Nephrology

Competency-Based Curriculum

Educational Rationale

Nephrology involves disease of the kidneys, its contiguous collecting system, and its vasculature. The kidneys play a key role in fluid, electrolyte, and acid-base regulation and are affected by a wide range of systemic disorders, drugs, and toxins.

The general internist should be able to be competent to evaluate and appropriately refer patients with glomerular disorders, asymptomatic urine abnormalities, tubulointerstitial diseases, renal vascular disease, renal failure, nephrolithiasis, tubular defects, and infections and neoplasms of the kidneys, bladder and urethra and for some of these conditions, also provide principal treatment. He or she should be able to manage fluid, electrolyte, and acid-base disorders, understand the ways in which systemic diseases may affect the kidneys, and recognize the potential nephrotoxicity of various therapeutic and diagnostic agents. The general internist must also be familiar with guidelines for predialysis management of patients with renal failure and be able to recognize indications for dialysis and for referral to a nephrologist.

The range of competencies in managing renal disease will depend on the availability of a nephrologist to the primary care internist. Although all general internist should know the indications for dialysis, in some cases, such as if a nephrologists is unavailable, the general internist may be responsible for initiating and maintaining patients on peritoneal dialysis. In most situations Hemodialysis will be the responsibility of the nephrologists, as will renal biopsies and nephrostomy tube placement.

Goals

A. Knowledge:

I. Upon completion of training, we expect our residents to:

  1. Acquire sufficient knowledge and experience to recognize nephrologic disorders.
  2. Accurately diagnose nephrologic diseases.
  3. Provide satisfactory care for patients with common and uncomplicated nephrologic diseases.
  4. Identify those circumstances when consultation and/or referral are appropriate.
  5. Learn to use diagnostic studies in a selective, efficient, and proper costeffective manner.
  6. Learn the indications and contraindications and benefits and risks of hemodialysis and peritoneal dialysis.
  7. The resident will need to understand the approach to and establish competence in the management of the following clinical situations:

    • Acute renal failure, chronic renal insufficiency, uremia, and ESRD
    • Basic electrolyte, acid-base and mineral disorders (abnormalities of water, sodium, potassium, calcium, phosphate, and magnesium balance)
    • Isolated hematuria and proteinuria, the nephritic and nephritic syndromes, acute glomerulonephritides and vasculitides.
    • Abnormalities of bone and mineral metabolism (e.g. nephrolithiasis, renal osteodystrophy)
    • Primary and secondary hypertension
    • Renal transplantation
    • Edema
    • Incontinence
    • Hemo/peritoneal dialysis- indications, contraindications, and complications
    • Manage anemia of CRF
    • Assess nutritional status of ESRD patients
    • Assess need for and determine type of vascular access for hemodialysis
    • Urinary tract infections

B. Skills

I. Upon completion of training we expect our residents to:

  • Know the nephrologic evaluation.
  • Be able to lead and function as part of a team providing nephrologic care
  • Know the indications, contraindications, and complications for peritoneal dialysis
  • Know the indications, contraindications, and complications for hemodialysis
  • Know the indications, contraindications, and complications of plasmapheresis
  • Know the indications, contraindications, and complications for renal biopsy
  • Know the indications, contraindications, and complications of continual renal replacement treatment (CAVHF, CAVHD, CVVHD, and CVVHF)
  • Understand appropriate circumstances for cost-effective diagnostic imaging and laboratory studies and their interpretation.
  • Know the indications, contraindications, risks, and benefits of various vascular access modalities
  • Identify those circumstances when consultation or referral is appropriate
  • Appreciate the value of functional evaluations and assessments

II. The resident should develop competence in the following procedures:

  • Calculation of creatinine clearance
  • Calculation of fractional excretion of sodium
  • Peritoneal cavity aspiration per indwelling dialysis catheter calculation of TTKG (transtubular potassium gradient)
  • Peritoneal dialysis catheterization (optional)
  • Suprapubic bladder catheterization (optional)
  • Femoral temporary hemodialysis catheter placement (optional)

C. ATTITUDES:

Upon completion of training, we expect our residents to appreciate those attitudes
valued and nurtured by nephrologists, including:

  1. Viewing medicine as humane science.
  2. Balancing art with science
  3. Recognizing the limitations of technology and the value of clinical insight
  4. Making difficult judgments when certainty is elusive.
  5. Understanding that testing, no matter how advanced or sophisticated, rarely substitutes for thorough, thoughtful evaluation by an informed clinician.
  6. Balancing intervention with patience.
  7. Recognizing limitations of our interventions.
  8. Appreciating the unique circumstances of caring for patients with chronic, usually incurable diseases.
  9. Learning the importance of functional considerations.

