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A 56-year-old man with stable chronic kidney disease (CKD) for two years following a single episode of calcium oxalate urolithiasis developed progressive elevation of his serum creatinine concentration. Urinalysis revealed pyuria and white cell casts, a few red blood cells, minimal proteinuria, and no crystals. Urine culture was sterile. Gallium scintigraphy was consistent with interstitial nephritis. Proton pump inhibitor intake was discontinued, and a short course of oral corticosteroids was initiated. Percutaneous kidney biopsy, performed because of the continued deterioration of renal function to a minimum estimated glomerular filtration rate (eGFR) value of 15 mL/min per 1.73 m2 and persistent pyuria, revealed deposition of oxalate crystals in the tubules and interstitium, pronounced tubular changes, and interstitial nephritis and fibrosis. Urinary oxalate excretion was very high, in the range usually associated with primary hyperoxaluria. However, investigations for primary or enteric hyperoxaluria were negative. He reported a diet based on various nuts high in oxalate content. Estimated oxalate content in the diet was, for years, approximately four times higher than that in the average American diet. The institution of a diet low in oxalates resulted in the rapid normalization of urinary oxalate excretion and urinary sediment and in the slow, continuous improvement of renal function to near normal levels (eGFR 59 mL/min/1.73 m2) before his death from a brain malignancy 3.5 years later. The manifestations of nephropathy secondary to dietary hyperoxaluria, including the urine findings, can be indistinguishable from other types of interstitial nephritis. The diagnosis of dietary hyperoxaluria requires careful dietary history and a kidney biopsy. Identifying dietary hyperoxaluria as the cause of CKD is important because the decrease in dietary oxalate intake without any other measures can lead to sustained improvement in renal function.

In the October issue of The Journal of Nuclear Medicine, the authors of the "Hot Topics" paper, "Nuclear Medicine Training: What Now?" suggested a path forward for training in nuclear medicine that "matches the needs of the evolving clinical specialty" by "combined, multispecialty training." (1). The American Board of Nuclear Medicine (ABNM) also endorses combined, multispecialty training that maintains high standards for nuclear medicine education, prepares physicians for practice in a changing environment, and advances the specialty.The ABNM has actively supported training leading to certification in nuclear medicine plus certification by the American Board of Radiology (ABR) in diagnostic radiology. The ABNM and the Society of Nuclear Medicine and Molecular Imaging (SNMMI) issued a joint policy statement in 2012 supporting all training pathways leading to dual certification (2). These pathways currently include the traditional 12-mo nuclear radiology or nuclear medicine fellowship after diagnostic radiology residency, the 16-mo nuclear medicine/nuclear radiology pathway during 4 y of diagnostic radiology residency, and the 5-y combined pathway within separate nuclear medicine and diagnostic radiology programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Support for these pathways is not meant to promote the "chaos of multiple training and certification pathways" but rather to facilitate institutions developing practical dual training pathways given local considerations, with robust training and subsequent certification in nuclear medicine and diagnostic radiology.After the joint ABNM and SNMMI statement in 2012, the ABNM took action to promote the development of dual training programs within 4 y of diagnostic radiology residency training. The changes made by the ABNM include the following:• Defining 16 mo of training in practical terms.• Removing the requirement for a minimum of 6 mo of continuous nuclear medicine training.• Giving training-program directors more discretion in allowing elective time.• Permitting contemporaneous nuclear medicine training with other fellowship training.• Recognizing non-ACGME-accredited nuclear medicine fellowship training in institutions with ACGME-accredited nuclear medicine residency or nuclear radiology fellowship programs.• Recognizing nuclear radiology training when ACGME nuclear medicine program requirements are met.The ABNM recognizes that it is a challenge for physicians to become proficient in nuclear medicine and diagnostic radiology in 16 and 32 mo, respectively. Recognizing also that the knowledge and skills required to advance the specialty of nuclear medicine and molecular imaging might require more than 4 y of training, the ABNM also supports 5-y combined training programs with nuclear medicine and diagnostic radiology residency programs that are separately accredited by the ACGME. The ABNM gives institutions broad leeway in determining how much nuclear medicine and diagnostic radiology training is required, so long as the mini...

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