Nephrology fellowship - Clinical Rotations

Fellows spend equal amounts of time on the following rotations over a 12 month period.

Harborview Medical Center Consult Service

This 350-bed county-owned hospital is a major center for the care of various common acute and chronic medical problems and the only Level 1 Trauma center in the region. The emergency service, surgical ICUs, trauma unit, burn center and medical surgical intensive care units are the most active in the region. Rotationa at Harborview typically provide extensive exposure to the management of fluid and electrolyte and acid-base disorders, acute kidney injury, intoxications, and other common renal disorders including refractory hypertension. The inpatient nephrology rotation is staffed by an attending nephrologist with two (2) clinical fellows. Each fellow will typically round with staff daily for 2-3 hours, see new consults, perform a history and physical examination, write a consult report in the electronic medical record, present the patient to staff, and provide recommendations to the primary inpatient teams until discharge or signoff. Fellows are also expected to teach medicine residents and medical students on the nephrology rotation. During this rotation, each fellow will participate in the Professors’ Rounds where they will present an interesting clinical case, discuss differential diagnosis, evaluation, therapy, and review current nephrology literature pertaining to that case. In addition, they are introduced to the basic concepts of Biostatistics and Epidemiology with a Journal Club formatted to learn the art of critiquing medical literature. The weekly biopsy conference is also telecasted to HMC for real- time participation. Fellows typically spend approximately sixty hours per week on this rotation. Call is shared with the VA Consult and VA Dialysis Fellows. Specific competency based goals include comprehensive care of patients with acute kidney injury (including pharmacology and nutrition), critical care nephrology with proficiency in acute intermittent hemodialysis and continuous renal replacement therapy (CVVH: continuous veno- venous hemofiltration); ongoing provision of chronic dialysis for inpatients (hemodialysis and peritoneal dialysis), diagnostic and therapeutic management of patients with unexplained renal disease (nephrotic/ nephritic syndrome, abnormal urine sediment); refractory and suspected secondary hypertension as well as guideline- based care of patients with chronic kidney disease.  

University of Washington Medical Center Consult Service

University of Washington Medical Center is a 450-bed comprehensive care facility and is ranked No. 1 as the best hospital in the state and in the Seattle metro area. The UWMC inpatient consult service has two (2) clinical fellows assigned each month under the supervision of a General Nephrology faculty and follows the same logistics as for the HMC inpatient consult service. Teaching of junior house- staff as well as one case presentation at the weekly UWMC Professors’ Rounds is expected of the fellows during this month. In addition, fellows attend other divisional conferences during the month including Glomerular conference, Fluid & Electrolyte conference, HLA conference, Journal club and Biopsy conference. Call is shared with the UW Transplant and Outpatient Rotation Fellows. Specific goals of mastery are: glomerulonephritidies, fluid and electrolyte disorders, acute kidney injury, critical care nephrology with provision of acute dialysis including hemodialysis and continuous renal replacement therapy [Slow Low- Efficiency Dialysis (SLED)], hypertensive crisis management, pharmacology in renal failure, anemia management, and nutrition as it pertains to renal failure. In addition, UWMC being a tertiary referral center, offers a unique experience in diagnostic and therapeutic management of renal disorders related to high- risk pregnancy, onco- nephrology, advanced liver disease, advanced heart failure mechanical support as well as chronic kidney disease resulting from complications of non- renal organ transplantation.

