40 T antigen transgenic mice using cell sorting technique. We demonstrated that low chloride stimulates prostaglandin release and COX-2 expression. Using COX-2 knockout mice, we demonstrated that COX-2 is critically important for renin response to low sodium intake. In parallel to the work on macula densa COX-2, we performed a series of studies to investigate the regulation and function of renal medullary COX-2. We have proved that hypertonicity has a direct stimulatory effect on COX-2 gene expression via reactive oxygen species-dependent activation of MAP kinase. More recently, we reported that intramedullary infusion of the COX-2 inhibitor NS-398 to Sprague-Dawley rats induced salt-sensitive hypertension, establishing an essential role of renal medullary COX-2 in stabilizing blood pressure during high salt intake.

In recent years, we conducted a series of studies to investigate the physiological function of membrane-associated PGES (mPGES-1). We found that within the kidney, mPGES-1 predominates in the distal nephron where its expression is highly inducible by salt loading; mice lacking mPGES-1 exhibit blunted natriuretic response to acute and chronic salt loading, in parallel with suppressed nitric oxide production. These mice also exhibit an exaggerated hypertensive response to angiotensin II infusion and mineralocorticosteroid excess. These results suggest that mPGES-1-derived PGE2 may play an important role in buffering the sodium-retaining and pro-hypertensive action of the renin-angiotensin-aldosterone system. In addition, we discovered that mPGES-1-drived PGE2 mediates diuretic response to water loading and lithium treatment.

Using conditional KO mice, we found that collecting duct PPARγ mediates thiazolidinedione (TZD)-induced fluid retention, a major side effect of the antidiabetic drug. To address the paradox of lack of hypertension in TZD-induced fluid retention, we investigated a potential blood pressure lowering effect of vascular PPARγ. Using conditional KO mice, we demonstrate that endothelial but not smooth muscle PPARγ contributes to the blood pressure lowering effect of TZDs. Moreover, endothelial PPARγ regulates microvascular transport of fluid together with fatty acids only in the adipose tissue via increasing capillary permeability in the local environment. The coupling of the transport processes for movement of fluid and nutrients from the circulation to the adipose tissue provides a teleological explanation of why this energy regulator can have a profound effect on fluid metabolism. More recent data show that PPARγ regulates circadian rhythms of blood pressure and heart rate as well as behavior and metabolism through a direct interaction with the core molecular clock in the peripheral tissues. It has been well established that disruption of circadian rhythms lead to metabolic syndrome as well as salt-sensitive hypertension. Together, our data indicate that PPARγ controls energy homeostasis via integrating fluid and fatty acid metabolism and circadian rhythms. We are exploring the potential role of dysregulation of PPARγ in the cardio-renal system in obesity that may lead to sodium and fluid retention and thereby increased blood pressure.

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15. Publications by Nephrology Faculty in last five years (RETURN TO TABLE OF CONTENTS) 2013 1. Rice WL, Van Hoek AN, Paunescu TG, Huynh C, Goetze B, Singh B, Scipioni L, Stern LA, Brown D

(2013). High resolution helium ion scanning microscopy of the rat kidney. PLoS ONE, 8(3), e57051. 2. Shihab FS, Lee S, Smith LD, Woodle ES, Pirsch JD, Gaber AO, Henning AK, Reisfield R,

Fitzsimmons W, Holman J, First MR: Effect of corticosteroid withdrawal versus continuation on tacrolimus and mycophenolate mofetil exposure in a prospective multicenter study. Am J Transplant. 13(2): 474-484, 2013

3. Shihab FS, Cibrik D, Chan L, Kim YS, Carmellini M, Walker R, Zibari G, Pattison J, Cornu-Artis C, Wang Z, Jiang H, Tedesco-Silva Jr H: Association of clinical events with everolimus exposure in kidney transplant patients receiving reduced cyclosporine. Clin Transplant. 27(2): 217-226, 2013

4. Cibrik D, Tedesco Silva Jr H, Vathsala A, Lackova E, Cornu-Artis C, Walker R, Wang Z, Zibari G, Shihab F, Kim YS: Randomized trial of everolimus-facilitated calcineurin inhibitor minimization over 24 months in renal transplantation. Transplantation. 95(7): 933-942, 2013

5. Narayanan M, Pankewycz O, El-Ghoroury M, Shihab F, Wiland A, McCague K, Chan L: Outcomes in African American kidney transplant patients receiving tacrolimus and mycophenolic acid immunosuppression. Transplantation. 95(4): 566-572, 2013

6. Gaber AO, Moore LW, Alloway RR, Woodle ES, Pirsch J, Shihab F, Henning A, Fitzsimmons W, Holman J, Reisfield R, First MR: Acute rejection characteristics from a prospective, randomized, double-blind, placebo-controlled multicenter trial of early corticosteroid withdrawal. Transplantation. 95(4): 573-579, 2013

7. Melancon K, Mulgaonkar SP, Delcoro C, Wiland A, McCague K, Shihab FS: Outcomes in ethnic minority renal transplant recipients receiving everolimus vs. mycophenolate: comparative risk assessment results from a pooled analysis. Transplantation. 96(12): 1073-1081, 2013

8. Narayan M, Pankewycz O, Shihab F, Wiland A, McCague K, Chan L: Long-term outcomes in African American kidney transplant recipients under contemporary immunosuppression: a four-yr analysis of the Mycophenolic acid Obsrvational Renal transplant (MORE) study. Clin Transplant Dec. 24, 2013 PMID: 24345868

9. Zhang Y, Li L, Kohan DE, Ecelbarger CM, Kishore BK. (2013). Attenuation of lithium-induced natriuresis and kaliuresis in P2Y2 receptor knockout mice. Am J Physiol Cell Physiol, 305, F407-F416

10. Kishore BK, Zhang Y, Geovrgyan H, Kohan DE, Schiedel AC, Muller CE, Peti-Peterdi J. (2013). Cellular localization of adenine receptors (AdeR) in the rat kidney, and their functional significance in the inner medullary collecting duct. Am J Physiol Renal Physiol 305:F1298-F1305

11. Kishore BK, Ecelbareger CM. (2013). Lithium: A versatile tool for understanding renal physiology. Am J Physiol Renal Physiol, 304, F1139-F1149.

