Contact Information

For more information, referral and appointments, please call (203) 785-4184.

Clinical Services

The faculty of the Yale Section of Nephrology provide broad expertise in the diagnosis and management of acute and chronic kidney diseases. A number of renal faculty members work together as a committed clinical practice group, providing round-the-clock primary care for patients with renal disease or hypertension and easy accessibility for consultation. Our clinical commitment is based in these values:

• Twenty-four, 7-day-a-week availability to the patient and the referring physician.
• Open communication with patients, families, and referring physicians.
• Demonstrated excellence in the principles and practices of medicine and nephrology.
• A principal care approach to patients with chronic kidney disease, advanced renal insufficiency, end stage renal disease, renal transplantation, and hypertension.
• A considered application of new approaches to therapy and diagnosis of renal diseases and their complications.
• Advocacy for our patients.

The services that the Yale Nephrology Group provide are comprehensive. In some circumstances, our services are chiefly consultative and collaborative, working hand-in-hand with referring physicians or groups. In other circumstances, our care is longitudinal and we serve as the principal caregiver for the patient. In nearly all instances, care is multidisciplinary, involving skilled nurses, dietitians, social workers, and other physicians.

Our practices are presently based at Yale-New Haven Medical Center, the Yale-Gambro Healthcare Dialysis Center, and the Veterans Administration - CT Healthcare System, West Haven. Inpatient care is provided on a 24-hour-a-day basis at both medical centers. Out-of-hospital patients are seen regularly in the Dana Clinic of Yale-New Haven Hospital, the Yale-Gambro Healthcare Dialysis Centers in New Haven and Branford, and the West Haven Veterans Administration - CT Healthcare System Dialysis Facility and Clinics.

The clinical services provided by the Yale Nephrology Group cover the discipline of nephrology in all its scope and depth. Special services include the following:

Evaluation and care of the patient with acute renal failure. This care is typically consultative and collaborative. Accurate diagnosis is pursued with vigor. Management intends to mitigate renal damage. As necessary, management will include acute hemodialysis, acute peritoneal dialysis, and/or continuous veno-venous hemodiafiltration.

Evaluation and treatment of the patient with glomerulonephritis. This care requires a kidney biopsy, which we perform ourselves commonly using CT scan guidance. Interpretation of the biopsy is done collaboratively with an expert renal pathologist at Yale. Ongoing management of the patient is most often directed by the attending nephrologist as a principal caregiver. Care is usually collaborated with a referring physician

Evaluation and treatment of the patient with electrolyte and/or acid-base disorders. This care is typically consultative and time-limited, but if the condition is chronic, care will involve a longitudinal relationship between patient and nephrologist.

Evaluation and management of the patient with hypertension. Patients with refractory hypertension, hypertension associated with suspected renal artery stenosis, hypertension with renal insufficiency, and hypertension associated with genetic defects are seen frequently by members of the Yale Nephrology Group. As indicated, patients are evaluated for curable causes of hypertension. Management involves longitudinal care relationships.

Evaluation and care of the patient with chronic kidney disease (CKD) and progressive renal insufficiency. This entails first uncovering the etiologic cause of the renal disease and treating that process specifically, then employing more generic interventions such as tight blood pressure control, dietary restriction of phosphorus, sodium, and potassium, early use of vitamin D analogues and phosphate binders to mitigate evolving bone disease, and treatment of anemia with erythropoietin or darbopoietin and iron. Dietary protein restriction is employed according to the discretion of the nephrologist.

Care of the patient with diabetic nephropathy. Yale Nephrologists prefer to engage the diabetic patient as soon as albuminuria is detected. Care is rendered collaboratively with a comprehensive diabetic care plan that includes tight blood pressure control, optimal control of blood glucose, control of hyperlipidemia, and careful employment of ACE inhibitors and/or Angiotensin Receptor Blockers (ARB).

Care of the patient with polycystic kidney disease. This includes patient and family counseling, tight blood pressure control, prompt treatment of infection, and cyst decompressions as necessary.

Diagnosis and management of renal osteodystrophy. This is facilitated by expert bone biopsy. All patients with established renal insufficiency are counseled regarding phosphate restriction and are prescribed vitamin D analogues in accord with blood concentrations of intact PTH.

Renal transplant care. All patients with renal failure are considered potential candidates for renal transplantation. We refer our patients to the Yale Transplantation Division in the Department of Surgery. Four of the Yale Nephrologists participate in pre-transplant evaluation and re-evaluation as members of the Yale Transplant Team. Dr. Bia, Dr. Formica, Dr. Lakkis and Dr. Rothstein provide expert post-transplant care longitudinally.