Educational Experience

A. General

The monthly nephrology elective for residents is presented by division faculty according to the appended schedule. Residents will be responsible for seeing all nephrology in-patient consultations and will also participate in the outpatient activities and practices of division staff/faculty.

1. Inpatient Experience (IP)

a. Inpatient consultations are called to residents by faculty or their offices.
b. The resident sees all consultations him/herself and verifies that the evaluation of the patient is complete by internal medicine standards.
c. Consultations are presented on rounds to the consulting physician, at times to be mutually arranged. Usual practice is for the resident to join consulting physician for hospital rounds each morning and evening, as applicable.
d. In each instance, the consultation is discussed with referring residents or attending physician, as applicable.
e. It is expected that at the time of presentation to the consulting physician, residents are totally familiar with the patient's problem(s), have read and reviewed pertinent literature, and are prepared to
knowledgeably discuss the problem at hand.

2. Ambulatory Experience (AM)

a. Outpatient activities for residents are conducted as arranged by their supervising attending
b. Residents are expected to attend all sessions, outpatient activities, and practices.
c. Patients are assigned in clinics and offices by the attending physicians. Every effort is made to select patients of "interest".
d. Depending on numbers of individuals on the rotations and clinic/office loads attempts are made to permit residents to spend the first few experiences seeing patients together with attending physicians, so as to better introduce them to the patient evaluation.

3. Didactic Conferences (DC)

Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties

Evaluations

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

  • Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
  • Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
  • Self-evaluation by In-service training examination scores
  • MKSAP study plan (MKSAP)
  • Participation and presentations at didactic conferences (DC)
  • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge

Goals and Objectives-PGY1 Learning Activities* Assessment
Describe the epidemiology, genetics, natural history, clinical expression of the renal disorders encountered in the inpatient setting. IP, AM, DC AE, DC, MKSAP
Describe the structure and function of the kidneys IP, AM, DC AE, DC, MKSAP
Summarize an approach to the evaluation of the common presentations of renal
disorders
IP, AM, DC AE, DC, MKSAP
Goals and Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Summarize an approach to the evaluation of common presentations in this specialty IP, AM, DC AE, DC, MKSAP
Interpret diagnostic tests used in the evaluation of inpatients with suspected renal disorders IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation
of inpatients with renal disorder
IP, AM, DC AE, DC, MKSAP

2) Patient Care

Goals and Objectives-PGY1 Learning Activities* Assessment
Effectively perform a comprehensive history and complete physical examination in patients with symptoms affecting this system IP, AM, DC AE, DC, MKSAP
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of disorders affecting this system IP, AM, DC AE, DC, MKSAP
Goals and Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Construct a comprehensive treatment plan and assess response to therapy. IP, AM, DC AE, DC, MKSAP
Counsel patients concerning their diagnosis, planned diagnostic testing and
recommended therapies.
IP, AM, DC AE, DC, MKSAP
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy. IP, AM, DC AE, DC, MKSAP

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1 Learning Activities* Assessment
Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills of patients
related diseases
IP, AM, DC
AE, DC, MKSAP
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients IP, AM, DC
AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education. IP, AM, DC
AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Set and assess individualized learning goals IP, AM, DC AE, DC, MKSAP
Analyze clinical experience and employ a systematic methodology for improvement IP, AM, DC AE, DC, MKSAP
Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care IP, AM, DC AE, DC, MKSAP
Goals and Objectives-PGY1 Learning Activities* Assessment
Apply empathy in all patient encounters IP, AM, DC AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and
other members of the health care team
IP, AM, DC AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending IP, AM, DC AE, DC, MKSAP
Compose clear and timely admission and progress notes and consultations IP, AM, DC AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate IP, AM, DC AE, DC, MKSAP
Teach colleagues effectively IP, AM, DC AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1 Learning Activities* Assessment
Be prompt and prepared for all clinical duties IP, AM, DC AE, DC, MKSAP
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all IP, AM, DC AE, DC, MKSAP
Respect patients and their families, staff and colleagues IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings IP, AM, DC AE, DC, MKSAP
Demonstrate integrity IP, AM, DC AE, DC, MKSAP
Respond to phone calls and pages promptly IP, AM, DC AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1 Learning Activities* Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty. IP, AM, DC AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information. IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Discuss how the health care system affects the management of inpatients with endocrine diseases. IP, AM, DC AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions. IP, AM, DC AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices IP, AM, DC AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized IP, AM, DC AE, DC, MKSAP

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY- 2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

Educational Resources

a. Supervising clinicians-didactic and bedside rounds and concurrent patient care
b. Medical literature including assessment of knowledge using the MKSAP
c. Bedside rounds with team and faculty.
d. Medical Grand Rounds weekly.
e. Scheduled didactic conferences including: medicine morning report, journal club, ambulatory care conference, EBM conference
f. Saint Barnabas Medical Center library, librarians, and online references/resources.

