NEPHROLOGY OUPATIENT DIALYSIS UNIT INPATIENT (BOND STREET) ROTATION
Each first year fellow rotates on the Outpatient Dialysis Unit Inpatient rotation with nephrology faculty members for 2-3 months during the first year of training. (Second year fellows round for 1-2 months on this rotation.) Fellows are expected to make initial evaluations and then present the history, physical findings, assessment and plans to the nephrology faculty member(s) of inpatients on this service.
Educational Goals:
- The outpatient dialysis service builds the foundations for a broad knowledge base in inpatient care of end stage renal disease patients, by providing fellows exposure and opportunities to manage these patients.
- The fellow is expected to develop competency in providing compassionate and thorough care to a medically and socially diverse group of hospitalized patients.
- Fellows serve as team leaders on these services and have opportunities to develop teaching, leadership, and management skills with residents and students.
- The purpose of this rotation is to provide first year fellows with the education and expertise to become proficient in inpatient care of dialysis patients and some patients followed in renal clinic. Second year fellows are able to gain further experience in caring for this group of hospitalized patients.
Objectives:
Patient Care
Each fellow will rate as valuable the importance of being a nephrologist to a medically and socially diverse group of patients
Each fellow will be able to obtain and document a complete history and physical, formulate a thorough assessment and plan, and communicate this assessment to the primary care team
Each fellow will demonstrate the ability to make daily assessments of their patients and convey that information to the team through a variety of methods, including daily written progress notes
Specific educational goals are to provide clinical expertise and opportunities to gain experience in:
- Pharmacology and drug dose modification during hemodialysis and peritoneal dialysis;
- Evaluation and medical management of medical complications in patients on dialysis including dialysis access, infections, with understanding of pathogenesis, prevention and treatment of complications;
- Nutritional requirements of patients undergoing hemodialysis and peritoneal dialysis;
- Radiology of vascular access and balloon angioplasty of vascular access;
Medical Knowledge
The fellow will demonstrate a knowledge and understanding of the pathophysiology, diagnostic evaluation, and therapeutic management of a core group of issues described above.
By the end of the outpatient dialysis inpatient month, each fellow will have attended and participated in the educational activities listed in the teaching methods section.
By the end of the outpatient dialysis inpatient, each fellow is encouraged to complete some of the recommended readings (below)
Communication Skills
Each fellow will demonstrate effective communication skills with the attending physician by discussing each consultation or admission in a timely fashion
Each fellow will discuss the ongoing care of each patient with the appropriate attending daily
Each fellow will demonstrate effective teaching and feedback skills with interns, residents and medical students.
Each fellow will model effective interpersonal communication skills with patients, families, and allied health professionals
Professionalism
Each fellow will demonstrate compassion and understanding to a group of socially, economically and racially diverse group of patients
Each fellow will rate as comfortable his/her ability to assume the leadership role on the healthcare team
Each fellow will model appropriate team function by including allied health professionals in management discussions
Practice-Based Learning and Improvement
The fellow will incorporate basic knowledge of evidence-based medicine in evaluation and management of patient medical problems
Each fellow will continue the process of acquiring skills and documenting the procedures required by the ABIM, as listed in the procedure summary
Each fellow will model practice based learning and effective information seeking in the daily care of patients
Systems-Based Practice
The fellow will demonstrate competence in the integration of inpatient and outpatient care, and a systems approach to care, by demonstrating appropriate follow-up/discharge plans for all patients he/she has admitted
The resident will demonstrate an awareness of issues cost-effective medicine in patient care, by discussing the cost implications of a case/month with the attending physician
Each fellow will rate as valuable the contributions of other members of the health care team into management plans for patients
Each fellow will routinely evaluate the socioeconomic needs of his/her patients, including health insurance, access to care and copayments necessary to provide care
By the end of consultation month, each fellow will have assumed care for patients of colleagues on the team and effectively transferred care of his/her own patients when not in the hospital
Teaching Methods:
Teaching methods include inpatient rounds with nephrology faculty members. In addition, radiological studies obtained are reviewed and if needed direct consultation is obtained from radiology faculty members. There are didactic sessions pertaining to the educational goals of this rotation during the Core Curriculum Conference, Combined Vascular Access/ Renal Interventional Radiology Conference, and Renal Rounds. Renal biopsy material is reviewed with our renal pathology faculty members. There is access to PUB MED and Up-to-Date as well as other electronic databases in the fellows’ office and all public workstations in the hospital. Recommended text include The Handbook of Dialysis, 3rd Ed., by Daugirdas, et al.*, Principles and Practice of Dialysis by Henrich and Drug Prescribing in Renal Failure Dosing Guidelines for Adults, 4th Ed. by Aronoff, et al.*
*Texts provided to each fellow, other texts are available in the Fellow’s office
Mix of Diseases:
Nephrology faculty members’ outpatient continuity clinic which may include those with chronic kidney diseases at various stages, as well as nephrotic syndrome, acute renal failure, and other problems as well.
