The goal of these rotations are to become well versed to outpatient dialysis practice and management. This is to provides a baseline knowledge that allows growth whether it is inpatient care, developing practice, established practice in both academic and private practice settings. Outlined below are general topics (each with multiple subtopics) for the various rotations. Expectations are to complete and understand all topics over your fellowship training (typically 1-2 topics per rotation, not all within one rotation).

In Center Hemodialysis (ICHD):
– Epidemiology and Outcomes
– Principles of Dialysis (Basics of Dialysis)
– Initiation and Maintenance ICHD
– Complications
– Vascular Access (resources available but encourage separate elective)
– Long Term Comorbidity Management of ESKD
– Patient Centered Care
– Administrative Duties and Economics

Home Dialysis
– Peritoneal Dialysis
– Home Hemodialysis

In-Center Hemodialysis Education Curriculum

This comprehensive, milestone-aligned curriculum guides learners longitudinally over 8 modules. Topics discussed range from foundational knowledge to systems-level mastery in chronic dialysis therapy. It integrates clinical science, technical expertise, patient-centered care, and administrative acumen across eight modules, each designed with educational depth and artistic potential in mind. Its design aligns with ACGME PC2 milestones for chronic dialysis therapy.

Didactic Requirements:

The framework of the didactic curriculum is centered around adult learning theory with clinical application.

– Review 1 topic per week (some are large and may require split over 2 weeks).
– Read, review, and understand assigned reading. Additional articles, guidelines, presentations, and resources will be on available on each topic.
– Complete the board style questions for the topic and turn them into Dr. Nysather at the end of each week/rotation for credit.

In Center Hemodialysis

Click on the image to enter the module

ACGME Milestone Mapping: PC2 Chronic Dialysis Therapy

Level	Competency	Modules Covered
L1	Identify dialysis indications and basic complications	Modules 1, 4
L2	Match modality and script to patient; assess access	Modules 2, 3, 5
L3	Modify prescriptions and treat complications	Modules 3, 4, 6
L4	Manage uncommon complications and develop strategies	All Modules 1–7
L5	Lead systems-level care and anticipate full spectrum	Modules 6–8

This structured progression ensures learners build from fundamental science through patient-centered practice and system leadership, meeting all PC2 milestones for chronic dialysis therapy.

Module 1: Foundations of In-Center Hemodialysis

• Epidemiology & Outcomes
  • Global and U.S. prevalence trends: disparities in health equity, access, and outcomes
  • Mortality drivers: cardiovascular disease, infections, withdrawal of care
  • Age, race/ethnicity, socioeconomic influences on initiation and modality choice
  • Modality distribution and referral patterns
• Uremic Toxicity: Pathophysiology & Clinical Impact
  • Neurologic, hematologic, dermatologic, and gastrointestinal sequelae
  • Toxin classification: small solutes, middle molecules, protein-bound
  • Uremic solute burden: guanidines, indoles, middle molecules
  • Uremia Sequelae: uremic pruritus, polyneuropathy, platelet dysfunction, neurological, cardiovascular, dermatologic
• Initiation Strategies
  • Shared decision-making during modality selection: patient values vs physiological triggers
  • Timing for chronic kidney disease progression vs. acute decompensation
  • Inpatient “urgent-start” pathways and transitional dialysis planning

Module 2: Principles & Prescription of Hemodialysis

• Fundamentals of Solute Removal: Physiology and Clearance
  • Diffusion, convection, ultrafiltration, adsorption
  • Dialysis dose modeling using Urea Kinetics: Kt/V and URR calculations; limitations and alternatives
  • Impact of compartmental kinetics and high-efficiency dialysis
• Prescription Design & Adequacy
  • Session parameters: time, blood flow, dialysate flow, surface area, duration
  • Adaptations for comorbid states, residual kidney function
  • Real-time adequacy tools and feedback systems (online clearance systems)
• Machine & Circuit Anatomy
  • Pumps, monitors, sensors, alarm hierarchies
  • Anticoagulation protocols: heparin, citrate, circuit patency measures
  • Safety checks: air detectors, pressure limits, venous clamp function
• Dialysate Composition
  • Individualized electrolyte, buffer settings (acetate vs bicarbonate), cardiac risk, and IDWG
  • Intradialytic sodium modeling to reduce cramps and hypotension
  • Magnesium and calcium titration based on cardiovascular risk

• Dialyzer Architecture
  • Membrane materials and biocompatibility
  • High-flux vs low-flux; reuse protocols and controversies
  • Ultrafiltration coefficient (Kuf), pore structure, surface area: how design affects performance
  • Biocompatibility: complement activation and cytokine response
• Water Treatment Systems
  • Stages: filtration, softening, RO, ultrafiltration (carbon filters, softeners, dechlorination)
  • Disinfection protocols and contaminant/microbiologic surveillance
  • Troubleshooting alerts, endotoxin control, distribution loop design

Module 3: Initiation & Maintenance of In-Center Hemodialysis

• Initiation Protocols  
  • Transitioning from ICU therapies (CRRT/SLED) to outpatient ICHD
  • Infection and sepsis: catheter management, antimicrobial dialysis
  • Acutely ill modifications: blood flow, ultrafiltration, dialysate temperature
• Chronic Management Strategies
  • Adjusting prescriptions across disease progression
  • Fluid status reassessment: bioimpedance, dry weight recalibration
  • Preserving residual kidney function with pharmacologic support

