Embed Size (px)
Citation preview
0
Duke University Medical Center Department of Medicine Division of Nephrology
Fellowship Curriculum
2015-2016
1
TABLE OF CONTENTS Section Page Faculty, Fellows and Staff Listing 3 Administration 5 Dialysis Units 6 Nephrology Training Program Goals and Objectives 7 Clinical Services 13 When to Contact the Attending 15 Progression in Responsibility 16
Acute Service 16 Transplant Service 18 Maintenance Dialysis Service 19
Outpatient Rotation 20 VA Service 20 Handoffs 22 Evaluation of Fellows and the Program 23 Outpatient Nephrology Clinics Duke Renal Clinic 24 Transplant Clinic 24 VA Clinic/ Home Dialysis Clinic 24 Conferences Nephrology Grand Rounds 25 Renal Pathology Conference 25 Clinical Case Conference 25 Journal Club 26 (Appendix B on pg. 67) Research Conference 26 Core Curriculum Lecture Series 26 (Appendix C on pg. 68) Multi-Disciplinary Transplant Conference 27 Transplant Morbidity and Mortality Conf. 27 VA Interdisciplinary Team Meeting 27 Basic Science Lab Meeting 27 Assessment System ESRD Program Outpatient Dialysis Units 28 Policies and Procedures 30 Criteria for Self-Dialysis 30 Hemodialysis Orders 31 CVVHD Orders 35 PD Orders at Duke 36 Emergency Dialysis 38 Dialysis for Poisons 39 Peritoneal Dialysis at the VA 39 CRRT at the VA 41 Renal and Pancreas Transplantation 45 Living Donor Transplants 47
2
TABLE OF CONTENTS
Deceased Donor Transplants 48 Immunosuppression Protocols 50 Percutaneous Renal Biopsy 57 Meetings 59 Moonlighting 59 (Also see Appendix A, pg. 66) ACLS/BLS Certification 59 Textbooks 59 Leave Time (Vacation,Sick,Holidays and FML) 60 Research Programs 63
Section Page Appendix A (GME Duty Hour Policy) 65 Appendix B (Journal Club Schedule) 67 Appendix C (Nephrology at Noon) 68 Appendix D (Fellows Rotation Schedule) 69 Appendix E (Friday Conference Schedule) 72
3
DIRECTORY OF FACULTY, STAFF, AND FELLOWS
Effective July 1, 2015 FACULTY MEMBER PHONE FAX PAGER# BOX# Thomas M. Coffman, MD 684-9788 684-3011 2456 103015 Michael S. Berkoben, MD 660-6860 681-1143 4667 2747 David W. Butterly, MD 660-6865 681-1143 4419 2747 Steven D. Crowley, MD 684-9788 684-3011 0625 103015 Matthew J. Ellis, MD 613-6133 684-8716 6429 3512 Kimberley J. Evans, MD 660-6865 681-1143 7444 2747 Mary H. Foster, MD 684-9788 684-3011 2925 103015 Susan Gurley, MD 684-9788 684-3011 7412 103015 Gentzon Hall, MD 4726 31108 Rasheeda Hall, MD 8038 2747 Eugene Kovalik, MD 660-6860 681-1143 5289 2747 Ruediger Lehrich, MD 660-6865 681-1143 2147 2747 John P. Middleton, MD 660-6860 681-1143 7238 2747 David Ortiz Melo, MD 660-6860 681-1143 4072 2747 Uptal Patel, MD 668-8649 668-7058 1164 3646 Patrick Pun, MD 660-6865 681-1143 2991 2747 John Roberts, MD 2081 2747 Mary Rogers Sorey, NP-C 660-6860 681-1143 5143 2747 Scott L. Sanoff, MD, MPH 668-3424 684-8716 4352 3512 Stephen R. Smith, MD 660-6865 681-1143 5416 2747 Matthew A. Sparks, MD 684-9737 684-3011 9216 103015 Robert F. Spurney, MD 684-9788 684-3011 5636 103015 Laura P. Svetkey, MD 660-6626 660-8802 2602 3487 Crystal Tyson, MD 660-6626 660-8802 2493 3487
RESEARCH FACULTY Pao-Hwa Lin, PhD 660-6685 3487 3075 FELLOWS Email Pager Box # Phone Shalini Bumb, MD [email protected] 8755 2747 864-553-1742 Blake Cameron, MD [email protected] 9423 2747 571-238-647 John Duronville, MD [email protected] 8315 2747 561-670-9288 Stacy Johnson, MD [email protected] 0188 2747 919-451-3798 Melissa Makar, MD [email protected] 9317 2747 919-699-5854 Robert Olivo, MD [email protected] 8757 2747 845-216-8340 Supreet Sethi, MD [email protected] 8758 2747 214-753-0474 Harpreet Singh, MD [email protected] 8857 2747 248-821-3455 John Stanifer, MD [email protected] 5938 2747 423-526-7113 Carol Traynor, MD [email protected] 7123 2747 BUSINESS OFFICE Mo Querey 668-2366 681-1143 2747 (Business Manager) Jill Rimmer 698-5533 681-1143 2747 (Fellowship Coordinator) CLERICAL SUPPORT STAFF Tracie Bach 660-6860 681-1143 2747(Berkoben, Kovalik, Middleton, Ortiz Melo, Sorey)
4
Peggy Carver 660-6865 681-1143 2747 (Butterly, Evans, Lehrich, Pun, Smith) Angela Smith 660-6877 681-1143 2747 PHONE PAGER BOX HYPERTENSION CENTER Laura P. Svetkey, MD, Director 660-6626 2602 3075 BUSINESS MANAGER Mo Querey, Business Manager 668-2366 2747 Teresa Grabarek, Financial Analyst 668-2321 2747 Jill Rimmer, Fellowship Coordinator 698-5533 2747 VA PHYSICIAN’S ASSISTANTS Valerie Kubacki, PA-C (Transplant) 286-0411 (x7631) 225-5855 VA Sara Krome, PA-C (Nephrology /PD) 286-0411 (x5173) VA 0291 VA NURSE PRACTITIONERS Kanni Abraham, NP (CKD Clinic) 286-0411 (x4763) VA 0385 Carol Haines, NP (CKD and Silver Clinics) 286-0411 (x5593) VA 0273 Kim Gitter, NP (Outpatient Dialysis unit) 286-0411 (x7891) VA 0388 VA MAIN RENAL OFFICE Kim Guillory-McLean 286-6949
PEDIATRIC NEPHROLOGY John W. Foreman, MD, Chief 684-3101 6638 3959 Rasheed A. Gbadegesin, MD 684-4246 0956 3959 Delbert R. Wigfall, MD 684-3101 1908 3959 Uptal D. Patel, MD 668-8008 1164 3646 TRANSPLANT SERVICE Transplant Coordinators: Carolyn Boone, RN 684-2686 2020 Rosalyn Carter, RN 323-0898 2113 Leslie C. Hicks, RN 684-2754 4148 Vanessa Neal, RN 684-2747 2898 Joanne Prinzhorn, RN 668-3049 7102 Judy W. Smith, RN 668-1855 6928 Sherri Swan-Nesbit, RN 613-0145 6138
5
DIVISION OF NEPHROLOGY ADMINISTRATION Interim Division Chief Stephen Smith, MD Clinical Director Stephen Smith, MD Business Manager Mo Querey Director, Duke Hypertension Center Laura P. Svetkey, MD Director, Site Based Clinical Research John P. Middleton, MD
Chief, VAMC Nephrology Susan Gurley, MD, PhD Medical Director, Renal Transplant Program Matthew Ellis, MD Director, Fellowship Training Program Ruediger Lehrich, MD Associate Director, Fellowship Training Program Matthew A. Sparks, MD Medical Directors of Dialysis Centers: DUMC / Morreene Road Kimberley Evans, MD Davita Durham East David Butterly, MD Davita Durham West TBD Davita Durham South John Middleton, MD Davita Vance County Michael Berkoben, MD Davita PD Ruediger Lehrich, MD Davita Roxboro Eugene C. Kovalik, MD VAMC Patrick Pun, MD
6
DIALYSIS UNITS Duke North 7800 Duke North 681-7880 Morreene Road Loretta Ezell, R.N. 684-3012 VAMC Cindy McAbee, R.N. 286-6972 Davita Durham East Takeila Stringfield 682-9698
Davita Durham South
Sara Williams, R.N. 544-5536 Davita Durham West Lisa Frankel, MSW 384-0712 Davita Henderson James Williams (252) 492-4239 Davita Roxboro Bridget Goodwin, R.N. (336) 597-9390 Davita Louisburg Bridget Goodwin, R.N. (919) 496-0300 Warren Hills (Fresenius) Paula Brown, R.N. (252) 257-0420
7
Goals and Objectives for Nephrology Fellowship
Legend for Learning Activities
AS = acute service JC = Journal Club PD= peritoneal dialysis clinic
TP = transplant service GR = Friday Grand Rounds CC= continuity clinic
DS = dialysis service CCS= core curriculum series DC= hemodialysis clinic
VA = VA consult RC = clinical research
conference / lab meeting
TC = transplant clinic
OP = outpatient rotation OM = online modules MR = mentored research
SIM = simulation training SR = self reflection
Legend for Evaluation Methods
AE = attending evaluation PS = patient survey CP= conference presentation
evaluation
AO = direct attending
observation
SP= supervised procedures SA = Self-assessment
IS = in service/online exam PL= procedure logs CL = clinic evaluation
360 = 360o evaluation PTD= program director review OPT = online post test
HO = handoff evaluation
Patient Care Goal: Fellows will develop the skill required to provide care independently to outpatient and
hospitalized adults with: hypertensive disorders, acute or chronic kidney disease, disorders of fluid,
electrolyte, and acid base homeostasis, glomerular diseases, and those with kidney transplants. Learning Objective Achieve
by
Fellowship
Week
Learning
Activities
Evaluation
Method
1. Record complete accurate history, including
detailed history of present illness and
pertinent family history
4 AS TP DS VA
CC
AO AE
2. Perform complete physical exam, specifically
demonstrating ability to assess volume status
and signs of uremia.
4 AS TP DS VA
CC AO AE
3. Order and interpret appropriate diagnostic
tests based upon information gathered from
history, physical exam and clinical judgment.
4. Perform independently
4
16
AS TP DS VA
CC AE
5. Perform and interpret the results of
urinalysis.
16 AS TP DS VA
CCS AE OPT
6. Demonstrate proficiency in temporary
dialysis catheter placement
8 AS TP DS VA
OR SP PL AO AE SA
7. Write appropriate hemodialysis orders 2 AS TP DS VA
CCS DC AE
8. Write appropriate CRRT orders 8 AS TP DS VA
CCS PL AE
9. Write appropriate PD orders 26 AS TP DS VA
CCS PD PL AE
10. Demonstrate proficiency in percutaneous
renal biopsy
52 AS TP DS VA
SP PL AO AE
11. Adjust medication doses appropriately for
renal disease and in the geriatric population
26 AS TP DS VA
OP DC PD AE
8
Medical Knowledge
Goal: Fellows will demonstrate knowledge required to provide care independently to outpatient and
hospitalized adults with: hypertensive disorders, acute or chronic kidney disease, disorders of fluid,
electrolyte, and acid base homeostasis, glomerular diseases, and those with kidney transplants.
Learning Objective Achieve
by week
#
Learning
Activities
Evaluation
Method
1. Acute Kidney Injury
a. Differentiate acute from chronic
kidney disease
b. Differentiate pre-renal azotemia from
acute tubular necrosis
c. Cite the differential diagnosis for
acute kidney injury
d. Select laboratory and radiologic
studies to diagnose cause of AKI
e. Prescribe appropriate fluid
management in AKI
f. Recognize the indications for RRT
16
16
4
8
4
8
AS VA CCS
JC GR
AE IS 360
2. Glomerular, Vascular and Interstitial
Kidney Diseases
a. Generate the differential diagnosis
for proteinuric and nephritic
disorders
b. Prescribe appropriate therapy for
glomerular disease.
c. Identify hereditary kidney disease
syndromes
d. Investigate the cause of
nephrolithiasis
e. Work up and treat urinary tract
infection
26
52
104
104
16
AS VA CC
CCS JC GR
AE IS 360 CL
3. Immunobiology and Transplantation
Medicine
a. Evaluate candidacy for kidney and
combined kidney/pancreas
transplantation
b. Evaluate candidacy for kidney
donation
c. Recall the mechanism of acute
cellular and humoral rejection
d. Prescribe induction and maintenance
immunosuppressive therapy and
adjust doses appropriately for the
clinical context
e. Prescribe appropriate therapy for
acute cellular and humoral rejection
f. Understand prophylactic and
preemptive therapy strategies for
management of CMV disease and
BK polyomavirus nephropathy.
26
26
26
52
52
26
TP TC VA CC
CCS JC GR
TP TC VA CC
AE IS 360 CL
AE IS 360 CL
9
g. Recognize and manage urinary tract
obstruction after transplantation
h. Recall the fundamental
methodologies for HLA typing and
cross matching
i. Diagnose cause of kidney transplant
dysfunction
j. Diagnose cause of fever in the
transplant patient
16
16
16
26
CCS JC GR
4. Chronic Kidney Disease
a. Stage CKD using K/DOQI
guidelines
b. Provide appropriate diet
recommendations for patients with
CKD based on eGFR
c. Manage iron therapy and EPO dosing
appropriately in CKD patients
d. Make appropriate recommendations
for management of calcium,
phosphorus, and PTH in CKD
patients
e. Arrange for timely placement of
access for dialysis
f. Manage CKD in the setting of
pregnancy
4
8
16
26
26
52
AS VA CC JC
GR
AE IS 360 CL
5. Disorders of Homeostasis
a. Evaluate and manage acid base
disorders
b. Evaluate and manage disorders of
potassium
c. Evaluate and manage disorders of
water handling
26
52
26
AS VA TP
CCS JC GR
AE IS 360 CL
6. Dialysis
a. Cite the different options for renal
replacement therapy and their risks
and benefits
b. Understand the mechanisms and
factors which modulate waste
removal and ultrafiltration in
hemodialysis, CRRT, and peritoneal
dialysis.
c. Cite the potential complications of
hemodialysis, CRRT, and peritoneal
dialysis.
d. Recognize alterations in medication
pharmacology with dialytic therapies.
e. Assess adequacy of dialysis in
hemodialysis and peritoneal dialysis.
f. Recognize mechanical and infectious
complications of hemodialysis and
peritoneal dialysis access.
g. Cite the indications for and
procedures for the maintenance of
vascular access patency
h. Understand the fundamentals of
4
4
4
26
4
4
16
104
DS AS TP VA
CC CCS OP
DS AS TP VA
CC CCS OP
AE IS 360
AE IS 360
10
dialysis water treatment systems and
appropriate monitoring thereof.
i. Recognize potential differences in
biocompatibility with different
hemodialysis membranes.
104
7. Miscellaneous
a. Cite indications, potential
complications, and fundamental
process of therapeutic
plasmapheresis
52 OP SA
Practice Based Learning and Improvement
Goal: Fellow will develop knowledge, skills and attitude conducive to continuous self-assessment and
demonstrate ability to research, evaluate and improve performance
Learning Objective Achieve
by week
Learning
Activities
Evaluation
Method 1. Identify and acknowledge gaps in personal
knowledge base.
52 JC GR SA SA IS PTD
2. Develop plan to remedy those gaps in
medical knowledge
52 SA SA PTD
3. Actively seek and incorporate constructive
criticism into practice
52 AS TP DS VA
CC
AE SA PTD
4. Educate and provide effective feedback to
residents and / or students during clinical
rounds
12 AS TP VA OR 360
5. Search for quality data in the medical
literature, apply to patient care, and share
with others.
52 GC GR RC CP AE PTD
6. Learn which resources are most valuable for
answering patient care questions in
Nephrology.
104 GC GR RC SA PTD
7. Critically appraise the medical literature
8. Summarize the fundamentals of research
methodology
9. Develop researchable hypothesis (es)
10. Prepare research proposal (and submission to
the IRB if appropriate)
11. Apply for funding for proposed research.
12. Apply appropriate statistical tests to
adequately interpret data
104
78
60
60
60
104
MR JC RC AE PTD
11
Interpersonal and Communication Skills
Goal: Fellows will demonstrate interpersonal and communication skills that result in effective
information exchange with patients, their families, and other healthcare staff
Learning Objective Achieve
by week
Learning
Activities
Evaluation
Method 1. Effectively explain disease diagnosis and plan
of care to patients and their families keeping in
mind language, cultural, educational, ethnic,
and religious differences.
104 AS TP VA DS
CC TC CCS
OM
360 PS
2. Provide appropriate information and obtain
informed consent for procedures.
2 AS TP VA DS AE
3. Exchange information with nurses, therapists,
and patient resource managers so that all are
apprised of the situation with each patient.
4 AS TP VA DS 360
4. Provide timely, complete, and concise
information to peers in handoffs.
2 HO AS TP VA
DS
360
5. Arrange and document adequate outpatient
Nephrology follow up for each discharged
patient.
4 AS TP VA DS AE
6. Develop proficiency in leading conferences
with patients and families.
52 AS TP VA DS
CCS
AE 360 SA
7. Effectively communicate “bad news,” for
instance, at time of need for initiation of
dialysis and non-candidacy for kidney
transplant or donation.
