Enhancing Education for Nephrologists in Fellowship and Practice

More than 37 million Americans living with kidney diseases deserve high-quality care. For the foreseeable future, however, the number of nephrologists in practice is expected to be insufficient to care for an expanding kidney disease population. Several factors are expected to exacerbate this problem, including an aging population, increasing complexity of care for kidney patients because of new therapies, the emerging concept of a cardiovascular-kidney-metabolic (CKM) syndrome, and forthcoming restrictions on US immigration among international medical graduates in both training and practice. To help address these challenges, the American Society of Nephrology (ASN) focuses on ensuring that physicians completing nephrology fellowship possess the competencies needed to enter effective, autonomous practice. ASN also provides educational resources so that clinicians caring for kidney patients can lead interdisciplinary care teams and remain current with their knowledge and skills throughout their careers. While ASN continues its long-standing support of physician-scientists and PhD researchers—which includes having its separately incorporated foundation (KidneyCure) provide an estimated $5 million in annual grant funding in 2026, 2027, and 2028—this Perspective focuses on the clinical nephrology workforce. To care for the entire spectrum of kidney diseases, a high-quality nephrology workforce requires superb fellowships, demonstrated competence, and a common understanding of the expertise that nephrologists with different levels of training possess. As recommended by the ASN Task Force on the Future of Nephrology in 2023, ASN adopted a classification that defines three levels of fellowship education1: Essential training includes the expected knowledge, skills, values, and attitudes necessary for every graduating nephrology fellow, including new advances in the field, obtained during a standard 2-year fellowship in nephrology. Essential training includes all the patient care, procedural skills, and medical knowledge competencies for nephrology expected by the Accreditation Council for Graduate Medical Education (ACGME).2 Individual training occurs during the second year of fellowship to provide opportunities for fellows who choose to learn through didactics and clinical experience beyond the standard experience for all fellows as part of Essential training (and required by ACGME). Individual training focuses on one or more highly specialized areas, such as glomerular diseases, onconephrology, and home dialysis. Advanced training provides a higher degree of proficiency in a focused clinical area of nephrology that requires education beyond what is available during the first 2 years of fellowship. Occurring during all or part of a third year of fellowship, Advanced training focuses on educational experiences pursued by a limited number of nephrologists who may be in ACGME-accredited disciplines (such as transplant nephrology, critical care, or palliative care) or nonaccredited programs (such as those areas noted for Individual training). Implementing this approach requires input from the broader nephrology community to determine the competencies expected for each of these levels of education. ASN anticipates developing curricula and educational tools to help programs train fellows in these competencies. For more than 30 years, cardiology has used a similar three-step approach to fellowship training for great success.3 Establishing mutually agreed on curricular and experiential standards for both Individual and Advanced training is important, as is determining how the graduates of Advanced training programs are assessed both on completing the training and throughout their careers. ASN will work with ACGME and the American Board of Internal Medicine (ABIM) to ensure that program requirements for nephrology fellowship training and the initial certification examination blueprint, respectively, align with the full scope of nephrology practice now and as it evolves. ASN and the rest of the nephrology community need to consider the value of such assessments through ABIM certification pathways or by exploring innovative alternative competency assessments developed and delivered by other entities. ASN is also committed to improving the pass rate for first-time takers of the ABIM nephrology initial certification examination. Although the pass rate for first-time takers has ranged from 75% to 82% in recent years, the eventual pass rate is 97%–98%, like other internal medicine subspecialties.4 Most (approximately 95%) of those who do not pass the examination on the first attempt do so on the second, indicating an opportunity for ASN to work with newly graduated fellows to improve the first-time pass rate. Since the need to improve performance crosses most areas of the ABIM examination, ASN will explore opportunities to improve and increase effective utilization for this purpose of the ASN Nephrology In-Training Examination, Board Review Course and Update, Kidney Self-Assessment Program, and Nephrology Self-Assessment Program. For example, ASN has already begun assessing the In-Training Examination, working with ABIM to increase