12. Roos KP, Bugaj V, Mironova E, Stockand JD, Ramkumar N, Rees S, Kohan DE. Adenylyl cyclase VI mediates vasopressin stimulation of collecting duct epithelial cell Na channel activity. J Am Soc Nephrol 24:218-227, 2013.

13. Li L, Garikepati RM, Tsukerman S, Kohan DE, Wade JB, Tiwari S, Ecelbarger CM. Reduced ENaC activity and blood pressure in mice with genetic knockout of the insulin receptor in the renal collecting duct. Am J Physiol 304:F279-F288, 2013.

14. Ramkumar N, Stuart D, Ying J, Kohan DE. A possible interaction between systemic and renal angiotensinogen in the control of blood pressure. Am J Hypertens 26:473-480, 2013.

15. Jhaveri KD, Sparks MA, Shah HH, Khan S, Chawla A, Inglesia E, Ferris M, Parker M, Kohan DE. Non-nephrology United States internal medicine subspecialty fellow survey on nephrology. Am J Kid Dis 61:540-546, 2013.

16. Hyndman K, Elmarakby A, Huang P, Kohan DE, Pollock DM, Pollock JS. Renal collecting duct principal cell NOS1 gene deletion causes salt-sensitive hypertension. Hypertension 62:91-98, 2013.

17. Ramkumar N, Ying J, Stuart D, Kohan DE. Overexpression of renin in the collecting duct causes hypertension. Am J Hypertens 26:965-972, 2013.

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18. Stuart D, Chapman M, Rees S, Woodward S, Kohan DE. Myocardial, smooth muscle, nephron, and collecting duct gene targeting reveals the organ sites of endothelin A receptor antagonist fluid retention. J Pharmacol Exp Ther 346:182-189, 2013.

19. Lynch IJ, Welch AK, Kohan DE, Cain BD, Wingo CS. Endothelin-1 inhibits sodium reabsorption by ETA and ETB receptors in the mouse cortical collecting duct. Am J Physiol 305:F568-F573, 2013.

20. Ramkumar N, Kohan DE. Proximal tubule angiotensinogen modulation of arterial pressure. Current Opinion Nephrol Hypertens 22:32-36, 2013.

21. Ramkumar N, Kohan DE. Role of collecting duct renin in blood pressure regulation. Am J Physiol 305:R92-R94, 2013.

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24. Jovanovich A, Chonchol M, Cheung AK, Kaufman JS, Greene T, Roberts WL, Smits G, Kendrick J; and the HOST Investigators: Racial differences in markers of mineral metabolism in advanced chronic kidney disease. Clin J Am Soc Nephrol 7:640-647, 2012 (PMID: 22383748).

25. Terry CM, Li L, Li H, Zhuplatov I, Blumenthal DK, Kim SE, Owen SC, Kholmovski EG, Fowers KD, Rathi R, Cheung AK: In vivo evaluation of the delivery and efficacy of a sirolimus-laden polymer gel for inhibition of hyperplasia in a porcine model of arteriovenous hemodialysis graft stenosis. J Control Release 160:459-467, 2012 (PMID: 22465391).

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30. He Y, Terry CM, Nguyen C, Berceli SA, Shiu YT, Cheung AK: Serial analysis of lumen geometry and hemodynamics in human arteriovenous fistula for hemodialysis using magnetic resonance imaging and computational fluid dynamics. J Biomech 46:165-169, 2012 (PMID: 23122945).

31. Okusa MD, Molitoris BA, Palevsky PM, Chinchilli VM, Liu KD, Cheung AK, Weisbord SD, Faubel S, Kellum JA, Wald R, Chertow GM, Levin A, Waikar SS, Murray PT, Parikh CR, Shaw AD, Go AS, Chawla LS, Kaufman JS, Devarajan P, Toto RM, Hsu CY, Greene TH, Mehta RL, Stokes JB, Thompson AM, Thompson BT, Westenfelder CS, Tumlin JA, Warnock DG, Shah SV, Xie Y, Duggan EG, Kimmel PL, Star RA: Design of clinical trials in acute kidney injury: A report from an NIDDK Workshop – prevention trials. Clin J Am Soc Nephrol 7:851-855, 2012 (PMID: 22442188).

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2011 1. Goldfarb-Rumyantzev AS, Wright S, Ragasa R, Ostler D, Van Orden J, Smith L, Efimova E,

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2. Bolin P Jr, Gohh R, Kandaswamy R, Shihab FS, Wiland A, Akhlagi F, Melancon K: Mycophenolic acid in kidney transplant patients with diabetes mellitus: does the formulation matter? Transplant Rev. 25(3): 117-123, 2011

3. Hanaway MJ, Woodle ES, Mulgoankar S, Peddi VR, Kaufman DB, First MR, Croy R, Holman J, INTAC Study Group: Alemtuzumab induction in renal transplantation. N Engl J Med. 364(20):1909-1919, 2011

4. Brennan DC, Legendre C, Patel D, Mange K, Wiland A, McCague K, Shihab FS: Cytomegalovirus incidence between everolimus versus mycophenolate in de novo renal transplants: Pooled analysis of three clinical trials. Am J Transplant. 11(11): 2453-2462, 2011

5. Pavlov IY, Shihab F, Delgado JC: Urine TGF-beta1 assay validation: spinning down urine samples could diminish TGF-beta1 signal. Clin Lab. 57(11-12): 1027-1029, 2011

6. Zhang Y, Listhrop R, Ecelbarger CM, Kishore BK. (2011). Renal sodium transporter/channel expression and sodium excretion in P2Y2 receptor knockout mice fed high NaCl diet with/without aldosterone infusion. Am J Physiol Renal Physiol, 300, F657-F668

7. Kohan DE, Prtichett Y, Molitch M, Wen S, Audhya U, Andress DL. Low doses of the selective endothelin A receptor antagonist, atrasentan, reduces residual albuminuria in subjects with diabetic nephropathy on renin-angiotensin blockers: A randomized controlled trial. J Am Soc Nephrol 22:763-772, 2011.