Patients with all forms of End Stage Renal Disease may be seen in this experience including those with diabetes, hypertension, chronic glomerulonephritis, chronic tubulointerstitial disease, genetic kidney diseases such as Polycystic Kidney disease, HIVAN, SLE as well as other diseases that may result in End Stage Renal Disease. Patients may also be followed from
Patient Characteristics:
Patients followed include hemodialysis and peritoneal dialysis patients from The Johns Hopkins Gambro Bond Street and 25th St. units who are admitted to Johns Hopkins Hospital. Inpatients may also include private patients admitted by full-time nephrology faculty members of The Johns Hopkins University School of Medicine. Inpatients continue to be followed both on regular floors and in the intensive care unit settings. There is a usual daily census of between 5-15 patients.
Some patients over the age of 70 are included in this rotation and fellows experience geriatric aspects of nephrology.
Types of Clinical Encounters:
Patients may be seen for consultation either by the admitting service or the emergency room, or as primary service patients if admitted by one of the nephrology faculty members at the 25th street or Johns Hopkins Gambro Dialysis Units or from the nephrology faculty member’s continuity clinic.
Procedures:
Procedures performed may include renal biopsies, urinalyses, placement of vascular access for hemodialysis and chronic renal replacement therapies, and hemodialysis, peritoneal dialysis and chronic renal replacement therapy treatments. Please see general curriculum regarding methods of evaluation of procedures and definition of proficiency. Nephrology faculty members supervise these procedures unless not on the premises at the time of the procedure or if the fellow has performed 10 vascular access procedures satisfactorily. All renal biopsies are supervised by a nephrology faculty member.
Services:
Fellows on this rotation will be asked to take care of patients by providing an outstanding standard of care as stated by the six core clinical competencies. Procedures involved are for patient care purposes. Fellows may facilitate care by phone calls for scheduling purposes however; other health care professionals will perform the most of these calls, unless the patient is admitted to the nephrology faculty member post percutaneous native renal biopsy with anticipated next day discharge where no house-staff are involved.
Reading List:
1. Afthentopoulos, I.E., et al., Sclerosing peritonitis in continuous ambulatory peritoneal dialysis patients: one center's experience and review of the literature. Adv Ren Replace Ther, 1998. 5(3): p. 157-67.
2. Albers, F.J., Clinical considerations in hemodialysis access infection. Adv Ren Replace Ther, 1996. 3(3): p. 208-17.
3. Beathard, Physical Examination of the Dialysis Vascular Access. Seminars in Dialysis, 1998. 11: p. 231-236.
4. Bergstrom, J., Nutrition and mortality in hemodialysis. J Am Soc Nephrol, 1995. 6(5): p. 1329-41.
5. Beto, J.A., et al., Variation in blood sample collection for determination of hemodialysis adequacy. Council on Renal Nutrition National Research Question Collaborative Study Group. Am J Kidney Dis, 1998. 31(1): p. 135-41.