University of Washington Medical Center Transplant Service

One (1) General nephrology fellow is assigned to the transplant rotation each month with 1st year fellows typically spending two (2) consecutive months on the Transplant service to fulfill the ACGME program requirements. For half of the academic year, the Transplant fellow is also assigned to and actively participates in the clinical service. On this rotation, fellows will see kidney and other non- renal organ pancreas transplant recipients while inpatient. This spans the continuum of follow the patient pre-operative assessment, through the transplant procedure itself and the immediate post-transplant course culminating in discharge. Rounds occur daily with the multidisciplinary medical - surgical transplant team. During this month, fellows will also evaluate pre-transplant donors and recipients and present the clinical course of the current patients in the weekly transplant team conference. With regards to didactics, fellows will attend the weekly Transplant Grand Rounds as well as present new literature articles on pertinent aspects of transplantation care twice during the month. During this rotation, fellows participate in all transplant outpatient clinics (Donor Evaluation, Pre- transplant and Post- Transplant/ Long Term follow up) that in addition to exposing them to all facets of outpatient transplant care, facilitates continuity of care of the new transplant recipients during that month. Time spent on service will be approximately sixty hours per week. Call is shared with the UW Consult and Outpatient Rotation Fellows. Competency goals are to master kidney transplantation and renal allograft biopsies. Specific goals are to develop expertise in donor and recipient pre-transplant evaluation, peri-transplant management, immune suppression and complications, performance and interpretation of renal biopsies, rejection management, immunocompromised infectious disease diagnosis and treatment, and management of allograft failure.

VA Puget Sound Consult Service

The overall goals of this rotation are to provide comprehensive training in in-patient consultative nephrology in the initial evaluation and management of patients with acute and chronic renal failure, fluid and electrolyte disorders, glomerular diseases as well as care of patients with end-stage renal disease. This rotation has one (1) clinical fellow assigned each month who, under the supervision of renal faculty, provides inpatient consultation to medical and surgical services at the Puget Sound VA hospital. The fellow works in close collaboration with the VA Outpatient Dialysis team and often assists in co-management and cross- coverage. VA renal faculty hold expertise in the provision of all forms of dialysis therapy (intermittent HD, peritoneal dialysis, Home hemodialysis), safety net population care, bone- mineral disease, telemedicine and geriatric nephrology. During this rotation, fellows also attend the Stone Clinic in collaboration with the urology department.

VA Puget Sound Outpatient Dialysis

The VA is an ideal health care system to provide modern training in the management of ESRD patients and in the utilization of innovative approaches to providing renal replacement therapy to urban and rural veterans. The Puget Sound VA Renal Dialysis Unit has been a national leader in home hemodialysis and it offers a unique opportunity for training, given its outstanding in-center hemodialysis center, peritoneal dialysis program, and active home hemodialysis program. In addition, VISN 20 has the largest number of rural counties among all the VISN's and provides a unique opportunity to train fellows on the issues related to rural renal care. One (1) clinical fellow is assigned each month to this block dialysis rotation that provides the essential clinical setting to master the outpatient care of ESRD patients and learn the science and particulars of the various dialysis modalities.

Outpatient Rotation

Each fellow will be assigned 3 months of Outpatient Rotation during the second clinical year. The scope of activity during this month is relatively broad and covers both educational and service related aspects. The recurring and assigned duties include once a week hemodialysis continuity care ‘shift’ delivered at an assigned Northwest Kidney Centers unit and twice monthly Home Dialysis Clinic, Post- Transplant Clinic and Glomerulonephritis Clinic. Fellows will also be expected to spend at least one week during the month with the Renal Histopathology faculty in learning the art and science of kidney biopsy preparation and interpretation. Fellows will also have opportunity to elect for additional experiences during this month including but not limited to Hypertension Clinic, Stone Clinic, Palliative Care Inpatient experience, Vascular Access management, Diagnostic Ultrasound and catheter insertion training, Onco- nephrology rotation at UW affiliated Seattle Cancer Care Alliance [Fred Hutchison Cancer Center], critical care nephrology [with ICU team], etc. Each fellow will also attend their assigned weekly continuity clinic and have the opportunity to complete scholarly projects during this month

Continuity Clinics

One half-day clinic per week for 24 months will be spent at one of the following locations:

  • University of Washington Medical Center
  • Harborview Medical Center
  • Veteran's Affairs Puget Sound