Inpatient training occurs solely at the Montefiore Hospital-Moses Division or the Montefiore Hospital-Einstein Division. Both hospitals provide all aspects of adult medicine, including active emergency rooms, special care units, active surgical and urology programs, transplant (Moses Division) and OB (Einstein Division).
The Moses Division has a 12 station acute hemodialysis unit located on NW-4. The Einstein Division has a 6 station acute hemodialysis unit. Acute hemodialysis is also provided at bedside in the critical care units and on general med-surg units with mobile hemodialysis machines equipped with portable RO units. Fellows are instructed on appropriate ordering and employment of hemodialysis. They are also educated on the order sets available to order this modality.
CVVHD/(SLED) and SCUF
CVVHD/(SLED) and SCUF are provided at both hospitals in the critical care units. This service is under the direct supervision of the nephrology team and can be ordered and directed only by a nephrologist. Order sets are employed to guide appropriate use of the CVVHD/SLED technology. Fellows are instructed on CVVHD/SLED and are given guidelines for employment of this modality.
Peritoneal dialysis is provided at both hospitals on designated nursing units. PD is always directly supervised by the renal team. Order sets are available for ordering peritoneal dialysis. The fellows are instructed on appropriate use of peritoneal dialysis and how to order this modality.
Outpatient maintenance dialysis programs exist at two Montefiore Dialysis Centers (Montefiore Dialysis Center III and Montefiore Dialysis Center IV). Each unit has approximately 175 hemodialyis patients and approximately 15 patients at each site are on home peritoneal dialysis and are followed at the sites for their dialysis care. During the second year of fellowship each fellow is assigned a cohort of patients to follow over the entire second year, including a group of home (PD) patients. Each fellow is mentored one-on-one with a faculty member for the year.
Kidney biopsies are performed at each Montefiore Hospital in the respective radiology suites, using ultrasound guidance by the renal fellow under the direct supervision of Nephrology Section Faculty. Each fellow will perform 10-20 biopsies in his or her first year.
Biopsies are processed for routine light microscopy, electron microscopy and special immunofluorescent microscopy in the Pathology Laboratories on site. Fellows examine each of the biopsies that they have participated in with her/his attending and the renal pathologist.
These renal biopsies also are reviewed at the monthly Renal Biopsy Conference, at which time the fellow presents a synopsis of the case and a discussion of the differential diagnosis, and a brief review of the literature pertinent to the current diagnosis and treatment of each case.
Fellows are assigned a two month rotation in Renal Transplant during their second year of fellowship. Transplant occurs at the Montefiore Hospital-Moses Division. Fellows round daily with the Renal Transplant team on the Transplant Unit.
During any one day, 5-10 patients are hospitalized on the transplant unit. These will include both new transplant recipients and prior recipients hospitalized for inter-current complications or rejection. The fellow participates integrally in their care. This fellow rounds daily with a Nephrology Section Faculty member, who is assigned to the transplant team. The fellow will review and participate in all allograft biopsies and allograft imaging studies.
Fellows also perform allograft biopsies under the supervision of the transplant surgeons and transplant nephrology faculty. At least 80 new renal transplants are performed yearly at Montefiore Hospital.
Fellows interact regularly with vascular surgery, interventional radiology, general surgery, and critical-care surgical teams. The fellows interact regularly and intensively with the cardiothoracic surgeons because of the frequency of consultation in the CICU.
The renal service provides all CVVH/SLED and SCUF and conventional dialytic care to CT surgical patients. In a similar vein, fellows interact on a primary basis with interventional radiologists, vascular and orthopedic surgeons when our dialysis patients are hospitalized on their services. The fellows gain insight and training in the recognition and proper form of intervention for common and uncommon access issues through these interactions.
The renal fellows round daily in the Surgical ICU when transplant or ESRD patients are there. The fellows order and supervise all CVVH/SLED, acute hemodialysis, and ongoing peritoneal dialysis in the Surgical ICU's.
Fellows gain a large experience with intensive-care nephrology by providing acute consultation for patients in the Medical ICU, Surgical ICU, Coronary ICU, Transplant Unit, and Cardiothoracic-ICU. CVVH/SLED is provided only by the nephrology service and is always under the direction of the nephrology service. Guidelines for the appropriate employment are reviewed with and provided to fellows and faculty who supervise this modality.
Aspects of ambulatory nephrology are learned through the fellow's experience in continuity clinic (x 24 months), transplant clinic and through the outpatient dialysis unit rotation during second year. Each fellow attends renal transplant clinic for 6 months during the first year; and each fellow attends transplant clinic for 2 months during the second year of fellowship. The second year fellows follow a cohort of out-patient hemodialysis patients weekly for a year.. Ambulatory topics are covered in weekly Renal Grand Rounds, the weekly Clinical Conference, and at weekly multidisciplinary patient care conferences.
Desktop computers at all of the Montefiore sites are equipped with Up-To-Date, an on-line based narrative textbook of nephrology that is updated quarterly by subscription; these computers are also supplied with Microsoft Office Software for fellows' use.
Pub-Med and Med-Line and access to the Albert Einstein College of Medicine Library is available to each fellow at all locations. This connection provides free, direct access to many journals on-line in full text versions as well as general medical textbooks and nephrology textbooks.
Each Montefiore hospital site has a library.
Each fellow is directed to participate in special interdisciplinary conferences on medical ethics, ethics of research, body fluid precautions, infectious disease concerns, and managed care issues offered by the Department of Internal Medicine and the School of Medicine [for all residents, and fellows].
Each fellow is given a number of resources and binder articles (covering up to date articles on ESRD, CKD and Transplant topics) at the start of fellowship and has a fund of money specifically dedicated for conference attendance.
Fellows are encouraged and given money to attend ASN and NKF educational meetings. We also send fellows to other educational conferences that are deemed appropriate for nephrology fellow education.