List of eligibility criteria

The AST Transplant Nephrology Fellowship Training Accreditation Program (the “Program”) is charged with accrediting institutions that have developed programs to provide specialty transplant nephrology training. As a result of the Program’s approval by the United Network for Organ Sharing (UNOS), graduates of accredited transplant nephrology fellowship programs are qualified to head UNOS approved transplant nephrology programs. The goal of this Program is to provide a basis for the standardization of transplant training and a method of uniform documentation of education for those who wish to lead transplant nephrology programs.

The following is a list of topics than an accredited transplant nephrology fellowship program is expected to cover during training of any transplant nephrology fellow.Transplant nephrology fellowship programs can go beyond these areas/topics, but at the minimum, should expose each transplant nephrology fellow to current practices or advanced learning in the specified areas below:

I. Transplant Immunology

a. Normal immune response
b. Response to allografts
c. Tolerance
d. Crossmatches, flow cytometry
e. Identification of anti-HLA antibodies/donor specific antibodies

II. Pharmacology/Immuosuppression

a. Available agents
b. Review mechanisms of the agents
c. Current pharmacotherapy
d. Investigational agents
e. Therapeutic drug monitoring of immunosuppressive therapies
f. Steroid avoidance and withdrawal
g. CNI elimination/minimization and withdrawal
h. Drug-drug interactions
i. Drug side effects
j. Review of the major traits in transplantation

III. Medical Complications of Transplantation

a. Infections

i. Bacterial
ii. Viral
iii. Fungal

b. Hypertension
c. Atherosclerosis
d. Hyperlipidemia
e. Transplant-associated hyperglycemia
f. Transplant associated malignancy

i. Viral driven malignancy (PTLD, cervical CA, Kapos's sarcoma, nasopharyngeal CA)
ii. Non-virally driven malignancy (renal cell, skin)

g. Hepatobiliary disease/HCV
h. Musculoskeletal and bone/mineral metabolism
i. Posttransplant erythrocytosis
j. Metabolic syndrome

IV. Organ Allocation
V. Pretransplant Evaluation of the Recipient
VI. Pretransplant Evaluation of the Living Donor
VII. Graft Dysfunction

a. Rejection
b. Mechanical complications
c. Infection
d. Nephrotoxicity
e. Recurrent disease
f. De novo disease
g. Renal artery stenosis

VIII. Expected Outcomes/Risk Factors

a. LRD
b. Deceased donor organs

i. SCD
ii. ECD
iii. DCD
iv. Pediatric en bloc

c. LURD
d. Race
e. HLA matching
f. Original disease

IX. Special issues in pediatric renal transplantation
X. Pregnancy and contraception
XI. Ethics
XII. Pancreas transplantation
XIII. Kidney transplantation in other solid organ transplant recipients (both after other organs, and the combined kidney/"other" organ)
XIV. Transplantation of ABO-incompatible and cross-match incompatible individuals
XV. Paired kidney exchange programs
XVI. Business and Administrative Aspects of Transplantation

Transplant Pathology Series

I. Review of Banff Criteria
II. Acute and chronic rejection, subclinical rejection
III. Calcineurin inhibitor toxicity
IV. Recurrent Disease
V. C4d staining
VI. BK nephropathy
VII. Thrombotic microangiopathy
VIII. Clinical management of pathologic findings
IX. Protocol transplant biopsies

Eligibility Criteria:

Each of the following criteria must be continuously satisfied by an accredited transplant nephrology fellowship training program:

  1. The transplant nephrology fellowship program must be UNOS approved as a renal transplant program. Notwithstanding the preceding sentence, transplant nephrology fellowship programs that are not UNOS approved will be evaluated by the Program on a case-by-case basis.
     