6. Blake, P., et al., Recommended clinical practices for maximizing peritoneal dialysis clearances. Perit Dial Int, 1996. 16(5): p. 448-56.
7. Block, G.A., et al., Association of serum phosphorus and calcium x phosphate product with mortality risk in chronic hemodialysis patients: a national study. Am J Kidney Dis, 1998. 31(4): p. 607-17.
8. Bloembergen, W.E., et al., Relationship of dose of hemodialysis and cause-specific mortality. Kidney Int, 1996. 50(2): p. 557-65.
9. Brady, J.P., J.W. Snyder, and J.A. Hasbargen, Vancomycin-resistant enterococcus in end-stage renal disease. Am J Kidney Dis, 1998. 32(3): p. 415-8.
10. Brunet, P., et al., Tolerance of haemodialysis: a randomized cross-over trial of 5-h versus 4-h treatment time. Nephrol Dial Transplant, 1996. 11(Suppl 8): p. 46-51.
11. Burkart, J.M., et al., Solute clearance approach to adequacy of peritoneal dialysis. Perit Dial Int, 1996. 16(5): p. 457-70.
12. CANUSA, Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc Nephrol, 1996. 7(2): p. 198-207.
13. Cimochowski, G.E., et al., Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron, 1990. 54(2): p. 154-61.
14. Clark WR, M.B., Kraus MA, Macias WL, Solute Control in Acute Renal Failure: Prescription and Delivery of Adequate Extracorporeal Therapy. Seminars in Dialysis, 1996. 9: p. 133-139.
15. Cobb, D.K., et al., A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med, 1992. 327(15): p. 1062-8.
16. Daugirdas, Nils Alwall Lecture: Urea Kinetic Modeling: Practical Consequences of the Regional Blood Flow Model. Part One. URR and Kt/V, . 1997.
17. Davies, S.J., et al., What really happens to people on long-term peritoneal dialysis? Kidney Int, 1998. 54(6): p. 2207-17.
18. Dougherty, M.J., et al., Endovascular versus surgical treatment for thrombosed hemodialysis grafts: A prospective, randomized study. J Vasc Surg, 1999. 30(6): p. 1016-23.
19. Duszak, R., Jr., et al., Replacement of failing tunneled hemodialysis catheters through pre-existing subcutaneous tunnels: a comparison of catheter function and infection rates for de novo placements and over-the-wire exchanges. J Vasc Interv Radiol, 1998. 9(2): p. 321-7.
20. Favre H, M.P., Stoermann C, Anticoagulation in Continuous Extracorporeal Renal Replacement Therapy. Seminars in Dialysis, 1996. 9: p. 112-118.
21. Feldman, H.I., S. Kobrin, and A. Wasserstein, Hemodialysis vascular access morbidity. J Am Soc Nephrol, 1996. 7(4): p. 523-35.
22. Flanigan MJ, R.M., Frankenfield D, 1998 Core Indicators Study-Anemia in Peritoneal Dialysis: Implications for Future Monitoring. Seminars in Dialysis, 1999. 12(3): p. 157-161.
23. Fried, L., et al., Recommendations for the treatment of lipid disorders in patients on peritoneal dialysis. ISPD guidelines/recommendations. International Society for Peritoneal Dialysis. Perit Dial Int, 1999. 19(1): p. 7-16.
24. Gokal, R., et al., Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. (Official report from the International Society for Peritoneal Dialysis). Perit Dial Int, 1998. 18(1): p. 11-33.
25. Haage, P., et al., Treatment of hemodialysis-related central venous stenosis or occlusion: results of primary Wallstent placement and follow-up in 50 patients. Radiology, 1999. 212(1): p. 175-80.
26. Hakim, R.M., et al., Effect of the dialysis membrane on mortality of chronic hemodialysis patients. Kidney Int, 1996. 50(2): p. 566-70.
27. Heimburger O, A.A., Dietary Requirements in Peritoneal Dialysis. Seminars in Dialysis, 1997. 10: p. 87-93.
28. Hull, A.R., The era of standardized prescription management for peritoneal dialysis must end. Perit Dial Int, 1996. 16(5): p. 434-6.
