Department of Internal Medicine

Nephrology Fellowship Program

John Stokes, M.D., Professor and Division Director
Lawrence Karniski, M.D., Professor and 
Coordinator of Fellowship Training Program

INTRODUCTION

The Nephrology Division of the Department of Internal Medicine at the University of Iowa is dedicated to providing outstanding clinical, teaching, and research programs within the Midwest as well as nationally and internationally. The division prides itself in participating in a program that is vigorous, friendly, and open to those who wish to seek answers to important clinical and biological problems.

The program at the University of Iowa Hospitals and Clinics (UIHC) and Veterans Affairs Medical Center (VAMC) are highly integrated, with clinical responsibilities at both medical centers shared by all members of the division. The major clinical programs include:

• An inpatient renal/medicine unit at UIHC devoted to caring for patients with special kidney problems and patients with end stage renal disease as well as patients with general medical problems
• A dialysis unit that serves patients with acute renal problems as well as stable patients requiring dialysis. The dialysis unit at UIHC has one of the largest home dialysis populations in the country
• A transplantation service that provides expertise in transplantation medicine to patients who receive kidney transplant as well as those who receive heart, lung, pancrease, and liver transplants
• A consultation and teaching service designed to provide responsive and up-to-date information regarding appropriate diagnostic and therapeutic management of patients with problems related to the kidney including fluid, electrolyte, acid-base disturbances, and hypertension
• Outreach programs in consultation with physicians having specific needs for expertise in dialysis, transplantation, and clinical nephrology

Members of the Nephrology Division participate in the instruction of medical students who are at various levels of their training. The renal consultation services provide the majority of our clinical teaching. Teaching sessions include a renal pathology conference, nephrology journal club, nephrology clinical conference, transplantation conference, and seminars in renal physiology.

There are three major areas of investigation represented within the division:

• membrane transport and cell biology
• neural control of renal function
• clinical trials

In addition to these primary programs, members of the division participate heavily in interdisciplinary research programs within the University of Iowa Carver College of Medicine. Major research programs include an O'Brien Kidney Disease Center, the Hypertension Specialized Center of Research (SCOR) on the molecular genetics of hypertension, the Pulmonary Disease SCOR, the Cardiovascular Program project, and the Cystic Fibrosis Research Center. The activities of the division echo strongly the national recognition of exciting progress in molecular medicine and society's challenge to provide care equitably and at an affordable cost. We are pleased to be a major contributor to the development of future generations of practicing and academic nephrologists.

The Nephrology Division has an NIH training grant directed at helping fellows develop their research skills in kidney disease, hypertension, and cell biology. The division also participates in the Graduate Training Program in Clinical Investigation sponsored by an NIH K-30 award. Fellows in our program are expected to participate in research under the sponsorship of a faculty member.

University Nephrology Consult Service

The University Nephrology Consult Service forms the core of the fellow's clinical learning experience.  Fellows will ordinarily spend 5-8 months in this rotation over the course of the two-year program.  During this time the fellow assumes significant responsibility for running the Nephrology Consult Service.  Under the supervision of the nephrology attending, the fellow will oversee the daily management and diagnostic evaluation of all patients on whom the service consults.  These responsibilities include the decisions regarding initiation of dialysis in acute renal failure, choosing the appropriate mode of dialysis, and writing and/or supervising the dialysis orders.  The fellow will also be intimately involved in teaching medical students and residents on the nephrology consult team.  In addition, the fellow will function as a liaison between the consultation service at the University Hospitals and the outside physicians regarding admission for evaluation and treatment of renal problems.

While on the consult service the nephrology fellow will learn how to manage acid base and electrolyte disorders, acute and chronic renal failure, hypertension, and other renal related diseases.  He/she will become familiar with the role of hemoperfusion in the management of drug intoxication and the use of ultrafiltration techniques.  The fellow will also become adept at hemodialysis and peritoneal dialysis catheter placement and percutaneous renal biopsies.

Renal Transplant Rotation

The Renal Transplantation rotation is designed to expose the fellow to the principles and practice of transplanting kidneys.  Each Nephrology Fellow will be assigned to 3 - 4 months on this service, working with one of the Nephrology Staff with a special interest in transplantation. 

