ASN and AST Take Joint Step Towards Transplant Nephrology Training

ACGME accreditation would advance transplant nephrology as a distinct medical sub-subspecialty and foster broad nationwide adoption of uniformly rigorous transplant nephrology training.  

Kidney transplantation is the optimal therapy for many patients with kidney failure, and the growing recognition of this fact within the U.S. government has yielded numerous federal initiatives to increase patients’ access to kidney transplants, such as the Advancing American Kidney Health Initiative (2019), the ESRD Treatment Choices (ETC) model (2021), the Organ Procurement and Transplantation Network Modernization Initiative and the Securing the U.S. OPTN Act (2023), and the Increasing Organ Transplant Access (IOTA) model (2024), among others. 

Increasing the number of patients who benefit from kidney transplantation calls for the highest quality of possible care at each step of the journey: before, during, and after their kidney transplant. Managing kidney transplant candidates, recipients, and living donors has become increasingly complex over time as scientific and clinical advancements have made it possible to transplant people who would never have been considered candidates in the past. 

The joint American Society of Nephrology (ASN) and the American Society of Transplantation (AST) Task Force on ACGME Accreditation for Transplant Nephrology (see Table 1), which aims to ensure every kidney transplant recipient and donor receives optimal care, recently applied for recognition of transplant nephrology as an accredited sub-subspecialty of nephrology. In an application to the Accreditation Council for Graduate Medical Education (ACGME), ASN and AST laid out how the clinical practice and focus of adult transplant nephrology is distinct from that of general adult nephrology. Between the growth of the kidney transplant patient population and the increasing complexity of patients as well as the landscape of transplant care delivery, many transplant nephrologists’ clinical practice is now solely dedicated to organ transplantation, primarily kidney-focused. By supporting a broad nationwide adoption of uniformly rigorous transplant nephrology training, ASN and AST hope to improve the quality of care provided to patients in both pre- and post-transplant phase.

General nephrologists have always had and will continue to have an important role to play in transplant care in the multidisciplinary kidney care team, such as helping identify candidates who might benefit, supporting people on dialysis in remaining healthy enough for transplantation, and assisting in longer-term post-transplant care. Transplant nephrologists complement general nephrologists in addressing aspects of care that are uniquely transplant-related, such as counseling candidates on their options to transplant, providing nephrological management in the perioperative setting, managing immunosuppression, and detecting and addressing transplant-related complications.

ACGME accreditation will open the door to many possible benefits for transplant nephrology that are not available to sub-subspecialties that lack accreditation. For example, transplant nephrology could obtain Centers for Medicare and Medicaid Services (CMS) designation. ACGME accreditation is required to obtain CMS Provider Enrollment, Chain, and Ownership System (PECOS) designation for any specialty, and CMS reimbursement rates for medical services are often tied to specialty designations. This means that CMS could identify transplant nephrologists—which is not possible today—and value their unique contributions in future value-based care models. Furthermore, the American Medical Association (AMA)’s Relative Value Scale Update Committee could consider the creation of new current procedural terminology code and relative value units associated with transplant nephrology. 

In addition, ACGME accreditation can support growth in transplant nephrology fellowship programs and positions as it will remove current disincentives for programs to offer positions to trainees on a J-1 visa (e.g., to obtain Non-Standard Training Recognition from ACGME) and could help support the funding of transplant fellows through graduate medical education funds from Medicare.

At present, trainees wishing to pursue a third year of training to specialize in transplant nephrology must first successfully complete the two-year general nephrology training program, a structure ASN and AST envision will remain in place should ACGME accreditation be awarded.

Importantly, ASN and AST are especially eager to ensure that ACGME certification of transplant nephrology does not result in the unintended consequence of additional exam (and financial) burden for transplant nephrologists. Contrary to widespread belief, ACGME accreditation does not require the development of another initial certification exam or additional maintenance of certification exams. ASN and AST have identified a spectrum of options that could potentially address concerns regarding additional exam burden as well as create opportunities for transplant nephrologists to demonstrate their excellence in their chosen field. Should ACGME grant transplant nephrology ACGME accreditation, ASN and AST are committed to working closely with the transplant nephrology community to determine the most appropriate approach to initial and ongoing certification.

Should the ASN-AST application for accreditation for transplant nephrology pass an initial ACGME review, it will be posted for a 45-day public comment period in June 2024, followed by additional review and consideration by various ACGME entities. ASN and AST will also host a series of town halls in advance of the public comment period deadline; details will be forthcoming. 

If you have questions or comments regarding this effort, please share them with ASN and AST at policy@asn-online.org.

Table 1. ASN-AST Task Force on ACGME Accreditation for Transplant Nephrology

• Deborah, B. Adey, MD, FAST
  San Francisco, CA
• Roy D. Bloom, MD, Chair
  Philadelphia, PA
• Beatrice P. Concepcion, MD, MS, FASN
  Chicago, IL
• Gaurav Gupta, MD
  Richmond, VA
• Michelle A. Josephson, MD, FASN, Nonvoting Ex Officio, ASN Past President
• Vineeta Kumar, MD, FASN, FAST
  Birmingham, AL
• Mark G. Parker, MD, FASN
  Portland, ME
• Deirdre Sawinski, MD, FAST, Nonvoting Ex Officio
  AST Board of Directors, Councilor-at-Large
• Neeraj Singh, MD, MBA, FASN, Vice Chair
  Shreveport, LA

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