52 AS TP VA DS
CC CCS
AE 360 SA
8. Initiate and participate in discussions of end of
life issues with the patient and family when
appropriate.
52 AS TP VA DS
CC CCS
AE 360 SA
9. Write and submit 1 abstract to a national
meeting (2 for 3 yr fellow)
10. Write and submit 1 manuscript for peer review
publication (2 for 3 yr fellow)
104 MR AO PTD
Professionalism
Goal: Fellow will demonstrate a commitment to carrying out professional responsibilities, adherence to ethical
principles, and sensitivity to diversity.
Learning Objective Achieve
by week
Learning
Activities
Evaluation
Method
1. Demonstrate ability to maintain respect,
compassion, empathy and patience with
patients, families and other members of
the health care team.
4 AS TP VA DS
CC TC PD DC
OM
AE 360
2. Document patient care activities in the
medical record appropriately and dictate
clinic notes and discharge summaries
within 24 hours.
4 AS TP VA DS
CC TC PD DC
AE 360 CL
12
3. Honestly admit errors and accept
responsibility.
4 AS TP VA DS
CC TC PD DC
AE SA PTD
4. Maintain a commitment to strong ethical
concepts of confidentiality, informed
consent, and justice.
4 AS TP VA DS
CC TC PD DC
AE SA PTD
5. Demonstrate commitment to excellence
by being on time and dressed in
appropriate attire.
4 AS TP VA DS
CC TC PD DC
AE PTD
6. Adhere to duty hour restrictions and
record duty hours with timeliness and
accuracy
4 AS TP VA DS
CC TC PD DC
PTD
7. Evaluate the ethical issues involved in the
conduct of research
78 MR JC OM AE TD
8. Provide honest and timely feedback
regarding the nephrology program
104 SR PTD
9. Participate in at least one performance
improvement activity
104 AS TP VA DS
DC CC
PTD
Systems Based Practice Goal: Fellow will understand how to practice quality health care and advocate for patients within the
context of the resources available to the individual patient
Learning Objective Achieve
by week
Learning
Activities
Evaluation
Method
1. Demonstrate ability to organize health
care team to optimally utilize
multidisciplinary resources for the patient
upon discharge from the hospital and also
in the clinic
26 AS TP VA DS
CC TC PD DC
AE 360 CL
2. Know when to request consultation with
other services and demonstrate how to
utilize their advice.
26
AS TP VA DS
CC TC PD DC
AE CL
3. Acknowledge medical errors and
demonstrate how to work within the
health care system to develop a plan to
prevent similar errors in the future.
52 AS TP VA DS
CC TC PD DC
AE CL
4. Select appropriate and cost effective
diagnostic testing that does not
compromise quality of care
52 AS TP VA DS
CC TC PD DC
AE CL
5. Cite the criteria for Medicare coverage
under the ESRD program and the benefits
of coverage.
104 DS DC AE CL
6. List sources of potential grant funding for
research project.
78 MR AE PTD
13
CLINICAL SERVICES
The Nephrology fellowship program at Duke University Medical Center provides
comprehensive training in clinical nephrology and in research in areas related to the kidney and diseases of the kidney. The nephrology training program at Duke University Medical Center is divided into two phases: clinical training and research training. This document will first describe the clinical training program, followed by a description of the research programs that are available to fellows in the division.
The inpatient clinical training program in Nephrology at Duke is divided among four services: (1) the Acute Nephrology Service at DUMC (2) the Transplant Service (3) the Inpatient Dialysis Service at DUMC, and (4) The VA Nephrology Service. The Acute Nephrology Service performs nephrology consultation on all of Duke Hospital, concentrating specifically on patients with acute renal failure in the intensive care units. Patients on maintenance HP and PD in the ICU are also followed by the Acute Service. The remainder of the consultative services at DUMC are handled by the Transplant and Inpatient Dialysis Services. The Transplant Service sees: (1) patients with kidney or kidney/pancreas transplants, and (2) patients awaiting imminent deceased donor renal transplantation, The Inpatient Dialysis Service consults on all the maintenance dialysis patients admitted to the hospital except those in the intensive care units. The VA Service handles all nephrology consultations at the Durham Veterans’ Affairs Medical Center. General descriptions with educational objectives and responsibilities on each service are provided below.
Each service has a fellow and/or resident who is responsible for coverage from 8 AM-5:30 PM on weekdays and 8 AM-Noon on Saturdays. After hours coverage is provided by the on-call fellow or resident who is responsible for all emergency consultations at both Duke and the VA. Any non-emergent consultations arising after hours may be deferred for subsequent attention by the appropriate service. If there is a question regarding the urgency of the consult, the patient should be evaluated by the fellow or resident on call. Any patient evaluated by the fellow or resident on call should be presented to the appropriate attending on call. A consultation in Maestro or the VA EMR should be completed for all new patients seen, to be cosigned by the appropriate service attending.
Our expectations regarding response times are as follows:
A) Emergency Room, Intensive Care Unit, and other acute consults should be
seen by the resident or fellow within one hour and presented to the attending within four hours.
B) All other consults should be seen by the fellow or resident on the day of the request and presented to the attending faculty member within 24 hours, regardless of the day of the week.
On weekends, one member of the faculty is assigned to cover all Duke services. The
VA consult attending covers the VA on weekends. On Monday through Thursday nights, there will be one faculty member on call for all Duke consults and the VA attending of the month will be on call for the VA.
In compliance with current RRC guidelines, all fellows and residents on the renal service are required to have at least one day free of clinical duties per week and they must not work more that a total number of 80 hours per week. To assure that we are achieving these goals, fellows are to record duty hours using Medhub.
14
In addition to the inpatient clinical rotations, each first year fellow will have three 1 week outpatient rotations during the year. During this time there are additional experiences in vascular radiology, vascular surgery, transplant surgery, peritoneal dialysis, and plasmapheresis as well as exposure to SLE clinic and Transplant Clinic. There will also be time reserved for preparation for conferences and planning for the second year.
GENERAL RESPONSIBILITIES OF ALL FELLOWS & RESIDENTS
1. Patient Consults: Fellows and Residents must play a primary role in providing
consultation and assistance in the management of patients, especially those needing dialysis or those who are recipients of renal transplants.
2. Daily Rounds on active patients. The Ward Staff expects and needs our
recommendations. Patients with active diagnostic and management problems need to be seen every day. On the weekends, be sure your cross-cover knows about the most pressing problems and will be familiar with them if called. It is extremely important for the attending and the other members of the consult team to actually visit the patients requiring decisions and to document that visit by completing a follow-up progress note.
3. Student Education: Fellows and Residents are expected to devote at least 2 hours
each week to the direct guidance and instruction of students on the service. 4. Clinical Participation in continuity clinic at Duke and VA as assigned. 5. Attendance at conferences. It is understood that patient care responsibilities
occasionally require a fellow to miss a conference. We expect that fellows will attend at least 85% of the Core Curriculum Series, Journal Club and Grand Rounds conferences. Attendance is recorded.
6. Participation in night and weekend on-call responsibilities. 7. Supervision of emergency dialysis treatments. The details of this supervision may vary
from on-site presence to immediate availability. The policy regarding emergency or on-call dialysis treatments is as follows:
a. Fellow/House Officer may leave the hospital if all patients on dialysis to be
dialyzed are hemodynamically stable. b. Fellow/House Officer may leave the hospital if the only patients left to be
dialyzed are routine (e.g. after permcath placement or graft de-clotting). c. Fellow/House Officer may not leave the hospital if they have placed a
temporary venous catheter for that treatment d. Fellow/House Officer must evaluate every dialysis patient who presents to the
ER at night for dialysis (may not phone in dialysis orders based on ER evaluation).
e. LPNs cannot take verbal orders. Therefore, if an LPN is on call, their orders must be written, or the Fellow/House Officer must find a physician who is present to write the order or an RN can take the verbal order.
f. Any patient who initiates hemodialysis or CVVHD must be reviewed with the Attending.
15
8. Preparation of individual Friday AM Clinical Conferences and Journal Clubs (see schedule).
9. Communicating with outside dialysis units. When a chronic dialysis patient is
discharged from the hospital, the fellow is responsible for contacting the patient’s home dialysis unit and primary nephrologist to communicate the details of the stay along with any new changes in the dialysis orders, such as changes in dry weight or antibiotic therapy. There is a standard fax form for this purpose and sending an email to the appropriate attendings for redundancy is encouraged.
10. Evaluation of attendings. Fellows are required to provide an evaluation of the clinical
attending at the end of each rotation. This is done through an on-line program. It should be completed within (5) days after the end of the rotation.
11. Evaluation of Program: Fellows are required to provide an evaluation of the training
program at the end of their first year of clinical training. This is an ACGME requirement.
When the Attending Faculty Member Should Be Contacted
These guidelines come with the understanding that the fellow should always use his/her judgment about this issue and certainly should call if there are any significant questions about management: The attending should be called after the fellow or resident has evaluated a patient in any of the following situations:
Patient is in the ICU or ED (unless consult is for maintenance HD and it is clear that HD is not required acutely)
Patient has Acute Kidney Injury (unless electrolytes and volume are satisfactory, and it is clear that HD will not be required acutely)
Electrolyte disturbance
Patient has ESRD and a dialysis related problem other than request for maintenance HD, e.g. PC associated bacteremia, volume overload.
Patient is on peritoneal dialysis
Patient requires medical clearance for transplantation.
Patient has had a change of status requiring renal replacement therapy other than planned during previous encounter.
These consultation issues require attending involvement acutely only if fellow or house officer desires attending input:
Consultation for maintenance HD.
Problems usually reserved for outpatient evaluation, e.g. longstanding proteinuria, HTN management after discharge.
The default for residents taking call is to contact the attending after any new consult and for any situation about which they have a question.
16
Progression in Responsibility
Over the course of clinical training, three levels of proficiency are identified. During the initial period which may comprise as little as one week but as long as necessary, the fellow is considered to be in the Provisional Phase. During this time, the fellow is directly observed by the attending during at least one entire history and exam (using the mini-CEX) in the inpatient setting and as many femoral catheter placements as necessary before the attending is satisfied, using standardized criteria, that the fellow is competent to perform these tasks independently (but always with attending backup available). The second level of proficiency, is marked by successful achievement of the objectives delineated in the Goals and Objectives earlier in this document. On the Acute Service a third level is achieved when the fellow is able to essentially run the service with attending backup. Typically this would mean supervising the more junior fellow (when there are two fellows on the service) and the resident on the service, providing assistance with procedures, and general teaching, backed up by the attending in purely supervisory / observation mode. Achievement of this third level does not by itself imply successful completion of the program, a determination made using the full assessment system. The second year of training is focused on research for fellows pursuing an academic career, the 4th Phase of training, although all fellows do a minimum of 2 weeks of clinical work the second year. Additional clinical time may be scheduled and will definitely be scheduled if needed for competency. Fellows planning to enter practice after 2 years of training typically spend additional time on the clinical services, and may choose a concentration in transplantation, interventional nephrology, or another area of mutual choosing such as administration and public policy.
DUKE HOSPITAL ACUTE SERVICE
The Duke Hospital Acute Service performs, on average, more than 20 consultations
per week. The service is staffed by a nephrology fellow, medicine resident, and any medical students assigned by the School of Medicine. The service evaluates all patients in Duke Hospital requiring nephrology consultation with the exceptions of patients on the 2nd floor, those patients on maintenance dialysis at the time of admission, and patients with kidney and/or pancreas transplants on any floor. Problems frequently encountered include acute renal failure in critically ill patients, the nephrotic syndrome, resistant hypertension, and complex fluid, electrolyte and acid-base disorders.
An attending physician conducts formal teaching rounds Mondays through Fridays. During teaching rounds, the consultations are presented, the differential diagnoses discussed, and the plans for evaluation and treatment discussed. The cases are therefore used as conduits for teaching. In addition, follow-up plans are discussed for all patients followed by the service.
17
Responsibilities of the Nephrology Fellow on the Acute Service include: 1. Provide consultation for all patients in Duke Hospital except for those who have
received kidney or kidney/pancreas transplants, those on maintenance dialysis at the time of admission who are not located in an ICU, and those located on the 2nd floor of Duke North or DMP 6 East (SICU). Prompt service, either alone or in conjunction with the resident or medical student, should be given to consultation requests from the intensive care units and from the Emergency Department. In general, patients in the intensive care units and in the Emergency Department should be evaluated within one hour and presented to the attending physician within four hours of the consultation request. Patients located elsewhere should be evaluated on the day of the consultation request and presented to the attending within 24 hours.
2. Provide timely hemodialysis therapy. Patients who require hemodialysis should be
identified as early in the day as possible (after consultation with the nephrology attending or fellow) and their names and locations given to the charge nurse. Hemodialysis orders should be written so that hemodialysis may commence by 8 AM. All hemodialysis orders at Duke must be written in Maestro. It is the responsibility of the fellow or resident to obtain written consent for hemodialysis on each patient admitted who needs dialysis. Patients must be consented to receive dialysis at the beginning of each hospitalization. This written consent must be on patient’s chart before dialysis can be initiated. Hemodialysis may not be initiated unless hemodialysis orders have been written. Fellows and medical residents may place temporary hemodialysis catheters in the femoral vein and internal jugular veins under the supervision of the attending. Once proficiency has been documented, the fellow may place lines independently.
3. Supervision of the resident. As time allows, the fellow should review consultations
performed by the resident before formal presentation to the attending physician. 4. Supervision and teaching of the medical students. The fellow should evaluate all
consultations performed by the medical students before formal presentation to the attending physician.
5. Provision of adequate follow-up for patients following discharge from hospital.
Patients may be seen in the Renal Private Diagnostic Clinic by an attending physician or by a fellow. In the event that a patient is followed by a nephrologist elsewhere, the fellow will be responsible for telephoning the nephrologist to describe the patient’s hospital course and any need for further intervention.
6. After hours and weekend “on call” duty for Duke Hospital and the VA as scheduled. 7. Examination of the urine sediment in all cases of acute renal failure. Examination of
the urine sediment may or may not be indicated in cases of chronic kidney disease. This skill should be taught to the resident and medical student.
8. Attendance at Journal Club on Thursday mornings 8:30 AM - 9:30 AM. 9. Attendance at Grand Rounds on Friday mornings 9:00 AM - 10:00 AM.
18
10. Attendance at Core Curriculum Lecture Series on Wednesdays from 12:15-1:15 PM. 11. Review of all renal biopsy specimens obtained by the fellow with the pathologist and
attending nephrologist. 12. Attendance at teaching rounds Mondays through Fridays. 13. Attendance at attending rounds on weekend days according to the schedule.
DUKE TRANSPLANT SERVICE
The Transplant Service is a fully consultative service that assists in the management of all kidney/pancreas transplant patients in the hospital and provides general nephrology coverage for the second floor of Duke North. Most transplanted patients are housed on 2100/2300 (Transplant Surgery) or 8100/8300 (General Medicine). Recently transplanted patients are cared for by the Surgery Transplant Service which is staffed by an attending, a Surgery P.A. and / or Intern, Resident, a Surgery Transplant Fellow, a Transplant Pharmacist, a Transplant Coordinator, and a Patient Resource Manager. We provide consultative service to assist with electrolyte & fluid management, dialysis if needed, blood pressure & blood sugar control, and other medical problems. Transplant patients further out with primary medical problems, including acute cellular & antibody mediated rejection, are admitted to the General Medicine Service. We provide consultative assistance in the management of these patients.
Continuity of care occurs in the setting of the outpatient transplant clinic on Wednesday AM in Clinic 1J, where the Nephrology Transplant Fellow will see recently transplanted patients, many of whom they will have seen in the hospital. Conferences include Journal Club, Fellows’ Lecture Series, Transplant Conference, Transplant Morbidity and Mortality Conference and Friday morning Grand Rounds.
Transplant Fellow Responsibilities: 1. Pre round on all consult patients in the intensive care units or any floor patients for whom decisions regarding renal replacement therapy need to be made. These rounds precede multidisciplinary transplant rounds with the surgeons (see below). 2. Participate in daily, AM multidisciplinary rounds with the surgeons (generally at 8:00 AM) 3. Provide temporary vascular access (vascath) for dialysis in coordination with the surgery or medicine team(s) as needed. 4. Make dialysis arrangements during hospital stay and at discharge; provide follow up to the outpatient dialysis units/providers regarding discharged patients.
5. Evaluate and follow all kidney/pancreas consults (any location in the hospital); patients must be presented to the attending within 24 hr.
6. Do all native & transplant kidney biopsies as indicated on in & outpatients with the attending on service.
19
7. Attend own continuity clinics and Wednesday AM Transplant Clinic in 1J. 8. Attend Journal Club on Thursday mornings 8:30 AM - 9:30 AM. 9. Attend Grand Rounds on Friday mornings 9:00 AM - 10:00 AM. 10. Attend Core Curriculum Lecture Series Lecture Series on Wednesdays from
12:15-1:15 PM. 11. Attend monthly Transplant Morbidity and Mortality Conference each second Wednesdays, 4 PM, Hanes Rm. 302.
