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) the use of the National Resident Matching Program to enhance the nephrology fellowship applicant selection process, (3) future nephrology workforce shortages, and (4) the continued subspecialization of nephrology. By working together, nephrology fellowship programs can overcome barriers that are raised by these issues and improve the fellowship training experience.