Hitesh H. Shah

Why Not Nephrology? A Survey of US Internal Medicine Subspecialty Fellows

BACKGROUND There is a decreased interest in nephrology such that the number of trainees likely will not meet the upcoming workforce demands posed by the projected number of patients with kidney disease. We conducted a survey of US internal medicine subspecialty fellows in fields other than nephrology to determine why they did not choose nephrology. METHODS A web-based survey with multiple choice, yes/no, and open-ended questions was sent in summer 2011 to trainees reached through internal medicine subspecialty program directors. RESULTS 714 fellows responded to the survey (11% response rate). All non-nephrology internal medicine subspecialties were represented, and 90% of respondents were from university-based programs. Of the respondents, 31% indicated that nephrology was the most difficult physiology course taught in medical school, and 26% had considered nephrology as a career choice. Nearly one-fourth of the respondents said they would have considered nephrology if the field had higher income or the subject were taught well during medical school and residency training. The top reasons for not choosing nephrology were the belief that patients with end-stage renal disease were too complicated, the lack of a mentor, and that there were insufficient procedures in nephrology. CONCLUSIONS Most non-nephrology internal medicine subspecialty fellows never considered nephrology as a career choice. A significant proportion were dissuaded by factors such as the challenges of the patient population, lack of role models, lack of procedures, and perceived difficulty of the subject matter. Addressing these factors will require the concerted effort of nephrologists throughout the training community.

Glomerular diseases seen with cancer and chemotherapy: a narrative review

Glomerular lesions have been recognized in a number of malignant diseases. Membranous nephropathy is the most common glomerular pathology associated with solid tumors. In Hodgkins disease, the most common lesion is minimal change disease, reflecting possibly an anomaly of T-cell function. On the other hand, in patients with chronic lymphocytic leukemia, a large proportion of glomerular lesions fall into the category of membranoproliferative glomerulonephritis. Membranous nephropathy is also the most common glomerular disease seen following stem cell transplantation, suggesting a possible immune-mediated mechanism. Chemotherapy agents such as interferon, anti-vascular endothelial growth factor agents, tyrosine kinase inhibitors, and bisphosphonates have also been associated with various glomerular diseases and thrombotic microangiopathy. Failure to recognize certain paraneoplastic glomerular diseases can lead to potentially unnecessary therapies. This review describes the association of glomerular diseases with solid tumors, hematological malignancies, stem cell transplantation, and chemotherapeutic agents. We also describe the pitfalls in diagnosis and the dilemma in treating these entities.

Career Choice Selection and Satisfaction among US Adult Nephrology Fellows

Although many anticipate that there will be an eventual shortage of practicing nephrologists, a complete understanding is lacking regarding the current factors that lead US adult nephrology fellows to choose nephrology as a career and their satisfaction with this choice. It is of great concern that interest in obtaining nephrology fellowship training continues to decline in the United States, especially among US medical graduates, and the reasons for this are unclear. The exposure that students and residents have to nephrology is likely to play an important role in the career choices that they make and their ultimate satisfaction with this career choice is likely influenced by several factors, including job opportunities. Some of the findings presented here suggest that there may be a high percentage of nephrology fellows who are dissatisfied with their career choice. Failure to understand the factors that influence trainees to choose nephrology as a career and those that affect their satisfaction with this choice may impair the ability to graduate a sufficient number of nephrologists to meet projected demand. In this article, a number of variables related to the choice of nephrology as a career and satisfaction with a career in nephrology are discussed. Some steps that the nephrology training community might take to help promote interest in nephrology and optimize the satisfaction that nephrology graduates derive from their careers are also proposed.

Case-Based Debates: An Innovative Teaching Tool in Nephrology Education

Medical educators have called for new teaching methods and materials that supplement the traditional lecture format, and education in a range of health professions, including medicine, nursing, and pharmacy, is using a game-based approach to teach learners. Here, we describe a novel teaching tool in a case-based debate using the game format. Two teams of first- and second-year nephrology fellows participated in a PowerPoint game-based debate about which tests to order to diagnose transplant-related case. Our pilot study assessed the participant acceptance of case-based debate sessions and rewards system, and participant perceptions of using this approach to teach fellows and residents the importance of each test ordered and its cost-effectiveness in medicine. Each test ordered requires an explanation and has a point value attached to it (based on relevance and cost of positive and negative test results). The team that comes up with the diagnosis with most points wins the game. A faculty member leads a short concluding discussion. Subjective evaluations found these case-based debates to be highly entertaining and thought-provoking and to enhance self-directed learning.

The Emerging Role of Biosimilar Epoetins in Nephrology in the United States

Biologic drugs, including epoetin, continue to play an important role in the management of medical conditions. However, biologics are costly and soon many of the patents on these drugs will expire, making way for non-brand name products (ie, biosimilars). It is only by introducing competition to the marketplace that costs will de-escalate. In Europe, a specific regulatory pathway for approving biosimilars has been in place since 2005. A similar review pathway in the United States has been developed by the US Food and Drug Administration. These guidelines for approving biosimilars are stringent, requiring preclinical pharmacodynamic and toxicologic studies, clinical studies to demonstrate bioequivalence and efficacy, and long-term postmarketing studies to monitor drug safety. Biosimilar epoetin has been used in Europe since 2007, and a wealth of data has been collected. These studies and reports indicate that the efficacy and safety profiles of biosimilar epoetin are similar to those of originator epoetin alfa. Biosimilars of epoetin alfa are expected to be among the first biosimilar agents to be approved for use in the United States. The availability of lower cost epoetins may have significant impact on the treatment of anemia of chronic kidney disease.