DUKE MAINTENANCE DIALYSIS SERVICE
This service is designed to provide dialysis care for all inpatients in Duke North Hospital who are on outpatient dialysis at the time of admission, excluding patients in ICU’s and those on 2100 and 2300 (taken care of by the Transplant Service). Inpatient Maintenance Dialysis Nephrology Consult Service Fellow Responsibilities:
1. Make the initial evaluation alone or with the Team house officer and follow all consult
patients; and present the patient to the attending within 24 hr. 2. Round with the attending, where an emphasis will be directed toward difficult
management decisions and toward teaching opportunities. The goal is for the fellow to be able to assume much of the attending role as the year progresses.
3. Receive calls about incoming consults before 4:30 PM and communicate these
referrals to the team.
4. Communicate with the pertinent outpatient dialysis centers to determine patient information, including recent lab tests, dialysis orders, and prescribed medications. Make certain that dialysis arrangements are made during hospital stay.
5. Provide a brief description of dialysis orders to the patient’s outpatient clinic at the time
of discharge, particularly in regard to medications prescribed (or changed) and differences in recommended target weights.
6. Attend own continuity clinic(s).
7. Attendance at Journal Club on Thursday mornings 8:30 AM - 9:30 AM.
8. Attendance at Grand Rounds on Friday mornings 9:00 AM - 10:00 AM.
9. Attendance at Core Curriculum Lecture Series Lecture Series on Wednesdays from
12:15-1:15 PM. 10. Present a case at case conference at least every other month.
20
OUTPATIENT ROTATION
Each first year fellow will have three one week outpatient rotations. The schedules for these are put together by the program director and vary according to the specific needs of the fellow and available opportunities. These periods are an opportunity for the fellow to be exposed to important areas of interest that are overlapping with the scope of a practicing nephrologist as well as a chance to see patients in the outpatient setting without being paged for inpatient issues. There are also ample opportunities to read, prepare for conferences, and lay the groundwork for activities in the second year. At a minimum, each fellow will observe placement of a cuffed dialysis catheter, balloon angioplasty of a PTFE graft or fistula, fistula lysis, creation of an AVF, placement of a PTFE dialysis graft, donor nephrectomy, kidney transplant, and therapeutic pheresis. Additionally, during this period the fellow will attend the CKD clinic, Transplant Clinic, their own continuity clinic, SLE Clinic, Hypertension Center Clinic, and outpatient dialysis / PD rounds including monthly CQI meetings. Part of the time will be used to select a mentor and make preparations for research activities in the second year.
THE VA NEPHROLOGY SERVICE
The VA Nephrology Service provides consultative support to all of the clinical services in the medical center, including the intensive care units. Thus, within the rotation, fellows will be exposed to all facets of consultative nephrology including fluid and electrolyte problems, acute and chronic dialysis, nephrologic diagnosis including renal biopsy, and transplant medicine. The Durham VA has a free-standing dialysis unit which delivers inpatient and outpatient hemodialysis where the fellows gain significant experience in the management of outpatient hemodialysis under the supervision of the VA Dialysis Director and the attending assigned to that shift. There are also opportunities to observe and participate in the active home dialysis program and the Chronic Kidney Disease (CKD) clinic at the VA. The Durham VAMC is one of a few VA medical centers with an active peritoneal dialysis program.
The Durham VA no longer has an onsite transplant program, however VA continues to support both kidney and combined kidney/pancreas transplant at one of its national transplant centers. Fellows are actively involved in the initial patient evaluation for transplant listing, donor evaluations, as well as management of the transplant recipient following the acute transplant episode. In both an inpatient and outpatient setting
On the consulting service, rounds are made each day with the Consult Attending, fellow, resident, and rotating students. Every Thursday morning, a multi-disciplinary Dialysis Conference is held to discuss patient conditions and dispositions, and to coordinate follow-up plans for hospitalized patients and outpatients. This conference is attended by the fellow, the consult and clinic attendings, dialysis staff, and the renal social workers. While rotating at the VA, the fellow attends the VA Renal Clinic, which is held on Tuesday morning, as well as the other regular conferences that are sponsored by the Division.
21
Responsibilities of the Nephrology Fellow on the VA Nephrology Service include: 1. Provide nephrology consultation for all patients at the Durham VA Medical Center. 2. Supervision of the resident. As time allows, the fellow should review consultations
performed by the resident before formal presentation to the attending physician. 3. Supervision and teaching of the medical students. The fellow should evaluate all
consultations performed by the medical students before formal presentation to the attending physician.
4. Provide timely hemodialysis therapy for hospitalized patients. Patients who require
hemodialysis should be identified as early in the day as possible and scheduling should be coordinated with the charge nurse in the Dialysis Unit. Hemodialysis may not be initiated unless hemodialysis orders have been written. The fellow is responsible for the insertion of temporary hemodialysis catheters.
5. Provision of adequate follow-up for patients following discharge from hospital.
Patients may be seen in follow-up in the VA Nephrology Clinic which meets every Tuesday morning. Appointments can be scheduled through Ms. Marcia Laing (x6949). In the event that a patient is followed by a nephrologist elsewhere, the fellow will be responsible for telephoning and/or writing a letter to the referring nephrologist to describe the patient’s hospital course and any need for further intervention.
6. After hours and weekend “on call” duty for the VA and Duke Hospital as scheduled. 7. Examination of the urine sediment in all cases of acute renal failure. Examination of
the urine sediment may or may not be indicated in cases of chronic renal failure. This skill should be taught to the resident and medical student.
8. Attendance at the Interdisciplinary VA Dialysis Conference on Thursday Mornings from
10:00 AM - 10:30 AM. The fellow should be prepared to discuss current issues with all of the patients that are being followed by the inpatient consulting service. With assistance from the VA Dialysis Director or designee, the fellow will present the VA patients who are nearing the need for chronic dialysis so that issues pertaining to their disposition can be addressed.
9. Attendance at Core Curriculum Series, Journal Club, and Friday AM Grand Rounds. 10. Review of all renal biopsy specimens obtained by the fellow with the pathologist and
attending nephrologist. 11. Attendance at teaching rounds Mondays through Fridays; rounds on Saturday and
Sunday as indicated. 12. Attendance at VA Nephrology Clinic on Tuesday mornings from 8:30 AM - 12:00 noon,
in the VA Outpatient Clinic-Area 8B.
22
Handoffs
Concise, yet complete handoffs are crucial for patient safety and we have a standardized approach to handoffs. Each service maintains a Handoff Document which is updated at the end of each day and saved to the computer system at Duke and to the VA as appropriate as is accessible to every fellow and attending. At the end of the day it is the responsibility of the fellow on each service to contact the oncoming SPIN call person with specific information such as any potentially problematic issue related to patients who will need to be dialyzed that night but have not yet been, consults that have been done on patients in the ED awaiting admission, what to do if CVVHD clots on a particular ICU patient, special considerations regarding anticoagulation or bath that might come up on patients on CVVHD, etc. This communication can be in person, over the phone, or by email. If there are no specific issues, a text saying so is sufficient. In the morning the SPIN call person will send the SPIN email to the other fellows, residents, and attendings on the services detailing significant events overnight including any new admissions. First year fellows will evaluate the quality of the handoff they received after change of services twice during the first year via an assessment tool in Medhub.
23
Evaluation of Fellows and Program
Fellows are evaluated using tools based on the six competencies. Each fellow meets with the program director at least every 6 months to review progress, identify strengths and weaknesses, and to plan for the next period of training and ultimately for post training. Patient Care Global Rating by Attending each rotation Procedure Log Direct Observation (line placement, biopsy, CEX) Clinic Performance Checklist 360° eval (Patient / Nurse / PRM / Self) Handoff assessment (peer) Medical Knowledge Global Rating by Attending Clinic Performance Checklist / 360° eval (Patient / Nurse / PRM / Self) Practice-Based Learning and Improvement Global Rating by Attending Standardized evaluation of Journal Club and Friday Conference presentations Portfolio Interpersonal & Communication Skills Global Rating by Attending Clinic performance checklist Direct Observation (CEX) 360° eval (Patient / Nurse / PRM / Self) Portfolio Professionalism Global Rating by Attending 360° eval (Patient / Nurse / PRM / Self) Portfolio Systems-Based Practice Global Rating by Attending Clinic Performance Checklist Portfolio The program is evaluated annually by the fellows and faculty. These data are used along with survey data from former fellows, the fellow survey, and board scores to make program improvements. This process is carried out by the Education Committee which includes at least two fellows as well as key clinical faculty.
24
OUTPATIENT NEPHROLOGY CLINICS
Fellows have continuity clinic at the VA Nephrology Clinic and the Duke Private
Diagnostic Center (PDC), alternating weeks. In addition, first year fellows will attend the VA Clinic during their rotations on the VA Nephrology Service and they will attend the Transplant Clinic during their rotations on the Transplant Service. Second year fellows also round on a shift of hemodialysis patients for 4-6 months and attend a home dialysis clinic each month for 6 months.
Outpatient Nephrology Clinic at Duke Clinic
Each fellow will be paired with a specific attending and a specific day and clinic time
will be assigned. Patients seen by the fellow in this clinic will include but not be limited to patients seen in the hospital in consultation, new evaluations for hypertension, proteinuria, or renal insufficiency, and renal and renal/pancreas evaluations. Patients will be seen first by the fellow, and then presented to the attending, who will confirm the findings and participate in management as needed. Responsibility for producing the clinic note and following up on lab results and correspondence with referring physicians lies with the fellow on patients he/she has seen.
Transplant Clinic at Duke Clinic
The kidney transplant clinic occurs daily from 8:30 AM until about 1 PM in Clinic 2C,
Duke Clinic. Patients discharged from the hospital following transplantation are followed in this clinic. In addition fellows will have the opportunity to evaluate patients for transplantation and participate in reevaluation of patients already listed. Fellows on the inpatient Transplant Service will attend this clinic on Wednesday mornings. Second and Third year fellows will attend 6-8 clinics per year on days of their choosing.
Nephrology Clinic at the Durham VAMC
This VA Nephrology Clinic serves as the major nephrology outpatient clinic at the Durham VA Medical Center. The primary diagnoses of the patients seen in this clinic consists of a heterogeneous mixture of severe hypertension, primary glomerular disease, and chronic renal insufficiency. In addition, pre-operative and living related donor evaluations are performed, along with the long-term outpatient follow-up of kidney and kidney-pancreas transplants. The clinic begins at 8:30 am on 8B. All fellows are expected to see a new consult prior to the start of their continuity clinic at 9:30. The continuity clinic consists of 5 thirty minute slots. Fellows are required to staff all new consults and returning patients with one of the clinic attendings. Fellows who plan on taking vacation which will impact on their continuity clinic must give at least a 30 day advance notice for their clinic to be rescheduled. This notice should be provided by e-mail to [email protected].
25
DIVISION OF NEPHROLOGY EDUCATIONAL CONFERENCES
The Division of Nephrology sponsors a number of educational conferences which residents are expected to attend. These provide a formal didactic supplement to their practical clinical experiences.
Nephrology Grand Rounds
Nephrology Grand Rounds is the primary teaching conference of the Division of
Nephrology and is held each Friday from 9:00 to 10:00 AM in room 1308 Duke North. Attendance is expected by all faculty, fellows, residents and students on service. Both clinical and basic science topics pertinent to nephrology are presented at this conference. The fellows will generally present one conference yearly. The topic and direction of discussion will be guided by a faculty-mentor. Speakers from outside the division and the university will also be incorporated into the conference schedule. Traditionally, the main purpose of this conference is to critically examine the data upon which our clinical practice decisions are based. Conference content should represent an organized, focused review of the clinical and basic science information pertinent to a chosen topic. The fellows’ presentations should be gauged to last approximately one hour allowing the remaining fifteen minutes for questions and answers. Pathology Conference and Clinical Case Conference occur in this time slot as described below approximately every 4-8 weeks. Fellow presentations will be evaluated using a checklist that will be reviewed with each fellow at the biannual meetings with the program director.
Renal Pathology Conference
Pathology Conference is held once every 6-8 weeks at 9:00 AM in lieu of Nephrology Grand Rounds. This conference is coordinated and moderated by the Renal/Immunopathology Service of the Department of Pathology. Its purpose is to provide a more formal didactic conference to supplement the fellows’ exposure in interpretation of renal pathology and the use of renal biopsy to guide clinical decision-making. Interesting cases are chosen for presentation from the clinical service's biopsy specimens of the previous month. A short clinical presentation should be prepared by the fellow or faculty member most familiar with the case. Salient features of the biopsy are reviewed by the pathologist and the clinical course and options for treatment are reviewed by the treating physician. The purpose of the Pathology conference is to provide additional experience for the fellow in viewing and interpreting renal pathology and to provide some rationale for the treatment course based on the pathologic specimen.
Clinical Case Conference
Clinical Case Conference is held once monthly as part of Nephrology Grand Rounds. Cases are chosen for presentation from the Transplant, Maintenance Dialysis, Acute, and VA Nephrology services. Cases are presented by the fellow or resident on the clinical service with the guidance of the attending who is designated for the conference as the Moderator (Dr. Lehrich). The Moderating attending has the responsibility of guiding case selection and drawing out discussion during the conference to maximize teaching benefit. The presenting fellow leads a discussion of pathophysiology and treatment options for the case presented. Pertinent literature should be reviewed and discussed. Two to three cases are reviewed each conference. The purpose of this conference is to provide the faculty and fellows up to date reviews of pathophysiology and treatment of renal diseases, fluid and electrolyte disturbances, and acid-base disorders. The presentation and discussion of each case
26
lasts for approximately 15-20 minutes, allowing ample time for discussion. The conference is designed to allow detailed discussion of a particular or unique aspect of the case and is not intended to be a “Textbook” review of the disease process. For example if a patient with membranous glomerulonephritis with pulmonary emboli is presented, the discussant may focus on hypercoagulability in membranous GN rather than reviewing the general topic of membranous GN. This conference will also allow a discussion among the faculty and fellows of the variety of approaches and treatment options that might be applicable to a particular case. Faculty and Fellows are encouraged to bring cases from clinic for discussion as well.
Journal Club
Journal Club is held each week on Thursdays at 8:30 to 9:30 AM in the Dept. of Medicine Conference Room 1103 near the Duke Hospital food court. Faculty members along with fellows are assigned on a rotating basis to present clinical or basic science literature with relevance to cardiovascular disease, nephrology and transplantation. To ensure that these areas are covered, two presenters are scheduled each week and assigned to review either Basic Science (Nature, Science, Cell, JCI, AJP, PNAS, or the Journal of Immunology) or Clinical Science journals (NEJM, Kidney International, Transplantation, JASN, AJKD, Hypertension, and the Lancet). The assignments allow coverage of pertinent data in outstanding periodicals relevant to nephrology to keep the faculty member and fellow abreast of new developments in the field of Nephrology. If you are scheduled to be a presenter, please bring 25 copies of your paper to distribute to the group. As part of the curriculum in systems based practice, medical knowledge, and practice based learning, presentations by fellows will be assessed using a checklist in order to help provide feedback for the fellows at their biannual meetings with the program director. Criticism of the paper should not be construed as criticism of the presenter.
Research in Progress
This conference is held in lieu of Grand Rounds on a schedule designed to expose new fellows early in the academic year to research going on in the division. The conference is led by the faculty member or fellow presenting their basic science or clinical research in progress. Its purpose is to provide a forum for the presenting faculty member or fellow to present and receive feedback on ongoing clinical or basic science research. It allows first-year fellows an opportunity to be exposed to research opportunities in the division so that they can make informed decisions regarding the research portion of the fellowship program.
Core Curriculum Lecture Series for Fellows This is a didactic conference which is held on Wednesdays at 12:15, lasting approximately one hour. This conference series is organized by Dr. Michael Berkoben. Attendance by all fellows in the first year is expected in the absence of emergent clinical responsibilities. Upper level fellows are expected to attend after the first part of the year which is taken up with introductory lectures to get the new fellows up and running. Each session is led by a faculty member from Nephrology or a related discipline, who has a particular expertise or interest in the topic area. This lecture series is designed to provide informal didactic sessions on a broad range of topics in nephrology as a supplement to the practical learning experience fellows gain through their clinical rotations. Areas covered are meant to augment what can be learned on the wards and topics will include issues relevant for board exams, to clinical practice, and to nephrology research. Topics covered include: fluids and electrolytes, calcium and phosphorous metabolism, acid-base physiology, hypertension, glomerular disease, chronic dialysis, aspects of transplantation, molecular
27
biology, and genetics. The lectures are held in Room 8262 or 1700B Duke North or occasionally in 00529 South (Nephrology Conference Room) from 12:15-1:15. The recommended text for the physiology lectures is: Rose, B.D. Clinical Physiology of Acid-Base and Electrolyte Disorders. Edition 5. McGraw-Hill, New York, 2001.
Multi-Disciplinary Transplantation “Listing” Conference
A “working” conference held weekly at 2 PM on Thursday in Hanes Rm. 302 reviews
all patients seen within the previous week who are being considered for kidney and/or pancreas transplantation. In addition, policy issues are discussed. All faculty, fellows, residents and students who have had contact with these patients are encouraged to attend. Staff from the typing lab, the transplant coordinators, transplant social worker, surgical senior staff, and house staff attend this conference as well.
