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Rachel Shaffer

Interest in nephrology as a career among United States medical graduates (USMGs) is declining—and has been on the decline for the better part of a decade. From 2002 to 2009, all internal medicine subspecialties increased the number of available positions, with the exception of geriatric medicine (which shrank overall) (1, 2). Yet, in 2009, nephrology was the only internal medicine specialty to attract fewer USMGs than in 2002, the result of a steady seven-year decrease in the number of USMGs entering the renal field (Figure 2.1). During that time, the number of USMGs in

Daniel Kochis

The workforce crisis hitting the field of nephrology extends beyond physicians to nurses, nurse practitioners, and physician assistants (PAs), who are often on the front lines in the battle against kidney disease. Nurses and nurse practitioners provide essential services to patients with kidney disease, working in hospitals, dialysis centers, and homes. They help bridge the growing gap between the number of patients with kidney disease and the availability of nephrologists.

Despite the essential role of nurses in caring for patients, the future of nursing is less than certain. In 2008, the average age for nurses reached 46, reflective of an

Rachel Shaffer

In contrast to adult nephrology, pediatric nephrology significantly increased its number of USMG fellows in recent years (1, 2). From 2002 to 2009, the number of pediatric nephrology fellows grew from 65 to 123, and the number of USMGs in pediatric nephrology fellowships jumped from 31 to 71, bringing USMGs up to 57.7 percent of the total from 47.4 percent.

During this time, more women also entered the specialty. In 2002, 34 pediatric nephrology fellows were women (53.3 percent); in 2009, 83 were women (67.5 percent). Yet pediatric nephrology may not be the bright spot it

Daniel Kochis

To facilitate the matching of internal medicine residents with nephrology fellowship training programs, nephrology first participated in the Electronic Residency Application Services (ERAS) in 2006 and the Medical Specialties Matching Program (MSMP) in 2007. MSMP—part of the larger National Residency Matching Program—is a service that pairs residents with available fellowship positions. Currently, 10 internal medicine specialties participate in MSMP (Table 6.1).

In 2011, continuing the downward trend that has plagued the nephrology fellowship match in recent years, the fewest number of residents applied for positions than in any year since the ASN first joined the MSMP (1

Tod Ibrahim

From boom to bust, the projections for the physician workforce in the United States reverse every 20 years. In the 1960s, experts projected a shortage of 40,000 physicians by 1975. During the 1980s and 1990s, some of the same experts predicted a surplus of up to 165,000 physicians by 2000. A few years ago, the country was expected to face a shortage of 55,000 physicians by 2020 (1). But with last year’s passage of the Affordable Care Act (ACA), which extends coverage to the uninsured, the country is now projected to need an additional 91,500 physicians by 2020

J. D. Schold

Policies governing the allocation of deceased donor organs must incorporate numerous factors, which are often very difficult to satisfy in a simultaneous manner. These policies can have a significant impact on patients’ lives, but we must carefully consider objective factors such as logistical operations and efficient resource allocation along with more subjective constructs such as equity and justice.

Perhaps an even more difficult challenge is to prospectively consider possible unanticipated changes in behavior by patients and caregivers that may arise from these policies. For certain, any changes in policy should be considered deliberately and conscientiously, with the best information available

David Goldfarb

A wide array of ethical issues comes into play regarding renal transplantation after prior solid organ transplantation. They include concerns about prevention and access. One must first understand the scope of the problem. The prevalence of chronic kidney disease (CKD) among prior non–renal organ transplant (NRTx) recipients is between 80 percent and 100 percent for those who survive three years. The more advanced stages of CKD, types IV and V, occur in 5–20 percent of patients by five years after NRTx, and they vary according to the type of transplant. CKD is lowest in heart–lung recipients and highest in intestine

In recent years, the 60- to 80-year-old age group on the kidney transplant waiting list has increased dramatically, decreasing their chances of ever receiving a kidney. Yet studies show that even those older than 70 can decrease their chance of death and increase the length of their life with a kidney transplant.

Evaluating elderly patients for a transplant should be an “exaggeration” of evaluating younger patients, said Gabriel Danovitch, medical director for the Kidney and Pancreas Transplant Program at the University of California, Los Angeles. Physicians should rule out coronary artery disease, other cardiovascular disease, and cancer. Patients should also

T. R. Srinivas

Kidney transplants are being performed in an era when higher-risk donor organs are being used. One could expect, given this scenario, that posttransplant renal function and graft survival would be adversely affected.

Refreshingly, recent studies show that kidney transplant function in the United States has improved in recent years, as has also graft survival.

In a study using Scientific Registry of Renal Transplant Recipients data from more than 90,000 recipients who underwent transplantation between 2003 and 2008, the estimated GFR 6 months after transplant averaged 54.3 mL/min/1.73 m2 (1). The decline in GFR between 6 and

Unrelated living donors in the United States have increased to the point where they were the most common category in 2009, most likely because of swaps and chains, said Gabriel Danovitch, medical director for the Kidney and Pancreas Transplant Program at the University of California, Los Angeles.

The total recipient pool reflects the populations undergoing dialysis; white persons form the largest category, followed by African American, Hispanic, and then Asian persons. But the donor pool reflects the demographics of the national population, meaning that African American and Hispanic individuals are overrepresented recipients and underrepresented donors. Danovitch believes that this largely