Transplant Fellowship Program

About the Program

The University of North Carolina’s Division of Abdominal Transplant Surgery was awarded fellowship certification by the American Society of Transplant surgeons in May 2000. A transplant surgical fellow applicant must be completing a residency in General Surgery (or the foreign equivalent). All ASTS certified fellowships in liver and kidney transplantation are a minimum of 24 months. The fellow will be integrally involved in all aspects of patient care: evaluation for transplantation both as an outpatient and under urgent inpatient circumstances; operative and peri-operative surgical, medical and immunosuppressive care; and post-transplant in-patient and chronic out-patient management.

Routine practices of a fellow’s education will include the following: both deceased and live-donor surgeries, laparoscopic live donor nephrectomy as well as laparoscopic and open native nephrectomies, and live partial liver donation. General surgery of all types is also performed, particularly on post-transplant patients and renal or liver failure patients. We are also a major referral for hepatobiliary surgery.
Program Description

I. Transplant Surgery Fellowship Program

The UNC Department of Surgery, Division of Abdominal Transplant provides a comprehensive service performing transplant procedures on adult and pediatric patients. On average each academic year we perform 60-80 kidney and liver transplants from deceased and live donors and 4-8 pancreas transplants. We also have a kidney transplant program for highly sensitized recipients. All multi-organ deceased donor procurements and live donor laparoscopic or open nephrectomies and live donor partial hepatectomies are performed by the transplant division. In addition, UNC Hospitals vascular access surgeries are performed by the transplant service with participation of the transplant fellows.

Currently, we train one fellow at a time. The fellow's training and responsibilities evolve with experience and clinical exposure during the academic year. The goal of our program is to train individuals who will not only be capable to perform surgery but also will be able to interact with all medical and supportive services and will be able to assume a leading position in managing the care of transplant recipients from the evaluation process to the long term post transplant follow up. Our renal and liver transplant services are led by the same surgical faculty which allows for exposure to a variety of surgical techniques and maintenance of adequate surgical skills during the entire period of training.

All potential transplant recipients are evaluated by the surgical team in the clinic environment. On average 5-7 new patients with chronic kidney disease and 5-8 new patients with end stage liver disease are seen each week for their evaluation prior to being listed for transplantation. At the present time, the clinical make-up of our renal service is 60% deceased donor kidney transplants and 40% living donors. Further, we continue to see our recipients in the clinic once a year for long-term follow-up. This approach provides the fellow with experience to the effects of long term immunosuppressive therapy and to all aspects of long term follow up of transplant recipients (graft failure, recurrent diseases, and side effects). Besides the surgical faculty in clinic activities, the fellow also interacts with the pre- and post-transplant coordinators, mid-level providers, and residents. The fellow functions in the clinic as an independent physician with surgical faculty accessible for immediate consultation.

The transplant fellow works with transplant trained mid-level providers, pharmacists, as well as nephrology and hepatology fellows to provide comprehensive care to patients remaining on the transplant floor and in intensive care units. This allows the fellow to focus on important aspects of recipient care and interaction with other team members. The transplant fellow leads rounds on all patients with a transplant faculty mentor at least once a day. The purpose of these rounds is to direct treatment and teach all members of the team. In the operating room our surgical fellows are exposed to all aspects of abdominal organ transplantation: procurement, back table procedures, biopsies and transplants. The goal of our training is to graduate a transplant surgeon who will be able to perform all transplant related surgeries independently after completion of the fellowship. A certain level of operative independence is granted to the trainee on an individualized basis and according to the progress of the trainee. A faculty member is present in the operating room at all times.

Our approach to transplantations is integrated and multi-disciplinary. For example, the nephrology fellow typically rounds with our service on a daily basis. The fellows are exposed to pre-transplant patients that require nephrectomies for disease. Peri-operative care for all kidney transplant recipients and donors is delivered by our team. For the hepatology side of our program, the teams communicate on a daily basis. For example, immunosuppressive decisions are initiated by the surgical service in cooperation with our medical colleagues. The fellow will be a principal decision-maker with respect to patient management decisions (including post-op care, immunosuppression, etc.). Educational opportunities are critical in our program. There are multiple transplant pathology review of cases that alternate between the hepatology (biweekly) and nephrology pathologists (weekly) with respect to interpreting allograft biopsies. The HLA lab attends our weekly kidney meeting to review histocompatibility issues. In addition, we have a weekly kidney conference to discuss patient related issues and a similar liver conference to discuss patient issues pertinent to the respective patient populations. On a bi-weekly basis we have a multidisciplinary hepatobiliary conference with the hepatologists, and radiologists to review complex cases and management decisions. To complicate this, a transplant educational conference series meets bi-weekly between September and June.