Transplant Morbidity and Mortality Conference
At this monthly conference outcomes for patients in the kidney transplant program are reviewed with special attention to adverse outcomes. The conference is attended by all members of the transplant team and is held on the third Wednesday of each month in Hanes Rm. 302.
Interdisciplinary VA Dialysis Conference
This is another “working” conference held weekly on Thursdays in the VA Dialysis Unit from 10:00 AM - 10:30 AM. Current issues pertaining to patients that are being followed by the inpatient consulting service are discussed. In addition, clinic patients who were seen during the preceding week who are nearing the need for chronic dialysis may be presented so that issues pertaining to their disposition can be addressed. Issues related to impending home dialysis patients are also discussed. VA faculty, fellow, residents and students are encouraged to attend. Staff from the dialysis unit, social work service, and dietary service will also be in attendance.
Basic Science Lab Meeting
The Duke Basic Science Multidisciplinary Lab Meetings meet every Monday from 9:00 AM - 10:00 PM in the 3rd floor conference room in MSRBII. This meeting is attended by faculty and fellows in the division of nephrology as well as other researchers from around Duke, UNC and NCCU campuses. The purpose of these meetings is to provide a forum for nephrology faculty, fellows and others engaged in nephrology related basic science research. These conferences typically showcase works-in-progress and allow for constructive suggestions regarding study design, statistical methods, data analysis and interpretation to be given in a supportive and stimulating atmosphere.
28
OUTPATIENT HEMODIALYSIS UNITS
The Division of Nephrology participates in the operation of 8 outpatient hemodialysis units and cares for more than 650 chronic dialysis patients. Every patient is the under the direct care of an Attending in Nephrology. Fellows participate in care of these patients when they are admitted to Duke Hospital or when they are evaluated in the Duke Emergency Department. In addition, each fellow is required to round on a shift of hemodialysis patients in one of the clinics for four to six continuous months in the second year of the Fellowship, under the direction of the rounding Attending. Typically the fellow will see the patients first and then walk around the unit with the attending a second time. During this period of time the fellow will also attend six monthly home dialysis clinics. The fellow will participate in all CQI activities in the unit for these 6 months. The individual units are described briefly below.
Morreene Road Dialysis Unit
This hospital-owned outpatient dialysis facility is currently located about one mile from the hospital on Morreene Road. This unit is administrated by the Duke Nephrology Division and run in conjunction with the inpatient dialysis staff on the 7th floor in Duke North. A home training facility for Duke (non-VA) system is operated through the Morreene Road Unit. The clinic has 16 hemodialysis stations and four teaching and assessment rooms for the home hemodialysis and peritoneal dialysis programs. Members of the faculty provide care for these patients.
Davita Duke Dialysis Units
The Division of Nephrology provides medical supervision of dialysis therapy provided through six privately operated units in Durham and surrounding counties. These units are not part of Duke University; five are owned by the Davita and co-managed by the Duke Division of Nephrology. One unit is located in Henderson, NC, about 40 miles north of Durham, one is located on Hood St in downtown Durham, a third unit is located in Durham at Western Park Place off of Hillsborough Road, a fourth in southwest Durham off Highway 54, the fifth in Roxboro, NC, about 30 miles north of Durham in Person County, and sixth in Louisburg, NC about 50 miles northeast of Durham. A seventh outpatient facility is owned by Fresenius Medical Care and is located in Warrenton, NC, approximately 60 miles north of Durham. Members of the faculty round on these patients according to our contractual obligations. In addition, senior fellows also rotate through these units to gain experience in management of chronic dialysis patients in the outpatient setting. Fellows may receive calls from these units regarding problems with patients. These should be discussed with the Medical Director of the patient’s unit or, if they are unavailable, the attending nephrologist on-call. The Durham West, Henderson, and Roxboro units provide peritoneal dialysis as well as HD. The Durham West unit provides home hemodialysis and nocturnal hemodialysis.
29
VA Dialysis Unit
The VA unit, located within the Durham VA Medical Center, provides acute, chronic
and transient dialysis to veterans living within the VISN 6 catchment area. Based on the nature of the groups of patients served by this unit, the weekly census is somewhat variable. On average the population consists of approximately 50 chronic dialysis patients along with the inpatients. In addition, the unit oversees the care of home dialysis patients and over 350 patients who receive their dialysis in community facilities under the financial sponsorship of VA.
The Durham VAMC has an active Home Dialysis Program providing patients with the
option for peritoneal dialysis services. The home dialysis patients are selected from the population of CKD patients followed in the VA Renal Clinics based on criteria such as motivation to participate in their care and limited co-morbid conditions which would complicate medical management in the home environment. The Home Dialysis Program is staffed by a PA, nurse coordinator and dialysis technician, under the direction of the Dialysis Director. Patients are evaluated in the Home Dialysis Clinic, which meets on 3B every Wednesday morning. Generally, patients are clinically assessed every 2-3 months and have laboratory assessments monthly. PD patients are trained in both CAPD and CCPD techniques. Dialysis adequacies and related outcomes are monitored utilizing standard protocols. Anemia, renal bone disease, hypertension and nutrition are aggressively managed, and are based on standards comparable to those developed for the in-center dialysis programs. Upper level renal Fellows will participate in the VA Home Dialysis Clinic to broaden their exposure in caring for ambulatory peritoneal dialysis patients.
30
DUKE UNIVERSITY MEDICAL CENTER PROGRAM, ADMISSION AND TREATMENT SELECTION POLICIES AND PROCEDURES FOR PATIENT WITH END-STAGE RENAL
DISEASE
Duke University Medical Center (DUMC) provides all forms of care to patients with end-stage renal disease (ESRD). The programs which are approved and available are: (1) renal transplantation from living donors (2) deceased donor renal or combined kidney-pancreas transplantation (3) in-center maintenance hemodialysis (4) training and support for self (usually home-based) intermittent cycler-controlled peritoneal dialysis, and (5) continuous ambulatory peritoneal dialysis (CAPD). DUMC is a teaching institution whose nephrology faculty and surgical renal transplantation faculty participate in patient care and in decision making. The dialysis and transplantation programs are closely coordinated and supported by (1) a nursing staff responsible for home training, coordination of efforts to identify and evaluate potential donors and, responsible for follow-up evaluation of patients who have received a renal graft or are being supported by maintenance dialysis (2) a social worker (3) a renal dietitian and (4) tissue typing personnel.
Treatment Objectives
It is our judgment that the objective of replacement therapy for ESRD is the extension of useful life to individuals whose principal cause of morbidity is uremia. Therefore treatment should be offered to those who are likely to assume an independent existence, free of excessive pain and suffering, once a technically successful regimen of dialysis and/or renal engraftment is provided. It is recognized that individuals with certain systemic diseases may be expected to develop unusual morbidity which renders independent existence difficult.
Criteria for Self-Dialysis
Patients who meet the following criteria are encouraged to perform self-dialysis: A. They must be able to undergo dialysis treatments without more than routine care and
observation. B. They must be judged by the physician, social worker and nurse to be rational,
emotionally stable and capable of learning self-dialysis. C. They must be willing to attempt self-dialysis. D. An adequate place (usually home) must be available for carrying out dialysis
treatments. E. If a partner is needed, he or she must be willing to undertake the responsibility and
have undergone and satisfactorily completed a period of training along with the patient.
F. If a partner is not needed, the patient must be willing to undertake the responsibility and have undergone and satisfactorily completed a period of training.
Review Process
A. The Multidisciplinary team at every dialysis unit consists of the Medical Director, the
treating Nephrologist, the unit Dietitian, the Charge Nurse, and the Medical Social Worker. This team meets monthly at the Duke-affiliated dialysis units to review parameters related to the patient’s medical care and his/her candidacy for renal transplantation. Every patient is invited to attend. Regardless, the conclusions of this meeting will be discussed with every patient if they choose not to attend.
B. A weekly joint medical and surgical transplantation meeting will be held. The
31
standing members of this committee are the nephrologists, renal transplantation surgeons, tissue typing laboratory representatives, nephrology social worker, nurse transplant coordinator, nurse clinicians, and cadaveric graft team. A weekly review will be made of all patients being actively considered for family renal transplantation and cadaveric transplantation. In addition, the names of all patients who meet the criteria for renal transplantation but are not awaiting transplant will be available and individual case discussion may be carried out at the request of any member of this group.
Preparing New Patients for Dialysis
Patients with renal failure, whether acute or new chronic, will need either vascular
access or a peritoneal dialysis catheter. Selection of the right tactic depends on the patient's long-term plans, the condition of vessels, the possibilities of peritoneal dialysis, and the desires of the patient and of the family. For early hemodialysis, we usually use a non-cuffed catheter for short-term (<2 weeks) or a permcath for intermediate term (< 3 months). More permanent solutions including fistula and graft should be discussed with the appropriate surgeons keeping in mind the requirements for immediate dialysis. In accord with the NKF K/DOQI Guidelines (http://www.kidney.org/professionals/doqi/kdoqi/p4_class_g2.htm), patients will be referred for modality access (consideration for placement of fistula, graft, or Tenckhoff catheter) when they attain CKD Stage 4 (estimated GFR 15-29ml/min/1.73m2).
Hemodialysis Orders
Hemodialysis is scheduled only by the nephrology teams and not by any other service.
Patients needing hemodialysis must be seen in consultation by the nephrology service if not on one of our inpatient services. Hemodialysis orders may be written by any house officer under the supervision of a nephrology fellow or attending, but will not be carried out without the review and co-signature of the fellow or attending on the appropriate renal service. Before initiating dialysis and with each new hospital admission, written consent must be obtained from the patient using standard consent forms that are available in the dialysis unit.
In general, the goals of hemodialysis are to control uremia, restore acid-base balance, reverse hyperkalemia, and normalize extracellular volume. Target weight must be assessed and recorded by the physician. Target weight is only an estimate and, as such, may need periodic reassessment as the patient gains or loses weight or as his response to hemodialysis becomes known. Often when the patient falls below an ideal extracellular volume, he will have the sudden onset of nausea, vomiting, leg cramps, abdominal cramps, back pain, seizures or other phenomena related to reduced cardiac output. In general we administer saline for these symptoms and usually see rapid improvement. Dialysis orders should provide instructions for this eventuality.
In hospitalized patients with known end-stage renal disease, the dialysis team must
communicate with the patient’s usual dialysis clinic and prescribe a dialysis treatment that is know to deliver adequate clearance of urea (either urea reduction ratio URR>68% or Kt/V >1.2). However, the Fellow should recognize that hospitalized patients are often quite ill and commonly have increased protein catabolism. Therefore, the dialysis prescription in the stable outpatient setting may provide inadequate clearance in many instances. It is essential that at the minimum, an inpatient dialysis prescription meets or exceeds the parameters of an adequate outpatient prescription. Details for measuring Kt/V and for empiric hemodialysis prescription are described below.
In patients who are initiating hemodialysis for chronic renal failure (or CKD stage 5),
32
the initial dialysis prescription should be written to avoid the risk of dialysis disequilibrium. This is a syndrome that runs the spectrum of muscle cramps, nausea, and headaches (least severe) to seizures and coma (most severe). Empirically, disequilibrium can be avoided if the initial treatments are prescribed to limit the rate of urea removal. One guideline that may be employed is to prescribe a K/V < 0.003 min -1 .(Handbook of Dialysis; JT Daugirdas, PG Blake, TS Ing, editors, Lipincott and Williams, New York, NY, 2001). The Fellow should discuss initial dialysis prescriptions in initiating patients with the Attending Physician on the service.
In general, pre-dialysis chemistries and hematocrit are the most important laboratory values. There is little point to ordering post-dialysis hematocrit and routine chemistries unless at least an hour has elapsed since the blood simply reflects the dialysate concentration of the substance being measured.
Minimal anticoagulation must be used in patients with known bleeding sites, patients who are immediately post-op and patients with pericarditis. These patients must have either "mini-heparinization" or no heparin. No-heparin dialysis requires one-on-one nursing and should be reserved for active bleeding situations. Heparin options: 1. No Heparin
Dialyzer is pre-treated with heparin and flushed periodically with saline to de-clot. No-heparin dialysis requires high blood flow and increased nursing attention. This protocol should be reserved for patients who are at a high risk of serious hemorrhage with heparin dosing. The drawbacks of no-heparin dialysis include that it occupies more dialysis nurse time (and pulls personnel attention from other patients on dialysis), it increases risk of dialyzer thrombosis and blood loss, and it requires frequent saline “flushes” and thus limits the volume of net ultrafiltration. 2. Mini-Heparin
Typically a loading dose of heparin (1000 u/cc) 1 cc IV push is given into the arterial line. Thereafter, an infusion of approximately 1000-2000 U total dose is provided through the remainder of the hemodialysis treatment. Use the heparin infusion pump into the arterial line. The dose may not have to be modified depending on the patient. The physician should be notified if it is necessary to modify dosage. 3. Systemic Heparinization
A loading dose of 2000U of heparin is provided. Characteristically, 3000U of additional heparin is given by continuous infusion throughout the treatment via the arterial line. Doses may have to be modified depending on patient conditions and progress of dialysis treatment. Typical dialysis orders:
33
Access: (Permcath, vascath, PTFE graft, AV fistula) Pre-dialysis lab tests: Dialyzer type Heparin: (Standard, mini, tight, or none) Bath: (0, 2, or 3 K, the default is 2; normal or low Ca; Na with or without modeling) Duration: (typically 2.5-4.5hours)
Blood Flow rate: (typically 300-500 ml/min: A SINGLE VALUE MUST BE ENTERED RATHER THAN A RANGE) Dialysate Flow rate: (typically 500-1000ml/min: A SINGLE VALUE MUST BE ENTERED RATHER THAN A RANGE)
Target Weight: (or L volume to be removed) Also give parameters for acceptable blood pressure. All hemodialysis orders at Duke must be written on the standardized dialysis order sheets, available at the Duke North dialysis unit. It is the responsibility of the Fellow and/or House Officer to have signed this order sheet and to have obtained consent for dialysis before the patient receives his treatment. Empiric prescription of hemodialysis: [A more complete discussion of this topic is available in Up-to-Date (http://www.utdol.com) and in the Handbook of Dialysis (JT Daugirdas, PG Blake, TS Ing, editors, Lipincott and Williams, New York, NY, 2001)] In order to prescribe an adequate hemodialysis treatment, a stable patient should have at least thrice weekly hemodialysis sessions that provide a Kt/V of at least 1.2. With regard to Kt/V, it is important to keep in mind that:
It was first advanced as a method of measuring hemodialysis in a post-hoc analysis if the National Cooperative Dialysis Study (Gotch FA, Sargent JA. A mechanistic analysis of the National Cooperative Dialysis Study (NCDS). Kidney Int. 28:526-34, 1985).
It was initially developed based on experience in thrice-weekly hemodialysis sessions
In contrast to the simpler determination of urea reduction ratio, calculation of Kt/V accounts for urea removal with volume ultrafiltration
It assumes that “dose” of hemodialysis can be estimated from urea kinetics
It is a “unitless” measure; K corresponds to urea clearance (ml/min), t corresponds to time on dialysis (min), and V is volume of distribution of urea (ml).
It has not been verified as a measure of “adequacy” in hospitalized patients or in acute renal failure.
Determining estimate for K: This is estimated from in vitro clearances for particular dialyzers. In the Duke system we currently have the F5, F200 and Polyflux 17L. Urea clearance increases with higher blood flows and dialysate flows. The table and graph below demonstrate these relationships for some of the F5 and F200 dialyzers.
34
Urea Clearances for Duke Dialyzers
100
150
200
250
300
350
1 2 3 4
Blood Flow
Ure
a C
lear
ance
(ml/
min
)
F5
F70NR
F200NR
Alwall GFS Plus 20
6L
8L
200 300 400 500
In practical terms, blood flow is limited by type of access. In catheters, it is often not possible (or useful) to increase blood flow greater than 350ml/min. With well-developed, low-resistance AV fistulae, a blood flow of up to 500ml/min is feasible. When initiating hemodialysis on a patient at risk for dialysis disequilibrium, namely a patient with long-standing renal failure, an empiric prescription should be written that will include a rate of urea removal < 0.003 min -1, for the first treatment. This should be obtained from the figure above and the patient’s estimated volume of distribution of urea (V). Determining Estimate of V: The most common way to estimate volume of urea distribution (total body water) is the Watson formula (Am J Clin Nutr 33: 27-39, 1980). Note that this estimate requires weight, gender, age, and height of the patient:
Males: V (in mL) = 2447-(95.16 X age in years) + (107.4 X ht in cm) + (336.2 X wt in kg)
Females: V (in mL)= (106.9 X ht in cm) + (246.6 X wt in kg) – 2097 mL
Completing the calculation for empiric hemodialysis prescription: With an estimate of K and V, you determine the time (t, in minutes) by solving the Kt/V = 1.2 equation, in stable patients. Determining delivered Kt/V from blood samples: In order to verify that an adequate dose of hemodialysis is delivered, it may be important to measure dose of Kt/V based on pre- and post-hemodialysis samples. By convention, the post sample is typically collected 15-30 sec after the dialysis pump speed has been slowed to ~50ml/min. To determine Kt/V from these samples, assuming single-pool kinetics of distribution of urea, the following formula can be used (from Daugirdas JT. Second-generation logarithmic estimates of single-pool variable volume of Kt/V: An analysis of error. J Am Soc Nephrol 4: 1205-13, 1993.):
35
Kt/V = -ln (R - 0.008t) + (4 - 3.5R) X UF/W
R = post BUN/pre-BUN
UF is ultrafiltrate volume (in L)
W is post-dialysis weight (in kg) Other characteristics of hemodialysis membranes used at Duke: The table below provide other physical and chemical features of dialyzers that are pertinent to patients dialyzed at Duke.