29. Klinkmann, H. and J. Vienken, Membranes for dialysis. Nephrol Dial Transplant, 1995. 10(Suppl 3): p. 39-45.
30. Kopple, J.D., et al., A proposed glossary for dialysis kinetics. Am J Kidney Dis, 1995. 26(6): p. 963-81.
31. Kopple, J.D., McCollum Award Lecture, 1996: protein-energy malnutrition in maintenance dialysis patients. Am J Clin Nutr, 1997. 65(5): p. 1544-57.
32. Krediet, R.T., Prevention and treatment of peritoneal dialysis membrane failure. Adv Ren Replace Ther, 1998. 5(3): p. 212-7.
33. Lameire N, B.W., Vanholder R, Consequences of Using Glucose in Peritoneal Dialysis Fluid. Seminars in Dialysis, 1998. 11(5): p. 271-275.
34. Marx, M.A., et al., Cefazolin as empiric therapy in hemodialysis-related infections: efficacy and blood concentrations. Am J Kidney Dis, 1998. 32(3): p. 410-4.
35. Nassar, G.M. and J.C. Ayus, Infectious complications of the hemodialysis access. Kidney Int, 2001. 60(1): p. 1-13.
36. Owen, W.F., Jr., et al., The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med, 1993. 329(14): p. 1001-6.
37. Perini, S., et al., Tesio catheter: radiologically guided placement, mechanical performance, and adequacy of delivered dialysis. Radiology, 2000. 215(1): p. 129-37.
38. Schillinger, F., et al., Post catheterization vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant, 1991. 6(10): p. 722-4.
39. Sherman, R.A. and T. Kapoian, Recirculation, urea disequilibrium, and dialysis efficiency: peripheral arteriovenous versus central venovenous vascular access. Am J Kidney Dis, 1997. 29(4): p. 479-89.
40. Sigler MH, M.M., Membranes and Devices Used in Continuous Renal Replacement Therapy. Seminars in Dialysis, 1996. 9: p. 98-106.
41. Silver, S.M., R.H. Sterns, and M.L. Halperin, Brain swelling after dialysis: old urea or new osmoles? Am J Kidney Dis, 1996. 28(1): p. 1-13.
42. Swartz, R.D., C.L. Boyer, and J.M. Messana, Central venous catheters for maintenance hemodialysis: a cautionary approach. Adv Ren Replace Ther, 1997. 4(3): p. 275-84.
43. Teehan, B.P., C.R. Schleifer, and J. Brown, Adequacy of continuous ambulatory peritoneal dialysis: morbidity and mortality in chronic peritoneal dialysis. Am J Kidney Dis, 1994. 24(6): p. 990-101.
44. Vonesh, E.F., et al., Peritoneal dialysis kinetic modeling: validation in a multicenter clinical study. Perit Dial Int, 1996. 16(5): p. 471-81.
45. Weinreich, T., Prevention of renal osteodystrophy in peritoneal dialysis. Kidney Int, 1998. 54(6): p. 2226-33.
46. Welage, L.S., et al., Influence of cellulose triacetate hemodialyzers on vancomycin pharmacokinetics. J Am Soc Nephrol, 1995. 6(4): p. 1284-90.
47. Zaleski, G.X., et al., Experience with tunneled femoral hemodialysis catheters. AJR Am J Roentgenol, 1999. 172(2): p. 493-6.
48. Zibari, G.B., et al., Preoperative vancomycin prophylaxis decreases incidence of postoperative hemodialysis vascular access infections. Am J Kidney Dis, 1997. 30(3): p. 343-8.
49. Keane, W.F., et al., Adult peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Perit Dial Int, 2000. 20(4): p. 396 – 411.
50. Teng, M., et al., Survival of patients undergoing hemodialysis with paricalcitol or calcitriol therapy. N Eng J Med, 2003. 349(5): p. 446 – 56.
