Fellowship Training Program in Pediatric Nephrology

Clinical Experience

The primary goal of the first year of the program is to enhance the trainees' knowledge of clinical pediatric nephrology and direct their interest towards a particular field of investigation. Thus, the first-year fellow assumes a major responsibility in the care of all infants and children hospitalized at the Kravis Children's Hospital with renal disease, renal disorders secondary to non-renal disease, fluid and electrolyte disturbances, and hypertension. When assigned to the inpatient service, the fellow performs all admissions and consultations, guides the pediatric house staff in the workup and management of such patients, and presents the patients for discussion at renal rounds, held daily with the attending on service. Many of the 150 inpatient consults we are asked to perform yearly are requested from the Pediatric (12 beds) and Neonatal (35 beds) Intensive Care Units.

The active pediatric cardiothoracic surgery and liver/small bowel transplant programs provide abundant clinical material for fellows to refine their skills at management of complex fluid, electrolyte, and acid-base disturbances. During this period the trainee learns to assess glomerular and tubular function, perform renal biopsies, and administer all forms of renal replacement therapy, including peritoneal and hemodialysis, and continuous arterio-venous and veno-venous hemofiltration.

Special attention is given to the interpretation of X-rays, ultrasonograms, nuclear scans, and other imaging techniques applied to the kidney and urinary tract.

All fellows participate in the Pediatric End-Stage Renal Disease Program. Fellows assigned to the dialysis unit supervise the scheduled dialysis treatments and provide medical care to their pediatric dialysis patients. The Division provides all forms of renal replacement therapy.

The Mount Sinai Health System has an outstanding history of success in transplantation, a service led by Jonathan Bromberg, M.D., Ph.D., and is one of the few sites in the tri-state area to perform laparascopic donor nephrectomies. Approximately fifteen pediatric renal transplants are performed yearly. The medical management of these children prior to surgery, in the operating room, and following the transplant surgery is the responsibility of our group.

In order to expose the trainees to the psychosocial and educational needs of patients with chronic renal disease and their families, weekly "team" conferences are held to discuss active dialysis and transplant patients. In addition to the faculty and trainees, these meetings are attended by the social worker, dietician, and transplant coordinator. Additional input may be requested from representatives of other social or educational agencies which provide services to children and their families.

The outpatient facility (5 E. 98th Street) is a major referral center for the Greater New York Area. More than 1,500 ambulatory patients are seen yearly, of whom approximately 250 are new patients. Clinics at this site are held thrice weekly (general pediatric nephrology and pediatric renal transplant). The program also provides outpatient care at a Queens, N.Y., affiliate, Elmhurst General Hospital. The latter site provides ample opportunity for the fellow to evaluate and manage common renal problems, such as hematuria, proteinuria, hypertension, acute glomerulonephritis, and recurrent urinary tract infections.

Trainees in the nephrology program collaborate closely with other pediatric subspecialties, including Pediatric Urology and Pediatric Rheumatology. In addition to monthly Renal-GU conferences, trainees are encouraged to attend weekly Pediatric Urology clinics at Mount Sinai. The Thursday morning Pediatric Nephrology clinic at Sinai, shared with Rheumatology, facilitates exchange between these two often overlapping disciplines. Our program also enjoys the strong participation of Pediatric Radiology, Nuclear Medicine, and Interventional Radiology for clinical services and didactic exercises. Fellows are encouraged to attend teaching conferences held by these affiliated disciplines.

In all inpatient and outpatient rotations, trainees are closely supervised by members of the sub-board certified nephrology faculty. The supervising attendings are responsible for certifying that trainees have successfully performed a minimum number of specific procedures (including hemodialysis, percutaneous renal biopsy, and supervision of hemo- and peritoneal dialysis) under direct supervision.

The division is active in several clinical study cooperatives including NAPRTCS and the New York/New Jersey Collaborative Studies Group. During the first year, the trainee is exposed to these and other clinical research projects that are ongoing in our division. Participation of the fellows in these projects provides an opportunity to learn about clinical study design and renal pathology. The second, third, and possibly fourth year of fellowship training are directed almost exclusively to research, although trainees continue to provide night and weekend coverage of the service and continue to provide care to those patients initially seen during the first year of training.

On-Call Schedule

Night and weekend coverage is provided by all the fellows, irrespective of the year of training. Fellows cover the service for one week at a time, including the weekend. Fellows on call are always backed up by members of the faculty, who round daily with the fellows on weekends.

Relationships to Other Programs

Trainees in our program participate in clinical activities related solely to Pediatric Nephrology. On the hospital wards, fellows generally act as consultants and, unlike the general pediatric residents, are not primarily responsible for the day-to-day care of patients. The nephrology trainees also perform special procedures, such as renal biopsy and catheter placement. Patients on the pediatric service are assigned by subspeciality. Should a patient require a nephrology consult, the trainees assigned to the consult service will be asked to evaluate the patient.