Surf
CUrea
(Qd
500)
Manuf Dialyzer Sterilization Vol (ml) KUF KoA Area 200 Qb 300 Qb 400 Qb Memb
Fresenius F5 ETO 63 4.0 450 1.0 170 206 225 LF PS
Fresenius F200NR ETO 112 56.0 1317 2.0 197 277 330 PS
GambroPolyflux
17LSteam 104 12.5 1027 1.7 194 264 310
Polyarylethersulfone,
Polyvinylpyrrolidone,
Polyamide Blend
Continuous Veno-venous Hemodialysis (CVVHD) In patients who are acutely ill and hemodynamically unstable, continuous renal replacement therapy (CRRT) may be preferred over intermittent hemodialysis. At Duke and the VA, we employ CVVHD as our predominant form of CRRT in these instances. Indications for CVVHD (as compared to conventional hemodialysis) will be reviewed with the service Attending on a case-by-case basis. There are several integrated systems for performing CVVHD. We currently employ the Prisma machine (Gambro; Lakewood, Colorado). The Prisma system uses a roller blood pump, the AN69 dialyzer filter, and gravity-driven dialysate flow. Orders will be reviewed in the Core Curriculum Series and on a patient by patient basis with the attending until the fellow is competent to write orders independently.
36
DUKE HOSPITAL
DUKE DIALYSIS INPATIENT PERITONEAL DIALYSIS (PD) ORDERS
Automated Peritoneal Dialysis (preferred mode while in hospital)
1. Dialysate glucose concentration:
1.5% 2.5% 4.25% 2. Solution delivery system: 3. Therapy time: Total treatment time_________________hrs 4. Cycler settings Number of cycles per night:___________. Volume to be instilled during each cycle___________mL. Last fill (to remain in abdomen during day) _____________ml. 5> Medication available with CCPD
37
Manual Exchange Peritoneal Dialysis (to be used if cycler is medically contraindicated)
1. Dialysate glucose concentration: 1.5% 2.5% 4.25% (This should be selected according to daily weight, blood pressure, and clinical status) 2. Dialysate exchanges: Volume (typically 1.5-3L) ________________L Exchange Rate (q2h if in ICU; q4-8h on routine ward)____________hrs 3. Medications A. Heparin 500 units per liter dialysate as needed for fibrin detection. B. Antibiotics: 4. If symptoms of peritonitis detected (i.e., cloudy effluent, abdominal pain), notify physician.
38
INSERTION OF NON-CUFFED DIALYSIS CATHETER
If a patient requires hemodialysis or CVVHD and there is not a suitable vascular
access, the Nephrology team will place a temporary non-cuffed dialysis catheter. Short-term access is usually obtained by placing a dual-lumen catheter over a wire (Seldinger technique) in the femoral vein. A temporary femoral dual-lumen dialysis catheter should only be left in place if the patient is restricted to bed rest and only for a maximum of seven days. An alternative site of placement is the internal jugular vein, and the maximal use of a temporary internal jugular vein should be two weeks. Due to the risk of subclavian vein stenosis, insertion of temporary dialysis catheters in the subclavian vein should be avoided.
These catheters are placed using the equipment that is stored in the 9300 dialysis unit. Since central vein catheters carry a substantial risk of infection, the level of barrier precautions used in placing the line needs to be greater than with peripheral IVs. Maximal barrier protections should be used when placing a central line for hemodialysis access, and this includes use of sterile gloves, gown, full-sized drape, cap and mask. (Morbidity and Mortality Weekly Report 51 (RR-10) Aug 9, 2002) If more immediate-term access is desired, a subcutaneously tunneled catheter (permcath) should be used. These can be placed by the Vascular Surgeons or Vascular Radiology. We recognize that the ideal solution to permanent vascular access is a well-functioning native arteriovenous fistula, but this is not always feasible in hospitalized patients.
EMERGENCY DIALYSIS
Duke University Medical Center maintains a team available for emergency dialysis at all times. Any hemodialysis treatment provided outside of the usual hours constitutes an emergency dialysis and must be specifically authorized by the nephrology attending. Dialysis should not be scheduled outside the regular hours of operation (8:00 AM - 7:00 PM, Monday - Saturday) because of communication problems. This is best avoided by rounding early each day. A dialysis sign-up sheet is maintained in the Hemodialysis Unit on the door after hours. When possible, this must be filled out the night before to allow smooth coordination with the Unit. Emergency dialysis should only be scheduled when the patient has problems which cannot be treated adequately by other techniques. This includes the use of oral Kayexalate-Sorbitol for hyperkalemia and oxygen and morphine for mild congestive heart failure.
The VA dialysis unit is open Monday, Wednesday and Friday 7:00 AM to 8:00 PM,
Tuesday and Thursday 7:00 AM to 6:00 PM and Saturday 6:00 AM to 4:30 PM. A dialysis RN and a dialysis technician are on call 24/7 and can be reached by calling the VA operator at 919-286-0411 and having them paged.
39
Dialysis for Poisons
When a patient becomes intoxicated from a medication or becomes poisoned,
extracorporeal techniques such as dialysis or hemoperfusion may be a useful part of supportive care. In our local experience, the most common poisonings or drug overdoses for which hemodialysis therapy is apt to be indicated are methanol, lithium, salicylates, N-acetyl procainamide (NAPA), and theophylline. NAPA, lithium and methanol are cleared adequately by standard hemodialysis (treatment of methanol intoxication should include ethanol infusion). Most other overdoses are handled adequately by general supportive measures.
PERITONEAL DIALYSIS USING THE HOME CHOICE CYCLER
VA Medical Center Patients requiring peritoneal dialysis may do either CAPD (manual exchanges) or APD (automated cycler assisted) also known as CCPD (continuous cycler assisted peritoneal dialysis). In our program the majority of peritoneal patients have opted to utilize a cycler (Baxter Home Choice) for nightly exchanges which frees them up during the day. Most patients will require the addition of a manual daytime exchange as their residual renal function declines 1. Peritoneal dialysis is generally a daily (or nightly) process. Most patients on APD (CCPD) will cycle 8-10 hours over night. Those patients on CAPD will divide their 4-5 daytime exchanges evenly throughout the day with a nightly dwell of 8 hours. 2. Estimated target weight: Weight may not represent euvolemia, but that volume status at which the patient is most stable. Dianeal selection is based on the patient’s weight and blood pressure.
Dialysis cycle program a. Cycle volume: Cycle volumes in stable chronic patients range from 2,000 ml to 3,000
ml per exchange. In general, greater exchange volumes will achieve more total solute clearance. Goal weekly Kt/V in PD is 1.7. Cycle volumes will be determined by an individual patients’ residual renal function, BSA, membrane characteristics and with consideration of possible volume related side effects such as difficulty breathing or leakage.
3. Specify the dextrose concentration of the bags: The concentration of dextrose is
varied to allow different amounts of fluid removal. 1.5% dextrose removes approximately 0 to 3 lb. in 10 hours. 2.5% dextrose will remove 1 to 5 lb. in 10 hours. 4.25% dextrose can remove as much as 5 lb. in 10 hours. A common prescription would include 3 2-liter bags of 1.5% dextrose and 2 2-liter bags of 2.5% dextrose to be administered in 5 2-liter cycles over the course of a night.
40
VAMC Pearls for Caring for PD patients: Due to the inexperience of the non-dialysis hospital staff, and the importance of preserving the integrity of the Tenckhoff catheter, it is the fellow's responsibility to assess any PD patient coming in house. Only VA Dialysis staff should perform procedures (collection of fluid samples, dressing changes, setting pt up on the cycler) for the PD patient. They are available 24 hrs daily to assist you. The VA Dialysis staff can only take orders from Nephrology Service providers. Quick basics include:
-it is ideal for PD patients to have private room for infection control purposes. -sample collection can only occur during a dwell. If there is no dwell, dialysate must
be instilled for 1-2 hours before sample collection. -hemoperitoneum should be treated with 500units/liter heparin in dianeal to prevent
clotting. -Inpatients who go home on IP antibiotics need to be trained by the Home Dialysis
Coordinator, Charles Thompson. He works M-F, 7-3:30pm.
-Peritonitis is usually treated with gram + and – coverage until speciation is obtained. -Detailed dosing info is available on 3b, however, briefly the loading dose IP is: Either -cefazolin 1.5 g, ceftazidime 1.5 g, heparin 1000 units all in 2 liters of dianeal. OR -vanc 2 g, gentamycin 0.6 mg/kg, heparin 1000 units all in 2 liters of dianeal. Loading dose to dwell 6-8 hours. Generally vanc levels are not obtained, as levels
run lower than for IV dosing, and we do not adjust maintenance IP dosing for that. If pt is septic, use IV dosing until stable.
-Orders are written and faxed to pharmacy (electronic will go live soon), and the
dialysis tech will take the bag down to be dosed, then instill the fluid. -Maintenance dosing is bag dependent. You must know what bags will be used to
write the orders. For example, if the patient uses 11.5 liters, we will hang 12 liters of fluid and to maintain the appropriate concentrations, dose per bag.
-vanc 20 mg/liter -gent 4 mg/liter -cefazolin 125 mg/liter -ceftazidime 125 mg/liter -heparin 500 units/liter
DVAMC NxSTAGE CRRT Provider Guide
41
Background and clinical overview: The DVAMC has two NxStage System One CRRT devices available for use at any time. This device is capable of delivering CVVH (convective clearance, therapy fluid infused on the blood side), CVVHD (diffusive clearance, therapy fluid infused around filter), and SCUF (no therapy fluid infused). The device is capable of delivering up to 72 hours of continuous therapy before requiring replacement of the filter. Standard bicarbonate premixed therapy fluid is provided, and heparin can be used for anticoagulation. Notable differences from Gambro Prisma: 1. Volumetric balancing instead of scales for balancing (hopefully less alarms) 2. No CVVHDF mode (must choose between CVVH and CVVHD) 3. Reportedly, increased patient tolerance of higher blood flows (ie 350 ml/min instead of 200 ml/min) 4. Reportedly, decreased system clotting and requirement for anticoagulation, perhaps due to increased blood flows. How the service will run: CRRT orders can only be entered by the Renal Consult team after a full consult is performed. For now, the SICU is the only location where CRRT can be ordered. The SICU team has received extensive training and the attendings are very familiar the NxStage device and CRRT in general. Please do your best to respond to consult requests for CRRT from the SICU promptly, and include the SICU team in treatment discussions. Ultimately, all aspects of CRRT prescriptions are prescription the responsibility of the Renal Consult team, but the SICU team has proposed joint nephrology/SICU CRRT rounds at 8 AM, and I think this is a great idea. Please do your best to comply. For patients in the MICU/CCU who need CRRT—for now, the SICU has agreed to accept INTERNAL patients for transfer for CRRT. DO NOT accept patients at outside hospitals who specifically need CRRT for now. Call the SICU charge nurse and attending (Charles Brudney or Andy Shaw) to arrange an internal transfer. CRRT Orders: CRRT orders will be entered on CPRS. The standard rules for dialysis consent still apply. CRRT orders are only good for 24 hours and must be re-entered daily after MD evaluation. The following condensed overview of the order set is shown on the next page. Important Points about the order set: 1. Therapy mode—again, only CVVH, CVVHD, and SCUF are available. 2. Blood flow rate—Most other centers use a blood flow rate of 350 ml/min and it is said that patients tolerate this well. Until we gain experience with this, it might be reasonable to shoot for a lower rate (ie 250-300 ml/min) and ramp up as patient hemodynamics allow. 3. UF rate—the standard order set allows ICU team (with ICU attending approval) to decrease the UFR or increase it by a maximum 50 ml/min/hr. This can be modified at your discretion. 4. Anticoagulation. It is very reasonable to start out without anticoagulation, especially if higher blood flows are ordered. If heparin is started, Consult with the ICU team regarding bleeding risk before ordering, and order the appropriate heparin protocol 5. Therapy fluid. For now, we are stocking a 2 meq/L and a 4 meq/L potassium fluid only. The calcium concentration is 3 mmol/L. If you require another fluid composition, please consult with me.
42
6. The notification parameters at the end of the order set are modifiable, but what is written is part of the standard order. You may edit these if needed. DVAMC CRRT Orders OVERVIEW.
2. Therapy: □CVVH □CVVHD □SCUF
3. Hourly Intake and Output and Vital Signs
4. Pt. Weight: □Q12 or □QDAY
5. Dressing changes to CRRT access catheter per SICU central line policy
6. Prime with NS per protocol.
5. Blood flow rate: ml/min (suggest 200-350)
6. □ Net Hourly Fluid Removal Rate: ml/hr (0-999 ml/hr) May be decreased as needed by ICU team, may NOT be increased by more than 50 ml/hr without approval from nephrology team.
7. Therapy Fluid Prescription: NxStage PureFlow: RFP: 400 (Lactate=0, Bicarbonate=35, Potassium=2, Sodium=140, Calcium=3, Magnesium=1, Chloride=111, Glucose=100. RFP: 401 (Lactate=0, Bicarbonate=35, potassium=4, Sodium=140, Calcium=3, Magnesium=1, Chloride=113, Glucose=100
□ Other Additives:
8. Therapy Fluid rate (for CVVHD and CVVH only): ml/shr (Recommend 20-25 ml/kg/hr or 2.0-12.0 L/hr)
9. Anticoagulant:
□ 1) None-Preferred (may give NS flush as needed)
□ 2) Heparin: IV, adminster pre-pump via arterial port. Before ordering heparin, ICU team must be consulted to assess bleeding risk. Monitor aPTT from post filter port q6h until stable, then q8h. Moderate bleeding risk: Bolus heparin: 1000 U Heparin Infusion: 200U/hr Goal aPTT 45-60 seconds. Adjustment: aPTT<60 and no filter clotting: no change aPTT <45 and filter clotting: increase infusion by 100 U/hr aPTT 61-70: decrease by 100 U/hr aPTT 71-90: stop infusion x 60 min decrease by 100 U/hr aPTT >90: stop infusion x 60 min decrease by 200 U/hr
Low Bleeding risk: Bolus heparin 2000 U Heparin Infusion: 500 U/kg/hr Goal: aPTT 45-80 seconds Adjustment: aPTT<80 and no filter clotting: no change aPTT <45 and filter clotting: increase by 100 U/hr aPTT 81-90: decrease by 100 U/hr aPTT 91-100: stop infusion x 60 min decrease by 100/hr aPTT >100: stop infusion x 60 min decrease by 200 U/hr
9. Labs:
Pre treatment: BMP, Phos, Mg, CBC, PT-INR, aPTT STAT Q6 Hour labs: BMP, Ca, Phos Q12 hour labs: CBC, Mg, ABG, Ionized Ca 10. ACEI must be discontinued prior to initiation of CRRT. Blood products are not to be given via
43
CRRT machine. 12. CRRT may be stopped for travel outside of the ICU or if patient is hemodynamically unstable at the discretion of the primary ICU team. NOTIFY RENAL FOR THE FOLLOWING: Potassium < 3.5 or > 6 meq/L after 6 hours of therapy CO2 [bicarbonate] < 15 or > 35 meq/L after 6 hours of therapy System Clotting Call VA Operator for renal fellow during business hours Call 970-7746 for Renal Fellow after 5pm or after 12 noon on weekends. Also notify the ICU Attending. Entering in orders CPRS: CRRT orders are found under the Clinic Screens/Renal/Dialysis/Durham ordering menu. Screenshots and notes below. 1. Enter therapy type. 2. Enter Blood flow rate, net fluid removal, fluid removal rate adjustment parameters for the ICU team, Therapy fluid rate and type. 3. Anticoagulation- select the most appropriate option. 4. If you selected one of the heparin protocols, the parameters are shown in the next screen. I recommend not altering any of these parameters. 5. Enter the appropriate heparin bolus and a heparin infusion. IMPORTANT: If you are just renewing an order, don’t reorder a bolus unless you really want one. 6. Order standing order labs instructions and enter any additional nursing orders here. 7. If you wish to order an initial set of labs, you may do so here. Otherwise, the SICU RN will enter and draw the subsequent standing order labs. 8. The notification parameters are automatically entered. If you wish to modify them, you may do so by right clicking the order. How will CRRT treatment data be documented? CRRT treatment data will be documented in the SICU charting system (Essentris). This includes hourly assessment of access pressure, flow rates, and fluid removal. Fluid removal will be documented and included in the daily fluid balance sheet. It can be found under the “GU” tab and the parameters that will be documented are shown below. THIS IS NEW for the VA and the System One is new for us. There may be kinks that need to be worked out. IF YOU HAVE ANY QUESTIONS OR HAVE PROBLEMS: Please let Dr. Pun know. Cell (919)672-2464, pager 2991, email [email protected] or [email protected]
Where to find and How to Print the New Hemodialysis Treatment Summary Notes
44
Durham VA and Brier Creek Hemodialysis Clinics 1. Click the Consult Tab (no longer visible under the Notes tab) 2. Look in the Consult Window and scroll down for consults names “CP HEMODIALYSIS”. The most recent CP HEMODIALYSIS note will have the most recent treatment. At current we plan to enter a new consult every 3 months, so you will need to select the most recent consult to find the most recent treatment notes. 3. Look in the Documents Window. This will have a list of all the individual treatment notes associated with the Consult. 4. Printing: If you wish to print a treatment note (for faxing etc.) select the desired note in window
If you try
to print using the Print command under the File menu, you will print out ALL the treatment notes filed in the consult—you probably don’t need/want to do that. Questions? Email [email protected] , ext 5496.