Besides the intensive clinical activities, we expect the fellow to participate in research activities. Although hands on laboratory experience may not be practical considering the busy clinical schedule during the academic year, we encourage and expect participation from the fellow in all clinical research meetings. We believe this approach creates a nurturing environment, encourages independent studies, indicates the importance of science and immunology in treating transplant recipients, and indicates that transplant is a dynamic multidisciplinary treatment modality requiring constant research involvement. We expect that the fellow will publish or will be involved in publishing 2-3 papers related to clinical and/or research studies. For interested individuals, we have opportunities to pursue full time basic research work after completion of a core clinical training.

Our research effort consists of clinical trials involving new immunosuppressive agents and protocols initiated by our faculty or the pharmaceutical industry. At the same time there are basic research studies related to stem cells, developmental biology and tissue engineering related to transplantation biology. There are also ongoing studies on recognition of tissue injury in antibody mediated renal graft rejection. Clinical work of the fellow is supported by four full-time transplant surgeons, nephrologists, hepatologists, pediatricians, pediatric hepatologists and nephrologists, transplant designated anesthesiologists, critical care specialists, transplant pharmacologists and pharmacists, social workers, clinical psychologists, transplant coordinators, immunologist, HLA lab staff, and general surgery residents in their fourth, second and first year of training, as well as research scientists.

II. CORE COMPETENCIES

  1. Patient care
  2. Medical knowledge
  3. Practice-based learning and improvement
  4. Interpersonal and communication skills
  5. Professionalism
  6. Systems-based practice

III. LEARNING OBJECTIVES

A: PGY I and II

  1. To gather and interpret essential and accurate information about the patient’s health status and condition.
  2. To learn principles of care for the critically ill patient and function within the hospital and intensive care setting.
  3. To expand the fund of knowledge from medical textbooks, journals, and electronic media.
  4. To participate in the education of the medical students and interns as well as attend and present at conferences.
  5. To learn to communicate effectively with other housestaff, medical students, nurses, and paramedical staff.
  6. To demonstrate compassion and integrity through respectful patient care and family interactions.
  7. To understand when expert medical advice is necessary.
  8. To function as a part of the larger health team environment by respecting the opinions of others.
  9. To present new and interesting ideas using the latest technology to provide high-quality patient care and education.

B. PGY IV

  1. To gather and interpret essential and accurate information about the patient’s health status.
  2. To learn the non-operative and operative management of kidney and liver diseases which lead to transplantation.
  3. To perform transplantation and general surgical procedures, including nephrectomies and hepatobiliary cases.
  4. To expand the fund of knowledge through journals and electronic media.
  5. To participate in the education of medical students and junior residents as well as attend and present conferences.
  6. To demonstrate compassion and integrity through respectful patient care and family interactions.
  7. To understand when expert medical advice is necessary.
  8. To function as a part of the larger health team environment by respecting the opinions of others.
  9. To present new and interesting ideas using the latest technology to provide high-quality patient care and education.
  10. To communicate effectively with other housestaff, medical students, nurses, and paramedical staff.

IV. ABDOMINAL TRANSPLANT DIDACTIC CURRICULUM OUTLINE

Weekly

  • Kidney Transplant Conf. 3:30 P.M on Mondays in the 4th floor Tx. Conf. Room
  • Liver Transplant Conf. 1:30 P.M. on Tuesdays in the 4th floor Tx. Conf. Room
  • Surgery Grand Rounds 7:30 A.M. in the 4th Floor Old Clinic Auditorium
  • Surgery M & M Conf. 5:00 P.M. on Wednesdays in the OR Classroom
  • Liver Pathology Conference 1:30 P.M. on 2nd and 4th Tuesday, on the 1st floor in Pathology Conf. Room
  • Renal Pathology Conf. 1:15 P.M. on Friday, on the 1st floor in Pathology Conf. Room

Bimonthly

  • Hepatobiliary Conference 1st and 3rd Wednesday of each month at 12:30 P.M. in the VIR Conference Room

V. Transplant Program Lecture Outline

A. Immunology

  1. Immunobiology of graft rejection
  2. Chronic rejection/ tolerance
  3. Histocompatibility systems (John Schmidt)
  4. Immunosuppression/monitoring

B. Organ Procurement (CDS)

  1. Organ Preservation
  2. Organ Allocation
  3. Brain Death Criteria/Non-heart beating donor
  4. Donor Quality/Organ selection criteria

C. Liver

  1. General Hepatobiliary
    • Anatomy and physiology
    • Diagnostic techniques – Radiologic, Endoscopic, Laparoscopic
    • Management of biliary diseases
    • Management of hepatic diseases  
  2. Management of fulminant hepatic failure
  3. Management of ESLD, cirrhosis, and portal hypertension
  4. Management of viral hepatitides
  5. Liver transplantation: pre-, peri-, and post-operative care

