Pediatric Nephrology Fellowship
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The Jackson Health System / Jackson Memorial Hospital Pediatric Nephrology Training Program, in affiliation with the Department of Pediatrics at the University of Miami Miller School of Medicine, is under the direction of Gaston Zilleruelo M.D., Professor of Pediatrics and include six full-time board certified pediatric nephrologists, one Voluntary Assistant Professor (Dr. Carlos Cuervo), a nurse liaison/case manager, dialysis nursing staff, clinical social worker, dietitian, psychologist, and administrative staff. The division is the main referral center for children with renal-GU disease in South Florida and it covers a total population over 4.0 million inhabitants. This assures an adequate clinical exposure for each fellow during the training program.
The Pediatric Nephrology Fellowship Training Program Curriculum is designed for each year to be alike, except that the degree of responsibility given to the fellow increases. Thus, the fellow is expected to demonstrate increasing knowledge and expertise improvement each year in an area of the Fellowship Training Program. The program is based on previous experiences in the teaching of fellows who have completed training in our Division; also, it follows the general guidelines developed by the ACGME and American Board of Pediatric for Training Programs in Nephrology.
- To provide an educational program which will enable pediatric nephrology fellows to become well-trained clinicians in all areas of pediatric nephrology
- To provide a structured training program that will enable pediatric nephrology fellows to become effective consultants assisting their clinical colleagues in the care of their patients
- To provide the pediatric nephrology fellows with opportunities to become effective teachers
- To provide the pediatric nephrology fellows with opportunities to develop skills and experience in clinical and laboratory research
- To provide the pediatric nephrology fellows with the understanding that the constantly changing base of knowledge in medicine demands they become lifelong students and provide examples of how to accomplish this goal
- To provide the pediatric nephrology fellows with sufficient preparation which will enable them to be accepted for and successfully obtain certification by the American Board of Pediatric Nephrology
ACGME Accredited: Yes
Residents or Fellows per year: 1
Duration: 3 Years
Postgraduate Training Required: Pediatrics
U.S. Citizenship Required: No
- Holtz Children’s Hospital
Completed a Residency in an ACGME accredited Pediatric Program.
All applicants should register through Electronic Residency Application Service (ERAS) for match in the fall each year.
Interviews are scheduled starting July 1 and up to September 30 each year.
Fellows on clinical rotations have an assigned attending faculty to supervise their activities at all times. A schedule with all the clinical activities for the whole academic year is distributed to the staff at the end of May each year. This Calendar reflects on a weekly basis the distribution for all the faculty and corresponding fellows, including time off for vacations or attendance to meetings. Unless in an emergency, in-patient fellows should not become involved in patient care from other rotations, i.e dialysis or out-patient clinics.
During the in-patient experience fellows are required to see and discuss evaluation and plan of care for each patient admitted to the renal service or consultations. This is usually done during the daily rounds, but if considered necessary, patient discussion may occur at any time day or night. Attending faculty should be readily available to discuss complex or difficult patients and give recommendations.
- Attending faculty will assume final responsibility for all the decisions implemented by the fellows under their direct supervision.
- Fellows should be able to discuss with the attending faculty at a mutually agreed time on a daily basis all the patients admitted to the renal service and any new consultations.
- Fellows have the responsibility to obtain a thorough history, physical examination and laboratory up-date in all the patients followed by the renal service, and are expected to present them for discussion with the attending faculty.
- Fellows have the responsibility to supervise the house staff regarding the specific implementation of the plan of care for the patients assigned to their team.
- If a fellow considers it necessary to come at night to the hospital to see a patient, attending faculty should be properly notified.
- Attending faculty should provide a backup support system when patient care responsibilities are unusually difficult or prolonged or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.
Fellows carry the first-call beeper for all inpatient consultations and admissions of the patients being followed by the Division of Pediatric Nephrology. They are responsible for the evaluation and plan of care for these patients after proper discussion with the nephrology attending. All new admissions are placed under a pediatric house staff team and followed by the renal service on a daily basis. The attending in the pediatric nephrology service supervises the fellow and makes daily rounds seeing and examining each patient. Usually rounds are done twice a day (morning and afternoons) or as required depending on acute unstable patients (PICU, NICU). During the first year of the program the pediatric nephrology trainee is responsible for rendering consults to other services such as Pediatric Intensive Care Unit, Pediatric Surgical Unit, and Newborn Special Care Units. The trainee does the initial evaluation and assessment of the patients problem and presents this finding to the attending pediatric nephrologists and discuss the patient care management issues and potential therapeutic interventions. The trainee and the attending pediatric nephrologist will develop a final plan of recommendations regarding the consultation. Fellows acquire experience in various procedures including renal biopsy during the inpatient rotation. Under attending supervision the fellow is required to perform renal biopsies under ultrasound guidance during the second and third years of the training programs.