8. Lyon-Roberts B, Strait KA, van Perusem E, Kittikulsuth W, Pollock JS, Pollock DM, Kohan DE. Flow regulation of collecting duct endothelin-1 production. Am J Physiol 300:F650-F656, 2011.

9. Hall A, Kohan DE, Lowichik A, Sikora M. Granulomatous interstitial nephritis in a patient with Crohn’s disease. Dialysis Transplant 40:172-173, 2011.

10. Stricklett PK, Strait KA, Kohan DE. Novel regulation of endothelin-1 promoter activity by protein kinase C. Cell Biochem Biophys 61:643-650, 2011.

11. Stegbauer J, Gurley SB, Sparks MA, Woznowski M, Kohan DE, Yan M, Lehrich RW, Coffman TM. Direct Actions of AT1 angiotensin receptors in the renal collecting duct regulate urinary concentrating mechanisms. J Am Soc Nephrol 22:2237-2246, 2011.













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13. Kohan DE, Inscho E, Wesson D, Pollock DM. Physiology of endothelin and the kidney. Comprehensive Physiology 1:883-919, 2011.

14. Kohan DE. Endothelin and collecting duct sodium and water transport. Contrib Nephrol 172:94-106, 2011.

15. Rabelink TJ, Kohan DE. Endothelin blockade in patients with diabetic nephropathy. Contrib Nephrol 127:235-242, 2011.

16. Barton M, Kohan DE. Endothelin antagonists in clinical trials: Lessons learned. Contrib Nephrol 172:255-260, 2011.

17. Kohan DE. Training the next generation of nephrologists. Clin J Am Soc Nephrol 6:2564-2566, 2011. 18. Wilson, B. D., Gibson, C. C., Sorensen, L. K., Guilhermier, M. Y., Clinger, M., Kelley, L. L., Shiu, Y.

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20. Damera S, Raphael KL, Baird BC, Cheung AK, Greene T, Beddhu S: Serum alkaline phosphatase levels associate with elevated C-reactive protein in chronic kidney disease. Kidney Int 79:228-233, 2011 (PMID: 20881941).

21. Li L, Blumenthal DK, Terry CM, He Y, Carlson ML, Cheung AK: PDGF-induced proliferation in human arterial and venous smooth muscle cells: molecular basis for differential effects of PDGF isoforms. J Cell Biochem 112:289-298, 2011 (PMID: 21069732).

22. Wali RK, Iyengar M, Beck GJ, Chartyan DM, Chonchol M, Lukas MA, Cooper C, Himmelfarb J, Weir MR, Berl T, Henrich WL, Cheung AK: Efficacy and safety of carvedilol in treatment of heart failure in chronic kidney disease: A meta-analysis of randomized trials. Circ Heart Fail, 4:18-26, 2011 (PMID: 21036889).

23. Chang, TI, Paik, J, Greene T, Desai M, Bech F, Cheung AK, Chertow GM: Intradialytic hypotension and vascular access thrombosis. J Am Soc Nephrol 22:1526-1533, 2011 (PMID: 21803971).

24. Chang TI, Shilane D, Brunelli SM, Cheung AK, Chertow GM, Winkelmayer WC: Angiotensin-converting enzyme inhibitors and cardiovascular outcomes in patients on maintenance hemodialysis. Am Heart J 162:324-330, 2011 (PMID: 21835294).

25. Kopple JD, Cheung AK, Christiansen JS, Djurhuus CB, Nahas ME, Feldt-Rasmussen B, Mitch WE, Wanner C, Göthberg M, T. Ikizler TA. OPPORTUNITYTM: A large-scale randomized clinical trial of growth hormone in hemodialysis patients. Nephrol Dial Transplant 26:4095-4103, 2011 (PMID: 21750157).

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27. Agar BU, Akonur A, Cheung AK, Leypoldt JK: A simple method to estimate phosphorus mobilization in hemodialysis using only predialytic and postdialytic blood samples. Hemodial Int 15:S9–S14, 2011 (PMID: 22093606).

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29. Agar BU, Akonu RA, Lo Y-C, Cheung AK, Leypoldt JK: Kinetic model of phosphorus mobilization during and after short and conventional hemodialysis. Clin J Am Soc Nephrol 6:2854-2860, 2011 (PMID: 22034502).

30. Brinton MR, Stewart RJ, Cheung AK, Christensen DA, Shiu Y-T E: Modelling ultrasound-induced mild hyperthermia of hyperplasia in vascular grafts. Theor Biol Med Model 8:42, 2011 (PMID: 22054016).

31. Cheung AK, Ward RA: Hemodialyzers. ASN Renal Weekends slide set, American Society of Nephrology, 2011.

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32. Raphael KL, Cheung AK: Implications of the Frequent Hemodialysis Network-Daily Trial. Sem Dialysis, 24:621-628, 2011 (PMID: 22098507).

33. Zhang J, Gu C, Noble NA, Border WA and Huang Y. Combining angiotensin II blockade and renin receptor inhibition results in enhanced antifibrotic effect in experimental nephritis. Am J Physiol Renal Physiol 2011, 301:F723-732.