  2. The transplant fellowship program director must be a transplant nephrologist who would be eligible for membership in the American Society of Transplantation. The AST Transplant Nephrology Fellowship Training Accreditation Program, LLC defines a transplant nephrologist as:
    • Someone who has completed a transplant nephrology fellowship program at a program accredited by the AST Transplant Nephrology Fellowship Training Accreditation Program, LLC, or
    • Someone who meets the qualifications to be a UNOS primary kidney transplant physician
  3. The transplant nephrology fellowship program must have a full-time faculty member or members capable of teaching a curriculum with a broad base of knowledge in transplant medicine, including the outlined transplant topics noted above. More specifically, the curriculum must include: training and experience in end-stage renal disease management; training in the selection of appropriate transplant recipients and donors; experience in the immediate and long term care of both living and deceased donor transplant recipients, as well as the appropriate management of the living donor; and training in the performance of renal transplant biopsies. Additionally, there must be an emphasis on the management of immunosuppressive agents and the evaluation of renal transplant dysfunction.
     
  4. Combined surgical and medical rounds should be conducted on a regular basis. The didactic section of the transplant nephrology fellowship program should follow the list of outlined transplant topics noted above. It is strongly recommended that transplant nephrology fellows participate in other educational opportunities, such as the AST/ASN Transplant Nephrology Core Curriculum, and the AST "T3: Timely Topics in Transplantation" webinar series. These and other educational activities are available on the AST website, www.myAST.org.
     
  5. Each transplant nephrology fellowship program must perform a sufficient number of kidney transplants to allow for adequate training. The minimum requirement is 50 kidney transplants per year for the training of one transplant nephrology fellow. If a program wishes to train a second transplant nephrology fellow, then an additional 30 kidney transplants must be performed per year. Therefore, programs that train two transplant nephrology fellows must perform a minimum of 80 kidney transplants per year. Each transplant nephrology fellow must be primarily responsible for 30 inpatient renal transplant recipients and 30 outpatient recipients (the inpatient and outpatient encounters may involve the same patients). Outpatient follow-up must be continuous for a minimum of at least three months after transplantation.
     
  6. A minimum of six months of training must be performed in inpatient clinical service in order to allow the transplant nephrology fellow's involvement in the care of at least 30 new transplant patients. The remaining training period should be designed to provide training and experience in tissue typing, experience on another organ transplant service, and exposure to transplant pathology. The transplant nephrology fellow should also be involved in activities that provide experience in transplant related scholarship. Examples of this include, but are not limited to, performing research, writing up case reports, and drafting reviews or chapters.
     
  7. The transplant nephrology fellowship program must provide patient co-management responsibility with transplant surgeons from the peri-operative through the outpatient period in both deceased donor as well as living donor transplant recipients. The transplant nephrology fellow must primarily manage the transplant recipient's medical care including, but not limited to, hypertension, diabetes, and dialytic problems. Transplant nephrology fellows must also serve as primary members of the transplant team and participate in making decisions about immunosuppression.
     
  8. The transplant nephrology fellowship program must provide training in the indications for, the performance of, and the interpretation of, renal transplant biopsies. Each transplant nephrology fellow must perform a minimum of 10 renal transplant biopsies during the training period. Documentation of the completion of these biopsies is required. Furthermore, the transplant nephrology fellowship program must provide didactic pathological experience with the transplant nephrology fellow reviewing renal transplant biopsies with an experienced renal transplant pathologist.
     
  9. It is encouraged that the transplant nephrology fellow gain experience in the evaluation and management of pancreas transplantation. Pancreas experience documentation and certification requirements should be addressed directly with UNOS.
     
  10. The transplant nephrology fellowship program must provide training and experience in an accredited histocompatibility/tissue typing laboratory and training and experience in the procedures and activities of an organ procurement organization.
     
  11. Each transplant nephrology fellow must observe at least 3 renal transplants, at least one of which is a living donor transplant and one a deceased donor transplant. Each transplant nephrology fellow must also observe at least 3 organ recovery procedures, at least one of which is from a deceased donor and one from a living donor
    .
  12. Each transplant nephrology fellow must obtain experience evaluating 25 potential kidney transplant recipients, and 10 potential living donors, as well as participate in selection committee meetings.
     