References

General Nephrology

  1. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999 Mar 16 ;130(6):461-70.
  2. Gluck SL. Acid-base. Lancet. 1998 Aug 8;352(9126):474-9. Review.
  3. Halperin ML, Kamel KS. Potassium. Lancet. 1998 Jul 11;352(9122):135-40. Review.
  4. Bushinsky DA, Monk RD. Electrolyte quintet: Calcium. Lancet. 1998 Jul 25;352(9124):306-11. Review.
  5. Kumar S, Berl T. Sodium. Lancet. 1998 Jul 18;352(9123):220-8. Review.
  6. Weisinger JR, Bellorin-Font E. Magnesium and phosphorus. Lancet. 1998 Aug 1;352(9125):391-6. Review.
  7. Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function--measured and estimated glomerular filtration rate. N Engl J Med. 2006 Jun 8;354(23):2473- 83.

Acute Renal Failure

  1. Barrett BJ, Parfrey PS. Clinical practice. Preventing nephropathy induced by contrast medium. N Engl J Med. 2006 Jan 26;354(4):379-86. Review.
  2. Marenzi G, Assanelli E, Marana I, Lauri G, Campodonico J, Grazi M, De Metrio M, Galli S, Fabbiocchi F, Montorsi P, Veglia F, Bartorelli AL. N- acetylcysteine and contrast-induced nephropathy in primary angioplasty. N Engl J Med. 2006 Jun 29;354(26):2773-82.
  3. Mehta RL. Continuous renal replacement therapy in the critically ill patient. Kidney Int. 2005 Feb;67(2):781-95.
  4. Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P, La Greca G. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet. 2000 Jul 1;356(9223):26-30.
  5. Schiffl H, Lang SM, Fischer R. Daily hemodialysis and the outcome of acute renal failure. N Engl J Med. 2002 Jan 31;346(5):305-10.
  6. Stacul F, Adam A, Becker CR, Davidson C, Lameire N, McCullough PA, Tumlin J; CIN Consensus Working Panel. Strategies to reduce the risk of contrastinduced nephropathy. Am J Cardiol. 2006 Sep 18;98(6A):59K-77K. Epub 2006 Mar 20. Review.
  7. Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med. 1996 May 30;334(22):1448-60. Review.

Chronic Renal Failure

  1. Hou FF, Zhang X, Zhang GH, Xie D, Chen PY, Zhang WR, Jiang JP, Liang M, Wang GB, Liu ZR, Geng RW. Efficacy and safety of benazepril for advanced chronic renal insufficiency. N Engl J Med. 2006 Jan 12;354(2):131-40.
  2. Drueke TB, Locatelli F, Clyne N, Eckardt KU, Macdougall IC, Tsakiris D, Burger HU, Scherhag A; CREATE Investigators. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med. 2006 Nov 16;355(20):2071-84.
  3. Singh AK, Szczech L, Tang KL, Barnhart H, Sapp S, Wolfson M, Reddan D; CHOIR Investigators. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med. 2006 Nov 16;355(20):2085-98.
  4. Wolf G, Ritz E. Combination therapy with ACE inhibitors and angiotensin II receptor blockers to halt progression of chronic renal disease: pathophysiology and indications. Kidney Int. 2005 Mar;67(3):799-812. Review.

Transplant

1. Halloran PF. Immunosuppressive drugs for kidney transplantation. N Engl J Med. 2004 Dec 23;351(26):2715-29. Review.

Faculty

Lyman, Neil, MD., Education Coordinator
Bonomini, Luigi, M.D.
Dhillon, Navdeep, M.D.
Goldberg, Ryan, M.D.
Gupta, Shabnam, M.D.
Madigan, John, D.O.
Mulgaonkar, Shamkant, M.D.
Nguyen, Kim, M.D.
Patel, Anup, M.D.
Pritsiolas, James, M.D.
Saldarini, John, M.D.
Shah, Nita, M.D.
Weng, Francis, M.D.
Zenenberg, Robert, M.D.