34. Westenfelder C. Earlier diagnosis of acute kidney injury awaits effective therapy. Kidney Int. 2011 Jun;79(11):1159-61.

35. Tögel F, Westenfelder C. The role of multipotent marrow stromal cells (MSCs) in tissue regeneration. Organogenesis. 2011 Apr-Jun;7(2):96-100.

36. Raphael KL, Wei G, Baird BC, Greene T, Beddhu S. Higher serum bicarbonate levels within the normal range are associated with better survival and renal outcomes in African Americans. Kidney Int. 2011 Feb;79(3):356-62.

37. Johnson-Davis KL, Fernelius C, Eliason NB, Wilson A, Beddhu S, Roberts WL. Blood enzymes and oxidative stress in chronic kidney disease: a cross sectional study. Ann Clin Lab Sci. 2011 Fall;41(4):331-9.

38. Murtaugh MA, Filipowicz R, Baird BC, Wei G, Greene T, Beddhu S. Dietary phosphorus intake and mortality in moderate chronic kidney disease: NHANES III. Nephrol Dial Transplant. 2012 Mar;27(3):990-6.

39. Scialla JJ, Appel LJ, Astor BC, Miller ER 3rd, Beddhu S, Woodward M, Parekh RS, Anderson CA. Estimated net endogenous acid production and serum bicarbonate in African Americans with chronic kidney disease. Clin J Am Soc Nephrol. 2011 Jul;6(7):1526-32.

40. Krishnamurthy VR, Baird BC, Wei G, Greene T, Raphael K, Beddhu S. Associations of serum alkaline phosphatase with metabolic syndrome and mortality. Am J Med. 2011 Jun;124(6):566.e1-7.

41. Jia Z, Wang N, Aoyagi T, Liu H, and Yang T. Amelioration of cisplatin nephrotoxicity by genetic or pharmacologic blockade of prostaglandin synthesis. Kidney Int 79(1):77-88, 2011

42. Brooks C, Cho SG, Wang CY, Yang T, and Dong Z. Fragmented mitochondria are sensitized to Bax insertion and activation during apoptosis. Am J Physiol Cell Physiol Physiol. 300(3):C447-55, 2011.

43. Zhang A, Jia Z, Wang N, Tidwell TJ, and Yang T. Relative contributions of mitochondria and NADPH oxidase to deoxycorticosterone acetate-salt hypertension in mice. Kidney Int 80(1):51-60, 2011

44. Zhu C, Huang S, Yuan Y, Ding G, Chen Y, Yang T and Zhang A. Mitochondrial dysfunction mediates aldosterone-induced podocyte damage: A therapeutic target PPARγ. Am J Pathol. 178(5):2020-31, 2011.

2010 1. Strait KA, Stricklett PK, Chapman M, Kohan DE. Characterization of vasopressin-responsive

collecting duct adenylyl cyclases in the mouse. Am J Physiol 298:F859-F857, 2010. 2. Zhang Y, Kohan DE, Nelson RD, Carlson NG, Kishore BK. Potential involvement of P2Y2 receptor

in diuresis of post-obstructive uropathy in rats. Am J Physiol 298: F634-F642, 2010. 3. Norby SM, Karniski LP, Schmidt DW, Kohan DE. Mentoring for subspecialty training program

directors: An unrecognized, unmet need? J Grad Med Education 2:206-209, 2010. 4. Chapman ME, Hu L, Plato CF, Kohan DE. Bioimpedance spectroscopy for the estimation of body

fluid volumes in mice. Am J Physiol 299:F280-283, 2010. 5. Jia Z, Aoyagi T, Kohan DE, Yang T. mPGES-1 deletion impairs aldosterone escape and enhances

sodium appetite. Am J Physiol 299:F155-F166, 2010. 6. Strait KA, Stricklett PK, Kohan RM, Kohan DE. Identification of two NFAT response elements in the

5'-upstream regulatory region of the ET-1 promoter. J Biol Chem 285:28520-28528, 2010. 7. Kohan DE: Endothelin, hypertension, and chronic kidney disease: New insights. Current Opinion

Nephrol Hypertens 19:134-139, 2010. 8. Zhang Y, Kohan DE, Nelson RD, Carlson NG, Kishore BK. Potential involvement of P2Y2 receptor

in diuresis of postobstructive uropathy in rats. Am J Physiol Renal Physiol. 2010 Mar;298(3):F634-42.

9. Tögel FE, Westenfelder C. Mesenchymal stem cells: a new therapeutic tool for AKI. Nat Rev Nephrol. 2010 Mar;6(3):179-83.

















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10. Brunswig-Spickenheier B, Boche J, Westenfelder C, Peimann F, Gruber AD, Jaquet K, Krause K, Zustin J, Zander AR, Lange C. Limited immune-modulating activity of porcine mesenchymal stromal cells abolishes their protective efficacy in acute kidney injury. Stem Cells Dev. 2010 May;19(5):719-29.

11. Zhang J, Noble NA, Border WA, Huang Y. Infusion of angiotensin-(1-7) reduces glomerulosclerosis through counteracting angiotensin II in experimental glomerulonephritis. Am J Physiol Renal Physiol. 2010 Mar;298(3):F579-88.

12. Chang TI, Cheung AK, Chertow GM. Blood pressure control in type 2 diabetes mellitus. Am J Kidney Dis. 2010 Dec;56(6):1029-31.

13. Beddhu S, Baird B, Ma X, Cheung AK, Greene T. Serum alkaline phosphatase and mortality in hemodialysis patients. Clin Nephrol. 2010 Aug;74(2):91-6.

14. Owen SC, Li H, Sanders WG, Cheung AK, Terry CM. Correlation of tissue drug concentrations with in vivo magnetic resonance images of polymer drug depot around arteriovenous graft. J Control Release. 2010 Aug 17;146(1):23-30.