  13. If a transplant nephrology fellowship training program cannot provide any aspect of the required elements, such as experience in living or deceased donor transplantation or tissue typing, the program can make arrangements with another accredited transplant nephrology fellowship training program to have the transplant nephrology fellow(s) receive training in that element at that program. In general, the amount time spent by a transplant nephrology fellow with an outside transplant nephrology fellowship training program should not exceed 3 months.
  14. There are two set pathways for transplant nephrology fellowship programs to follow:
    • A standard one-year transplant nephrology fellowship, which is designed for nephrologists who have successfully completed a standard ACGME (or foreign equivalent for Canadian programs) nephrology fellowship. Training under the standard fellowship is to be completed within 12 continuous months.
    • An alternative pathway designed for nephrology fellows who have a more in depth academic interest in transplantation and wish to pursue active research related to transplantation over the span of a two or three year training period
  15. Transplant nephrology fellows who wish to pursue the alternative pathway must currently be enrolled in an ACGME approved (or foreign equivalent programs) nephrology fellowship program at an accredited center. Transplant nephrology fellows must have already completed the clinical rotations for their general nephrology fellowship program. The alternative pathway does not require fellows to be board-eligible or board-certified at the initiation of the transplant nephrology fellowship if the fellow is concurrently enrolled in an ACGME-certified (or foreign equivalent programs) standard nephrology fellowship with the following expectations:
    • The transplant nephrology fellowship program is accredited by the AST Transplant Nephrology Fellowship training Accreditation Program, LLC.
    • All clinical training that is counted towards the transplant nephrology fellowship training is done in addition to the standard renal fellowship clinical requirements. This must be documented by the transplant nephrology fellowship training program director who will certify that the transplant nephrology fellow has completed all requirements for both fellowship programs.
    • Research performed during this training should be relevant to the field of transplantation.
    • In order to be considered qualified to head UNOS approved renal transplant programs, the transplant nephrology fellow must be board-certified in nephrology by the American Board of Internal Medicine (ABIM) or the foreign equivalent, by the end of the training.
  16. Transplant nephrology fellows who wish to partake in the alternative pathway are required to complete all of the eligibility criteria outlined above, but the requirements are to be spread out over two or three years, while the transplant nephrology fellow pursues active research related to transplantation. In addition to the requirements for the standard one-year renal transplant fellowship:
    • The inpatient experience is to be two or three months per academic year (or calendar year), totaling a minimum of 6 months. This flexibility is designed to allow fellows on grants requiring protected time to fulfill both research and clinical obligations.
    • The outpatient exposure is to be increased compared with the standard one-year program. It must include a primary responsibility for the longitudinal follow-up and care of at least 30 transplant patients in the outpatient clinic for a minimum of 3 continuous months each year for a minimum of 2 training years. The transplant nephrology fellow is expected to participate in transplant related conferences throughout the training period.
       
  17. Documentation that the transplant nephrology fellow has successfully completed the prerequisite number of 30 in-patient and 30 outpatient recipient management experiences; 3 surgical observations; 3 procurement observations; 10 renal transplant biopsies; 25 recipient evaluations, and 10 living donor evaluations must be kept. Documentation should, at a minimum, be in the form of a log that contains the signature of the transplant physician present. This documentation must be kept by the transplant nephrology fellowship program and the transplant nephrology fellow.
     
  18. Each transplant nephrology fellow is required to complete an evaluation form ever 6 months and at the completion of the 12 month fellowship. The evaluations are to be submitted on a form prescribed by the Program. Transplant nephrology fellows who pursue the alternative pathway are required to complete evaluation forms every 6 months until completion of the transplant nephrology fellowship. Each transplant nephrology fellowship program director will be responsible to ensure that the transplant nephrology fellow receives and completes the appropriate forms. Upon receipt, the forms will be reviewed for adequacy and compliance with the requirements contained herein.
     
