Massachusetts General Hospital | Transplant Center

Overview

The program is American Society of Transplant Surgery (ASTS)-approved. Each year, there is one transplant surgical fellow and a 4th year surgical resident, 3rd year surgical resident, and intern on the service. The program is integrated between the surgery and the nephrology fellowship programs in order to benefit from the expertise of all its members. The program thrives from a true multidisciplinary effort.

Staff coverage and supervision in the transplant unit is provided by both a staff transplant surgeon as well as a staff transplant nephrologist at all times. In addition, a clinical nephrology fellow rotates through the transplant unit on a monthly basis.

Transplant rounds are held twice daily with the transplant surgeon and transplant nephrologists, residents, fellows, and other support staff in attendance. Decisions regarding immunosuppression are made with reference to jointly established policy guidelines and protocols. Infectious disease consultants are present on morning and evening rounds and available at all times. 

There are weekly Chief's Rounds, which is an academic conference conducted by Dr. Paul Russell, professor emeritus and former Chief and founder of the Transplant Unit. This conference involves clinical presentations with additional  research focus, provided by members of the Transplant Biology Unit, particularly Dr. David Sachs, as well as the head of the Bone Marrow Transplant Unit. Dr. Tom Spitzer and Dr. Benedict Cosimi (former director of the transplant division). Also, members of the hepatology unit present and discuss lever transplant patients. The sessions are an opportunity for the fellow to present clinical cases.

There is a weekly transplantation conference, which again brings together members of the different departments working in transplantation-related fields. During these sessions, invited guests both national and international, present different areas in the field of transplantation. The fellow also has the opportunity to present research and clinical reviews at these conferences.

Both the Division of Nephrology and Massachusetts General Hospital are equal opportunity employers. Before beginning the Transplant Fellowship Program in Nephrology, a candidate should have completed at least two (preferably three) years of training in internal medicine and be board-certified or board-eligible in nephrology.

Education

(1) The Transplant Fellow will attend (with the other renal fellows) a weekly didactic conference which currently follows the guidelines established by The AST’s Primer on Transplantation. The current scheduled topics are:

a. Management of chronic renal insufficiency and therapeutic options

b. Principles of alloimmunity

c. Histocompatibility testing, cross-matching and immune surveillance

d. Organ procurement, preservation and allocation policies

e. Principles and pharmacology of immunosuppression

f. Evaluation of the organ transplant recipient

g. Evaluation of the living donor

h. Transplant surgical procedures and complications

i. The immediate post-transplant period

j. Post-transplant medical complications

k. Post-transplant infections

l. Diagnostic imaging following transplantation

m. Pathology aspects of renal and pancreas transplantation

n. Ethical, legal, psychosocial and financial aspects of renal and pancreas transplantation

(2) The fellow will be attend:

a. Transplant Center Conference - Monday evenings.

b. Chiefs Rounds - Wednesdays mornings.

c. Renal Grand Rounds - Mondays noon.

d. Renal Fellow Interhospital Renal Rounds – Tuesdays mornings.

e. Daily Transplant Rounds.

f. Pathology Conference, Thursdays p.m.

(3) As part of the program, the transplant fellow will be involved with 3 presentations at Journal Clubs, renal conferences, and at least 4 additional educational sessions.

(4) Will attend the AST and ASN annual meeting and be given the option of attending the AST sponsored Transplant Nephrology Fellows symposium.

(5) Will learn the basic statistical principles as applied to transplantation.

Clinical Experience

The transplant nephrology fellow will develop expertise in the following areas of renal and pancreas transplantation through medical, surgical, and research experience and by satisfying the requirements of the American Transplant Society and the American Society of Nephrology.

1. Pretransplant Renal Evaluation (work-up of at least 30 potential recipients)

Trough participation in the already established multidisciplinary transplant recipient evaluation clinics, the fellow will understand the risks and benefits of dialysis versus renal transplant and will be involved with the counseling, evaluation, education, and selection of potential recipients for kidney transplantation, as well as kidney-pancreas transplants.

