1. Inpatient Hepatology Rotation (5 months) — The fellow spends more time on the inpatient services than on any other rotation during the fellowship. During these months the fellow sees a wide range of acute liver disease in two distinct settings. On the wards, the fellow manages decompensated cirrhosis and acute on chronic liver failure and also provides consultative services to the hospital’s general medicine teams. On the ICU and surgical services the fellow works closely with transplant surgeons and intensivists to manage a spectrum of critical illness from acute liver failure to peri- and post-transplant complications. Both services offer the opportunity to perform procedures for a variety of indications, including upper endoscopy, colonoscopy and liver biopsy.
2. Outpatient Hepatology Clinics (4 months) — In our outpatient clinics the fellow gains important experience in general hepatology, including viral hepatitis, alcoholic liver disease, metabolic liver disease and liver cancer. The fellow rotates through specialty clinics for hepatocellular carcinoma, nonalcoholic fatty liver disease and cholestatic liver disease. While our primary training site is in San Francisco, the fellow has the option of seeing patients at some of our outreach locations across the Bay area.
3. Transplant Continuity Clinic (weekly throughout the fellowship) — The fellow attends transplant clinic once or twice weekly, depending on the demands of the current rotation. In Transplant clinic, the fellow manages complications of liver transplantation and immunosuppression in patients who have received a liver transplant within the last month. This clinic, which manages patients with both liver and simultaneous liver-kidney transplantation, is run by hepatologists and nurses; surgeons provide consultative services when necessary.
4. Academic Conferences (daily throughout fellowship) — Most days of the week include regularly scheduled clinical and academic conferences. The fellow presents at monthly case conference and journal club and prepares one grand rounds presentation during the fellowship. The fellow also participates in weekly transplant selection committee, radiology and pathology conferences, monthly M&M conference and quarterly research conference. Conferences in general gastroenterology are also available through CPMC’s gastroenterology fellowship.

Objectives

By the end of the fellowship year, our fellow will have had the opportunity to meet (and surpass) the ACGME requirements for training in transplant hepatology, including:

1. Presentation of 10 potential transplant candidates at selection conference
2. Clinical follow-up of at least 3 months for 20 new transplant recipients
3. Clinical follow-up of at least 6 months for 20 transplant recipients who have survived more than one year after transplantation
4. Observation of 1 cadaveric liver procurement and 3 liver transplant surgeries
5. Interpretation of 200 native and/or allograft liver biopsies
6. Performance of 30 percutaneous liver biopsies

Additional, rotation-specific objectives related to the ACGME Transplant Hepatology program requirements include:

Inpatient Hepatology 

1. Demonstrate competence in the management of complications of cirrhosis, including refractory ascites, hepatic hydrothorax, hepatorenal syndrome, hepatopulmonary syndrome, portopulmonary hypertension and refractory portal hypertensive bleeding.
2. Demonstrate competence in the ethical considerations relating to liver transplant donors and recipients, including living donors, deceased donors and donors with cardiac death.
3. Demonstrate competence in the management of fulminant liver failure.
4. Demonstrate knowledge of the principles of donor selection and rejection.

Outpatient Hepatology

1. Demonstrate competence in the diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma.
2. Demonstrate competence in the management of chronic viral hepatitis in the pre-, peri- and post-transplantation settings.
3. Demonstrate competence in the nutritional support of patients with chronic liver disease.
4. Demonstrate competence in the prevention of acute and chronic liver disease.

Transplant Clinic

1. Demonstrate knowledge of the organizational and logistic aspects of liver transplantation, including the role of the nurse coordinators and social workers, organ procurement and UNOS policies regarding organ allocation.
2. Demonstrate knowledge of transplant immunology, including infectious and malignant complications of immunosuppression.
3. Demonstrate knowledge of indications for, contraindications for and complications of allograft biopsy.

Research Rotation

1. Systematically analyze clinical practice using quality improvement methods and implement changes with the goal of practice improvement
2. Locate, appraise and assimilate evidence from scientific studies related to patients’ health problems.