Inpatient Nephrology Consult Service: UI Hospitals & Clinics
The University of Iowa Hospitals & Clinics Nephrology Consult Services form the core of the fellow's clinical learning experience. Fellows will spend 8-10 months rotating through the 2 consult services in the course of the two-year program. A couple of years ago our traditional one consult service was split into 2 as the volume of consultations increased. The goal of creating an Acute service (acute floor or ICU consults) and Chronic service (all ESRD admissions) was to provide quality and safe patient care in a consultative role and to continue to maintain the education value of the renal consult service for our trainees. The Acute service (Team A) is staffed by 1 renal fellow, 1 nephrology staff and incorporates all resident and student learners. The Chronic service (Team B) is staffed by 1 renal fellow and 1 staff.
For each of these services, the fellow assumes significant responsibility for running the Nephrology Consult Service. Under the supervision of the attending nephrologist, the fellow will oversee the daily management and diagnostic evaluation of all patients on whom the service consults and learn how to manage acid base and electrolyte disorders, acute and chronic kidney disease, hypertension, intoxications, and other renal-related diseases. The fellow’s responsibilities will include decisions regarding initiation of dialysis, selection of modality and writing and/or supervising dialysis prescription for patients with acute kidney injury. The fellow will become familiar with all the modalities of continuous renal replacement therapy (CRRT), the role of hemoperfusion in the management of drug intoxication and the use of ultrafiltration techniques. In addition, the fellow will also become adept at percutaneous renal biopsies. The fellow will also be intimately involved in teaching medical students and residents on the nephrology consult A team and will function as a liaison between the consultation service at UI Hospitals & Clinics and the referring physicians/teams.
Inpatient Nephrology Consult service: VAMC
The Iowa City Veterans Affairs Medical Center is conveniently located adjacent to the University of Iowa Hospitals. The nephrology fellow oversees three basic services at the Iowa City VA Health Care System: inpatient consults, outpatients in the renal clinic, and organizing and performing procedures. This interaction with the VA is designed to provide maximum exposure to the unique aspects of nephrologic care in this patient population.
During the course of the year, the nephrology fellow will rotate through several outpatient nephrology clinics. The individual clinics emphasize different areas of nephrology, allowing the fellow to participate in all aspects of outpatient care.
The Continuity of Care (COC) clinic meets weekly for a half day and actively involves the fellow in the long-term management of renal-related problems. In this clinic, individual patients will be followed by a specific fellow for the course of his or her fellowship training. Each patient will also be staffed by an attending nephrologist; however, the fellow is responsible for making diagnostic and therapeutic decisions, contacting the patient with test results, and functioning as the primary nephrologist for the care of the renal problems. Increased responsibility will be given as the fellow advances through the training program.
The Renal Stone Clinic is a clinic that guides the metabolic evaluation of the patient with nephrolithiasis and provides management strategies for prevention (pharmacologic, dietary and lifestyle modifications) and definitive treatment (urology referral) of stone disease.
The Veterans Administration Clinic is a general nephrology clinic that exposes the fellow to the unique aspects of care in this patient population, with a predominance of renovascular hypertension, diabetes, and geriatric renal disease, in a predominantly male population.
The Transplantation clinics at the University of Iowa Hospitals & Clinics and VAMC provide the opportunity for the fellow to participate in the outpatient evaluation of the pre-transplant patient and potential donors, as well as the immediate and long-term management of the immunosuppressive therapies and complications of the post-transplant patient.
The Rare Renal Disease and the Renal Genetics Clinic is a multidisciplinary clinics are staffed by specialists in adult nephrology, pediatric nephrology, genetic counseling, renal nutrition and social and financial support personnel. The clinics have a national and international reputation in treating complement-medicated renal diseases, atypical hemolytic uremic syndrome and C3 glomerulopathies. In addition, the clinics have a longstanding collaboration with the Iowa Institute of Human Genetics and Molecular Otolaryngology and Renal Research Laboratory (under the scientific direction of Dr. Richard Smith), which provides onsite comprehensive state of the art genetic testing, functional complement assays and molecular diagnostic tools to facilitate evaluation of genetic and acquired abnormalities that form the bases of rare kidney disease.
Our dialysis program, under the leadership of Dr. Mony Fraer, gives our fellows an in-depth exposure to the main modes of outpatient dialysis therapies, center and home (hemodialysis and peritoneal dialysis), enabling them to formulate realistic strategies to select the option most suited to their ESRD patients. Care for the ESRD patient involves a multidisciplinary team approach that includes the fellow, staff nephrologist, social worker, dietician, and nurses.
Center Dialysis
The fellow will be assigned to a dialysis shift (at University of Iowa Hospitals & Clinics ) as the primary provider, along with one staff. This is a 6 month rotation during each training year. This continuity of care allows the fellow to experience the day-to-day management of the ESRD patients on maintenance dialysis. The fellow will round once weekly with the staff on these and will gradually assume independent responsibility in decision-making for these patients. All facets of patient care will be covered, including monthly lab review, dietary recommendations, adjustments in dialysis prescriptions, evaluation of access problems, and social issues. In the second year of training, the fellow will switch to work with another staff and group of patients on a new hemodialysis shift.
Home Dialysis Program
We currently have about 30 patients on home therapies (hemodialysis or peritoneal dialysis) in our program (one of the longest-running in the country). Each patient is seen monthly in the clinic by the assigned staff and fellow. For those patients beginning training for home therapies, the fellow rounds once weekly with the staff and makes any necessary changes in the treatment plan.
Continuous Renal Replacement Therapies
Over the course of your training, the fellow will become familiar with all the modalities of continuous renal replacement therapy (CRRT), the role of hemoperfusion in the management of drug intoxications, and, with the use of ultrafiltration techniques for patients requiring this modality.
Kidney and kidney pancreas transplant services are provided at the University of Iowa Organ Transplant Center and at the affiliated VA Transplant Center. The University of Iowa transplant program is the only multi-organ transplant program (Kidney, Liver, Pancreas, Heart, Lung) in the State of Iowa. The VA transplant center is one of a handful of VA programs that perform kidney transplants and the only center that performs kidney pancreas transplants.
Stable transplant inpatients are cared for on a multidisciplinary transplant unit where Transplant Nephrology has admitting privileges and primary responsibility for patients admitted to the Transplant Nephrology Service. Transplant Nephrology also provides consultative services to Transplant Surgery and Transplant Hepatology as well as patients with kidney and liver transplants who are admitted to all other services including critical care units. The renal divisio has an AST accredited transplant nephrology fellowship program where 1 fellow is admitted per year.
Each general nephrology fellow will be assigned for 3 to 4 months on this transplant service, working with one of the Transplant Nephrology staff on the inpatient service and with several staff in the Transplant outpatient clinics, sometimes alongside the Transplant Nephrology fellow. During the course of the rotation the fellow will learn the indications and complications of transplantation, the psychological impact of transplantation, and the principles of histocompatibility testing in the selection of donor kidneys. The fellow will also be exposed to the process of assessing suitability for living-related donor transplantation and will acquire an understanding of the modes of action, pharmacology, and complications of immunosuppressive drug regimens.
By being involved in the workup and management of graft dysfunction, the fellow will learn to recognize the clinical pathology of acute and chronic rejection, drug toxicity, and recurrent primary disease and will gain experience in the needle biopsy of the transplanted kidney. In addition to the day-to-day management of the organ transplant service inpatients, the fellow will participate in the Outpatient Transplant Clinic and the Transplant Conferences.