2. Kidney Donors (evaluation of at least 20 potential donors, and involvement with the surgical procedures in at least 4 live donor nephrectomies)

The trainee will be educated in the pros and cons of using living donors; the short- and long-term risks and follow-up of the live kidney donor; the evaluation, education and counseling of the living-related and unrelated kidney donor; and the differences between the open procedure and laparoscopic procedure.

3. Cadaveric

The transplant nephrology fellow will be involved in at least 5 multi-organ retrievals, and be involved with:

(1) The principals of organ preservation

(2) The identification and evaluation of a deceased donor organ

(3) The surgical aspects of renal, liver, heart, and pancreas procurement from the cadaveric donor

(4) Procedure for procuring non-heart-beating donors

It is the expectation that the transplant nephrology fellow will:

(1) Obtain a detailed knowledge immunology of transplantation, including the normal immune response, immune and inflammatory responses to the allograft, immunogenetics, and tissue typing.

(2) Gain an in-depth knowledge of induction and maintenance immunosuppressive therapy, including the mechanism of action and pharmacology of drug interactions, safety, side effect profile, and efficacy of immunosuppressive therapy, including new investigational therapies, e.g., tolerance protocols.

(3) Obtain knowledge about prophylactic therapy with antiviral agents to prevent cytomegalovirus infection, HSV, Pneumocystis jiroveci, as well as urinary tract infections. Will understand the pharmacology, drug interactions, pharmacokinetics, safety, and side effect profiles.

(4) Gain expertise in the post renal transplant care of in patients as well as out patients and knowledge of the expected clinical outcomes and analysis of risk factors.

(5) Obtain knowledge of the management of the diagnosis and management of acute rejection, as well as the evaluation and treatment of nonimmunologic causes of acute kidney transplant dysfunction.

(6) Gain knowledge about the evaluation and treatment of surgical complications of renal transplant, as well as the evaluation, prevention, and treatment of medical complications including cardiovascular disease, opportunistic infection, bone disease, and malignancy.

(7) Be involved with the management of chronic allograft dysfunction, including chronic rejection, both cellular and humoral, recurrent disease within the allograft as well as de novo disease.

(8) Gain an understanding of the special considerations for pancreas-after-renal transplantation as well as simultaneous pancreas and renal transplantation.

(9) Consider issues of pregnancy in renal transplant recipients.

Pediatric Renal Transplantation

In addition, the transplant fellow will be exposed to pediatric renal transplantation, and the special consideration involved in evaluating a donor and selection of immunosuppression, as well as issues related to growth and development with renal transplant.

5. Tissue Typing

The renal transplant fellow will be required to spend at least 2 weeks in the Histocompatability Lab, learning the principles, methodology, and interpretation of tissue typing and crossmatching for renal transplantation, including various lymphocytotoxic assays, ELISA, and flow crossmatch.

6. Renal Pathology

The fellow will perform at least 20 transplant biopsies and will review the biopsies with renal pathologists according to the Banff criteria. The fellow will attend the weekly renal pathology conference and present patients at monthly morbidity and mortality conference.

7. Family Meetings 

The fellow will be involved with family meetings, to discuss the risks and benefits of transplant with the patient, family, psychiatrist, nephrologists, surgeon, transplant coordinator, and social worker, and will learn about the ethics of organ donation.

8. Waiting List

The transplant nephrology fellow will be involved with creating and managing the renal transplant waiting list, and will attend the weekly interdisciplinary transplant conference to determine candidacy.

9. Organ Procurement

The fellow will obtain knowledge of other procurement and transplant systems, including UNOS, as well as the economics of transplantation. The fellow will be involved with organ awareness programs.