Module 4: Complications and Safety Monitoring of Hemodialysis

• Hemodynamic Instability
  • Pathophysiology of intradialytic hypotension: preload, myocardial stunning
  • Mechanisms: preload, vasodilation, LV stunning
  • Pharmacologic and fluid-based countermeasures
  • Interventions: midodrine, thermal control, sodium and ultrafiltration profiling
• Fluid Management & IDWG
  • Weekly weight patterns and interdialytic fluid limits
  • Managing thirst, salt intake, and symptomatic overload
  • IDWG analysis across weekly treatment cycles and interdialytic fluid limits
  • Target weight estimation and dynamic adjustment
• Electrolyte Disruptions
  • Potassium kinetics and fatal arrhythmia prevention
  • Calcium-phosphate imbalances: calcific risk mitigation
• Infection Prevention & Control
  • Catheter vs AV access protocols
  • Vaccination schedules, hand hygiene compliance
  • CLABSI prevention: chlorhexidine, alcohol caps, antibiotic lock use
  • Facility-wide microbial surveillance strategies, cultures, and audit tools
• Malnutrition & Systemic Inflammation
  • PEW: protein-energy wasting syndromes
  • IDPN and intradialytic supplementation techniques
  • Catabolic stress, inflammation, and appetite loss
  • IDPN protocols, repletion guidelines
  • Serum albumin and trend as surrogate marker of outcome

Module 5: Vascular Access Management

• Access Design & Physiology
  • Mapping vasculature: duplex ultrasound, flow volume metrics
  • Fistula vs graft: patency, longevity, cardiovascular impacts
  • Cannulation mastery: buttonhole complications, rope-ladder variants
• Access Failure & Interventions
  • Dysfunction diagnostics: recirculation, stenosis
  • Steal syndrome and central venous stenosis risk factors
  • Access salvage: angioplasty, thrombectomy, surgical revisions
  • Recirculation diagnostics: ultrasound dilution, pressure ratios
  • High-flow syndromes and cardiac decompensation
• Cannulation & Maintenance
  • Buttonhole technique benefits and infection risks
  • Rope ladder approach and vessel longevity
• Catheter Management
  • Exit site protocols, tunnel infection recognition
  • Lock solutions: heparin, citrate, antimicrobial combinations
  • Bridge therapy planning for failed permanent access

Module 6: Long-Term Comorbidity Management

• Role of inflammation, functional iron deficiency
  • Iron indices interpretation and IV iron protocols
  • ESA resistance: inflammation, infection, micronutrient depletion
  • Red cell indices and transfusion thresholds
  • Role of inflammation, functional iron deficiency

• Mineral & Bone Disorders
  • Classification and pathophysiology: adynamic disease, osteitis fibrosa
  • Diagnostic imaging and bone biopsy indications
  • Therapeutic targets: phosphate binders, calcimimetics, PTH control including surgical intervention
• Cardiovascular Burden
  • Interplay of volume status, vascular calcification, and LV hypertrophy
  • Beta-blocker, ACE inhibitor use in HD population
  • Arrhythmia surveillance and pacemaker considerations
• Multisystem Disease Management and Metabolic Rehabilitation
  • Glycemic control strategies for HD-adapted diabetes
  • HIV, COVID-19, immunosuppressant pharmacokinetics
  • Macronutrient balance and intradialytic hypoglycemia avoidance
  • Drug dosing and dialysis clearance: high vs low protein binding agents
  • Rehabilitation and physical functioning metrics

Module 7: Patient-Centered & Ethical Care

• Shared Decision & Palliative Planning
  • Goals of care discussions
  • Ethical frameworks and interdisciplinary planning
  • Prognostic discussions and modality reevaluation
  • Withdrawing dialysis: ethical, emotional frameworks
  • Hospice coordination and advanced care planning
• Psychosocial Integration
  • Psychiatric screening tools and mental health referral
  • Sexual health, fertility, and relationship support
  • Reentry programs for work, education, and lifestyle integration with vocational rehabilitation and activity planning post-dialysis
• Preventive Measures
  • Multimodal vaccination protocols
  • Skin surveillance (calciphylaxis, pressure ulcers), cancer, dental and ophthalmologic care

Module 8: Systems Leadership, Economics & Administration

• Facility Oversight
  • Water safety policies, infection control rounds
  • Alarm audits, environmental protocols, disaster planning
• Quality, Safety, & Ethics
  • Dashboard metrics: hospitalization, adequacy, infection
  • Mortality review, root cause analysis, continuous quality improvement
  • Navigating ethical dilemmas: informed refusal, non-adherence
• Medical Director Roles
  • Staff education and credentialing
  • ESRD Network reporting and CMS compliance
  • Telehealth integration, home program partnerships
• Financial Literacy for Nephrologists
  • Dialysis billing: CPT codes, MACRA, bundled payments
  • Profit/loss awareness, capital equipment negotiation
  • Resource stewardship and cost-conscious care

ASN NDTS (Nephrologists Transforming Dialysis Safety)

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