at Every Level of Nephrology
A glance at the website for the division of nephrology brings a short paragraph into focus. It includes these three sentences, which could easily be considered a vision statement: “We are devoted to training the next generation of nephrologists in a supportive environment that cultivates their individual passions. We are dedicated to creating and maintaining a diverse and inclusive community. We are Stanford Nephrology.”
A New Division Chief
When associate professor Tara Chang, MD, MS, assumed the position of chief of the division of nephrology in early 2021, she was following directly in the footsteps of her mentor, Glenn Chertow, MD, MPH. Chang has only good things to say about Chertow: “He had a critical role in shaping my career. And it’s really through his efforts that our division is so diverse with regard to women and with regard to race and ethnicity, both at the faculty level and at the fellowship level.”
Tara Chang, MD, MS
The way Chang ended up with nephrology as her specialty reflects her approach to many things: “I was never one of those people who had a grand plan for life. Opportunities arose and I took them as they came. As an example, UC-San Francisco wasn’t actually my first choice for residency but matching there changed my trajectory. I met fantastic faculty in nephrology there, so I decided to specialize in this field.”
Her research program covers almost everyone with kidney disease, which has a great deal of overlap with cardiovascular disease. Chronic kidney disease is a risk factor for many cardiovascular diseases, including premature coronary disease, hypertension, and atrial fibrillation. “What has been cool in recent years,” she says, “is that more and more the cardiology community is recognizing the importance of the kidneys. While cardiology is still ahead of nephrology in terms of clinical trials, we are seeing more and more studies with a primary kidney outcome and a secondary cardiovascular outcome. It’s an exciting time for us to partner with the cardiovascular community because there are many new therapies coming down the pike.”
Race, Ethnicity, and Kidney Disease
Kidney disease disproportionately affects people who are Black or of Hispanic ethnicity and those in lower socioeconomic groups. A lot of the reason is a lack of access to care, risk factors such as diabetes, and a scarcity of options for food. The kidney community is trying to understand how to do better.
The estimated glomerular filtration rate (eGFR) is an important basic way to assess a patient’s kidney function. The formula used to calculate it includes factors such as age, gender, and race, for which the choices are Black or non-Black. The use of racial data is of enough concern that the National Kidney Foundation and the American Society of Nephrology have appointed a task force to look into it and report back.
Chang notes that “there’s been a lot of scrutiny into how we include race in clinical care, including how we calculate the eGFR. Changing the way we calculate it is just the tip of the iceberg, but it may spur more of us to think more deeply about issues of race and ethnicity and medicine.”
Goal setting is an important early step for a person in a new position of responsibility. Chang feels that she ascended to become chief of a division that already had a number of strong goals in place, causing her to want “to continue a lot of the things that Glenn prioritized: investing in training fellows and taking care of them and trying to have fellows and faculty in the division who look like the patients we serve. I have other evolving goals, but I want input from faculty in the division on such matters. We have an awesome faculty, and I want them around me forever. I need their help to set the course.”
Adetokunbo Adenike Taiwo, MD, MS
One of those faculty members is clinical assistant professor Adetokunbo Adenike Taiwo, MD, MS, whose path into nephrology was similar to that of her chief. “When I started my residency, I was uncertain what specialty I would choose. Nephrology was not at the top of my list. During my training at the University of Chicago, we took care of a predominantly African American population. The burden of kidney disease in the community made a deep impression on me. Every time I was on call, I admitted several patients with either acute or end stage kidney disease.”
Kidney Transplantation at Stanford
Caring for patients with kidney failure was challenging. Taiwo explains why: “They were often the sickest patients in the hospital. I spent the bulk of my residency taking care of very sick people and trying to get them to feel well enough to return home to their family. Many of these patients were hospitalized frequently with complications related to kidney disease. It just seemed like they never had a great quality of life.”
Getting the sickest patients to life saving transplant is a long, bumpy, uncomfortable path, and it often ends with patients being short of their goal. Dialysis saves them from immediate death, but it takes a long time to get a kidney transplant; the standard waiting time is seven to 10 years in the San Francisco Bay Area. With kidney transplantation, unlike transplantation of other organs where the sickest patients are the ones who are prioritized for transplant, “you have to be fit enough to be transplanted,” says Taiwo. After 10 years on dialysis, the sad reality is that many patients are not healthy enough or have developed complications such as severe vascular disease that make them ineligible for transplantation.
When Taiwo rotated through the kidney transplant service, she encountered a very different set of patients.
“I love asking patients the first time they show up to my clinic after transplant, ‘What’s different?’ Hearing how much better they feel makes this field so fulfilling”
Her story continues: “Here I was on a rotation where I was seeing end stage kidney disease patients coming in for follow-up after their kidney transplant, and they looked so well. Knowing that these patients were similar to patients I took care of in the hospital setting really changed my view. I went into medicine to make a difference, to see people get better, to see people go from sick to well. When I saw how much kidney transplantation changed quality of life, it simply blew me away.”
Taking care of transplant patients, she says, “is rewarding every single time. I love asking patients the first time they show up to my clinic after transplant, ‘What’s different?’ Hearing how much better they feel makes this field so fulfilling.”
A Fellow Also Drawn to Transplant
Unlike Taiwo and Chang, Ruth Romero, MD, a second-year fellow, says she “actually wanted to do nephrology since I was in medical school when I learned about electrolytes and fluid balance. It’s very interesting, and it’s challenging to learn it very well.”
Adetokunbo Adenike Taiwo, MD, MS (left) and Ruth Romero, MD (right)
Romero says that she chose “Stanford for my fellowship first because of the faculty. I feel like there is a very good balance here between clinical work and teaching. A lot of the faculty take much of their time to teach us every day when we are rounding. We also have teaching conferences almost every day.”
Romero is also interested in transplant nephrology after having done six months of transplant clinic at Stanford. She says, “We saw transplant patients every one or two weeks; this was pre-COVID. It was such a life-changing experience for everybody. More than half were Latin people, so we had a lot in common because I’m from Ecuador.”
Noting that diabetes and high blood pressure in the U.S. put people at risk of developing kidney disease, she says that there are “certain diseases in the Latin community that also put patients at risk of having end stage renal disease at an early age.”
Beginning in July 2021, Romero will spend a year as a transplant fellow at USC. After that, she says, “it is very likely I’m going back to my home country. I will take all the experiences I had here and bring them back to my native country to practice medicine there.”
Perhaps she heard this advice from the new chief of her division: “This is the thing I tell my fellows: If you approach everything with your best effort and come through when you say you will, opportunities will continue to present themselves to you.”