Clinical Responsibilities of the Transplant Nephrology Fellow

Assessment of patients referred for renal transplantation, in association with a staff transplant nephrologist. After evaluating the patient, the fellow will present to the transplant team for possible listing or scheduling of living-related donor transplants. Living Donor TransplantsThe fellow will examine and evaluate living donor candidates during their pre-admission testing day. Potential donors will also be examined at this time. The patients will be presented and reviewed with the staff nephrologist.Inpatient CareThe renal transplant unit consists of 18 beds. Four of these are ICU beds. The service is shared by the Hepatobiliary Surgery service, where kidney and pancreas transplants are performed, as well as heart and lung transplants. It is expected that the Transplant Fellow will spend at least 6 months in the inpatient clinical service.Outpatient Follow-upThe renal transplant fellow will participate (for 12 months) in the longitudinal follow-up of renal and pancreas post-transplant patients. In addition, he/she will be expected to attend (for a period of 3 months) a multidisciplinary transplant recipient and living donor selection clinic. Patients will be reviewed by the staff physician prior to discharge from the clinic. The fellow will review blood work and patient concerns with the clinic nurses, and also be responsible for calls from outside referring physicians and internists, requesting medical assistance. Back-up is always available by the attending nephrologist or surgeon. The fellow is expected to take regular Call along with the transplant surgical fellow and other trainees covering the transplant unit.

Educational Resources

Tissue Typing Coordinators

Dr. Susan Saidman, director of the Tissue Typing Laboratory of Massachusetts General Hospital. The transplant fellow spends a two-week rotation in the Tissue Typing Lab in order to become familiar with the methodology, utility, and reliability of various tissue typing, cross match and immune surveillance technology.

Renal Pathology Coordinators

The transplant fellow will learn the art of renal biopsy, under the auspices of Dr. Winfred Williams, Dr. Nelson Goes, Dr. Eliot Heher, Dr. Waichi Wong and Dr. Mario Rubin, who will supervise the performance of the biopsies at MGH. The interpretation of transplant biopsies will be coordinated with Dr. Robert Colvin, Chief of Pathology and Renal Pathologist at MGH. The fellow will gain experience with the interpretation of these biopsies, the knowledge of Banff criteria, and a translation of clinical issues.

There is a weekly renal pathology conference at MGH, at which these biopsies are reviewed.

Weekly Transplant Conference

Coordinator, Dr. Francis Delmonico, Division of Transplant Surgery, Director of New England Organ Bank. Topics in transplantation are presented by members of the nephrology, immunology, and transplant community in areas of basic science research as well as in clinical care. These conferences are attended by members of both divisions and attendance by the fellow would be required.

Morbidity and Mortality Rounds

Coordinator, Dr. James Markmann, Chief of Transplantation. These rounds review all medical and surgical complications and are prepared in coordination with the clinical fellow.

There are ample opportunities for the transplant fellow’s participation in clinical and/or basic science research. Clinical and animal studies in tolerance, ABO incompatibility and desensitization are ongoing.

Interested applicants should submit their application through ERAS between July 1st and January 15th for positions beginning July 1, 2011. We strongly recommend that applicants complete the ERAS application process before December 1 as this will facilitate timely interview dates. Fellowship programs can access applications on December 1st. We will then invite outstanding candidates for a one-day interview process to be scheduled in December or January. We do sponsor visas for exceptional trainees. We will also adhere to the recommendations of the American Society of Nephrology in that all applicants offered a position will not be required to make a final decision before February 1, 2011.

Please click here to begin your application through ERAS.

For additional information, please contact:

Wendy De Mille, Nephrology Academic Coordinator and ESRD Program Manager
Division of Nephrology
Massachusetts General Hospital
55 Fruit Street, GRB 1003K
Boston, MA 02114
Phone: (617) 726-3706
Fax: (617) 726-2288
Email: wdemille@partners.org  

Fellowship Training Program

Phone: 617-726-3706
Fax: 617-726-2288
Email: wdemille@partners.org