  19. The transplant nephrology fellowship program director must provide a letter and a certificate of completion to each transplant nephrology fellow within two months of successful fellowship completion. The letter must state that the transplant nephrology fellow has met all of the above criteria and is capable of being certified as a UNOS transplant physician if the training occurred at a UNOS approved transplant program. A copy of this letter and certificate, along with a written statement validating the transplant nephrology fellow's participation in the required didactic sessions and patient management experiences must be sent to the Transplant Nephrology Fellowship Training Accreditation Program, LLC office for inclusion in the transplant nephrology fellowship program's file.

For accreditation or re-accreditation applications contact Felicia Lembesis, flembesis@AHredchair.com

Initial Application Process

Initial accreditation application must be completed online. The application fee of $2,500 (checks made payable to "AST TNFTAP") should be sent to the AST Transplant Nephrology Fellowship Training Accreditation Program, LLC office. The application fee covers administrative fees, as well as travel expenses associated with the site visit (discussed below). If the AST Transplant Nephrology Fellowship Training Accreditation Program, LLC Review Committee determines, based on its review of the application, that an applicant transplant nephrology fellowship program is unsuitable for site visit review, the application fee minus $500 will be returned to the applicant transplant nephrology fellowship program

Site Review

Each initial transplant nephrology fellowship program applicant will be visited by two members of the review committee which is composed of nephrologists chosen from the membership of the American Society of Transplantation. Accredited transplant nephrology fellowship training programs are also subject to a site visit conducted by one or two reviewers (such number to be at the discretion of the committee) in connection with the re-accreditation process to be undertaken every six years. In special situations, additional visits may be required, as determined by the committee, particularly for re-accreditation of transplant nephrology fellowship programs previously placed under review.

Committee members will be assigned to evaluate transplant nephrology fellowship programs that are in geographic regions distant from their own programs. Prior to the site visit, the names of the site reviewers will be sent to the applicant programs transplant fellowship program director. If the transplant fellowship program director objects to the reviewer(s), the committee will select an alternate reviewer(s). The site visit must include 30 minute interviews with the medical director of the transplant program, the transplant nephrology fellowship program director, the nephrology program director, the transplant program surgical director, the transplant pathologist, a general nephrology fellow, and a current transplant nephrology fellow, if there is one in training.

Research or scholarly activities should be reviewed with the transplant nephrology fellowship program director. If the transplant nephrology fellowship program determines to allow transplant nephrology fellows to train via the alternative pathway, then a 30 minute interview with the research director must also take place. Additionally, the hospital wards and clinic, and the outlined didactic program will be reviewed. If the transplant nephrology fellowship program is not UNOS approved, the program’s survival data will need to be reviewed. A standardized form will be completed by the site reviewers, reviewed by the committee, and then submitted for final review to the AST Transplant Nephrology Fellowship Training Accreditation Program, LLC Board of Managers.

Application and Review Time Line for New Applicants

Initial accreditation applications may be accepted at any time. The site visit will occur within six months following receipt of payment of the application fee and the completed application. The chair of the review committee will communicate the review summaries with a recommendation to the board of managers. Notification of a decision with respect to accreditation will be provided to the prospective transplant nephrology fellowship programs via certified letter (or via Federal Express for Canadian programs) from the chairperson of the committee. Transplant nephrology fellowship programs will not be able to begin training a transplant nephrology fellow under the Program until the proposed transplant nephrology fellowship program has been approved. Prospective transplant nephrology fellowship programs should apply for accreditation at least one year prior to training a transplant nephrology fellow.

Once approved, accreditation is in effect for three years, provided that the accredited transplant nephrology fellowship program complies with the published program criteria. Accredited transplant nephrology fellowship programs must go through the re-accreditation process every three years, subject to the applicable expiration date as follows. All accredited transplant nephrology fellowship programs will be provided with a fixed expiration date, measured from the approval date. Transplant nephrology fellowship programs approved for initial accreditation between January 1 and June 30 will have an expiration date of June 30. Transplant nephrology fellowship programs approved for initial accreditation between July 1 and December 31 will have an expiration date of December 31.

