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The Renal Epidemiology Training Program at The University of North Carolina at Chapel Hill (UNC-CH) prepares trainees to conduct epidemiologic research in the broad field of nephrology. The ongoing need for well-trained research faculty in the field of renal epidemiology is clear when considering the personal and economic impact of end-stage renal disease (ESRD) and chronic kidney disease (CKD) on individuals and society. The impact of renal disease on society is most often described in terms of ESRD, defined as the permanent failure of native kidney function resulting in the need for renal replacement therapy, including dialysis or renal transplantation. Diabetes, hypertension and glomerular diseases are the three most common causes of kidney failure. In 2000, almost 420,000 Americans received renal replacement therapy, and there has been a steady increase in the incidence and prevalence of ESRD over more than two decades (USRDS 2002). However, recent estimates have indicated that there are 12.6 times more patients with CKD as there are ESRD patients in the U.S. Medicare system (USRDS 2002). Although CKD patients have fewer associated medical problems then patients with ESRD, they have far more health burdens than non-CKD patients do in similar age groups (USRDS 2002). The many health complications among those with CKD has lead to estimates that CKD patients are 5 to 10 times more likely to die than to reach ESRD. Additionally, the economic impacts of ESRD and CKD are immense, with ESRD patients representing approximately 0.3% of the Medicare population and consuming over 10 times their proportion of expenditures, and CKD patients representing 3.5% of the Medicare population and consuming 9% of the Medicare budget.

Substantial progress in understanding and treating renal disease has been made over the past two decades. Although advances have been made in relevant basic sciences, clinical sciences, and epidemiology, the integration of these fields in the realm of nephrology has been insufficient. Given the tremendous clinical and public health burden of ESRD and CKD, epidemiological research on prevalence and etiology has been limited. The available epidemiological studies often concentrate on data derived from the end-stage renal disease program and on the impact of diabetes and hypertension on kidney disease. Continuing increases in the incidence and prevalence, and differences in geographic and racial distributions of ESRD and CKD suggest that there are numerous risk factors yet to be explored. These factors include genetics, socioeconomic factors, a myriad of environmental and occupational exposures, chronic infectious states, pre- and perinatal influences on the developing kidney, dietary factors, prescription and over-the-counter drugs and many other areas. Knowledge of these risk factors will lead to better understanding of modifiable risk factors and development of early interventions at both public health and clinical levels. There has also been limited research into the etiology of numerous glomerular diseases.

The strength of our training program stems from the collaboration between the faculty in the Division of Nephrology and Hypertension with the Department of Epidemiology in the School of Public Health, and strong ties to the Departments of Pathology (Nephropathology), Genetics, Dental Ecology, and the Epidemiology Branch of the National Institutes of Environmental Health Sciences (NIEHS). Candidates obtain the formal education and practical experience required for a Masters of Public Health and/or a Doctorate in Epidemiology. Opportunities for research in populations of patients that represent the scope of renal diseases, dialysis patients, and renal transplant recipients are available through well-established databases and ongoing patient registries. Study opportunities and databases are also available for evaluation of risk factors and outcomes in broader based general population and Medicare recipient samples. Additionally, candidates have the opportunity to relate current immunologic/serologic and bioanalytical techniques with the research tools and perspective of an epidemiologist through the well-established basic science laboratories of the training faculty, including the Molecular Immunology Laboratory, Nephropathology Laboratory, Genetics Laboratory and the extensive basic science laboratories of the NIEHS.

The Renal Epidemiology Training grant supports funding for two post-doctoral trainees and two pre-doctoral trainees (currently one, expanding to two in 2006). Postdoctoral trainees are expected to primarily be medical doctors who are also interested in clinical training to become board certified nephrologists. However, trainees with doctoral degrees in other fields such as pathology, molecular biology, immunology, pharmacology, nursing, physical rehabilitation, veterinary medicine and genetics may also apply to the program. Overall, approximately 80 to 90% of postdoctoral candidates will be MDs, while 10 to 20% will have PhDs. The predoctoral trainees may have a master's level education and/or and undergraduate degree and work experience in fields including, but not limited to, epidemiology, pharmacology, physical rehabilitation, nursing, social work, biostatistics, health education and health policy. In certain circumstances, a predoctoral trainee might be retained as a postdoctoral trainee in order to complete research, publish papers, and apply for transition funding.

This training program is designed to extend over two years for post-doctoral and approximately three to five years for predoctoral students. A third year is available at the postdoctoral trainee level for certain candidates, depending on the research project. The training period for postdoctoral students is recommended for physicians being trained for research within a subspecialty by the National Research Council (Careers in Clinical Research: Obstacles and Opportunities. Eds.: Kelley WN, Randolph MA. Washington DC: National Academy Press; 1994) and the American Board of Internal Medicine Task Force on Subspecialty Internal Medicine (Ann Intern Med. 1996;124:686-691). The duration of training for both levels of trainees allows the completion of formal training in epidemiology and biostatistics, as well as completion of a research project in the field of Nephrology.

In summary, our training program offers training in an ever-expanding field of research. This training program merges education in epidemiology and nephrology from well-established programs at the University of North Carolina, and focuses on the areas of concern within the field of nephrology and hypertension, including nephropathology, environmental exposures, genetics and renal disease etiology. The educational goals of the proposed program emphasize formal course work, leading to an advanced degree in epidemiology, a research project that applies this knowledge in the field of nephrology, a mentor relationship, and a series of enrichment seminars. We have assembled an experienced and diverse group of trainers/educators in an institution that is strongly committed and ideally suited to epidemiologic education with an emphasis in nephrology. This program soundly answers the need for individuals trained in classic and clinical nephrology and epidemiology, with an emphasis on environmental, genetic and cardiovascular issues that are pertinent to all types of renal diseases.

Trainee Requirements:

Candidates must be US citizens or permanent residents, agree to fulfill the pay-back provision, have evidence of superior previous academic performance, have at least 2 letters of recommendation of highest enthusiasm, and, preferably, have previous clinical or research experience and publications. The most important criterion for selection will be the assessment of the applicant's potential for independent research.

All candidates are required to submit a written application, including a description of their career goals and their research interests. Emphasis is placed on identifying mature candidates with a commitment to epidemiology. Priority is given to those candidates who, because of their training experience, demonstrate an ability to focus their research interests.

Candidates judged to be competitive based on their written applications are required to visit the program. At that time, candidates are seen by appropriate clinical and research faculty based on the applicant's research interests. Each candidate sees at least one faculty representative from the Division of Nephrology and Hypertension and one from the Epidemiology Department. Following review of the written material and completion of the interviews, the Training Advisory Committee is responsible for selecting the trainees who will be offered positions in the program.