15. Redon J, Martinez F, Cheung AK. Special considerations for antihypertensive agents in dialysis patients. Blood Purif. 2010;29(2):93-8.

16. Huang CX, Tighiouart H, Beddhu S, Cheung AK, Dwyer JT, Eknoyan G, Beck GJ, Levey AS, Sarnak MJ. Both low muscle mass and low fat are associated with higher all-cause mortality in hemodialysis patients. Kidney Int. 2010 Apr;77(7):624-9.

17. Levin NW, Kotanko P, Eckardt KU, Kasiske BL, Chazot C, Cheung AK, Redon J, Wheeler DC, Zoccali C, London GM. Blood pressure in chronic kidney disease stage 5D-report from a Kidney Disease: Improving Global Outcomes controversies conference. Kidney Int. 2010 Feb;77(4):273-84.

18. Astor BC, Matsushita K, Gansevoort RT, van der Velde M, Woodward M, Levey AS, Jong PE, Coresh J; The Chronic Kidney Disease Prognosis Consortium, Astor BC, Matsushita K, Gansevoort RT, van der Velde M, Woodward M, Levey AS, de Jong PE, Coresh J, El-Nahas M, Eckardt KU, Kasiske BL, Wright J, Appel L, Greene T, Levin A, Djurdjev O, Wheeler DC, Landray MJ, Townend JN, Emberson J, Clark LE, Macleod A, Marks A, Ali T, Fluck N, Prescott G, Smith DH, Weinstein JR, Johnson ES, Thorp ML, Wetzels JF, Blankestijn PJ, van Zuilen AD, Menon V, Sarnak M, Beck G, Kronenberg F, Kollerits B, Froissart M, Stengel B, Metzger M, Remuzzi G, Ruggenenti P, Perna A, Heerspink HJ, Brenner B, de Zeeuw D, Rossing P, Parving HH, Auguste P, Veldhuis K, Wang Y, Camarata L, Thomas B, Manley T. Lower estimated glomerular filtration rate and higher albuminuria are associated with mortality and end-stage renal disease. A collaborative meta-analysis of kidney disease population cohorts. Kidney Int. 2011 Jun;79(12):1331-1340.

19. Kaysen GA, Larive B, Painter P, Craig A, Lindsay RM, Rocco MV, Daugirdas JT, Schulman G, Chertow GM; FHN Trial Group. Baseline physical performance, health, and functioning of participants in the Frequent Hemodialysis Network (FHN) trial. Am J Kidney Dis. 2011 Jan;57(1):101-12.

20. FHN Trial Group, Chertow GM, Levin NW, Beck GJ, Depner TA, Eggers PW, Gassman JJ, Gorodetskaya I, Greene T, James S, Larive B, Lindsay RM, Mehta RL, Miller B, Ornt DB, Rajagopalan S, Rastogi A, Rocco MV, Schiller B, Sergeyeva O, Schulman G, Ting GO, Unruh ML, Star RA, Kliger AS. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010 Dec 9;363(24):2287-300.

21. Chang TI, Paik J, Greene T, Miskulin DC, Chertow GM. Updated comorbidity assessments and outcomes in prevalent hemodialysis patients. Hemodial Int. 2010 Oct;14(4):478-85.

22. Appel LJ, Wright JT Jr, Greene T, Agodoa LY, Astor BC, Bakris GL, Cleveland WH, Charleston J, Contreras G, Faulkner ML, Gabbai FB, Gassman JJ, Hebert LA, Jamerson KA, Kopple JD, Kusek JW, Lash JP, Lea JP, Lewis JB, Lipkowitz MS, Massry SG, Miller ER, Norris K, Phillips RA, Pogue VA, Randall OS, Rostand SG, Smogorzewski MJ, Toto RD, Wang X; AASK Collaborative Research Group. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med. 2010 Sep 2;363(10):918-29.

23. Toto RD, Greene T, Hebert LA, Hiremath L, Lea JP, Lewis JB, Pogue V, Sika M, Wang X; AASK Collaborative Research Group. Relationship between body mass index and proteinuria in hypertensive nephrosclerosis: results from the African American Study of Kidney Disease and Hypertension (AASK) cohort. Am J Kidney Dis. 2010 Nov;56(5):896-906.




























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24. Alves TP, Wang X, Wright JT Jr, Appel LJ, Greene T, Norris K, Lewis J; AASK Collaborative Research Group. Rate of ESRD exceeds mortality among African Americans with hypertensive nephrosclerosis. J Am Soc Nephrol. 2010 Aug;21(8):1361-9.

25. Menon V, Tighiouart H, Vaughn NS, Beck GJ, Kusek JW, Collins AJ, Greene T, Sarnak MJ. Serum bicarbonate and long-term outcomes in CKD. Am J Kidney Dis. 2010 Nov;56(5):907-14.

26. Daugirdas JT, Greene T, Chertow GM, Depner TA. Can rescaling dose of dialysis to body surface area in the HEMO study explain the different responses to dose in women versus men? Clin J Am Soc Nephrol. 2010 Sep;5(9):1628-36.

27. Chawla V, Greene T, Beck GJ, Kusek JW, Collins AJ, Sarnak MJ, Menon V. Hyperlipidemia and long-term outcomes in nondiabetic chronic kidney disease. Clin J Am Soc Nephrol. 2010 Sep;5(9):1582-7.

28. Stevens LA, Schmid CH, Greene T, Zhang YL, Beck GJ, Froissart M, Hamm LL, Lewis JB, Mauer M, Navis GJ, Steffes MW, Eggers PW, Coresh J, Levey AS. Comparative performance of the CKD Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal Disease (MDRD) Study equations for estimating GFR levels above 60 mL/min/1.73 m2. Am J Kidney Dis. 2010 Sep;56(3):486-95.

