Nephrology Learning Objectives
Authors: Holly Koncicki and Sandeep
Mallipattu
Editor: Lauren Peccoralo
I. General Learning Objectives
A. Clinical
Skills Learning Objectives: Residents should be able to:
1. Evaluate and recognize patients who are at risk for ARF (co-morbidities, medications) and how these patients should be managed both acutely and chronically.
2. Interpret an urinalysis and continue workup if indicated
3. Recognize when nephrology should be consulted in both an inpatient and outpatient setting.
4. Recognize the need for emergent hemodialysis.
B. Interpersonal
Skills Learning Objectives
1. Discuss treatment options with patients
C. Procedural
Skills Learning Objectives
1. Interpret urine sediment and incorporate it into management.
*Intern focused
topics
II. Medical Knowledge Learning Objectives
A. Acute Renal Failure
1. *Use GFR as the primary test used to estimate the degree of renal function
2. *Describe the major causes of ARF and diagnostic approach used to establish the correct diagnosis
3. *Differetiate between prerenal, postrenal and intrarenal acute renal failure
4. Treat acute renal failure depending on the diagnosis
5. Describe the renal response to decreased renal perfusion and the different disorders in which renal ischemia can lead to reduction in GFR
6. Understand the pathogenesis of post-ischemic and toxic ATN
7. Readings:
a. Stevens L, Coresh J, Greene T, Levey A. Assessing Kidney Function – Measured and Estimated Glomerular Filtration Rate NEJM 2006; 354: 2473 – 83
http://eresources.library.mssm.edu:2368/cgi/content/full/354/23/2473
b. Singri N, Ahya S, Levin N. Acute Renal Failure JAMA 2003;289(6):747-751
http://eresources.library.mssm.edu:2213/cgi/reprint/289/6/747
c. Abuelo, J. Normotensive Ischemic Acute Renal Failure NEJM
2007;357:797-805.
http://eresources.library.mssm.edu:2368/cgi/content/full/357/8/797
d. Madaio M, Harrington J. The Diagnosis of Glomerular Disease
Archives of Internal Medicine 2001;161: 25 – 34
e. Barret B, Parfrey P. Preventing Nephropathy induced by Contrast
Medium NEJM 2006;354:379-86
http://eresources.library.mssm.edu:2368/cgi/content/full/354/4/379
f. Kodner C, Kudrimoti A. Diagnosis and Management of Acute
Interstitial Nephritis. American Family Physician 2003: 67: 2527
g. Naughton C. Drug-Induced Nephrotoxicity Am Fam Physician. 2008;78(6):743-750
h. McDonald M, Swagerty D, Wetzel L. Assessment of Microscopic
Hematuria in Adults Am Fam Physician 2006;73:1748-54
i. Kamel K, Ethier J, Richardson R, et al. Urine Electrolytes and Osmolality: When and How to Use Them Am J Nephrol 1990;10:89-102.
j.
B. Chronic Renal Failure
1. *Use
the estimation of GFR as the primary test used to estimate the degree of renal
function
2. *Describe
the main risk factors for CKD
3. *Determine
the main populations to screen for CKD and the appropriate tests used for
screening
4. Describe the pathophysiology behind the different types of CKD
5. Manage
CKD in terms of blood pressure and glycemic control
6. Know
the utility of ACE inhibitors and ARBS in CKD
7. Describe
the main complications of CKD including anemia and cardiovascular disease and
know how best to treat and prevent these complications
8. Readings:
a. Atkins RC. Proteinuria reduction and progression to renal failure in patients with type 2 diabetes and overt nephropathy. Am J Kidney Dis 2005; 45:281.
b. Hostetter Th. Prevention of end-stage renal disease due to type 2 diabetes. NEJM 2001; 345:910.
http://eresources.library.mssm.edu:2368/cgi/content/full/345/12/910
c. Lewis EJ. Renoprotective effect of angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. NEJM 2001; 345:851.
http://eresources.library.mssm.edu:2368/cgi/content/full/345/12/851
d. Brenner BM. Effect of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. NEJM 2001; 345:861
http://eresources.library.mssm.edu:2368/cgi/content/full/345/12/861
e. Klahr S. The effect of dietary protein restriction and blood pressure control on progression of chronic renal disease. NEJM 1994; 330:877
http://eresources.library.mssm.edu:2368/cgi/content/full/330/13/877
f. Jacobson H. Chronic Renal failure: pathophysiology, management. Lancet 1991; 338:419-423
g. Levey AS. National Kidney Foundation K/DOQI. Clinical Practice Guidelines for Chronic Kidney Disease: Evaluaiton, Classification and Stratification. Am J Kidney Disease 2002 39(Suppl 1):S1.
h. Lim VS. Protein Metabolism in patients with chronic renal failure: Role of uremia and dialysis. Kidney Int 2000 58:1.
http://eresources.library.mssm.edu:2106/ki/journal/v58/n1/full/4491649a.html
i. Aljama P. New Insights in ESRD. Kidney Int. 2002 80:1.
http://eresources.library.mssm.edu:2231/Issue.asp?IssueID=533152
j.
Singh AK. The controversy surrounding hemoglobin and
erythropoiesis-stimulating agents: what should we do now? Am J Kidney Dis.
2008 Dec;52(6 Suppl):S5-13.
k.
Hage, FG et al.