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.  He/She 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, the Transplant Conference, and the daily management of other transplant outpatients during "Call-in Rounds."

Dialysis Rotation

The dialysis rotation is designed to give the Nephrology fellow experience in the day-to-day management of patients with chronic renal failure dialyzed either at home (hemo- and peritoneal dialysis) or as outpatients in a hemodialysis unit.  The fellow takes an active role in teaching the students and housestaff the theory and practice of dialysis management.

Activities include daily rounds on all outpatients dialyzed in-center and discussion of these patients with the dialysis staff.  The fellow is expected to attend the weekly center patient review conference and the home dialysis patient review conference.  These conferences are designed to enable all members of the dialysis team to discuss each patient in depth.  All facets of patient care will be covered including social problems, dietary recommendations and alterations in the daily dialysis prescription according to the metabolic status of the patient.  The fellow will also participate in other dialysis modalities such as hemofiltration, hemodiafiltration, and pediatric dialysis, as they occur. 

The fellow will also round daily on patients undergoing home dialysis training and will participate directly in the patient training program.  In addition, the dialysis fellow will attend the weekly home dialysis clinic (hemo- and peritoneal) and will function as a direct link between these patients and the dialysis team when patients call regarding dialysis problems at home.  Ongoing aspects of the home program will be discussed with dialysis attending staff daily.

These activities are intended to give fellows an in-depth exposure to all modes of dialysis and enables them to formulate realistic strategies regarding patients with end-stage renal failure.

Veterans Administration Medical Center Nephrology Service

The Iowa City Veterans Affairs Medical Center is conveniently located adjacent to the University of Iowa Hospitals. The nephrology fellow is not assigned to a specific VA inpatient rotation; however, the fellow serves three basic services at the VA Medical Center. First, the fellow will periodically rotate through the VA outpatient renal clinic and take an active role in the management of various aspects of renal diseases and hypertension.  Second, the fellows and staff assigned to the University Dialysis service will serve as the consult team at the VA, seeing 3-4 consults per week.  Third, the renal fellow on call will be available during off hours to respond to emergent consults at the VA Medical Center.  This interaction with the VA is designed to provide maximum exposure to the unique aspects of nephrologic care in this patient population without the renal fellow spending time in activities not educational in nature.

Renal Pediatrics

This rotation, typically one month in the first year, is designed to give the fellow exposure to certain aspects of nephrology not typically encountered during the year.

During this rotation, the fellow will participate in inpatient rounds with a pediatric nephrologist three times per week.  The fellow will also attend two pediatric clinics, one involved in the outpatient care of the general pediatric nephrology patient and the other dealing with chronic renal failure in the pediatric population.  The fellow is expected to take an active role in the evaluation and acute management of pediatric renal consults and may participate in renal biopsies and access procedures for dialysis.

Renal Outpatient Rotations

During the course of the year, the individual 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 clinic actively involves the renal fellow in the long-term management of renal-related problems. In this clinic, individual patients will be followed by a specific fellow during the course of his or her fellowship training. Each patient will be staffed by an attending nephrologist; however, the fellow is responsible for making diagnostic and therapeutic decisions, contacting the patient with test results, and function 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 designed to expose the Nephrology Fellow to the medical work up and management of the patient with nephrolithiasis.  The clinic is staffed by both a urologist and a nephrologist, with a nutritionist available to provide consultation in arranging specialized diets for diagnostic and therapeutic purposes.

The Veterans Administration clinic exposes the fellow to the unique aspects of care in this patient population including renal-vascular hypertension, diabetes and geriatric renal disease together with the socio-economic issues relevant to these patients.

The Transplantation clinic provides exposure to the outpatient evaluation of the pre-transplant patient and potential donors and permits immediate- and long-term management of the immunosuppressive therapies and complications of the transplant patient.

 

Hemodialysis
	Procedures	20,824
	Home Patients (average)	22
	Center Patients (average)	120
Peritoneal Dialysis
	Procedures	3,480
	Home Patients (average)	9
Kidney Transplantation
	Kidneys Transplanted	105
Consultations		754 (inpatient)

For additional information, please contact:  lawrence-karniski@uiowa.edu

Link to Division Description