29. Kwong YT, Stevens LA, Selvin E, Zhang YL, Greene T, Van Lente F, Levey AS, Coresh J. Imprecision of urinary iothalamate clearance as a gold-standard measure of GFR decreases the diagnostic accuracy of kidney function estimating equations. Am J Kidney Dis. 2010 Jul;56(1):39-49.

30. Daugirdas JT, Depner TA, Greene T, Levin NW, Chertow GM, Rocco MV, Stokes JB; Frequent Hemodialysis Network (FHN) Trial Group. Effects of reduced intradialytic urea generation rate and residual renal clearance on modeled urea distribution volume and Kt/V in conventional, daily, and nocturnal dialysis. Semin Dial. 2010 Jan-Feb;23(1):19-24.

31. Daugirdas JT, Depner TA, Greene T, Levin NW, Chertow GM, Rocco MV; Frequent Hemodialysis Network Trial Group. Standard Kt/Vurea: a method of calculation that includes effects of fluid removal and residual kidney clearance. Kidney Int. 2010 Apr;77(7):637-44.

32. Wang H, Liu H, Jia Z, Guan G, Yang T. Effects of Endogenous PPAR Agonist Nitro-Oleic Acid on Metabolic Syndrome in Obese Zucker Rats. PPAR Res. 2010;2010:601562.

33. Jia Z, Aoyagi T, Yang T. mPGES-1 protects against DOCA-salt hypertension via inhibition of oxidative stress or stimulation of NO/cGMP. Hypertension. 2010 Feb;55(2):539-46.

34. Wang H, Liu H, Jia Z, Olsen C, Litwin S, Guan G, Yang T. Nitro-oleic acid protects against endotoxin-induced endotoxemia and multiorgan injury in mice. Am J Physiol Renal Physiol. 2010 Mar;298(3):F754-62.

35. Shihab FS, Bennett WM, Andoh TF. Role of cellular cholesterol in pharmacologic preconditioning with cyclosporine in experimental kidney transplantation. Am J Nephrol. 2010;31(2):134-40.

2009 1. Kohan DE, Baird BC. The changing phenotype of academic nephrology -- a future at risk? Clin J Am

Soc Nephrol. 2009 Dec;4(12):2051-8. 2. Raphael KL, Strait KA, Stricklett PK, Baird BC, Piontek K, Germino GG, Kohan DE. Effect of

pioglitazone on survival and renal function in a mouse model of polycystic kidney disease. Am J Nephrol. 2009;30(5):468-73.

3. Kohan DE, Rosenberg ME. The chronic kidney disease epidemic: a challenge for nephrology training programs. Semin Nephrol. 2009 Sep;29(5):539-47.

4. Zhang X, Mernaugh G, Yang DH, Gewin L, Srichai MB, Harris RC, Iturregui JM, Nelson RD, Kohan DE, Abrahamson D, Fässler R, Yurchenco P, Pozzi A, Zent R. beta1 integrin is necessary for ureteric bud branching morphogenesis and maintenance of collecting duct structural integrity. Development. 2009 Oct;136(19):3357-66.

5. Kohan DE. Biology of endothelin receptors in the collecting duct. Kidney Int. 2009 Sep;76(5):481-6. 6. Kishore BK, Nelson RD, Miller RL, Carlson NG, Kohan DE. P2Y(2) receptors and water transport in

the kidney. Purinergic Signal. 2009 Dec;5(4):491-9. 7. Zhang Y, Nelson RD, Carlson NG, Kamerath CD, Kohan DE, Kishore BK. Potential role of purinergic

signaling in lithium-induced nephrogenic diabetes insipidus. Am J Physiol Renal Physiol. 2009








































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May;296(5):F1194-201. 8. Raphael KL, Strait KA, Stricklett PK, Miller RL, Nelson RD, Piontek KB, Germino GG, Kohan DE.

Inactivation of Pkd1 in principal cells causes a more severe cystic kidney disease than in intercalated cells. Kidney Int. 2009 Mar;75(6):626-33.

9. Kohan DE, Rosenberg ME. Nephrology training programs and applicants: a very good match. Clin J Am Soc Nephrol. 2009 Jan;4(1):242-7.

10. Beddhu S, Baird BC, Zitterkoph J, Neilson J, Greene T. Physical activity and mortality in chronic kidney disease (NHANES III). Clin J Am Soc Nephrol. 2009 Dec;4(12):1901-6.

11. Navaneethan SD, Yehnert H, Moustarah F, Schreiber MJ, Schauer PR, Beddhu S. Weight loss interventions in chronic kidney disease: a systematic review and meta-analysis. Clin J Am Soc Nephrol. 2009 Oct;4(10):1565-74.

12. Beddhu S, Ma X, Baird B, Cheung AK, Greene T. Serum alkaline phosphatase and mortality in African Americans with chronic kidney disease. Clin J Am Soc Nephrol. 2009 Nov;4(11):1805-10.

13. Beddhu S, Nigwekar SU, Ma X, Greene T. Associations of resting heart rate with insulin resistance, cardiovascular events and mortality in chronic kidney disease. Nephrol Dial Transplant. 2009 Aug;24(8):2482-8.

14. Kramer H, Tuttle KR, Leehey D, Luke A, Durazo-Arvizu R, Shoham D, Cooper R, Beddhu S. Obesity management in adults with CKD. Am J Kidney Dis. 2009 Jan;53(1):151-65.

15. Navaneethan SD, Beddhu S. Associations of serum uric acid with cardiovascular events and mortality in moderate chronic kidney disease. Nephrol Dial Transplant. 2009 Apr;24(4):1260-6.