transparency around initial certification examination pass rates for fellowship programs, and helping program directors better understand and address gaps in learning and clinical experiences of their fellows. Recognizing that nephrologists alone cannot meet the needs of every American living with kidney diseases, ASN in January 2026 launched a Task Force on Strengthening the US Dialysis Care Team with the American Nephrology Nurses Association, National Kidney Foundation, and Renal Physicians Association. This collaboration is intended to expand the cohort of skilled, nephrology-trained advanced practice providers (APPs) working with nephrologists to allow nephrologists to spend their time with patients requiring the most complex decision making and clinical care. Building on this initiative, ASN aims to better understand the current training experiences and scopes of practice of APPs in various clinical settings and help the nephrology community to anticipate how their roles may evolve in the future. In addition, ASN is currently partnering to improve the skills of nephrologists. These partnerships include working with the American Heart Association, American Kidney Fund, and National Kidney Foundation so that CKM results in high-quality care for people living with kidney diseases. The American Heart Association issued a Presidential Advisory in 2023 advocating for a multifaceted, concerted, and patient-centered effort involving multilevel partnerships among clinical entities, policymakers, payers, and numerous stakeholders, as well as the enhancement of education and research related to CKM.5 This work includes providing vital learning opportunities for nephrology fellows, nephrologists in practice, APPs, and other health professionals. The advent of new genetic tests, diagnostics, and treatments for glomerular diseases has resulted in ASN partnering with the International Society of Glomerular Disease, GlomCon, and other experts. This collaboration helps (1) guarantee that the larger community of nephrologists in practice has the skills to use these new tools to care for people across the full spectrum of glomerular diseases and (2) identify nephrologists and centers with the expertise to care for those with the most complex glomerular disorders. Recently, ASN announced a comprehensive program that will train the kidney workforce in the implementation of the new immune-mediated therapies across a spectrum of conditions from GN to transplantation.6 To enhance education for nephrologists, ASN is: Articulating the role of nephrologists and other health professionals (particularly APPs) in providing kidney care (in 2026 and 2027). Defining Essential, Individual, and Advanced training for nephrologists (in 2029 and 2030). Working with ACGME to ensure that program requirements for nephrology fellowship training align with the expectations for Essential competency and that all training programs are equipped to meet all such expectations (ongoing, although ACGME is next scheduled to update the nephrology fellowship program requirements by 2035). Helping nephrology fellows to complete initial ABIM certification and nephrologists in practice complete continuing certification through ABIM (ongoing). Exploring how the graduates of nephrology Advanced training programs (and potentially those who complete extended Individual training experiences) are assessed both on completing training and throughout their careers (ongoing). Providing educational opportunities for nephrology fellows and nephrologists in practice to address gaps in their Essential, Individual, or Advanced training (ongoing although likely to be reinvented by 2030). Offering continuing education to nephrologists and other health professionals who provide kidney care (ongoing although likely to be reinvented by 2030). This plan has at least three limitations. First, ASN is only one of the organizations responsible for ensuring high-quality education for nephrologists. As previously mentioned, ACGME accredits fellowship training, ABIM certifies and recertifies nephrologists, and other specialty societies care deeply about certain focused aspects of nephrology practice. Second, clinically active nephrologists are part, but not all, of the workforce, which also includes APPs as well as nephrologists and health professionals focused on research, education, and administration. Moreover, the training pipeline for pediatric nephrology is completely different than for adult nephrology, requiring ASN to partner with the American Society of Pediatric Nephrology. Third, technology, particularly artificial or augmented intelligence, is fundamentally changing every aspect of health care, including nephrology, by harnessing complex datasets, enhancing diagnostic accuracy, customizing treatment, and reducing administrative burden. Through its Partnership for Responsible Augmented Intelligence in Kidney Health, ASN is pursuing earlier detection of kidney diseases, more precision stratification of people at risk for kidney diseases, and improved treatment for kidney diseases and kidney failure.7 Undergraduate, graduate, and continuing medical education for nephrologists must keep pace with these changes, and ASN stands ready to help lead the way.