45
KIDNEY AND PANCREAS TRANSPLANTATION The transplant evaluation process is initiated by a faxed Referral Form from the referring physician or dialysis unit to the Kidney Transplant Office (919 668-3897 or 919 668-3407); the kidney transplant assistants & nurse coordinators then handle initial intake, review, and scheduling. Patients who appear to meet our inclusion & exclusion criteria are scheduled for a single day transplant evaluation, which includes an educational session and appointments with a nephrologist, transplant coordinator, social worker, and financial coordinator, in addition to the performance of blood work, an EKG, and a CXR. A transplant surgeon also evaluates each patient (this evaluation will happen on the same day or as soon as possible, at least within one year of listing; all patients must see a surgeon prior to transplantation). Most initial evaluations are conducted at Duke South, and a limited number are performed at satellite clinics in Wilmington and Raleigh. Kidney Transplant Recipient (Living & Deceased Donor) Inclusion Criteria: Expressed interest in transplant eGFR < 20mL/min/1.73m2 For deceased donor recipients, legal resident of the Unites States (citizen or legal alien) If patient has HIV, must have CD4 count consistently > 200 and clinical clearance by Duke Infectious Disease Physician Patients > 70 years old must have a potential living donor at the time of listing. Presence of a consistent & reliable support system, including the ability to obtain anti-rejection medications after transplant & reliable transportation Ability to arrive at Duke Hospital within 6 hours For deceased donor candidates, patient must have a home residence for greater than three months in North Carolina or one of the following states: South Carolina, Georgia, Tennessee, Virginia, or West Virginia Pediatrics candidates must measure weight ≥10 kg, length ≥ 80 cm, or acceptance by surgeon Exclusion Criteria: Past history of cancer (other than skin) within 2 years, unless approved by the multidisciplinary team
Body mass index (BMI) > 403. Liver biopsy demonstrating ≥ stage 3 fibrosis unless cleared
by hepatologist Active substance abuse (alcohol or other) Inability or unwillingness to perform self-catheterization in the setting of an unsatisfactory urinary drainage system Persistent non-adherence with medications, dialysis treatment, &/or medial recommendations Uncontrolled hyperparathyroidism as evidence by intact PTH > 1500 Myocardial infarction within the last 6 months or active myocardial ischemia. Mean pulmonary artery pressure > 35mmHg by catheterization or echocardiogram Transient ischemic attack or stroke within the last 6 months Severe restrictive or obstructive pulmonary disease Systemic infection
46
Non-healing ulcer or wound Medical or psychosocial risk factor(s) that make transplant surgery unsafe. Untreated or uncontrolled psychiatric disorders that would affect the ability to care for self Patients in Long term care facility or other institutional setting Kidney-Pancreas & Pancreas Transplant Recipient Selection Criteria Pancreas Alone Inclusion Criteria:
Expressed interest in transplant Age 21-55 years Intended recipient must be post kidney transplant or have experienced life-threatening
complication of Type I Diabetes supported by an endocrinologist.
Confirmation of Type 1 diabetes (serum C-peptide level < 1). Legal resident of the United States (citizen or a legal alien). GFR > 60 ml/min/1.73 sq meter (native kidneys or renal allograft). If patient has HIV, must have CD4 count consistently > 200 and clinical clearance by Duke
Infectious Disease physician
Presence of a consistent and reliable support system including the ability to obtain anti-
rejection medications after transplant and reliable transportation.
Patient must have a home residence for greater than three months in North Carolina or one of
the following states: South Carolina, Georgia, Tennessee, Virginia, or West Virginia
Simultaneous Kidney-Pancreas All inclusion criteria listed above for Pancreas Alone except for an eGFR < 20mL/min/1.73m2 Exclusion Criteria: Past history of cancer (other than skin) within last 2 years unless approved by multidisciplinary team. BMI (Body mass index) greater than 30 Patients whose liver biopsy demonstrates stage 3 fibrosis or greater unless cleared by hepatologist. Active substance abuse (Alcohol, tobacco or drugs) Inability or unwillingness to perform self-catheterization in the setting of an unsatisfactory urinary drainage system. Persistent non-adherence with medications, dialysis treatments, and/or medical recommendations Uncontrolled hyperparathyroidism as evidenced by intact PTH >1500. Myocardial infarction within last 6 months or active myocardial ischemia. Mean pulmonary artery pressure by catheterization > 35 mm Hg or estimated peak right ventricular systolic pressure > 50 mm Hg by echocardiogram. Transient ischemic attack or stroke within last 6 months Severe restrictive or obstructive pulmonary disease. Evidence of acute symptomatic infection until resolved. Non-healing ulcer or wound.
47
Medical or psychosocial risk factor(s) that make transplant surgery unsafe. Untreated or uncontrolled psychiatric disorders that would affect the ability to care for self Patients in long term care facility or other institutional setting. Living Kidney Donor Inclusion Criteria:
Patient presents voluntarily for consideration as a donor Patient must have the ability to give informed consent for evaluation and transplant procedure. Age 18-70. ABO compatibility with intended recipient or eligibility to participate in ABO incompatible
protocols or Paired Donor Exchange
HLA cross match negative or eligibility to participate in positive cross match protocols Presence of a consistent and reliable support system that does not include the recipient as a
primary care provider Measured GFR by nuclear medicine study greater than or equal to 80 ml/min/1.73 m2. Donor has active health insurance.
Exclusion Criteria:
Donor’s choice not to proceed with donation. Suspicion of donor coercion. Suspicion of illegal financial exchange between donor and recipient. Transmissible infection that would pose a significant risk to the recipient, such as HIV
infection, active symptomatic infection, or active mycobacterial infection.
Active diabetes mellitus Hypertension or medical treatment for hypertension. Any history of melanoma. Malignancy within 5 years except non-melanoma skin cancers. BMI >35 Abnormal proteinuria as determined by urine microalbumin to creatinine ratio Women less than 6 months post-partum. Medical assessment that considers multiple risk factors that when combined makes donation an unsafe risk.
Active substance abuse Untreated or uncontrolled psychiatric disorders (including evidence of suicidality) Incarcerated individuals due to the concern for coercion. Kidney Transplantation from Living Donors The cornerstones of consideration for living donation include: 1) explaining to recipients & their family the absolute & relative risks & benefits of renal replacement therapy in the form of living donor transplantation versus deceased donor transplantation versus various modes of dialysis; 2) educating patients concerning expected wait times for standard versus extended criteria donor kidneys versus the limited wait time for a living donor kidney; 3) presenting information to potential donors in a manner that does not cause any degree of coercion or undue pressure; 4) understanding that kidney donation is a voluntary & elective procedure & should not be undertaken if there is any concern that the loss of a kidney would subject the donor to excessive long term morbidity or mortality.
48
To assure that neither the recipient nor any other members of the family put undue pressure on potential donors, we customarily proceed as follows: At the time of the recipient’s evaluation for transplant listing, he should be versed on the average waiting times for deceased & living donor organs. He should be encouraged to consider any living donors. He should be informed that any related or unrelated potential donors should phone the transplant office directly (& independently of the patient) & ask for Leslie Hicks. It should be explained that donors with blood types different from their intended recipient can often facilitate living donation through direct ABO-incompatible (ABOi) transplantation, or paired donor exchange. A brief telephone screening will occur & if living donation criteria are met, donors will be asked to collect a serum sample for blood typing and cross matching with the recipient (the potential donor need not be local for this to occur; samples can be mailed). If the donor meets criteria & is a suitable blood type with negative cross match, or if the donor & recipient are aware & wish to proceed with either defined ABO incompatible or cross match positive protocols (all of a recipient’s potential donors should be screened for ABO compatibility and negative cross match before consideration of these protocols), or participate in paired donor exchange, donors will be invited to Duke for an evaluation. Evaluation consists of an educational session, a meeting with donor advocate (Amy Miller), an appointment with social work, & a general history and physical exam by a nephrologist. In addition, routine laboratory studies including urine studies (urinalysis & assessment for proteinuria), blood studies, EKG, & a CXR are completed. Other studies may be ordered at the discretion of the examining physician. Healthy volunteers who are considered the "best donor" (by medical history, age, social factors, and compatibility with the recipient) then undergo helical CT scanning and meet the donor surgeon. The donor nephrectomy & recipient transplant are then scheduled. Kidney Transplantation from Deceased Donors The Carolina Donor Services (CDS) procurement coordinators will perform all of the procurement and preservation functions. However, the in-house coordination of each renal transplant remains the responsibility of the respective transplant centers. The transplant nurse/coordinator is the primary point of interaction with CDS once the transplant surgeon on call has determined that an offered deceased donor kidney would be suitable for transplantation to one or more Duke recipients. The transplant nurse coordinator will initiate contact with the rest of the transplant team according to the call scheme, which is designed to make certain that all involved in the transplant procedure have timely and accurate information. The initial notification of an available kidney will come from the CDS coordinator to the transplant surgeon on call. If a kidney is judged to be acceptable, the CDS Procurement Coordinator will notify the Duke transplant nurse/coordinator on call and will relay the necessary donor and recipient information.
49
The Duke coordinator will instruct the acceptable potential recipient to travel to our emergency room and will determine the estimated time of arrival of the recipient. The Duke transplant nurse coordinator will notify CDS's procurement coordinator and the Duke team of the recipient status and estimated time of arrival at Duke. The Nephrology Fellow &/or Attending will also be notified at this time. Upon arrival to the hospital, the Nephrology team will evaluate the patient in conjunction with the Transplant Surgeons to assure that the patient has had a satisfactory work up & that there are no new medical issues that would increase the peri- or post-operative risk. CDS's procurement coordinator will coordinate the transportation, tissue typing and final cross-match of the accepted kidney and will notify the Duke procurement nurse coordinator of the final cross-match results. The CDS procurement coordinator will call the Duke transplant nurse coordinator about any change in the status of the kidney. The Duke transplant nurse coordinator will call the CDS procurement coordinator about any change in the recipient's status. Notification of the potential transplant, time estimates, final cross-match results and changes in recipient or kidney status will be communicated with Duke as follows: CDS will call: The Transplant Nurse/Coordinator The Transplant Nurse/Coordinator will call: Transplant Surgeon Nephrology Fellow/Attending PACU or Short Stay Charge Nurse SICU Charge Nurse
50
Duke University Hospital
Kidney and Pancreas Immunosuppression Guidelines
October 22, 2012
ISP Plan Transplant Type Maintenance Therapy Induction
Therapy
Low Risk Renal
Transplant
1st Deceased or Living
Donor
not high risk
Selected 2nd
Transplants
Steroid Taper
Myfortic 720mg q12h
Prograf-begin at 3 mg
q12h
None
Moderate Risk
Renal
Transplant
Or
Kidney/Pancreas
Transplant
-Black race
-SLE pts
-Kidney Pancreas
-Peds en bloc recipients
Moderate Risk of ATN
-Non-heart Beating Donors
-Adult receiving pair of
Deceased Donor kidneys
-Other at discretion of
Surgeon
Steroid Taper
Myfortic 720mg q12h
Prograf-begin at 3 mg
q12h
Basiliximab
20mg start in OR
and POD 4
High Risk Renal
Transplant
-Presensitized,Peak PRA
>40
-2nd
Transplant w/ early
graft
loss
-3rd
or greater transplant
Pancreas alone
Steroid Taper
Myfortic 720mg q12h
start POD 4
Prograf-begin at 3 mg
q12hr
Thymoglobulin
1.5mg/kg
(rounded to
nearest 25mg) x
4 doses
Start in OR
Steroid
Withdrawal
Zero PRA
No autoimmune diseases
↑ BMI
Steroid taper as
follows:
500mg in OR 250 mg
POD 1
125 mg POD 2
125 mg POD 3
90 mg POD 4
Myfortic 720mg q12h
POD 4
Prograf-begin at 3 mg
q12hr
Thymoglobulin
1.5mg/kg
(rounded to
nearest 25mg) x
4 doses
Start in OR
PAK Pancreas after Kidney
Transplant
Steroid Taper to lowest
dose 5mg daily
Myfortic 720mg q12h
start on POD 4
Tacrolimus-begin 3mg
q12h
Thymoglobulin
1.5 mg/kg
(rounded to
nearest 25mg x 4
doses – start in
OR)
51
Inpatient Steroid Taper
POD 0 500 mg Solumedrol
POD 1 180 mg prednisone
POD 2 90 mg prednisone
POD 3 60 mg prednisone
POD 4 30 mg daily
Recommended OP Prednisone Taper
At 2 weeks 25 mg
At 4 weeks 20 mg
At 8 weeks 15 mg
At 12 weeks 10 mg
At 16 weeks 5 mg
PCP Prophylaxis after Kidney Transplant
1. All patients will be prescribed PCP prophylaxis after transplant
2. Standard Treatment options (Choose 1):
a. Septra 1 DS oral TIW for 12 months or
b. Dapsone 100 mg by mouth for 12 months
c. Pentamidine 30 mg aerosolized monthly for 12 months
CMV Disease Screening and Management After Transplantation
DNA PCR screening for cytomegalovirus (CMV) reactivation is performed on all kidney, SPK and Pancreas
patients after transplantation. Screening is based on the serologic status of both the recipient and donor at the
time of the transplant event.
Donor/Recipient Status Recommended Action
High Risk Patients (D+/R-, OR D+/R+, D-/R+ with Thymoglobulin induction
1) Prophylaxis with Valcyte 900mg daily (or as adjusted for GFR) for 6
months
Intermediate Risk Patients (D+/R+ or D-/R+) with no Thymoglobulin Induction
1) No prophylaxis
2)
Low Risk Patients (D-/R-)
1) No prophylaxis or pre-emptive monitoring is needed. 2) HSV serology should be drawn on the recipient within 30
days of transplant to determine HSV reactivation risk 3)
HSV negative recipient and
not on Valcyte
1) No prophylaxis if donor HSV status is known and is negative
2) Institute HSV prophylaxis with Acyclovir if donor HSV status is
unknown or positive.
Addition Practice Considerations:
1. It is permissible to use external laboratories for screening testing. If external lab test is positive, it is
preferred that patient be retested at Duke to establish baseline viral load and to monitor response to
therapy. Alternatively, patients should receive subsequent checks at the same laboratory.
2. If ,during the 6 month post transplant period, the recipient receives Thymoglobulin for rejection the
clock resets and begins a new 6 month period.
3. At completion of the 6 months of prophylaxis, recipients will begin being every 2 week screening for 3
months with CMV PCR tests.
4. At any time during the period of prophylaxis, if the patient presents with typical symptoms of CMV
infection (nausea, vomiting, diarrhea, fever of unknown origin, leukopenia, headache, cough, fatigue)
begin monitoring CMV PCRs every 2 weeks.
52
Treatment of Positive CMV DNA PCR detected during Monitoring
Clinical Presentation Laboratory Results Recommended Action
Asymptomatic viral load of <250 copies/ml
1) Initiate DNA PCR Serum
Screening every 2 week (prefer
Duke or use of same external lab
facility)
Asymptomatic or minor symptoms of infection (increase in fatigue, low grade fever)
viral load between 250 -10, 000 copies/ml
1) Valcyte 900mg daily (renal adjustment required) .
2) Routine labs every 2-3 weeks with PCR quantitative testing to monitor progress (prefer Duke or use of same external lab facility).
Symptomatic (nausea, vomiting, diarrhea, fever without other cause, leukopenia, headache, cough, fatigue)
PCR viral load > 10, 000 copies/ml
1) Valcyte 900mg BID (renal adjustment required)
2) Routine labs every 2-3 weeks with PCR quantitative testing to monitor progress (prefer Duke or use of same external lab facility).
Highly suspicious tissue invasive disease with symptomatic disease
PCR viral load > 10, 000 copies/ml
1) IV Ganciclovir (renal adjusted) via PICC until undetectable PCR
2) Routine labs every 2-3 weeks with PCR quantitative testing to monitor progress ( prefer Duke or use of same external lab facility).
3) When viral load undetectable, switch patient to oral Valcyte 900 mg daily x 90 days.