16. Huang Y, Border WA, Lawrence DA, Noble NA. Mechanisms underlying the antifibrotic properties of noninhibitory PAI-1 (PAI-1R) in experimental nephritis. Am J Physiol Renal Physiol. 2009 Oct;297(4):F1045-54.

17. Zhu W, Masaki T, Cheung AK, Kern SE. In-vitro Release of Rapamycin from a Thermosensitive Polymer for the Inhibition of Vascular Smooth Muscle Cell Proliferation. J Bioequiv Availab. 2009 May 9;1:3-12.

18. Redon J, Martinez F, Cheung AK. Special considerations for antihypertensive agents in dialysis patients. Blood Purif. 2010;29(2):93-8.

19. Cheung AK. Is lipid control necessary in hemodialysis patients? Clin J Am Soc Nephrol. 2009 Dec;4 Suppl 1:S95-101.

20. Levin NW, Kotanko P, Eckardt KU, Kasiske BL, Chazot C, Cheung AK, Redon J, Wheeler DC, Zoccali C, London GM. Blood pressure in chronic kidney disease stage 5D-report from a Kidney Disease: Improving Global Outcomes controversies conference. Kidney Int. 2010 Feb;77(4):273-84.

21. Goldfarb-Rumyantzev AS, Chelamcharla M, Bray BE, Leypoldt JK, Lavasani I, Nelson N, Lavasani T, Baird B, Cheung AK. Volume indicators and left ventricular mass during aggressive volume management in patients on thrice-weekly hemodialysis. Nephron Clin Pract. 2009;113(4):c270-80.

22. Preston JS, Tasdizen T, Terry CM, Cheung AK, Kirby RM. Using the stochastic collocation method for the uncertainty quantification of drug concentration due to depot shape variability. IEEE Trans Biomed Eng. 2009 Mar;56(3):609-20.

23. Cheung AK, Greene T. Effect of membrane permeability on survival of hemodialysis patients. J Am Soc Nephrol. 2009 Mar;20(3):462-4.

24. Terry CM, Kim SE, Li L, Goodrich KC, Hadley JR, Blumenthal DK, Parker DL, Cheung AK. Longitudinal assessment of hyperplasia using magnetic resonance imaging without contrast in a porcine arteriovenous graft model. Acad Radiol. 2009 Jan;16(1):96-107.

25. Daugirdas JT, Depner TA, Greene T, Silisteanu P. Solute-solver: a web-based tool for modeling urea kinetics for a broad range of hemodialysis schedules in multiple patients. Am J Kidney Dis. 2009 Nov;54(5):798-809.

26. Daugirdas JT, Meyer K, Greene T, Butler RS, Poggio ED. Scaling of measured glomerular filtration rate in kidney donor candidates by anthropometric estimates of body surface area, body water, metabolic rate, or liver size. Clin J Am Soc Nephrol. 2009 Oct;4(10):1575-83.

27. Weinberg JM, Appel LJ, Bakris G, Gassman JJ, Greene T, Kendrick CA, Wang X, Lash J, Lewis JA, Pogue V, Thornley-Brown D, Phillips RA; African American Study of Hypertension and Kidney Disease Collaborative Research Group. Risk of hyperkalemia in nondiabetic patients with chronic kidney disease receiving antihypertensive therapy. Arch Intern Med. 2009 Sep 28;169(17):1587-94.







































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28. Weinberg JM, Appel LJ, Bakris G, Gassman JJ, Greene T, Kendrick CA, Wang X, Lash J, Lewis JA, Pogue V, Thornley-Brown D, Phillips RA; African American Study of Hypertension and Kidney Disease Collaborative Research Group. Risk of hyperkalemia in nondiabetic patients with chronic kidney disease receiving antihypertensive therapy. Arch Intern Med. 2009 Sep 28;169(17):1587-94.

29. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P, Van Lente F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009 May 5;150(9):604-12.

30. Young JM, Terrin N, Wang X, Greene T, Beck GJ, Kusek JW, Collins AJ, Sarnak MJ, Menon V. Asymmetric dimethylarginine and mortality in stages 3 to 4 chronic kidney disease. Clin J Am Soc Nephrol. 2009 Jun;4(6):1115-20.

31. Greene T, Daugirdas JT, Depner TA, Gotch F, Kuhlman M; Frequent Hemodialysis Network Study Group; National Institute of Diabetes and Digestive and Kidney Diseases; National Institutes of Health. Solute clearances and fluid removal in the frequent hemodialysis network trials. Am J Kidney Dis. 2009 May;53(5):835-44.

32. Madero M, Sarnak MJ, Wang X, Greene T, Beck GJ, Kusek JW, Collins AJ, Levey AS, Menon V. Uric acid and long-term outcomes in CKD. Am J Kidney Dis. 2009 May;53(5):796-803.

33. Greene T. Randomized and observational studies in nephrology: how strong is the evidence? Am J Kidney Dis. 2009 Mar;53(3):377-88.

34. Li L, Hu B, Greene T. A semiparametric joint model for longitudinal and survival data with application to hemodialysis study. Biometrics. 2009 Sep;65(3):737-45.

35. Stevens LA, Schmid CH, Greene T, Li L, Beck GJ, Joffe MM, Froissart M, Kusek JW, Zhang YL, Coresh J, Levey AS. Factors other than glomerular filtration rate affect serum cystatin C levels. Kidney Int. 2009 Mar;75(6):652-60.

36. Pogue V, Rahman M, Lipkowitz M, Toto R, Miller E, Faulkner M, Rostand S, Hiremath L, Sika M, Kendrick C, Hu B, Greene T, Appel L, Phillips RA; African American Study of Kidney Disease and Hypertension Collaborative Research Group. Disparate estimates of hypertension control from ambulatory and clinic blood pressure measurements in hypertensive kidney disease. Hypertension. 2009 Jan;53(1):20-7.

