The Down-to-Earth Goals of Two Nephrology Fellows

Two current nephrology fellows share a common background through their residencies at University of Miami/Jackson Memorial Hospital in Florida. Since coming to Stanford two years apart for fellowship, their pathways have diverged somewhat, although their long-term dedication to nephrology and their friendship is unchanged.

Dimitri Augustin, MD, MS, is a fourth-year postdoctoral fellow in nephrology who grew up in South Florida and received both his undergraduate and medical degrees from the University of Miami. He earned a master’s in biochemistry and molecular biology with a biotechnology focus at Georgetown University before medical school. Those studies “opened my eyes to ask how translational research, biotechnology, and medical devices can fit together,” he says. During the third year of his internal medicine residency in Miami, he met Daniel Watford, MD, MPH, a first-year resident.

Watford, currently a second-year fellow in the division of nephrology, was born and raised in Durham, North Carolina. He did his undergraduate work at Princeton University followed by medical school and a master’s of public health at UNC–Chapel Hill. The next step in his career provided the first opportunity for him and his wife to live in the same city. “I couples-matched with my wife, who is an anesthesiologist—now in chronic pain medicine—to Jackson Memorial Hospital in Miami for residency,” he says. “I completed three years of residency and a year of chief residency there.”

Watford explains his cross-country path to Stanford: “I got acquainted with Stanford in a couple of ways. One was through Dimitri Augustin who was one of my senior residents when I was an intern. We hit it off early, initially in more of a mentor relationship that quickly blossomed into a close friendship.”

Another factor in Watford’s decision had to do with an American Society of Nephrology (ASN) meeting in 2016 “where I was a ‘Kidney STARS’ participant. This program aims to stimulate interest in nephrology among medical students and residents through travel funding to attend the ASN national meeting as well as a multitude of networking opportunities. While attending the meeting in Chicago I met the chief of nephrology, Glenn Chertow, and several other Stanford faculty members during a social event. The combination of that opportunity and my connection with Dimitri spearheaded me coming here.”

Watford met his wife, who was originally from Seattle, at a pre-med summer program at Yale in 2007. She did both undergraduate and medical school at the University of Washington before residency in Miami. For fellowship, “Stanford was on our radar, both because it’s a fabulous training program, and because of the added attraction of being on the West Coast, making it possible to be closer to my wife’s family. Dr. Chertow was very supportive through the whole process of recruiting and has made us truly feel part of a family.”

Once the two friends arrived at Stanford for their fellowships two years apart, they followed different research pathways.

Before Augustin started his fellowship, he was thinking about the intersection of technology and medicine: “I thought there were definitely areas within nephrology that could benefit from technology, but I didn’t have any specific ideas at that time.” He also had interests in interventional nephrology and vascular access for patients who must undergo kidney dialysis several times a week.

While he was a fellow of the Stanford Biodesign Program a few years ago, he says, “I learned about the device innovation process and how it could be used in medicine. One need we started looking into involved problems with hemodialysis fistula maturation.”

Dialysis patients require surgery to create a connection, called a fistula, between their vascular system and the dialysis machine. The surgery connects an artery to a vein, after which the vein dilates and thickens to withstand the blood flow required to send blood through the dialysis machine. There is a period of time following the surgery before the fistula is mature enough to be used for dialysis. That period may last over 90 days.

Methods for determining how mature a fistula is—and how ready it is for dialysis—can include repeated physical exams and at times an ultrasound study. Augustin hopes to find a better way. “During that maturation time,” he explains, “the patient has to use a temporary catheter, and that can be associated with an increased risk for infections and hospitalizations.”

Augustin and his colleagues are in the very early days of designing and creating a wearable device for assessing fistula maturation. With the help of a Kidney Innovation Accelerator (KidneyX) award, they are validating the concept and understanding how the data would be used.

KidneyX is an initiative of the U.S. Department of Health and Human Services and the ASN. The first 15 KidneyX awards are funding different concepts to redesign dialysis. Augustin’s KidneyX Redesign Dialysis Phase 1 prize is helping to fund development and testing of their concept to monitor arteriovenous fistula maturation in real time.

While the road ahead for the device is very long, and it may be many years before it comes before the U.S. Food and Drug Administration for marketing approval, Augustin says that “Fistula maturation is a real problem area that I have an interest in, am dedicated to, and want to make changes in.”

On the other hand, Watford’s particular interest comes into play further along the kidney disease process when a patient is in line for a kidney transplant. Northern California has one of the longest kidney transplant wait lists in the country: nine to 10 years for cadaver donation. Given such long waiting periods, during which time the health status of the patients is ever changing, Watford became interested in devising ways to best gauge how well these patients will do both prior to and after transplant. The ultimate goal is to determine a means for providers and transplant programs to ensure the most suitable and medically optimized candidates remain on the transplant list and are offered organs in a time when wait lists are growing ever longer.

The transplant readiness assessment clinic (TRAC) is a novel way for patients to be reassessed for readiness to undergo transplant. TRAC was spearheaded by associate professor Jane Tan, MD, PhD, MS, and clinical assistant professor Xingxing Cheng, MD, MS. As patients move up the wait list toward the one-year point until likely transplant, Watford explains that “we bring them back to TRAC to reassess their physical function. We are using two measurements to assess their readiness: the six-minute walk test and the one-minute sit-to-stand test, with the goal of correlating these measures to outcomes such as removal from wait list or death before transplant as well as some post-transplant outcomes such as rehospitalization and mortality.”

The hope is that these two objective measures will prove useful in determining patients’ readiness for transplant and provide a tool for programs with the longest waiting times to more effectively manage their wait lists.

Should these two fellows achieve their research goals, many patients with kidney disease at Stanford and elsewhere will undoubtedly benefit.