Pre-Dialysis Care of the patient with established renal disease receives enormous emphasis in our program. Our goal is to engage patients early in a care plan that aims to retard deterioration of renal function and thwart the complications of chronic kidney disease. Essential components of care include expert treatment of the primary renal disease, tight blood pressure control to values less than 125-130/75-80 mm Hg, careful employment of ACE inhibitors and/or ARB to maximal tolerated doses, early management of phosphorus and calcium balances, early attention to evolving secondary hyperparathyroidism and renal osteodystrophy with calcitriol or its analogs, correction of anemia with erythrypoietin or darbopoietin and iron, and nutritional teaching. Counseling regarding dialysis and transplantation options is done in coordination with nurses, social workers, and dietitians from the Yale-Gambro Healthcare Dialysis Center. Informational classes for patients with progressive renal insufficiency and their families are held monthly at the Yale-Gambro Healthcare Dialysis Center with one-on-one sessions available on request. As renal replacement with dialysis or a transplant becomes necessary, we intensify care so that transition onto dialysis or transplantation occurs without complication.

Our Renal Failure Program is one of the oldest in the state. We provide primary care for over 250 patients with chronic renal failure treated with home peritoneal dialysis or hemodialysis at the Yale-Gambro Dialysis Center and the Veterans Administration - CT Healthcare System Dialysis Facility. Our out-of-hospital dialysis services include home peritoneal dialysis by personalized prescription and in-center hemodialysis with state-of-the-art technology. Yale's dialysis services have been invigorated through partnership with Gambro Healthcare, an integrated renal services corporation which links clinical expertise among several university dialysis programs. These presently include Yale University, Beth Israel-Deaconess Medical Center of Boston, Boston University Medical Center, Columbia University in New York, George Washington University Medical Center in Washington, D.C., Duke University, Emory University in Atlanta, Medical College of Virginia in Richmond, University of Miami, University of Texas at Houston and at Dallas, University of Oklahoma, University of Colorado, Washington University-Jewish Hospital in St. Louis, Johns Hopkins University Medical Center in Baltimore, and the University of California at San Diego.

Our partnership with the Gambro Healthcare Corporation and these University programs provides state-of-the art technology and collaborative mechanisms for continuous quality improvement in delivery of care. Maintenance of excellence in process of care and in patient outcomes are the top priorities in our program. We scrutinize our provision of care monthly through a wide-ranging quality assurance and quality improvement program, which is facilitated by the computerized medical information system provided by the Gambro Healthcare Corporation.

The hemodialysis centers at Yale service over 170 patients and are located in New Haven and Branford with 35 and 12 stations respectively. The peritoneal dialysis center at Yale is immediately adjacent to the hemodialysis unit in New Haven, and services over 60 patients who dialyze at home. We employ only biocompatible dialysis membranes in the hemodialysis process and serve all patients with either high efficiency or high flux cartridges. Prescriptions for hemodialysis are individualized to achieve optimal clearances according to international standards. Hemodialysis patients are seen by Yale nephrologists 6 days per week. Our patients on home peritoneal dialysis are taught to dialyze with automated cyclers as appropriate. As with hemodialysis, the peritoneal dialysis prescriptions are individualized to achieve optimal clearances according to international standards. Peritoneal patients are seen at least monthly, and often weekly, by Yale nephrologists. Free parking is availabe at all outpatient Yale-Gambro Healthcare dialysis facilities.

Quality standards which are tracked monthly include the following:

• Adequacy of dialysis by urea removal kinetics: we aim for all hemodialysis patients to achieve a minimum KT/V for urea of 1.3; because we believe there is a clinical benefit to greater clearances, we strive to achieve KT/V urea > 1.5 for all HD patients; we aim for all PD patients to achieve weekly total KT/V > 2.1.
• Anemia management: we aim for all patients to have a minimum hematocrit > 32; we believe optimal hematocrit is 35 - 36 and strive for this utilizing an erythropoietin sliding scale protocol.
• Iron management: we aim for all patients to have % transferrin saturation > 25 - 30% and ferritin > 200.
• Calcium, phosphate, PTH management: we aim for all patients to have corrected calcium 9 - 10.5, phosphate less than 5, and intact PTH between 80 - 250. To achieve these targets, we engage the patient in continuous instructional feedback regarding their diet and use of phosphate binders, and employ a vitamin D analogues sliding scale protocol.
• Nutritional status: we aim for all patients to have a serum albumin > 3.8; to achieve this we engage the patient in continuous instructional feedback regarding diet, serially assess albumin, prealbumin, transferrin, and body weight, and prescribe or supply a variety of enteral supplements.
• Vascular access integrity and performance: We employ a vascular access surveillance protocol which serially tracks intra-access blood flow using Transonic, dynamic venous needle pressures on hemodialysis and recirculation values. We refer patients for vascular access angiography and repair when venous pressures or recirculation ratios exceed threshold values.
• Infection management: All occurrences of infection are tracked and logged for quality improvement activities.
• Hospital utilization: All hospitalizations are reviewed monthly for quality improvement activities.

The dialysis program at the Veterans Administration - CT Healthcare System services over 40 patients on hemodialysis or peritoneal dialysis. Both the hemodialysis and home peritoneal units are located on the VA campus and are attended by full-time Yale nephrologists.

Renal failure care also includes referral, as appropriate and as desired, for renal transplantation. Yale nephrologists participate in pre-transplant evaluation, not only for our own patients, but for patients referred from the New York-New England region as well as post-transplant care