37. Gregory MC. Cost-effective dialysis for the developing world. Ethn Dis. 2009 Spring;19(1 Suppl 1):S1-65-7.

38. Charlton MR, Wall WJ, Ojo AO, Ginès P, Textor S, Shihab FS, Marotta P, Cantarovich M, Eason JD, Wiesner RH, Ramsay MA, Garcia-Valdecasas JC, Neuberger JM, Feng S, Davis CL, Gonwa TA; International Liver Transplantation Society Expert Panel. Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation. Liver Transpl. 2009 Nov;15(11):S1-34.

39. Shihab FS. Preconditioning: from experimental findings to novel therapies in acute kidney injury. Minerva Urol Nefrol. 2009 Sep;61(3):143-57.

40. Delgado JC, Pavlov IY, Shihab FS. Post-transplant increased levels of serum sCD30 is a marker for prediction of kidney allograft loss in a 5-year prospective study. Transpl Immunol. 2009 Dec;22(1-2):1-4.

41. Delgado JC, Fuller A, Ozawa M, Smith L, Terasaki PI, Shihab FS, Eckels DD. No occurrence of de novo HLA antibodies in patients with early corticosteroid withdrawal in a 5-year prospective randomized study. Transplantation. 2009 Feb 27;87(4):546-8.

42. Shihab FS, Bennett WM, Andoh TF. Donor preconditioning with a calcineurin inhibitor improves outcome in rat syngeneic kidney transplantation. Transplantation. 2009 Feb 15;87(3):326-9.

43. Tögel F, Westenfelder C. Stem cells in acute kidney injury repair. Minerva Urol Nefrol. 2009 Sep;61(3):205-13.

44. Tögel F, Zhang P, Hu Z, Westenfelder C. VEGF is a mediator of the renoprotective effects of multipotent marrow stromal cells in acute kidney injury. J Cell Mol Med. 2009 Aug;13(8B):2109-14.

45. Tögel F, Cohen A, Zhang P, Yang Y, Hu Z, Westenfelder C. Autologous and allogeneic marrow stromal cells are safe and effective for the treatment of acute kidney injury. Stem Cells Dev. 2009 Apr;18(3):475-85.

46. Jia Z, Wang H, Yang T. Mice lacking mPGES-1 are resistant to lithium-induced polyuria. Am J Physiol Renal Physiol. 2009 Dec;297(6):F1689-96.































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47. Soodvilai S, Jia Z, Wang MH, Dong Z, Yang T. mPGES-1 deletion impairs diuretic response to acute water loading. Am J Physiol Renal Physiol. 2009 May;296(5):F1129-35.

48. Wang N, Symons JD, Zhang H, Jia Z, Gonzalez FJ, Yang T. Distinct functions of vascular endothelial and smooth muscle PPARgamma in regulation of blood pressure and vascular tone. Toxicol Pathol. 2009;37(1):21-7.

49. Chen Q, Xu S, Huang S, Zhang A, Feng Q, Guo X, Guo M, Yang T, and Chen R. Suppression subtractive hybridization analysis of gene expression during late kidney development identifies the developmentally regulated gene rPEA3. Nephron Exp Nephrol 111:103-115, 2009.

50. Feng Q, Huang S, Zhang A, Chen Q, Guo X, Chen R, and Yang T. Y-Box protein 1 stimulates mesangial cell proliferation via activation of ERK1/2. Nephron Exp Nephrol 113:e16-e25, 2009





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16. Nephrology Fellows: Current and graduates in previous ten years (RETURN TO TABLE OF CONTENTS) Name and current position Years in Program Board Certified in Nephrology Donald Morris, M.D. 2002-04 yes Private practice Matthew Cyphers, M.D. 2003-05 yes Private practice Shital Shah, M.D. 2003-05 yes Private practice in Salt Lake City, UT Josephine Abraham, M.D. 2004-06 yes Assistant Professor, Division of Nephrology University of Utah Arsalan Habib, M.D. 2004-07 yes Assistant Professor, Division of Nephrology University of Utah Madhukar Chelamcharla, M.D. 2004-07 yes Private practice Terrence Bjordahl, M.D. 2005-07 yes Assistant Professor, Division of Nephrology University of Utah Jay Reddy Kaluvapalle, M.D. 2005-08 yes Private practice Kalani Raphael, M.D. 2006-09 yes Assistant Professor, Division of Nephrology University of Utah Duncan McGregor, M.D. 2007-09 yes Private practice Christopher Rich, M.D. 2007-09 yes Private practice Emily Peterson, M.D. 2009-11 yes Private practice Cuong Nguyen, M.D. 2008-11 yes Private practice Magdalena Sikora, M.D. 2009-11 yes Private practice Karl Roos, M.D. 2009-12 yes Private practice Vidya Raj Krishnamurthy, M.D. 2009-12 yes

113

Private practice Niru Ramkumar, M.D. 2010-13 yes Instructor, Division of Nephrology University of Utah Andrea Nelson, M.D. 2011-13 yes Clinical Instructor University of Utah Yuqiang Ge, M.D. 2011-13 yes Private practice Nestor Almeida, M.D. 2011-14 pending Private practice Aaron Fearday, M.D. 2012-14 pending Private practice Amanda Hall, D.O. 2013-15 Current clinical fellow Residency: University of Utah Owolabi Oguyenne, M.D. 2013-15 Current clinical fellow Residency: Baystate Medical Center/Tufts University Zachary Freestone, D.O. 2014-16 Current clinical fellow Residency: University of Las Vegas Tahir Zaman, M.D. 2014-16 Current clinical fellow Residency: University of Utah

Documents

University of Utah Nephrology Fellowship Program · 2020-01-27 · Curriculum Vitae and Personal Statement through ERAS Three letters of recommendation through ERAS International