Nephrology and osteopathic medicine: Closer than we realize

At first glance, nephrology may seem to be an odd fit for osteopathic medicine, which has traditionally emphasized primary care.

The past decades have seen an increase in chronic kidney disease (CKD) rates, in part due to increases in diabetes mellitus and hypertension, the most common causes. Kidney disease via exposure to pollution is less common, but cases connected to pollution are also on the rise. Data from the Centers for Disease Control and Prevention (CDC)/NIDDK for 2021 shows that 1 in 7 or 15% of the adult population, 37 million people, are estimated to have CKD. The highest-risk groups include those over 65 years of age of Black, Hispanic/Native American or Asian heritages and individuals of all ethnicities who are living in poverty.

The passage of the Affordable Care Act (ACA) of 2010 and expanded Medicaid has led to more patients diagnosed and treated early in the course of their illnesses. Research has led to a number of novel diagnostic tests for early diagnosis of kidney disease such as urine albumin and a host of serological assays. Early diagnosis has yielded targeted therapy for both the underlying pathology but also the systemic ramifications of kidney disease such as hypertension, bone disease, anemia and volume control. A better understanding of the immune system has led to higher kidney transplantation rates and less medication-induced adverse effects, leading to a longer graft survival and better quality of life.

Lack of specialists

This is met by a growing shortage of nephrologists, not only in the U.S. but also worldwide; the recent pandemic has only added to the shortages of all medical personnel.

Although once a highly sought-after specialty, interest in nephrology has declined over time. Students and house staff can be intimidated by the physiological basis and complexity of the patient’s illnesses; a lack of nephrologists means a lack of mentors to champion the specialty and demystify it. For many years, more than 30% of available nephrology fellowship positions have been left unfilled following the NRMP nephrology fellowship match.

Good news for nephrology

However, at the same time, the number of DOs pursuing nephrology fellowships has steadily increased.

Nephrologists experience a high level of career satisfaction and respect from other clinicians for their in-depth understanding of the continuity between physiology and clinical practice. An in-depth understanding of not only renal physiology but that of the endocrine, immune and cardiovascular systems, among others, is essential to address the systemic impact and treatment of kidney diseases. Within the scope of practice includes primary or secondary kidney diseases, transplantation, disorders of sodium, water and other electrolytes, acid base, hypertension, endocrine and cardiovascular systems.

A career in nephrology begins with a three-year Accreditation Council for Graduate Medical Education (ACGME) accredited residency in internal medicine prior to a two or more years fellowship in kidney diseases. Additional year(s) of research or further training in related areas such as transplant, interventional or critical care, represent some of the additional training opportunities available.

Nephrology offers a number of research, clinical, educational and leadership opportunities for its physicians. Clinical nephrology usually balances hospital consultative work, acute and chronic dialysis, outpatient office visits and rounding in the outpatient dialysis units.

In the outpatient setting, nephrologists closely follow patients with advanced CKD, especially after the initiation of renal replacement therapy or transplantation; developing a close physician-patient relationship is a hidden gem of clinical nephrology. In the outpatient office setting, nephrologists manage not only the acute manifestations of illnesses, but also complications of CKD, including blood pressure control, volume control, lipids, bone disease, anemia and acid base disorders.

Who pursues nephrology

The American Society of Nephrology (ASN) has closely tracked the demographics of fellows in nephrology programs. A recent study of data from 2009-2020 found that while international medical graduates (IMG) are still the best represented in fellowships, representation of DO graduates has steadily risen during this time.

An explanation for the increased interest of DOs for nephrology can be found in the osteopathic principles. Chronic kidney disease affects almost all aspects of life, the whole-person concept and the structure-function relationship. Nephrology is also one of the most physiologically based specialties, and the body’s ability for self-repair parallels the scope of the specialty and osteopathic principles.

More details about osteopathic medicine and nephrology are available here.

Generating interest

The American College of Osteopathic Internists (ACOI) has been working with ASN to develop educational, mentorship and leadership programs for DO students and residents interested in careers in nephrology. A number of ASN educational leaders have spoken at ACOI educational conferences and work closely with ACOI leadership to further partnerships and opportunities.

In order to generate interest in nephrology as a career, the ASN has established a one-week summer program for medical and PhD students with an interest in all aspects of nephrology. These are held in the Mount Desert Isle Biological Laboratory in Bar Harbor, Maine or at the University of Chicago. The Kidney TREKS Program, Tutored Research Education for Kidney Scholars, incorporates physiology, clinical medicine and day-to-day life of patients with kidney disease, balanced with baseball games and exploration.

A similar program, Kidney STARS, STudents And ResidentS, is a travel scholarship to attend the annual meeting of ASN and the accompanying educational program for students and residents. These students are paired with a mentor for the entire annual meeting who guides their interaction and curates a track specifically for them. Recently, ASN launched a $2.7 million five-year loan mitigation pilot program for those choosing a career in adult or pediatric nephrology. Each candidate selected will be given a $50,000 award for reduction in tuition debt. Year two candidates will be from groups underrepresented in medicine.