Renal Adjusted Dosing Recommendations Ganciclovir Dosing Recommendations Valganciclovir Dosing Recommendations
Cr Clearance IV treatment dose IV prophylaxis dose Cr Clearance Dose
> 70 ml/min 5 mg/kg q12h 5 mg/kg q24h > 60 ml/min 900 mg po Q24h
50-69 ml/min 2.5 mg/kg q12h 2.5 mg/kg q24h 40-59 ml/min 450 mg po Q24h
25-49 ml/min 2.5 mg/kg q24h 1.25 mg/kg q24h 25-39 ml/min 450 mg po Q48h
10-24 ml/min 1.25 mg/kg q24h 0.625 mg/kg q24h 10-24 ml/min 450 mg po QT/F
< 10 ml/min (HD) 1.25 mg/kg qMWF or after HD 0.625 mg/kg qMWF or after HD < 10 ml/min or HD Not recommended
BK Polyomavirus Screening and Management
53
Definitions:
Screening: assessment for BK viremia at a predetermined frequency in patients with no recent history of viremia.
Surveillance: close monitoring of BK viral levels in patients with active viremia. Screening: The following principles should guide screening for BK virus. 1. Serum BK PCR will be checked at regular intervals based upon time from the transplant event and treatment for rejection*:
Time from Transplant or Treatment for Rejection (months)
Lab Frequency (minimum)
1 to 12 Monthly
13 to 24 Every 3 months
25 to 36 Every 6 months
* Screening should be reinitiated at time-zero following treatment for rejection that requires IV steroid or lymphocytes depleting therapies.
2. Serum BK PCR should be checked for any unexplained elevation in serum creatinine >30% above baseline. 3. Serum BK PCR should be checked within 2 weeks of any biopsy performed for an elevation in serum creatinine. Surveillance: This protocol should be followed in those with BK viremia. 1. Following the initial detection of BK viremia, serum BK viral load testing should be
performed every 2 weeks.
2. All attempts should be made to use the same laboratory during surveillance testing.
3. Patients should be screened for donor specific antibodies following the first detection of BK viremia (ideally, though not necessarily, prior to reduction of immune suppression).
4. Based upon available data, patients should be categorized by their perceived risk of
rejection using the following definitions. a. High Risk: Patients are considered ‘high risk’ if any of the following apply.
i. cPRA≥20% ii. Cross-match positive transplant iii. ABOi transplant iv. History of DSA v. History of rejection vi. <30 days from transplant with DR mismatch.
b. Low Risk: patients who do not meet the definition of ‘high risk’.
54
5. The following actions should be taken with the initial detection of viremia, based upon the
level of virus initially detected and patient’s rejection risk category (high vs. low risk as defined above):
Viral Load Low Risk High Risk
Detectable, <1,000 copies/mL
Reduce antimetabolite dose by 25%
CONSIDER: Reducing antimetabolite dose by 25%
≥1,000 copies/mL
Reduce antimetabolite dose by 50%
CONSIDER: Reducing antimetabolite dose by 50%
6. The following actions should be taken based upon subsequent levels of viremia, based
upon the level of virus detected and patient’s rejection risk category (high vs. low risk as defined above)
Viral Load Low Risk High Risk
Undetectable
Return to routine screening protocol if undetectable for 4 consecutive weeks. Consider 25% increase in antimetabolite and/or CNI if VL remains undetectable for >4 weeks
Return to routine Screening protocol if undetectable for 4 consecutive weeks. Consider 25% increase in antimetabolite and/or CNI if VL remains undetectable for >4 weeks
Less than previous, or <1,000 copies/mL
No Change
No Change
Increased from previous and ≥1,000 copies
Reduce antimetabolite dose an additional 50%. (Stop antimetabolite if already at minimum BID dose) If antimetabolite on hold, reduce CNI dose by 25% (minimum FK506 trough 4ng/mL, CyA trough ng/mL75)
CONSIDER: Reduce antimetabolite dose an additional 50%. (Stop antimetabolite if already at minimum BID dose) If antimetabolite on hold, reduce CNI dose by 25% (minimum FK506 trough 4ng/mL, CyA trough ng/mL75)
55
7. The following actions should be taken if the serum creatinine increases >30% from
baseline in the setting of BK viremia (high vs. low risk as defined above):
Low Risk High Risk
Review: CNI troughs, current IS, ACEI/ARB , diuretics. Discuss: volume status, BP, ASA/Plavix, UTI symptoms, and possible bx. Check UA+Urine Culture (treat if positive) Repeat creatinine within 3-7 days+PT/PTT/INR, CBC Proceed to biopsy if creatinine remains elevated and no contraindications.
Review CNI troughs, current IS, ACEI/ARB , diuretics Discuss: volume status, BP, ASA/Plavix, UTI symptoms, and possible bx Check UA+Urine Culture (treat if positive) Check PT/PTT/INR, CBC if not done within 4 weeks. If creatinine unexplained and no contraindications proceed to biopsy (admit or SSU).
8. If biopsy is pursued, the following management guidelines should be considered based
56
on the biopsy result (high vs. low risk as defined above):
Biopsy Result Low Risk High Risk
BK Nephropathy only (viral inclusions and/or + SV40 staining)
Discontinue antimetabolite. If antimetabolite already on hold>2 weeks without fall in VL, reduce CNI dose by 25% (minimum FK506 trough 4ng/mL, CyA trough 75ng/mL) Consider adjuvant treatment, particularly if mod-severe interstitial inflammation Adjuvant Treatment Options : 1. IVIG (1-2g/kg) – preferred if
severe interstitial inflammation
2. Leflunomide (40mg Qday) if antimetabolite is held;
3. Cidofovir (0.25 to 0.5mg/kg Qwk x4+pre/post hydration).
Consider: 50% reduction in antimetabolite. If antimetabolite already on hold>2 weeks without fall in VL, reduce CNI dose by 25% (minimum FK506 trough 4ng/mL, CyA trough 75ng/mL). Consider adjuvant treatment, particularly if mod-severe interstitial inflammation Adjuvant Treatment Options : See “Low Risk” protocol
BK Nephropathy and ACR without arteritis (Could this all be BK?)
Consider: Methylprednisolone 250-500mg IV x1-3 days Consider: IVIG (1-2g/kg) if steroids given and/or mod-severe interstitial inflammation Maintenance IS based upon review/discussion of pathology Consider Adjuvant Treatment : 1. IVIG (1-2g/kg) – if not given
above 2. Leflunomide (40mg Qday) if
off antimetabolite ; 3. cidofovir (0.25 to 0.5mg/kg
Qwk w/pre/post hydration);
Same as Low Risk Protocol
Acute Cellular Rejection w/arteritis or Antibody Mediated Rejection (AMR) With or without BKN
Treat rejection per protocol, based upon path (ACR vs. AMR) Maintenance IS based upon review/discussion of pathology Consider Adjuvant Treatment : 1. IVIG (1-2g/kg) –
recommended if not given above
2. Leflunomide (40mg Qday) if antimetabolite is held;
3. cidofovir (0.25 to 0.5mg/kg Qwk w/pre/post hydration);
Same as Low Risk Protocol
No BK nephropathy or Rejection
Continue IS management per BK viremia protocol
Continue IS management per BK viremia protocol
57
PERCUTANEOUS RENAL BIOPSY
Biopsy of a native kidney is indicated for patients with undiagnosed renal disease where histologic information may be useful to the patient's treatment, for assessment of the degree of involvement by a known disease (e.g. lupus) which will yield information influencing duration and intensity of therapy, and occasionally for other purposes. Each decision should be reviewed carefully with the house staff, the Ward Attending, and the Nephrology Attending. A Renal Attending should be present. Before the first renal biopsy, the novice should become familiar with the precise anatomy and function of the biopsy needle that he intends to use and should familiarize himself with the techniques in detail before approaching the patient.
Prior to biopsy, the procedure must be fully explained to the patient and the patient should be coached in breath holding and breathing on command. He should understand that there will be some back pain, possibly some urinary tract bleeding and occasionally more severe complications, including major blood loss, displacement of the kidney, and rarely loss of the kidney. Written Consent must be obtained. Careful historical review of the patient's recent bleeding tendencies should be carried out and in addition, a PT/PTT and platelet count should be normal. Biopsy Instrument A spring-loaded biopsy “gun” of 15 or 18 gauge is provided in the ultrasound area. Technique Precise technique will be demonstrated at the time the biopsy is done. It is important that the patient be as comfortable as possible and that his upper abdomen be propped up usually by a rolled towel. We greatly prefer that blood pressure is within acceptable range, usually less than 150/90. Either the left or the right kidney may be biopsied but only one at any "sitting" should be approached. The left is preferred. Most attendings now prefer to use the needle guide. There should be ascertainment that both kidneys are present prior to the biopsy for native kidney biopsies. Generally, 2-3 "cores" are obtained in order to obtain adequate tissue for all three kinds of microscopy.
58
After the Kidney Biopsy Orders: the patient should remain at bed rest overnight after native biopsy, for 6 hours after transplant kidney biopsy. Blood pressure and pulse should be taken at 15 and 30 minute intervals for the first hour and at hourly intervals for the first 4 hours. Fluids should be encouraged. If blood appears in the urine, each voiding should be kept in a separate numbered container in order to allow the clinician to follow the degree of bleeding. Hematocrit should be ordered the following morning. Analgesia may be required because of back pain. An order set is available in Maestro. Transplant biopsy patients may get out of bed after 6 hrs observation in the absence of evidence of bleeding. Native biopsy patients are generally observed overnight. 1. Orders
a) Complete bed rest x __ hours. b) P and BP q 15 min x 4, q 30 min x 4, q 1 hr x 4 until stable c) Encourage fluids d) Save each voiding in separate numbered containers e) Hct this PM and in AM f) Call HO or Fellow for any change in vital signs (Beeper #)
2. Procedure note specifying analgesia, technique, kidney biopsy, test specimen submitted
for. 3. Patient should be cautioned to avoid trauma to kidney and heavy lifting for four weeks. 4. The procedure note and orders must be written and either the fellow or the attending must call the floor nurse taking care of the patient to give report before the patient returns to the floor. Specimen Preparation: Place the specimens on saline moistened gauze. Place in a plastic jar with the patient’s name medical record number, date, and “kidney biopsy” on the label. Take to the immunopathology lab in the 4th floor green zone in Duke North or page the courier 970-4176 to take the specimen. At the VA, transport specimen to the path lab.
Histology slides are generally ready for review at 2:30 PM the next day at the Immunopathology Lab at Duke.
59
PROFESSIONAL MEETINGS
The Division will provide up to $750 for travel expenses so that research fellows may
attend the Annual Meeting of the American Society of Nephrology. Expenses in excess of $750 will have to be covered by personal funds or may be supplemented by the faculty mentor’s general research funds. With the approval of the Program Director, the Division may support a fellow’s travel to one additional meeting at which a paper is to be presented. These policies are contingent upon the availability of funding.
****************
MOONLIGHTING
With the approval of the Program Director and the Chairman of the Department of Medicine, certain limited moonlighting activities may be allowable for upper level fellows not on clinical rotations. Moonlighting is limited to 4 nights per month and may not be on the night before clinic. All moonlighting hours count toward the 80 hr per week limit. These activities must be approved in advance via the electronic process in Medhub which requires the approval of the Program Director, Department Chair, and Designate Institutional Official for GME. The Division has adopted the Moonlighting policy of Duke Hospital - see Appendix A.
****************
ACLS/BLS CERTIFICATION
Up-to-date ACLS/BLS certification is required for all fellows. If certification lapses, a fellow can be pulled form the clinical service and salary withheld until certification is made current. To schedule training and certification sessions, call the Hospital Education Department at 684-4293.
****************
TEXTBOOKS
New fellows will be provided a copy of the Handbook of Dialysis, Handbook of Kidney Transplantation and the NKF, Primer on Kidney Diseases at the Fellow Orientation.
60
LEAVE OF ABSENCE AND VACATIONS
The American Board of Internal Medicine specifies that trainee’s total leave time (vacation, holiday, parental, family leave, or illness (including pregnancy) must not exceed one month per year. If leave, in excess of one month per year is needed, training must be extended to make up that time. Specific dates of leave must be requested in advance in writing and approved by the Program Director. This policy covers the Nephrology Training Program as well as the Biomedical Scholars Training Program. Sick leave must be reported to the Program Director.
Vacation
Official vacation time is three weeks per year. Vacation time is essential and must not be forfeited to compensate for extended illness, late starts, parental leave, or other reasons. Vacation may not be taken on the acute service during months when only one fellow is scheduled for that service. Request for vacation must be in writing (email is fine), entered via Medhub and approved by the program director. If you are continuing in the fellowship program the following academic year, you may not carry over any unused vacation time.
Maternity/Parental Leave
61
Department of Medicine Parental/Long Term Leave Policy Background: The Department of Medicine takes the step of developing and implementing Parental/Long Term Leave Policy for Residents and Fellows for the following reasons:
• To be consistent with its core values of fairness, equity, and respect and its missions of
education, research, and excellent clinical care
• To support the mental and physical health of all trainees and their families
• To maintain the integrity of its training programs
• To create consistency among all of its divisions and programs
• Compliance with ABIM policies
ABIM Leave and Vacation Policies: Up to one month per academic year is permitted for time away from training, which includes vacation, illness, parental or family leave, or pregnancy-related disabilities. Training must be extended to make up any absences exceeding one month per year of training. Vacation leave is essential and should not be forfeited or postponed in any year of training and cannot be used to reduce the total required training period. Department of Medicine (DOM) Training Program Long Term Leave Policy: Consistent
with the ABIM standard, the DOM policy allows for up to one month of long‐term leave due to
illness, disability, or family emergency during the twelve months of any calendar year of training. Time away would include the one month leave stated in the ABIM policy. Any absences exceeding one month per year of training must be made up. Specific
modifications to this policy structured around pregnancy‐ related disabilities” and parental
leave are described below.
DOM Training Program Maternity Leave Policy: The ABIM includes “pregnancy‐related
disabilities” under the umbrella of long term leave and, therefore, allows only up to one month of leave during a twelve month training period, without having to make up additional time. The DOM believes that more time off is appropriate and desirable and offers those mothers taking maternity leave during training the option of having up to ten weeks of paid leave, inclusive of the 1 month leave as approved by the ABIM. The Department also supports a return to work
policy that provides for an additional 2‐week return‐to‐work transition period. Note: In keeping
with the ABIM requirements, any absences exceeding one month per year of training must be made up, and Departmental policies require that any unused vacation be applied to this category of leave.
2 Weeks of Transition Back to Work: The DOM believes that the return to work period is
particularly stressful, both physically and psychologically, for new parents. Therefore, the Department recommends that the two weeks prior to full time return to work consist of a “transition period.” This period is intended to consist of a controlled clinical experience (i.e., limited hours without overnight call) and prescribed curricular modules. Because these two transition weeks are time in training, they do not need to be made up.
62
Pay Status: Any or all of the maternity leave weeks (i.e., leave up to 10‐ weeks, 2 transition
weeks as well as make‐up time) will be paid leave with continued medical insurance
coverage. Commencement of Maternity Leave: If the start of the maternity leave is prior to the expected week of childbirth (e.g., in the case of medical necessity prior to due date),
additional make‐up time may be required or post‐partum leave may be shortened based on
individual circumstances. Leave in Excess of 10 Weeks + 2 Weeks Transition: For leave beyond that described above, the trainee may elect to take leave without pay and medical insurance may be
purchased by the resident or fellow through COBRA. Additional make‐up time will be
required, possibly up to completion of an extra training year. Repeat Maternity Leave or Requests for Extended Leave: For trainees who request more
than one maternity leave during a single training period, the required number of make‐up
weeks will exceed the sum of make‐up weeks accrued during the multiple long‐term leaves.
In this case, the trainee will be required to make up a full academic year to maintain the integrity of the training program. For the purposes of this policy, residency training and fellowship are two separate training periods. Paternity Leave Policy: To be consistent with ABIM policies, the Department does not have the flexibility to provide additional time away for paternity leave. On request by the trainee the program will attempt to make schedule adjustments to accommodate up to 1 week off, however training may be extended if total leave in any given year exceeds ABIM policy. Trainees in Combined Training Programs (Med Peds / Med Psych): The ABIM’s “Time in Training” standard is consistent with the requirements established by other specialty boards that also include allowances for up to one month of leave during the twelve months of any calendar year of training along with the mandate that any absences exceeding one month per year of training must be made up.
Non ABIM Years of Training: The DOM elects to adopt a competency‐based standard to
determine whether or not absences exceeding one month must be made up during those fellowship years not required by ABIM. The Fellowship Program Director will be responsible for providing justification based on the ABIM’s Six Core Competencies for any change in the length of the fellowship. Institutional NIH Fellowship Training Grants: NIH institutional training grants have strict guidelines governing leave for recipients that may place additional restrictions on DOM Parental Leave Policy.
