American Board of Internal Medicine Nephrology

Over the past decade, the American Board of Internal Medicine (ABIM) has adapted to internal medicine community feedback, and the ABIM Nephrology Board has been active and responsive to the pressing issues and concerns of the nephrology community. This perspective provides a brief overview of these issues and insights into the Nephrology Board's work. ABIM is a physician-led, nonprofit, independent evaluation organization, offering Initial Certification and Maintenance of Certification (MOC) in internal medicine and its subspecialties, including nephrology. The ABIM Nephrology Board defines the standards of the discipline across Certification and MOC. Over 60 practicing nephrologists make up the ABIM Nephrology Board, Approval Committees, and Item-Writing Task Forces. Success of Longitudinal Knowledge Assessment and Changes to MOC More than 74,000 physicians are maintaining over 85,000 certifications through the Longitudinal Knowledge Assessment (LKA) that launched in 2022. In 2024, 84% of 1100 nephrologists who were due for a nephrology assessment and chose to enroll in one opted for the LKA over the traditional 10-year MOC examination. An advantage of the LKA is that it is offered at no additional cost to the annual MOC fee, while there is an additional test center fee for the 10-year MOC examination. Recent changes include increasing the LKA question time limit from 4 to 5 minutes and immediate feedback and rationales on all questions, including those being pretested, to further enhance the formative aspect of the LKA. ABIM is also introducing focused practice versions of some LKAs in 2026 with a greater proportion of questions, approximately 30%, focused on specialized areas of practice (such as malignant hematology and classical hematology in hematology) to better align with the needs of physicians working in specific subspecialties. In 2024, in response to physician feedback, ABIM eliminated a requirement for physicians to earn some MOC points every 2 years, leaving only the requirement to earn 100 MOC points every 5 years. Adoption of Race-Free eGFR Formula in All ABIM Assessments In 2021, the National Kidney Foundation-American Society of Nephrology (ASN) Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases endorsed the use of the 2021 CKD Epidemiology Collaboration serum creatinine–based equation for estimating GFR that had been refit without a race variable.1 ABIM implemented the race-free serum creatinine-based equation in the LKA in July 2022 and in Certification and traditional 10-year MOC examinations in fall 2022. Major pathology and laboratory leadership organizations have committed to implementation of race-free GFR estimation and examinees now encounter these values in routine practice. Using a single, race-neutral calculation in a standardized examination ensures every examinee applies the same data without inference, thereby improving fairness and consistency in test interpretation. Nephrology Initial Certification and Training Data Over the past decade, the performance of first-time test takers on the Nephrology Certification Examination has shown a notable decline. The pass rate was 98% in 2010 but has gradually decreased since then, stabilizing at approximately 80%. This trend has garnered discussion in the nephrology community, raising important questions about changes in training environments, examination content, examination difficulty level, and candidate preparedness. A detailed analysis of performance trends from 2010 to 2019 suggests that much of the decline is associated with lower scores of incoming nephrology trainees on their Internal Medicine Certification Examination and comparatively weaker performance among graduates of smaller fellowship programs.2 The decline in performance on the Nephrology Certification Examination parallels a broader decrease in interest in the field as evidenced by a shrinking number of applicants pursuing nephrology training and a persistent shortfall in filled fellowship positions.3 Community-driven efforts to improve candidates' readiness for independent practice are both essential and actively underway. These initiatives span local interventions during fellowship training such as identifying at-risk fellows early with the ASN in-training examination and broader national strategies led by organizations such as the ASN and National Kidney Foundation.4 In addition, there are grassroot efforts to improve medical education in nephrology such as Renal Fellow Network, GlomCon, UKidney, nephrology podcasts, NephJC, NephMadness, and other free open access medical education resources.5 New Procedure Requirements for Nephrology Certification Recently, the ABIM Nephrology Board updated the procedural requirements for eligibility for initial certification in nephrology for fellows beginning training on or after July 1, 2024.6 This process spanned 3 years, emphasizing evidence-based decision-making within ABIM governance and prioritizing input from external stakeholders aimed at fostering trust and collaboration with physicians and the public.7 In recognition of the changing landscape of nephrology practice and fellowship training, the Nephrology Board revised the procedure requirements by adopting ABIM's Opportunity to Train standard for temporary vascular access placement and percutaneous kidney biopsies and added home hemodialysis. The decision process for these changes has been previously published, with