Fellows may also be required to see patients in the emergency room in consultation. The pediatric emergency room is located in the first floor of the Children’s Hospital Center in the East Tower. After the patient is seen in the emergency room the fellow will discuss the patient with the pediatric nephrology attending.
OUTPATIENT CLINICS EXPERIENCE
Outpatient clinics are held Monday through Thursday in different locations throughout the Medical Center. Fellows are responsible for starting the clinics on time, coordinate with nurse liaison census for each clinic and provide and easy flow of patients to be seen. In addition, fellows are assigned continuity clinics on a rotating basis during the periods in which they are not in inpatient service. Still, when they cannot attend clinics, they remain involved in the follow up of their patients through the discussion in the weekly out-patient review. After each patient is seen in clinic, the fellow writes his/her notes and discusses findings and plan of care with the renal attending. Fellows are responsible to follow all clinic laboratory results from patients seen in the corresponding clinic and implement plans of care discussed during the out-patient clinic review. Participation at the weekly transplant conference will teach the criteria of selection for transplant and management of complications post-renal transplant. Also, during the clinic rotation fellows are required to perform complete urinalysis of those patients seen at the MCCD Clinic on Wednesday mornings.
During the dialysis rotation fellows will acquire longitudinal experience in the therapeutic modalities of hemo and peritoneal dialysis. First rotation in dialysis will serve as an orientation to all the patients managed with End Stage Renal Disease in the Program and to learn basic aspects of dialysis which will be taught by the dialysis attending for that month. Fellows will learn about the indications of dialysis, evaluation of dialysis efficiency, nutritional requirements in dialysis and most common complications. Fellows will make rounds on a daily basis on each hemodialysis patient. Patients are seen with the pediatric dialysis nurse in charge and consultation to the dietary services and social worker will be decided as needed. Acute dialysis, hemofiltration and transplant experience is obtained during the inpatient rotation and also at the transplant clinic located in the transplant center. Fellows are responsible for completing a monthly clinic evaluation note for all the patients receiving treatment at the Pediatric Dialysis Unit and should participate actively with the members of the interdisciplinary team in the weekly dialysis patient review. Fellows attend Quality Assurance/ Quality Improvement (Triage Meetings) and learn how to supervise ESRD care of the patients. Particular attention is given to cover topics of renal osteodystrophy, anemia management, hypertension and electrolyte abnormalities. Fellows will study the Kidney Diseases Outcome Quality Initiative (K-DOQI) of the National Kidney Foundation in order to understand the clinical pathways used in ESRD care.
Fellows are encouraged to participate in all administrative discussions of the pediatric nephrology facility particularly in reference to the Dialysis Unit and outpatient clinics.
RENAL PATHOLOGY EXPERIENCE
Each trainee will be exposed to issues of renal pathology by direct contact with the renal pathologists, Drs. Laura Barisoni and David B. Thomas and will be taught the basic principles of this discipline. Trainees will be expected to understand the patterns of immunofluorescent microscopy and their relationship to the pathogenesis diagnosis and prognosis of renal diseases. Transplantation immunology and tissue typing will be taught by the tissue-typing laboratory under the Direction of Dr. Phillip Ruiz.
All fellows will be required to attend the monthly Pediatric Renal Biopsy Conference. They will be responsible for presenting the clinical history relating to a particular patient along with the impression of the diagnosis based upon the light microscopy, fluorescent antibody stains and electron-microscopy. Each trainee will be required to evaluate all renal biopsies, which they perform with the renal pathologist on a timely basis. During the second year of training, it would be expected that the trainee would perform the biopsy procedure itself after counseling the patient and family with regard to the risk and benefit of the procedure. Moreover, it will also be expected that the trainee discuss the biopsy result with the patient and family after reviewing this with one of the faculty members to be certain that appropriate information is transmitted to the family. This latter step will require that the trainee review the renal biopsy with both the faculty member who will be supervising the trainee as well as the renal pathologist before discussion with the family. For one month, during the first two years, the fellows will have a full-time experience in pathology. During this time, they will be expected to become familiar with the immunopathology of the kidneys as it relates to various diseases and to transplantation. Also, the fellows will review with the Pediatric Pathologist and renal attending all renal and urologic specimens and in particular kidneys that have been removed and tumors of the kidney. Feedback for the evaluation of this experience will be provided directly by Dr. David Thomas to the Program Director.
Fellows will have one month rotation through the Radiology Department in which will observe and learn the various renal/bladder imaging modalities, including renal/bladder ultrasounds, VCUG, CT scans, and MRI. Special emphasis will be in Nuclear Medicine where they will be under the direct supervision of Dr. George Sfakianakis learning how to read and interpret renal scans.
Fellows will develop more expertise in the interpretation of imaging tests during the weekly Uro-Radiology Conferences where they are in charge of selecting cases, helping to collect films and reviewing them during or after the conference. Feedback for the evaluation of this experience will be provided directly by Dr. Sfakianakis to the Program Director at the end of the rotation.