Treatment with erythropoiesis-stimulating agents in chronic kidney disease patients with cancer

Treatment of anemia remains an important component in the care of patients with nondialysis chronic kidney disease (CKD) and end-stage renal disease (ESRD). Erythropoietin-stimulating agents (ESAs) remains a key anemia treatment strategy in this patient population. However, anemia management in this group can become more complicated by prior or current history of malignancy. There has been a great deal of work both scientifically and in clinical trials in oncology that have revealed certain concerns and risks of ESA use in patients with cancer. In this review, we will bring together knowledge from nephrology and oncology literature to help nephrologists understand the implications for ESA treatment when CKD/ESRD is complicated by cancer. We also suggest an approach to the management of anemia in this patient group with active or previous malignancy.

Long-term response to peginterferon in hepatitis C virus-associated nephrotic syndrome from focal segmental glomerulosclerosis

Abstract Hepatitis C virus (HCV) infection is a global public health problem. Chronic HCV infection is an important cause of chronic liver disease. Since the first reported association between HCV and membranoproliferative glomerulonephritis (MPGN) in 1993, HCV has been described with other types of glomerular diseases, although less frequently. Focal segmental glomerulosclerosis (FSGS) is one such glomerular disease that has been rarely reported in association with HCV. Antiviral therapy with interferon and ribavirin has been shown to be beneficial in HCV-associated MPGN. The optimal therapy of HCV-associated FSGS is not currently known. To our knowledge, long-term response to pegylated interferon monotherapy in treatment of HCV-associated FSGS has not been reported. We report an adult patient with HCV-associated FSGS who presented with nephrotic syndrome and renal failure. Treatment with pegylated interferon alfa-2a monotherapy resulted in sustained virological response with a clinical remission of nephrotic syndrome and stabilization of renal function. Patient continued to remain in clinical remission of nephrotic syndrome with stable renal function, 5 years after treatment. We also briefly review the literature on HCV-associated glomerular diseases, particularly HCV-associated FSGS.

Novel educational approaches to enhance learning and interest in nephrology.

The number of U.S. medical graduates pursuing careers in nephrology has declined over the last several years. Some of the proposed reasons for this declining interest include difficult-to-understand or unstimulating kidney pathophysiology courses in medical school; disheartening inpatient elective experiences; and few opportunities to experience the other aspects of nephrology careers such as outpatient nephrology clinics, outpatient dialysis, and kidney transplantation. Novel and alternative educational approaches should be considered by the nephrology training community to enhance the understanding of nephrology from medical school to fellowship training. Newer teaching methods and styles should also be incorporated to adapt to todays learner. These innovative educational approaches may not only increase interest in nephrology careers, but they may also enhance and maintain interest during nephrology fellowship. In this article, we will review several educational approaches that may enhance teaching and learning in nephrology.

Palliative care experience of US adult nephrology fellows: a national survey

Abstract Palliative care (PC) training and experience of United States (US) adult nephrology fellows was not known. It was also not clear whether nephrology fellows in the US undergo formal training in PC medicine during fellowship. To gain a better understanding of the clinical training and experience of US adult nephrology fellows in PC medicine, we conducted a national survey in March 2012. An anonymous on-line survey was sent to US adult nephrology fellows via nephrology fellowship training program directors. Fellows were asked several PC medicine experience and training questions. A total of 105 US adult nephrology fellows responded to our survey (11% response rate). Majority of the respondents (94%) were from university-based fellowship programs. Over two-thirds (72%) of the fellows had no formal PC medicine rotation during their medical school. Half (53%) of the respondents had no formal PC elective experience during residency. Although nearly 90% of the fellows had a division or department of PC medicine at their institution, only 46.9% had formal didactic PC medicine experience. Over 80% of the respondents program did not offer formal clinical training or rotation in PC medicine during fellowship. While 90% of the responding fellows felt most comfortable with either writing dialysis orders in the chronic outpatient unit, seeing an ICU consult or writing continuous dialysis orders in the ICU, only 35% of them felt most comfortable “not offering” dialysis to a patient in the ICU with multi-organ failure. Nearly one out of five fellows surveyed felt obligated to offer dialysis to every patient regardless of benefit. Over two-thirds (67%) of the respondents thought that a formal rotation in PC medicine during fellowship would be helpful to them. To enhance clinical competency and confidence in PC medicine, a formal PC rotation during fellowship should be highly considered by nephrology training community.

Evidence-based nephrology-rheumatology debates: a novel educational experience during nephrology fellowship training.

Abstract Medical educators have called for novel learning methods that supplement the traditional lecture format. Fellowship education involves didactics and pedagogic strategies using a variety of learning tools in order to improve critical thinking skills. Debating is one such tool that can enhance critical thinking skill. However, to the best of our knowledge, evidence-based debating among two different internal medicine subspecialty fields during fellowship training has never been reported. In this article, we describe an innovative educational experience for trainees using the evidence-based debate format. Two teams consisting of equal number of first- and second-year nephrology and rheumatology fellows participated in our annual interdivisional debate session. Topics that have been debated over the last three annual debate sessions include management of small vessel vasculitis and lupus nephritis. To assess the educational experience of the debate session, all fellow participants were asked to complete an anonymous on-line survey following the debate. The survey consisted of several questions using a 5-point Likert scale. All fellow participants enjoyed the debate format and found this experience to be thought-provoking and to enhance their self-directed learning.