RESEARCH PROGRAMS IN THE DIVISION OF NEPHROLOGY
63
The research programs in the nephrology division cover a wide range of practical issues related to kidney disease and hypertension. These programs were initiated in 1964 by Dr. Roscoe R. Robinson and their initial focus was renal physiology. More recently, these areas of study have evolved toward the application of molecular and cell biology approaches to the study of issues related to clinical problems in nephrology and hypertension. Specific areas of study include: the immunology of kidney allograft rejection, mechanisms of immunological kidney injury, the genetics of hypertension, molecular aspects of signal transduction by G-protein associated receptors, uremic and metabolic bone diseases and the molecular control of bone formation and development. These programs exist in a setting of significant interaction with investigators in basic science departments here and at our neighboring institution and the breadth of issues being investigated is rich and diverse. This diversity of effort provides a broad base of opportunities for trainees as well as an exemplary environment for laboratory endeavor. Nephrology fellows are encouraged to participate in ongoing research in the division. This typically occurs during the second and third years of the fellowship. In addition, with prior approval of the program director, fellows may complete their research training in laboratories outside of the division. For fellows who are interested in pursuing careers in basic or clinical research a Biomedical Scholar Program is available which provides additional concentrated training in research. Fellows in this program will do 12 months of clinical training followed by 2-3 years of research with an identified faculty mentor. The ACGME requirements for Nephrology will be met after the second year of fellowship. The rationale for this extended training sequence is to provide adequate preparation and training for fellows in the skills that will be required for successful pursuit of careers in basic or clinical research. A listing of faculty with brief listing of their research interests is provided below: FACULTY RESEARCH INTERESTS Thomas M. Coffman, MD Inflammatory responses in the kidney, the
renin-angiotensin system Steven D. Crowley, MD Immune system in hypertension Matt Ellis, MD Kidney Transplantation Mary H. Foster, MD Proximal Determinants of Nephritogenic
Autoimmunity Arthur Greenberg, MD Hemodialysis Vascular Access, fluid and
electrolyte disorders, hypertension in ESRD patients
Susan Gurley, MD, PhD Animal Models of Diabetes Mellitus Eugene Kovalik, MD Glomerulonephritis Ruediger Lehrich, MD Cardiovascular outcomes in CKD John P. Middleton, MD Clinical trials to limit progression of CKD and
to improve clinical outcomes in ESRD
64
Uptal Patel, MD Epidemiology and health services research in Nephrology
Patrick H. Pun, MD Cardiovascular outcomes in chronic kidney
disease. Development of new therapeutic strategies for the prevention of sudden cardiac death in CKD patients. Disorders of bone and mineral metabolism. Improving deliver of care for pre-dialysis chronic kidney disease patients.
John Roberts, MD Medical Education Research Scott Sanoff, MD, MPH Kidney Transplantation Stephen R. Smith, MD Kidney Transplantation Matthew A. Sparks, MD Vascular control of hypertension and diabetes Robert F. Spurney, MD Biology of the podocyte Laura P. Svetkey, MD Non-pharmacological treatment of
hypertension, the genetics of salt sensitivity in African Americans
65
APPENDIX A DUKE UNIVERSITY HOSPITAL
Office of Graduate Medical Education Duty Hour Policy
Background Providing graduate medical trainees (trainees) with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and trainee well being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on trainees to fulfill service obligations. Didactic and clinical education must have priority in the allotment of trainees’ time and energies. Duty hour assignments must recognize that program directors, faculty, and trainees collectively have responsibility for the safety and welfare of patients and adherence to this policy. The institution is committed to the promotion of an educational environment, support of the physical and emotional well-being of its graduate medical trainees, and the facilitation of high quality patient care. Policy As an accredited ACGME sponsoring institution with ACGME accredited programs, DUH shall maintain compliance with ACGME requirements or ACGME's interpretation of such requirements; therefore, this policy will be superseded by any applicable revisions to ACGME institutional, common or specialty specific program requirements. Programs must maintain compliance with this policy and any additional specifications provided by individual ACGME Review Committees in order to maintain sponsorship by DUHS. This policy applies to all institutions at which trainees rotate and to all trainees in ACGME accredited or internally sponsored programs. Duty Hours a. Duty hours are defined as all clinical and academic activities related to the graduate medical education program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. b. Duty hours must be limited to 80 hours per week, averaged (when averaging is allowed by the relevant RRC) over a four-week period, inclusive of all in-house call activities and all moonlighting. c. Trainees must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged, (when averaging is allowed by the relevant RRC) over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities, including at- home call. d. Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period (and must consist of an 8-hour period) provided between scheduled duty periods. Intermediate-level trainees must have 14 hours free of duty after 24 hours of in-house duty. On-Call Activities The objective of on-call activities is to provide trainees with continuity of patient care experiences. In-house call a. PGY-2 trainees and above must be scheduled for in-house call no more frequently than every third night, averaged (when averaging is allowed by the relevant RRC) over a four-week period. b. Trainees must not be scheduled for more than six consecutive nights of night float. c. Continuous on-site duty, including in-house call, must not exceed 16 hours for PGY-1 trainees.
66
Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours on continuous duty in the hospital. Residents may be allowed to remain on-site for no longer than four additional hours for effective transitions of care and didactic learning. Trainees must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty. At-home call a. At-home call must not be so frequent or taxing as to preclude rest and reasonable personal time for each trainee. b. The frequency of at-home call is not subject to the every third night limitation. Trainees taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. At-home call cannot be assigned on these days. c. When trainees are called into the hospital from home, the hours trainees spend in-house are counted toward the 80-hour limit. d. The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue. Moonlighting a. Because graduate medical education is a full-time endeavor, the program director must ensure that moonlighting does not interfere with the ability of the trainee to achieve the goals and objectives of the educational program. b. Internal and External Moonlighting must be counted towards the 80 hour maximum hour limit. c. PGY-1 trainees are not permitted to moonlight. Oversight a. Each program must have written policies and procedures consistent with the Institutional, Common and Program Requirements for trainee duty hours and the working environment. These policies must be distributed to the trainees and the faculty. Trainees are required to log duty hours. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service. b. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create trainee fatigue sufficient to jeopardize patient care. c. Surveillance of duty hours will be the continuing responsibility of the Resident Environment Section of the Institutional Committee for Graduate Medical Education (ICGME) who will report to the full ICGME at least biannually. d. Violations of the duty hour standards may result in institutional sanctions, such as withdrawal of program sponsorship or Corrective Actions for Associate Members of the Medical Staff.
Duty Hours Exception Some RRCs may grant exceptions for up to 10% of the 80-hour limit, to
individual programs based on a sound educational rationale. However, prior permission of the ICGME
is required.
S:\1Rhea\website\Duty Hours Policy_2011.docDUMCPage 2 6/6/2012
67
APPENDIX B
NEPHROLOGY JOURNAL CLUB July 2015 – June 2016
Room 1103, DHN
8:30-9:30 a.m.
July January
2 No Journal Club 7 R. Hall, Traynor
9 Ellis, Ortiz-Melo 14 Roberts, Duronville
16 Smith, Sanoff 21 Berkoben, Johnson
23 Sparks, Johnson 28 Research in Progress-Spurney
30 Research in Progress-Scialla
August February
6 Svetkey, Foreman 4 Butterly, Bumb
13 Butterly, Roberts 11 Ortiz-Melo, Cameron
20 Berkoben, Cameron 18 Gbadegesin, Olivo
27 Research in Progress-Gbadegesin 25 Research in Progress-Tyson
September March
3 No Journal Club 3 Sanoff, Sethi
10 Patel, Stanifer 10 Lehrich, Stanifer
17 Pun, Tyson 17 Ellis, Diamantidis
24 Research in Progress-Foster 24 Research in Progress-U. Patel 31 Smith, Makar
October April
1 Evans, Olivo 7 Foster, Singh
8 Research in Progress-Diamantidis 14 Research in Progress-G. Hall
15 Kovalik, Lehrich 21 Nagaraj, Traynor
22 G. Hall, Sethi 28 Research in Progress-Svetkey
29 Research in Progress-Gurley
November May
5 ASN 5 Gurley, Duronville
12 Middleton, Bumb 12 Spurney, Cameron
19 Research in Progress-Coffman 19 Research in Progress-Sparks
26 No Journal Club 26 Middleton, Bumb
December June
3 Scialla, Makar 2 Research in Progress-R. Hall
10 Research in Progress-Pun 9 Evans, Sethi
17 Crowley, Singh 16 Kovalik, Olivo
24 No Journal Club 23 Research in Progress-Crowley 31 No Journal Club 30 Johnson, Stanifer
If you have a conflict with your assigned date, you are responsible for identifying a substitute presenter.
Please be sure to notify Jamie Hartless of any changes made.
68
APPENDIX C
Core Clinical Curriculum Schedule 2015-2016 Revision June, 2015
Date Topic Speaker
Orientation Schedule
07/03/15 How to get stuff done at Duke John Roberts
07/07/15 Hemodialysis Basics Mike Berkoben
07/07/15 Potassium Mike Berkoben
07/08/15 Acute Kidney Injury Kim Evans
07/09/15 CRRT Basics Eugene Kovalik
07/10/15 Peritoneal Dialysis Basics Rudy Lehrich
07/15/15 Urinalysis Arthur Greenberg
Regular Schedule
07/22/15 Acidosis John Roberts
07/29/15 Alkalosis Mike Berkoben
08/04/15 Acid Base Problem Based Learning Sparks/Roberts
08/12/15 Sodium Homeostasis Mike Berkoben
08/19/15 Hyponatremia Ruediger Lehrich
08/26/15 Sodium/Water Problem Based Learning Sparks/Roberts
09/02/15 Assessment of Kidney Function Julia Scialla
09/09/15 Management of CKD Eugene Kovalik
09/16/15 CKD and ESRD Bone Mineral Metabolism Ruediger Lehrich
09/23/15 Hemodialysis I John Middleton
09/30/15 Hemodialysis II John Middleton
10/07/15 Home Modalities (PD, Home Hemodialysis) Ruediger Lehrich
10/14/15 Special Topics in CKD/ESRD (Pregnancy/ Nutrition) Eugene Kovalik
69
10/21/15 CKD/ESRD Problem Based Learning Sparks/Lehrich
10/28/15 ANCA associated Vasculitis/Anti-GBM disease
11/04/15 No Session- ASN
11/11/15 Multiple Myeloma, Amyloidosis & Light Chain Disease
11/18/15 Lupus Nephritis
11/25/15 HUS and TTP
12/02/15 Membranous/Minimal Change/Misc
12/09/15 FSGS
12/16/15 Glomerular Problem Based Learning
12/23/15 No Session- Holiday Schedule
12/30/15 No Session- Holiday Schedule
01/06/16 Transplant Evaluation
01/13/16 Transplant Immunosuppression
01/20/16 Transplant Infectious Complications
01/27/16 Transplant Clinical Care
02/03/16 Transplant Problem Based Learning
02/10/16 Disorders of Calcium/Phosphorus
02/17/16 Nephrolithiasis
02/24/16 Calcium/Phos/Stones Problem Based Learning
03/02/16 Tubulointerstitial Kidney Disease
03/09/16 ADPKD
03/16/16 Tubulointerstitial/ADPKD Problem Based Learning
70
03/23/16 Hypertension I
03/30/16 Hypertension II
04/06/16 Hypertension Problem Based Learning
04/13/16 Urinary Tract Infections
04/20/16 Ethics in Nephrology
04/27/16 End of Life, Palliative Care
05/04/16 Kidney Imaging
05/11/16 Magnesium
05/18/16 Drug Metabolism and Pharmacokinetics
05/25/16 Critical Care Nephrology CVVHD
06/01/16 Critical Care Problem Based Learning
06/08/16 Kidney Pathology I
06/15/16 Kidney Pathology II
06/22/16 Kidney Pathology III
06/29/16 Open
Core Research Curriculum Schedule 2015-2016 Revision June, 2015
Date Topic Speaker
July Research Integrity
August Data Management
71
September Basic Science Statistics
October Mouse Models in Research
November Tips for a Successful Research Career
December Intracellular Signaling
January Human Genetics Methodology
February Clinical Research Statistics I
March Clinical Research Statistics II
April Global Health
May Basic Mechanisms of Glomerular Diseases
June Research in Education
APPENDIX D
Dates Weeks Acute Acute UL* Transplant Dialysis VA
1-Jul Orientation
6-Jul Week 1 (overlap) Duronville Cameron @ Traynor*** Singh Makar
13-Jul Week 2 Duronville Bumb Traynor*** Singh Makar
20-Jul Week 3 Duronville Olivo Traynor*** Singh Makar
27-Jul Week 4 Duronville Sethi Bumb Singh Makar
3-Aug Week 5 Makar Olivo Duronville Traynor Singh
10-Aug Week 6 Makar Olivo Duronville Traynor Singh
72
17-Aug Week 7 Makar Stanifer Duronville Traynor Singh
24-Aug Week 8 Traynor Olivo Sethi Duronville Singh
31-Aug Week 9 Singh Stanifer Makar Duronville Traynor
7-Sep Week 10 Singh Sethi Bumb Duronville Traynor
14-Sep Week 11 Singh Bumb Makar Duronville Traynor
21-Sep Week 12 Singh Cameron Makar Duronville Traynor
28-Sep Week 13 Traynor Sethi Singh Makar Duronville
5-Oct Week 14 Singh Sethi Bumb Makar Duronville
12-Oct Week 15 Traynor Bumb Sethi Makar Duronville
19-Oct Week 16 Traynor Stanifer Singh Makar Bumb
26-Oct Week 17 Duronville Sethi Traynor Singh Makar
2-Nov Week 18 Duronville Traynor Singh Makar
9-Nov Week 19 Duronville Cameron Traynor Singh Makar
16-Nov Week 20 Duronville Sethi Traynor Stanifer Makar
23-Nov Week 21 Makar Sethi Bumb Traynor Singh
30-Nov Week 22 Makar Bumb Duronville Traynor Singh
7-Dec Week 23 Makar Bumb Duronville Traynor Singh
14-Dec Week 24** Makar Olivo Duronville Traynor Singh
2-Jan Week 26 Singh Cameron Makar Duronville Traynor
4-Jan Week 27 Singh Bumb Makar Duronville Traynor
11-Jan Week 28 Singh Bumb Makar Duronville Traynor
73
18-Jan Week 29 Singh Stanifer Makar Duronville Olivo
25-Jan Week 30 Traynor Sethi Singh Makar Duronville
1-Feb Week 31 Traynor Sethi Singh Makar Duronville
8-Feb Week 32 Traynor Bumb Singh Makar Duronville
15-Feb Week 33 Traynor Cameron Singh Makar Duronville
22-Feb Week 34 Traynor Stanifer Bumb Sethi Makar
29-Feb Week 35 Duronville Bumb Traynor Singh Makar
7-Mar Week 36 Duronville Olivo Traynor Singh Stanifer
14-Mar Week 37 Traynor Bumb Sethi Singh Makar
21-Mar Week 38 Makar Stanifer Sethi Traynor Duronville
28-Mar Week 39 Makar Sethi Duronville Bumb Singh
4-Apr Week 40 Makar Sethi Duronville Traynor Singh
11-Apr Week 41 Makar Stanifer Duronville Traynor Singh
18-Apr Week 42 Singh Sethi Duronville Traynor
25-Apr Week 43 Singh Makar Duronville Traynor
2-May Week 44 Traynor Singh Makar Duronville
9-May Week 45 Traynor Singh Makar Olivo
16-May Week 46 Duronville Traynor Singh Makar
23-May Week 47 Duronville Sethi Singh Makar
30-May Week 48 Bumb Duronville Traynor Singh
6-Jun Week 49 Makar Duronville Traynor Olivo
74
13-Jun Week 50 Singh Makar Duronville Traynor
20-Jun Week 51 Traynor Singh Makar Duronville
27-Jun Week 52 Duronville Traynor Singh Makar
4-Jul Week 53 Makar Duronville Traynor Singh
Notes:
* Acute upper level fellow
@ Overlap week (last week of 2014--‐15 schedule, overlap begins 7/6/15 until 7/12/15. Upper level coverage begins 7/13/15.
** Week 25 runs from 12/14/15 to 12/22/15
*** Traynor will start August 1st, transplant service will be attending only (total of two weeks)
Overlap week: Bumb – Acutes, Sethi – Transplant, Olivo – Dialysis, Stanifer – VA
75
APPENDIX E NEPHROLOGY FRIDAY MORNING CONFERENCE
JULY 2015 – JUNE 2016 DHN, Room 1308 (unless noted otherwise)
9:00 – 10:00 a.m.
July January
3 No Conference 1 No Conference
10 8 Clinical Case Conference
17 15 Blake Cameron
24 Kim Evans (Maestro Care) 22 DOCK Updates
31 29 Matthew Ellis
August February
7 GME Orientation 5 Robert Olivo
14 Alison Ashley-Koch 12 Pathology Conference
21 19 DOCK Updates
28 Pathology Conference 26 Supreet Sethi
September March
4 4 Tazeen Jafar (Duke-Nus)
11 Clinical Case Conference 11 Clinical Case Conference
18 David Ortiz-Melo 18 Wissam Kourany
25 Pathology Conference 25 DOCK Updates
October April
2 1
9 Clinical Case Conference 8 John Stanifer
16 15 Scott Sanoff
23 Pathology Conference 22 Shalini Bumb
30 ASN Abstracts 29 John Duronville
November May
6 CANCELLED – ASN 6 Shashi Nagaraj
13 Clinical Case Conference 13 Pathology Conference
20 20 Melissa Makar
27 CANCELLED 27 Harpreet Singh
December June
4 Christian Faul (U of Miami) 3 Eugene Kovalik
11 Pathology Conference 10 Clinical Case Conference
18 Stacy Johnson 17 Carol Traynor
25 CANCELLED 24
If you have a conflict with your assigned date, you are responsible for identifying a substitute presenter.
.Please be sure to notify Jamie Hartless of any changes made.