The trainee’s responsibility for teaching will include informal discussions with medical students and pediatric house officers. Medical students and medical house officers on elective in pediatric nephrology will work closely with the fellow during the four months that he/she is on the in-patient service. During the clinic rotation, the teaching of students and house officers will be done by the fellow together with the renal attending. The fellows’ presentations will be reviewed prior to their delivery at a conference; there will be a critique of the conference provided by the pediatric nephrology faculty. A strong emphasis on developing teaching skills and the ability to communicate complex information will be the goal of this training program as these skills are particularly pertinent to the care of children with renal disorders. The trainee will be precepted by the renal attending in all areas of patient care. However, the level of responsibility in teaching and patient care will increase during each year of the training.
- Fellow will be encouraged to participate in the teaching of medical students by given periodic lectures on the subject of UTI and nephrotic/nephritic syndrome.
- Fellows may also participate in formal lectures for House Staff and Board Review Sessions.
- Fellows will make every effort to attend all the teaching/scholarly activities scheduled by the Division. Attending faculty should facilitate and encourage timely attendance to these activities.
Board Exam Requirements
Complete three years of fellowship and a Scholarly Work Product under the supervision of a designated Scholarly Oversight Committee. As a result of this product, it is expected a manuscript publication in a peer reviewed journal for which the fellow is the first author.
Educational & Other Experience
- First Year of the Training Program
In the first year, the Fellow will have four months assigned to the in-patient service, three months assigned to the dialysis unit and two months of elective rotations covering radiology and renal pathology. During the first year the fellow will develop a basic understanding of renal function in health and disease, the various types of kidney disease, procedures and techniques in the assessment of kidney structure and function, and will establish an association with one or more of our faculty for clinical and/or basic research. The fellow will have two months assigned to research.
- In the second year, the trainee will have four months assigned to the in-patient service, two months in pediatric dialysis and one month in the out-patient clinics. In addition, fellow will cover one clinic per week during all the rotations, except during in-patient call. Fellow will begin and in-depth assessments of specific areas of clinical nephrology and will further develop his/her teaching expertise. By this time he/she should be in the midst of a research project, have abstract(s) ready for submission to a local regional or national meeting, and begin writing a formal report as a paper for publication. The second year of the program will have a total of four months for protected research. This period of research will have a detailed timeline with periodic reviews with the corresponding mentor.
- In the third year, the trainee will have four months of in-patient on call service one month in out-patient clinics. The fellow will complete his/her initial research, finish papers for publication, and will be encouraged to submit a research grant for future funding. The third year of the program will have a total of six months of protected research, This period of research will have a detailed timeline with on-going periodic reviews with the corresponding mentor.
There is an active research component involving both faculty and fellows. Faculty and fellows actively participate in clinical discussions, rounds and conferences to promote a spirit of inquiry and scholarship. Research experience for the fellows is progressive and supervised as described in section C. There is an extensive list of possible research areas with several ongoing funded research projects. Fellows participate in periodic meetings with the faculty to review on-going research protocols and future research projects. Fellows are exposed to cutting edge research in the field during the Annual Pediatric Nephrology Seminar.
The program Director is directly involved in several clinical research programs. Areas of research interest for the program director include lipids in renal disease, management of FSGS, L-carnitine deficiency in dialysis, exercise rehabilitation in pediatric dialysis patient and management of end stage renal disease in HIV nephropathy. Our faculty in pediatric nephrology is actively involved in research related to proteinuria, low-birth weight nephropathy, growth and nutrition in uremia (Carolyn Abitbol), and hypertension, catheter related bacteremias and renal transplant complications (Jayanthi Chandar).
- Night-call responsibilities: during the eight months of direct patient care in the first year of the training program, the trainee is responsible for weeknight calls four out of seven days, for four months. During the second year there are four months of inpatient experience in which they have night calls, four out of seven days for four months. During the third year of training, trainees are responsible four out seven days for four months. Always fellows have the backup of a full-time faculty who is serving as the attending pediatric nephrologist. Weekend and holiday periods are shared by the trainee in the first year of the program and/or trainee in the second year of the program and faculty attendings. Every effort is made to be certain that the night-call activity does not interfere with the trainee’s ability to learn and actively participate in the care of patients. In those situations where the service becomes too busy, the attending physician may assume a primary role with regard to night-call responsibilities. Fellows are not allowed to participate in moonlighting activities.
Gaston Zilleruelo, M.D.
Physicians Services / Housestaff Office
Jackson Memorial Hospital
East Tower Room 1004
1611 NW 12th Avenue, Miami, Florida 33136
Graduate Medical Education Office
Jackson Memorial Hospital
1611 NW 12th Avenue, Miami, Florida 33136