Due process

If a transplant nephrology fellowship program is denied accreditation, the program may re-apply after correction of the identified deficiencies. A transplant nephrology fellowship program also has the option to withdraw its application at anytime during the initial or re-accreditation application process. If a transplant nephrology fellowship program feels the decision of the board of managers is incorrect, the transplant nephrology fellowship program may appeal the decision to the board of managers within 60 days of their initial denial decision. A final decision will be communicated to the transplant nephrology fellowship program director within 120 days of receipt of the appeal.

Accreditation and Re-accreditation

Once a transplant nephrology fellowship program is accredited, the accreditation status will be in effect for three years provided that the accredited transplant nephrology fellowship program pays its annual dues by the published deadline and otherwise complies with the published program criteria. Each accredited transplant nephrology fellowship program is required to submit an annual report to the AST Transplant Nephrology Fellowship Training Accreditation Program, LLC office for each calendar year during the term of accreditation. Such annual reports are to be submitted on the form prescribed by the committee, which includes providing the name(s) of those individuals trained or being trained by the transplant nephrology fellowship program, the number of renal transplants performed during the applicable period, and other pertinent data. For the duration of the accreditation period, each accredited transplant nephrology fellowship program is required to pay an annual renewal fee of $1,200 which will be billed 90 days prior to the program’s accreditation expiration date to maintain accreditation status in good standing.

Any changes in transplant nephrology fellowship program operations, such as UNOS inactivity or changes in transplant faculty (transplant fellowship program director, medical director…) must be communicated in writing to the AST Transplant Nephrology Fellowship Training Accreditation Program, LLC office within 30 days. Failure to notify the Program office may result in the placement of a transplant nephrology fellowship program in under review status (as described below).

Each accredited transplant nephrology fellowship program must apply for re-accreditation every three years on the online application. A re-accreditation site visit is generally only required every six years (as described above), unless significant issues are reported, suspected, or found. The decision as to whether or not to conduct a site visit before the expiration of six years will be at the discretion of the committee.

Transplant nephrology fellowship programs applying for re-accreditation will be invoiced at least six months prior to the expiration date of the transplant nephrology fellowship program’s accreditation. Each transplant nephrology fellowship program up for re-accreditation must submit payment and the completed application within 90 days from the date of the certified notification letter and invoice. The site visit and review process must take place prior to the transplant nephrology fellowship program’s expiration of accreditation. For transplant nephrology fellowship programs that are training transplant nephrology fellows, it is expected that the site visit will take place in the second half of the training/academic year (typically January – June). Failure to submit the fee and renewal application within 90 days of the date of the notification letter and invoice will result in the placement of the program under reivew or a loss of the transplant nephrology fellowship program’s accreditation, with consequences as described below.

Expiration dates for re-accredited transplant nephrology fellowship programs will be provided based upon the date of initial accreditation approval.

Loss of Accreditation

If deficiencies in an accredited transplant nephrology fellowship program are identified by the committee based upon the transplant nephrology fellowship program’s annual report, re-accreditation application, site visit report, fellow’s evaluation form, or other feedback mechanism, the subject transplant nephrology fellowship program will be placed “under review” for a period of up to two years to address the noted deficiencies. Transplant nephrology fellowship programs will be notified by Certified Mail (or via Federal Express for Canadian programs) within 30 days of the board of managers review of the committee’s findings. If a transplant nephrology fellowship program feels the decision of the review committee is factually incorrect, the transplant nephrology fellowship program may appeal the decision to the board of managers within 60 days of the initial decision and present those facts or explanations which the transplant nephrology fellowship program believes shows that the determination was inappropriate. A final decision will then be communicated to the transplant fellowship program director within 120 days of receipt of the appeal.

