This article reviews trends and issues related to adult nephrology fellowship education in the United States. The number of nephrology fellowship programs and trainees has continued to increase slowly despite limitations in funding of graduate medical education. The use of the Electronic Residency Application System has provided information for the first time on the number, demographics, and behavior of applicants that can be used as baseline data for tracking trends in fellowship applications and for formulating training policies. Issues that nephrology training programs face are discussed in this review: (1) A more stringent graduate medical education regulatory environment, (2) T he objective of this article is to provide a summary of the trends and issues in adult nephrology fellowship education in the United States. Future decisions on education and policy issues require accurate information regarding the demographics of nephrology trainees and programs. These data are available from several national sources and are reviewed. With the use of an electronic application system, data are now available for the first time about the number and demographics of applicants for nephrology training. As the specialty of nephrology evolves and the training environment changes, fellowship programs will have to deal with a number of important matters. This article discusses issues that are related to accreditation, a formal match in nephrology, workforce needs, and further subspecialization. These issues are complex and often controversial but are raised to foster constructive dialogue among the relevant constituencies.