the goal of having certification standards reflect real-world nephrology practice.7 Not all fellows are required to perform the procedure to competence to be eligible for board certification, but fellows requesting the training to the level of competent and independent performance must be provided the opportunity to train.6 Maintaining an opportunity to train acknowledges the spectrum of clinical practice and the importance of continuing to anchor core procedures within the specialty. The Nephrology Board also strengthened the requirement for peritoneal dialysis training, and fellows are now expected to participate in the interprofessional delivery of peritoneal dialysis.6 Accreditation Council for Graduate Medical Education Program Accreditation in Transplant Nephrology In recent years, enthusiasm has grown among transplant nephrologists to establish recognition, distinct from general nephrology, based on the additional specialty training required to be a medical director of a transplant program, the increasing complexity of the regulatory aspects of transplantation, and the increasing number of patients being referred, transplanted, and in need of post-transplant care. Establishing Accreditation Council for Graduate Medical Education (ACGME) accreditation and the recognition of transplant nephrology as a distinct entity may entice entry into the field. For example, J-1 visa holders would be able to delay their waiver by additional training in an ACGME accredited program. In December 2023, ASN and the American Society of Transplantation established a task force to explore accreditation of transplant nephrology as a distinct ACGME pathway entity based on the criteria established in 2006 by the New and Emerging Disciplines in Internal Medicine report.8 On September 30, 2025, the ACGME approved the proposed program requirements for establishing transplant nephrology as an accredited subspecialty of nephrology beginning July 1, 2026. Understandably, the intersection of ACGME accreditation with ABIM certification has received great attention. The transplant nephrology community could potentially approach the ABIM Nephrology Board about becoming a tertiary discipline. If that happens, ABIM would undertake an extensive community vetting process to determine the interest, necessity, and viability of transplant nephrology as a distinct subspecialty within general nephrology.8 If ultimately recognized as a tertiary discipline of nephrology, transplant nephrology would become a distinct certificate requiring eligibility criteria and assessments for initial certification and MOC. Another option the community could consider, regardless of the decision about seeking recognition as a new tertiary discipline, is to review the evidence supporting an LKA focused assessment in transplant nephrology. ABIM's Competency-Based Medical Education Pilot Special Consideration Pathway for International Medical Graduates Who Complete Medicine Residency Abroad and an ACGME-Accredited Fellowship Currently, International Medical Graduates (IMGs) who have completed internal medicine residency training outside the United States are eligible to pursue fellowship training in the United States or Canada if they are considered an “exceptionally qualified candidate” per ACGME definition.9 This designation, which needs institutional Graduate Medical Education Committee approval, is determined by the program director and the fellowship selection committee based on demonstrated clinical excellence and notable achievements including advanced clinical or research training, scholarly productivity, or leadership experience.9 Unless eligible for an ABIM Special Consideration Pathway, these physicians with advanced qualifications remain ineligible for ABIM Board Certification in Internal Medicine and in their subspecialty after completion of fellowship, significantly restricting their ability to practice independently in the United States.10 To address this barrier, ABIM launched a competency-based medical education pilot through which “exceptionally qualified” IMGs who have completed internal medicine training outside the United States or in a program with ACGME International Advanced Specialty Accreditation may become eligible for the Internal Medicine Certification Examination on satisfactory completion of an ACGME-accredited fellowship.10 On passing the Internal Medicine Certification Examination, they would become eligible for the certification examination of the subspecialty training they completed. ABIM will collect data during this 5-year pilot to include board pass rates, percentage of participants practicing in the United States, and other important metrics. If the pilot is successful, it could expand opportunities for qualified IMGs to practice and contribute meaningfully to nephrology care in the United States. Summary The ABIM Nephrology Board will continue to collaborate and partner with the broader nephrology community and stakeholders to advance the pressing issues in nephrology. Analyzing the implementation of the new procedural requirements and the pilot pathway for IMGs, partnering with the nephrology community to improve candidates' readiness to enter the profession and help address workforce issues, partnering with the nephrology transplant community to assess the transplant nephrology subspecialty, and evaluating the transformative nature of artificial intelligence on assessments will remain top priorities in the coming years.