Critical Care Nephrology: The Formidable Combination

What is nephrology critical care?

The census of hospitalized critically ill patients has risen over the last decades (1). As this population expands, leaders of intensive care units (ICUs) are attempting to diversify the healthcare team. A rapidly expanding area within the diversified ICU team is nephrology critical care. The combination of nephrology and critical care is a seamless amalgamation of physiology, pathobiology, and organ crosstalk, which renders the clinician equipped with expertise in acute kidney injury, acid-base/electrolyte disorders, and volume management (Figure 1).

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Importantly, as the critically ill population becomes sicker, reliance on extracorporeal support therapies (kidney replacement therapy, hemoperfusion, immunomodulation, plasma exchange, extracorporeal organ oxygenation or CO₂ removal, etc.) is essential to state-of-the-art care in settings of severe multiorgan failure (2). A deep understanding of the intricacies in the provision of these therapies is a valuable asset to any ICU practice. The COVID-19 pandemic stressed the importance of supply of these therapies and reinvigorated the value of the nephrologist in the ICU (3).

How to train in nephrology critical care

There are two tracks to become dual board certified in nephrology and critical care medicine: 1) 3-year combined fellowship or 2) two separate fellowships in succession. For the combined 3-year fellowship, trainees often have the option of blending the two over the total time in training or completing one field followed by the other. When formally separating the two fellowships, either at the same institution or different institutions, it should be noted that nephrology followed by critical care allows for a 3-year completion time (2-year nephrology, 1-year critical care); however, critical care followed by nephrology results in a 4-year completion time (2 years for both programs), as even with the 2-year critical care base, nephrology training requires an additional 2 years to be board eligible.

An alternative is to become a nephrologist focused on critical care. In this track, trainees customize their fellowship to accommodate more ICU rotations and develop specific skills in bedside ultrasonography and multifaceted organ support. The training can be further complemented by research year(s) for those interested in academic medicine in the scholar track. How does one go about deciding their path? Multiple factors come into play such as location, training opportunities, and work-life balance. However, an important question to ask yourself is: How do you envision your future practice? The answer may be intercalating time as an intensivist and a nephrologist or being a full-time nephrologist focused on the comprehensive spectrum of acute care nephrology.

Why train in nephrology critical care?

A recent survey of clinicians dual certified in nephrology and critical care revealed overall high employment satisfaction, although some participants highlighted difficulties in job search/availability post-training. The survey also noted that about one-half of dual-certified clinicians are currently working in academic medicine (4). This is likely in part due to it being easier to negotiate a dual appointment between two divisions in academic hospitals. There remains no clear structure and less flexibility for this dual appointment in private practice settings, particularly those with close ICU models. The average compensation appears to be higher in dual practice as compared to nephrology alone. The practice of acute care nephrology remains an exciting and innovative field with dynamic collaboration, constant scientific discovery, and evolving technologies. Although we are not needed every day, we can offer complementary expertise when we have a chance. At the end of the day, the intensivist is not only waiting for dialysis but for the acute care nephrologist to come.