D. Kidney

  1.  Anatomy and physiology
  2. Acid-base, fluids and electrolytes, hypertension
  3. Management of chronic renal failure
  4. Renal transplantation: pre-, peri-, and post-operative care

E. Pancreas

  1. Anatomy and physiology
  2. Exocrine/Endocrine function
  3. Sequelae of diabetes
  4. Pancreas transplantation: pre-, peri-, and post-operative care

F. Special Issues in Pediatric Transplantation

G. Systemic Considerations of Organ transplantation

  1. Pulmonary, Cardiovascular, Infection, Psychiatric, Metabolic/endocrine, Hematologic
  2. Neoplasm and transplantation

H. ICU considerations in Organ Transplantation

  1. Metabolic responses to injury, fluid, electrolyte management, nutritional management of the surgical patient
  2. Hemostasis and surgical bleeding, shock, physiologic monitoring of the ICU patient

I. Research/Future Directions

  1. Bio-Artificial Hepatocyte Technology
  2. Stem Cell Therapy
  3. Ischemia/Reperfusion

VI. Apprenticeship Curriculum

  1. Pre-operative and post-operative clinics.
  2. Operating room instruction.
  3. Tutorial sessions for residents presenting at conferences.
  4. Ward Rounds.
  5. General surgical call, which fosters independence and effective telephone communication skills.
  6. Optional research including retrospective chart reviews, prospective studies, database outcome analysis, and laboratory investigation.

Current Fellow

Ninad Deshmukh, MD (2009-2011)

Past Fellows

Robert A. Watson, MD (2005-2007)
Kerri Ann Simo, MD (2007-2009)

Applicant Requirements

  • USMLE Steps 1-3
  • US Residency or equivalent (visa) paperwork
  • Ability to obtain NC permanent medical license
  • US Graduates
    • Graduation from school accredited by LCME or AOA  
    • 1 year accredited graduate training
  • Foreign Graduates
    • ECFMG certified
    • 3 years of accredited graduate medical training

Credentialing

Abdominal Transplant Surgery credentialing requires standard completion of all requirements to practice General Surgery (American Board of Surgery licensed) and the completion of an American Society of Transplant Surgeons’ accredited fellowship.

For fellowship candidates, such credentialing under Medical Staff requires U.S. residency or equivalent (VISA paperwork) and a NC permanent medical license as described below.

Except for graduates of foreign medical schools, applicants must have graduated from a medical school accredited by the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association (AOA) and have successfully completed at least one year of accredited graduate training. They must also have passed the United States Medical Licensing Examination (USMLE) or its equivalent. For foreign medical graduates, all steps of the USMLE must be completed in addition to being able to obtain a NC permanent medical license. Physicians who are graduates of schools that are not accredited by the LCME or the AOA (foreign medical schools) must have been individually certified by the Educational Commission for Foreign Medical Graduates, have successfully completed at least three years of accredited graduate medical training, and have passed the USMLE or its equivalent.

The specific procedures required for completion of an American Society of Transplant Surgeons’ accredited fellowship include: abdominal cadaveric organ procurement and living donor procurement of abdominal organs and/or parts of organs (e.g. partial liver resections for live donation). In addition, they must be able to order immunosuppressive medications for care of the abdominal organ transplant patient. Other routine privileges may include vascular access procedures for hemodialysis or liver replacement therapies and future cell therapy, as well as all procedures covered under General Surgery.

All medical and surgical directorships of abdominal organ transplant programs must be transplant fellowship trained individuals.

How To Apply

Accepting applications for 2011 - 2013. Please provide the following:  

  • Transplant Fellowship application buttona letter of interest
  • current curriculum vitae
  • three letters of reference
  • documentation of USMLE steps 1-3
  • ECFMG certification (foreign graduates)
  • a recent photograph
  • a personal statement addressing your career interests
  • VISA (if applicable)
  • Interested applicants are also required to register with the National Residency Matching Program. Visit www.nrmp.org for further details.

Please send all items as a complete package. Incomplete applications will not be accepted.
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Contact 

Dr. David A. Gerber
Program Director
Department Transplant Surgery
4024 Burnett Womack CB# 7211  
Chapel Hill, NC 27599
Phone: 919-966-8008
Fax: 919-966-6308

Carleta Long
Fellowship Coordinator
UNC-CH Department of Surgery
4024 Burnett Womack CB #7211
Chapel Hill, NC 27599
Phone: 919-843-1796
Fax: 919-966-6308
cscott@med.unc.edu