If the deficiencies are not addressed and remedied before the second anniversary of the “under review” notification, accreditation status will be revoked. The board of managers may revoke a transplant nephrology fellowship program’s accreditation status without placing the program under review if it determines that the transplant nephrology fellowship program has no intent to comply or participate in the accreditation process, or if the level of deficiencies is determined to be so severe as to constitute a danger or other emergency situation.

Deficiencies that may result in placement of a transplant nephrology fellowship program under review or loss of its accreditation status include a material failure to comply with the accreditation criteria, including, but not limited to, a failure to meet the minimum number of kidney transplants required, inadequate training of transplant nephrology fellows, loss of core transplant faculty, probation by UNOS, failure to train any transplant nephrology fellow within the past 5 years, as well as failure to submit annual reports, required fees, or re-accreditation applications within the 90 day period.

While a transplant nephrology fellowship program is under review, it must notify all current and prospective enrollees promptly that the program is under review. Transplant nephrology fellowship programs that are under review cannot enroll new transplant nephrology fellows. Transplant nephrology fellows, who are already enrolled in the transplant nephrology fellowship program at the time of notification of under review status, may continue to train in the transplant nephrology fellowship program while the program is under review. This situation will be reviewed on a case by case basis by the committee to determine the level and quality of training being provided to the existing transplant nephrology fellows and the severity of the deficiencies. Factors considered in the decision to allow existing transplant nephrology fellows to continue to train may include the anticipated timing of re-institution of good standing status, the impact and severity of the deficiency in the training, and the possibility of implementing ameliorating or compensatory measures for the training deficiency in order to provide the adequate training and experience to such transplant nephrology fellows. Such determination will be made in the discretion of the committee and the board of managers. While a transplant nephrology fellowship program is under review, it will still be required to generally fulfill the accreditation criteria, including submission of the annual reports and fees.

Transplant nephrology fellowship programs under review are also required to provide interim reports every six months. Interim reports are to be submitted within 90 days of the request. Failure to submit an interim report within 90 days of the request will result in that program’s loss of accreditation. The reports are to be provided on a form designated by the committee, and will update the committee on the transplant nephrology fellowship program’s status in addressing and resolving the deficiencies that placed it under review. The interim reports will be reviewed by the committee to determine the status of remediation and compliance. Once the committee determines that the deficiencies have been satisfactorily remedied or cured, the committee will make a recommendation to the board of managers as to whether the subject transplant nephrology fellowship program should be returned to good standing status. The committee may determine that a site visit is required prior to determining if a transplant nephrology fellowship program may return to good standing status. If a transplant nephrology fellowship program is not returned to good standing status before the end of the two year review period, then the transplant nephrology fellowship program’s accreditation will be automatically revoked.

Notification of loss of accreditation will be sent by Certified Mail (or via Federal Express for Canadian programs) from the board of manager's chair. If a transplant nephrology fellowship program feels that the decision of loss of accreditation is incorrect, the transplant nephrology fellowship program may appeal the decision to the board of directors within 60 days of the initial decision. A final decision will then be communicated to the transplant nephrology fellowship program director within 120 days of receipt of the appeal.

Reinstitution of Accreditation

If a transplant nephrology fellowship program loses accreditation, it must reapply de novo, i.e., it must satisfy the eligibility criteria, submit a completed application form, pay the application fee, and host a site visit. Additionally, a transplant nephrology fellowship program that is applying for reinstitution of accreditation must submit a statement explaining the steps taken to prevent the reasons for the original loss of accreditation from occurring in the future.

Transplant nephrology fellowship programs that are not accredited by the AST Transplant Nephrology Fellowship Training Accreditation Program, LLC, or that are awaiting accreditation or reinstitution of accreditation shall refrain from referencing the AST Transplant Nephrology Fellowship Training Accreditation Program, LLC in any way alleging that they are or were accredited or affiliated with the Program.