Kidney transplantation is the optimal treatment for kidney failure (1). As recently as 2019, there were 244,000 kidney transplant recipients (2) with a functioning kidney allograft, and this number continues to grow (3, 4). Thus, it is very important that we strive to ensure our workforce is trained to be able to care for this group of patients. A 2020 review article (5) estimates there are 1200-1400 transplant nephrologists in the United States. There are 149 accredited nephrology training programs in the United States (6) and <50% (63/149) of these with accredited transplant nephrology programs (7). Less than 10% of nephrology fellows usually pursue an additional year of transplant training (Figure 1).
The Accreditation Council for Graduate Medical Education (ACGME) requires a minimum of 2 months of clinical experience during nephrology fellowship training on an active transplant service (ACGME core program requirements, section IV.A.6.a).(2)) in managing all aspects of kidney transplant care (8). This longitudinal care includes preemptive listing or waitlist candidacy assessment; immediate posttransplant care (at least 10 new transplants); and the management of immunosuppression, rejection, and long-term care of the patient with a kidney transplant. To achieve this, the nephrology fellowship program should be a transplant center or have a written agreement with a transplant center (ACGME common program requirements, section II.D.4.c)). Outside rotations for fellows for transplant education should be arranged for trainees.
The ultimate goal of fellowship training is to adequately prepare fellows to be able to provide compassionate, appropriate, and effective peri-transplant care for kidney transplant recipients and kidney donors. When these trainees graduate, they help create a shared care model between transplant centers and general nephrologists. Moreover, reflecting this point, 11% of the American Board of Internal Medicine (ABIM) nephrology subspecialty blueprint for the board examination covers transplant-related topics (9). Thus, the core curriculum of any nephrology fellowship program should heavily emphasize transplantation topics.
When these trainees graduate, they help create a shared care model between transplant centers and general nephrologists.
Apart from conventional fellowship training, online education, including the use of social media platforms (FOAMed [free open access medical education]), can be used to supplement the training. Continuing medical education (CME) symposiums and webinars are great tools to stay abreast with advances in kidney transplantation, and a lot of these resources are available on social media platforms for free. Early introduction of kidney transplantation in medical education, at the student or resident level, can spark interest in nephrology and/or transplant. In addition to rotation on consults and dialysis service, exposure to patients with kidney transplant is important, as we have done at our institutes. Out of 4 weeks, students/residents spend 2 weeks in consult service and 1 week each in dialysis and transplant rotation. Regarding nephrology fellows, it would be ideal if there were exposure from early in the first year of fellowship.
The care of the kidney transplant recipient is complex and involves a multidisciplinary team approach that manages medical care, financial, and social work concerns. This makes the recipient an important stakeholder in posttransplant care and outcomes (10), highlighting the importance of more structured transplant education during fellowship. Robust CME opportunities for practicing physicians in general nephrology should be prioritized, and an enhanced transplant representation in national meetings is desired.
In conclusion, a renewed focus on kidney transplant education is the first step in enabling nephrology trainees, which will eventually lead to improved kidney transplant care and achieve the goals of the Advancing American Kidney Health Initiative.
References
- 1.↑
Abecassis M, et al. Kidney transplantation as primary therapy for end-stage renal disease: A National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQITM) conference. Clin J Am Soc Nephrol 2008; 3:471–480. doi: 10.2215/CJN.05021107
- 2.↑
United Network for Organ Sharing (UNOS). Transplant trends. More deceased-donor organ transplants than ever. 2021. https://unos.org/data/transplant-trends/
- 3.↑
United States Renal Data System (USRDS). 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020. https://adr.usrds.org/2020
- 4.↑
2019 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. OPTN/SRTR 2019 Annual Data Report: Kidney. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, Rockville, MD; United Network for Organ Sharing, Richmond, VA; University Renal Research and Education Association, Ann Arbor, MI. https://srtr.transplant.hrsa.gov/annual_reports/2019/Kidney.aspx
- 5.↑
Concepcion BP, et al. The transplant nephrology work-force in the United States: Current state and future directions. Adv Chronic Kidney Dis 2020; 27:336-343.e1. doi: 10.1053/j.ackd.2020.05.005
- 6.↑
Brotherton SE, et al. Graduate medical education, 2019-2020. JAMA 2020; 324:1230–1250. doi: 10.1001/jama.2020.14635
- 7.↑
Transplant Nephrology Fellowship Training Accreditation Program, LLC. List of accredited transplant nephrology fellowship programs. Accessed May 25, 2021. http://www.txnephaccreditation.org/programs
- 8.↑
Accreditation Council for Graduate Medical Education (ACGME). ACGME Program Requirements for Graduate Medical Education in Nephrology. July 1, 2020. https://www.acgme.org/Portals/0/PFAs-sets/ProgramRequirements/148_Nephrology_2020.pdf?ver=2020-06-29-162357-583
- 9.↑
American Board of Internal Medicine (ABIM). Nephrology Certification Examination Blueprint. Accessed May, 25, 2021. https://www.abim.org/Media/iohh2ahg/nephrology.pdf
- 10.↑
Sawinski D, et al. Introduction to kidney transplantation: Long-term management challenges. Clin J Am Soc Nephrol [published online ahead of print March 10, 2021]. doi: 10.2215/CJN.13440820; https://cjasn.asnjournals.org/content/early/2021/04/01/CJN.13440820
