Special Section

Special Section

These are certainly interesting times for nephrology education. As the number of patients with chronic kidney disease increases, the number of trainees seeking careers in nephrology is not keeping pace. The nephrology workforce forms the ASN, so this month we examine personnel issues, including changes in the education of nephrologists-to-be and those maintaining certification. Other topics of interest include international medical graduates, women, transplant nephrologists, and pediatric nephrologists.

In 2007, only 21 percent of practicing nephrologists were women, and females filled 36 percent of nephrology training slots. We asked three women to talk about gender issues in the profession.

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The work lives of most pediatric nephrologists differ significantly from those of our internal medicine colleagues in all aspects of the career pathway. Changing patient and trainee demographics and expectations have spurred a renewed interest in evaluation of our current training processes with an eye toward the future.

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U.S. nephrology training program directors (TPDs) are increasingly joining forces to meet many of today’s current challenges. These efforts are spearheaded by the American Society of Nephrology’s (ASN) TPD executive committee. The committee consists of members elected by the TPD community to serve three-year terms, and is led by the ASN Education Director for Nephrology Fellowships.

For years, international medical graduates (IMGs) have comprised a significant percentage of the fellows in nephrology training programs who prepare to provide treatment to the rapidly growing population of patients suffering from kidney disease. In the 2006–2007 school year, physicians trained in foreign institutions constituted 47 percent of the fellowship class, an increase over the historic low of 38 percent in 2002–2003, and a return to the high percentages posted in the late 1990s.

The United States will face a shortage of nephrologists during the next decade. This shortfall will occur despite the fact that the number of nephrology fellows nearly doubled during the past 20 years, from 460 in 1987 to 863 in 2008 (1,2). The current disparities—by ethnicity, socioeconomic status, and geographical location—among patients with kidney disease will worsen as a result of this shortage.

For this issue's focus on hypertension, we have assembled a small portfolio of articles describing recent provocative advances in the study of hypertension.

Most people with chronic kidney disease (CKD) have high blood pressure. Treatment of hypertension in patients with CKD is considered critical to prevent CKD progression and related cardiovascular events. However, questions remain about the appropriate BP goal. Most evidence indicates there is no benefit of treating to a goal any lower than 140/90 mm Hg, but there is some suggestion that such a goal may be appropriate for patients with albuminuria.

Hypertension is a common condition that is a significant risk factor for development of other cardiovascular diseases. The prevalence of hypertension is higher in men than women until after menopause, when the prevalence reverses and is higher in women. In addition, more women die of cardiovascular disease each year than do men.

Although cardiologists and nephrologists have debated for years about the relative contributions of the vasculature and the kidney to the pathogenesis of hypertension, new data have emerged that may recast essential hypertension as an autoimmune disease. These studies do not discount the importance of vascular tone and regulation of intravascular volume in the determination of blood pressure.

In the United States we are currently experiencing the phenomenon of the “graying of America,” whereby the population is growing older and the proportion of those 65 years and older is rapidly increasing. Data from the U.S. Census Bureau predict that the number of individuals 65 years and older will double in the next 20 years. Most of this growth is happening in the “oldest old”—that is, 85 years and older.