The scope of coronary heart disease in patients with chronic kidney disease.
J Am Coll Cardiol.
2009 Jun 9;53(23):2129-40
C. Disorders of water balance:
1. Hyponatremia/Hypernatremia
a. *Understand the mechanisms by which hyponatremia occurs
b. *Describe the clinical findings of hyponatremia
c. Manage hyponatremia in the inpatient setting based on clinical and laboratory findings
d. Describe the side effects of treatment of hyponatremia
e. Understand the mechanisms by hypernatremia occurs and the basic principles involved in the differential diagnosis and treatment
f. Readings:
a. Adrogue, H J., Madias, N E. Hyponatremia NEJM 2000 342:1581-1589
http://eresources.library.mssm.edu:2368/cgi/content/full/342/21/1581
b. Gross P. Treatment of severe hyponatremia. Kidney International 2001; 60:2417
http://eresources.library.mssm.edu:2106/ki/journal/v60/n6/full/4492691a.html
c. Adrogue, H J., Madias, N E. Hypernatremia NEJM 2000 342: 1493-1499
http://eresources.library.mssm.edu:2368/cgi/content/full/342/20/1493
2. Polyuria
a.
*Describe the differential diagnosis of a patient
complaining of polyuria
b.
Decide which tests to order to diagnose the cause
of polyuria.
c. Readings:
a. Strange K. Regulation of solute and water balance and cell volume in central nervous system. J Am Soc Nephrology 1992; 3:12.
b. McManus ML. Mechanism of disease: regulation of cell volume regulation in health and disease. NEJM 1995; 333:1260.
http://eresources.library.mssm.edu:2368/cgi/content/full/333/19/1260
D. Renal Replacement Therapy in treatment of
Renal Failure
1. Recognize
the indications for emergent dialysis
2. *Describe
the types of renal replacement therapy and which patients are appropriate for
which types of therapy
3. Understand
the basic principles of diffusion and ultrafiltration with dialytic therapy for
ESRD
4. Anticipate
complications of the different types of renal replacement therapy.
5. Readings:
a. Meyer MM. Renal Replacement Therapies. Critical Care Clinic 2000; 16:29.
b. Ifudu O. Care of patients undergoing hemodialysis. NEJM 1998; 339:1054.
http://eresources.library.mssm.edu:2368/cgi/content/full/339/15/1054
c. Eknoyan G. Effect of dialysis dose and membrane flux in maintenance hemodialysis. NEJM 2002 347:2010.
http://eresources.library.mssm.edu:2368/cgi/content/full/347/25/2010
d. Diaz-Buxo JA. Early referral and selection of peritoneal dialysis as treatment modality. Nephrol Dial Transplant 2000 15:147.
http://eresources.library.mssm.edu:5388/cgi/content/full/15/2/147
e. Schiffl H. Daily hemodialysis and the outcome of acute renal failure. NEJM 2002 346:305.
http://eresources.library.mssm.edu:2368/cgi/content/full/346/5/305
E. Hyperkalemia
1. *Describe the etiologies and consequences of hyperkalemia
2. *Manage hyperkalemia in the acute setting
a. Evans K, Greenberg A. Hyperkalemia: A Review. J Intensive Care Med 2005; 20; 272 http://eresources.library.mssm.edu:4441/cgi/reprint/20/5/272
F. Glomerulonephritis
1. Recognize the presentation of gomerulonephritis.
2. Identify systemic diseases which may contribute to different types of glomerulonephritis.
3. Understand the workup for glomerulonephritis.
a. Madaio M, Harrington J. The Diagnosis of Glomerular Disease. Archives of Internal Medicine 2001;161:25 http://eresources.library.mssm.edu:2217/cgi/content/full/161/1/25
b. Donadio J, Grande J. IgA Nephropathy. NEJM 2002; 347:738 http://eresources.library.mssm.edu:2368/cgi/content/full/347/10/738
c. Fabrizi F, Lunghi G, Messa P, Martin P. Therapy of hepatitis C virus-associated glomerulonephritis: current approaches. J Neprol. 2008; 21:813 http://eresources.library.mssm.edu:9359/public/JN/Article/Article.aspx?UidArticle=95771610-7D91-4E36-802D-24954794B676
d. Hudson BG, Tryggvason K, Sundaramoorthy M, Neilson EG. Alport’s Syndrome, Goodpasture’s Syndrome and Type IV Collagen. NEJM 2003; 348:2543 http://eresources.library.mssm.edu:2368/cgi/content/full/348/25/2543
e. Rodriguez-Iturbe B, Musser JM. The current state of poststreptococcal glomerulonephritis. J Am Soc Nephrology. 2008:19: 1855-64 http://eresources.library.mssm.edu:6533/cgi/reprint/19/10/1855
G. Nephrotic Syndrome
1. *Recognize eitologies for proteinuria.
2. *Initate workup for proteinuria.
3. Understand presentation of Nephrotic Syndrome and management.
a. Carroll M, Temte J. Proteinuria in Adults: A Diagnostic Approach Am Fam Physician 2000;62:1333-4
b.
Charlesworth J, Gracey D, Pussell B. Adult
Nephrotic Syndrome: Non specific strategies for Treatment. Nephrology 2008; 13:45-50.
http://eresources.library.mssm.edu:2097/cgi-bin/fulltext/119414887/HTMLSTART