51. Hufnagel, G., et al., The influence of automated peritoneal dialysis on the decrease in residual renal function. Nephrol Dial Transplant, 1999. 14: p. 1224 -1228.
52. Correa-Rotter, R. and Cueto-Manzano, A., The problem of the high transporter: Is survival decreased? Proceedings of the ISPD, 2001. 21: S75 – S79.
53. Cueto-Manzano, A.M. and Correa-Rotter, R., Is high peritoneal transport rate an independent risk factor for CAPD mortality? Kidney Int, 2000. 57: p. 314 -320.
54. Scully, R.E., et al., Case Records of the Massachusetts General Hospital, Weekly Clinicopathological exercises, Case 31-2001. N Engl J Med., 2001. 345(15): p. 1119 – 1124.
55. Alpert, M.A., and Ravenscraft, M.D., Pericardial involvement in end-stage renal disease. Am J Med Sci, 2003. 325(4): p. 228 – 36.
56. Locatelli, F., et al., Treatment of anaemia in dialysis patients with unit dosing of darbepoetin afla at a reduced dose frequency relative to recombinant human erythropoietin (rHuEpo). Nephrol Dial Transplant, 2003. 18: p. 362 – 369.
57. Mann, H. and Stiller S., Sodium modeling. Kidney Int, 2000. 58: S79 – S88.
58. Izumotani, T., et al., Correlation between peritoneal mesothelial cell cytology and peritoneal histopathology with respect to prognosis in patients on continuous ambulatory peritoneal dialysis. Nephron, 2001. 89: 43 – 49.
59. Miyata, T., et al., Toward better dialysis compatibility: Advances in the biochemistry and pathophysiology of the peritoneal membranes. Kidney Int, 2002. 61:375 – 386.
Pathologic Material:
Fellows review patient percutaneous renal biopsies as well as other pathologic material with renal pathology faculty members and nephrology faculty members.
Other Educational Resources:
Other educational resources may be purchased via the fellow’s stipend. Courses are offered throughout the year by The Johns Hopkins School of Medicine regarding various topics, including Computer Skills by the Welch Library.
Method of Evaluation:
The fellow is evaluated using the ABIM form for Evaluation of Clinical Competence, Categories evaluated include the core competencies of Patient Care, Medical Knowledge, Practice Based Learning , Interpersonal and Communication Skills, Professionalism, Systems Based Learning, evaluation of procedures above, and Moral and Ethical Behavior, and Overall Clinical Competence as a Specialist In Nephrology. The American Board of Medical Specialties Generic Form for Global Ratings of Resident Performance, and the Mini-Clinical Evaluation Exercise (CEX) form are also used which evaluate the 6 core competencies. Please see general Curriculum for details of the evaluation. These evaluations are filled out every six months by the nephrology faculty member. The fellow evaluates the teaching of the nephrology faculty member using the form provided.
Responsibilities/Supervision:
The nephrology fellow on this rotation is responsible for the initial evaluation of inpatients and subsequent follow up evaluations of the patients on the team. The nephrology fellow contacts the nephrology faculty members prior to the start of renal replacement therapy. The Nephrology fellow communicates any concerns to the nephrology faculty member that might mandate review of the patient prior to rounds scheduled later in the day. Each nephrology faculty member discusses patients and reviews the medical note presented to the faculty members on a daily basis. The nephrology faculty members confirm the history, physical findings, and assessment and plans after interviewing and examining patients. The nephrology faculty members discuss with the fellows any modifications of the history, physical findings, assessment and plans, which differ from the fellows’ initial evaluation. The nephrology fellow discusses with the house officers and other staff agreed upon recommendations by the nephrology fellow and the nephrology faculty member. Individual nephrology faculty members may feel the need to personally communicate with some physicians. The nephrology faculty members supervise procedures unless not on the premises at the time of the procedure or if vascular access placement has been found to be satisfactory after placement of 10 catheters. The nephrology faculty members supervise all renal biopsies.
(Revised 7/1/05)
