A highly specialized clinic provides efficient care for patients with rare or complicated urinary tract conditions and offers patients, clinicians and researchers a win-win-win scenario.
For patients, the concept of a combined clinic offers clear benefits from a time and convenience standpoint. And in terms of care, the real-time collaboration of two subspecialists in the room with a patient family results in a more nuanced and informed personal care plan. But for physicians and clinician-researchers, combined clinics offer an additional perk: educational collaboration and direct access to a prime population for clinical studies.
“As a urologist, I’m often looking at ultrasounds or renal scans, and the nephrologist is looking at blood pressure, protein, electrolytes and creatinine,” says Daryl McLeod, MD, co-director of the urology portion of the Urology and Nephrology Combined Clinic at Nationwide Children’s Hospital. Chief of Urology V. Rama Jayanthi, MD, is the urology team’s other co-director of the clinic. “When surgery may be necessary, it’s important for a nephrologist to be there. They bring a separate level of expertise to decide if, when and potentially what type of surgery is needed.”
Without a combined clinic, patients facing surgical intervention for complicated urinary or renal concerns would be seen separately by each subspecialty. At best, the physicians would exchange emails or a phone call to share detail or thoughts about the case. In a combined clinic like the one at Nationwide Children’s, however, the doctors meet with the patient family simultaneously and discuss medical management or surgery in real time.
“Especially in pediatrics, urologists trained primarily in surgery really appreciate having a nephrologist to manage medication and monitor kidney-related medical problems, such as hypertension or growth delay,” says Dr. McLeod.
Nephrologists in the shared clinic have a similarly appreciative perspective about the importance of combined visits with urologists.
“Urologists can offer a unique perspective on immediate or long-term nonmedical management, especially for children with structural urinary tract disorders. The urologist brings the ability to manipulate or augment the urinary tract to prevent injury to the kidney — something nephrologists can’t do with medical management,” says John David Spencer, MD, the nephrology team’s co-director of the combined clinic. “We work to prevent problems and provide medical treatment, whereas urologists bring in the surgical perspective when a procedure may be required. It’s really a complementary two-way street in that regard.”
And the cross-disciplinary benefits don’t end there. From a research standpoint, clinician-scientists can use combined clinics as a goldmine for recruitment of patients with rare or complex conditions. Commonly seen diagnoses include posterior urethral valves, recurrent infections caused by vesicoureteral reflux, kidney stones, pyelonephritis, structural kidney disease, urinary obstruction affecting a solitary kidney or both kidneys, and other urinary tract issues interfering with kidney health.
“Having all these kids in one place centralizes and simplifies our opportunity to enroll them in studies,” says Dr. McLeod, whose research focuses on urinary tract obstruction leading to kidney failure. “We’re interested in making lives better and being groundbreaking in how we look at and diagnose these conditions, and having all of the patients in the same clinic allows us to do that much more efficiently.”
Dr. Spencer and fellow nephrology co-director for the combined clinic, M. Brian Becknell, MD, PhD, also have targeted research interests that benefit from the high concentration of complex patients. They and their colleagues in the hospital’s Nephrology and Urology Research Affinity Group and Center for Clinical and Translational Research have studies underway exploring the cause of obstructive uropathies and bladder outlet obstruction, the cause of recurrent urinary tract infections, and the potential clinical biomarkers that could be used to predict these conditions or their complications.
“Through this clinic we have a nice collection of the exact population we need — this is where all those patients are being seen and followed longitudinally,” says Dr. Spencer. “That allows us to obtain clinical data on the patients and evaluate their health outcomes, and it also allows us to collect biospecimens to do preclinical testing or translational research to start to identify which patients are most at risk.”
The combined clinic serves just under 2 percent of the general pediatric urology clinic’s population and a considerably greater percentage of the general nephrology clinic’s population; 161 patients were seen in the combined clinic in 2017 and a projected total of 185 patients will be seen in 2018. The clinic operates one day per month out of the urology clinic space and accepts referrals.
“With a combined service like this, the treatment plan becomes a truly collaborative decision,” says Dr. Spencer. “Through direct discussion, there’s the possibility to minimize the unnecessary use of antibiotics and even surgical interventions, and on the flipside to perhaps identify an early opportunity for surgical intervention that could prevent chronic renal failure. I think there’s a real strength and importance in collaboration.”