Nephrology Curriculum The Educational Purpose Nephrology involves the diagnosis and management of diseases of the kidneys, its contiguous collecting system, and its vasculature. Commonly encountered conditions in Nephrology that the resident should be competent and comfortable in assessment and management of include disorders of fluid, electrolyte, and acid-base balance; acute renal failure, chronic kidney disease, nephrolithiasis, and infections. Other problems include disorders involving the glomerulus, asymptomatic urine abnormalities, tubulointerstitial disorders, renal vascular diseases, tubular defects, renal disease in pregnancy; renal transplantation, including pre-transplant, and posttransplant care. The resident should also understand how systemic diseases affect the kidneys, and recognize the potential toxicities of various therapeutic and diagnostic agents. The resident must understand current strategies to delay or prevent kidney disease. The resident must be competent in managing patients with chronic kidney disease who are not yet on dialysis and know indications for initiating dialysis. The resident should also recognize when consultation of a Nephrologist is appropriate in the management of any of the aforementioned conditions. Patient Care Goal #1: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Objective #1: Residents must be able to gather essential and accurate patient information to assess patient concerns, with special attention to the following presentations:

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Abnormall U Ab Urinalysis i l i ((proteinuria, t i i hematuria, bacteruria, and pyuria) Suprapubic

H it dU Hesitancy and Urgency

Flank Pain

Oliguria or Anuria

Dysuria

Hypertension

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Edema

Uremia

Gross Hematuria

Incontinence

Renal Colic

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Renal Mass

Renal Bruit

Objective #2: Residents will be able to develop and carry out patient management plans by making informed decisions on diagnostic and therapeutic interventions, counseling and educating patients and their families, and preventing health problems or maintaining health based on patient information and preferences, up-to-date scientific evidence, and clinical judgment with special attention to the following illnesses or conditions:

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Acid-Base Disorders

Urinary Tract Infection: Cystitis

Acute Renal Failure

Immunizations for Patients with Renal Failure

Fluid and Electrolyte Disorders

Adjustment of medications in patients with renal disease

Preventing Diabetic Nephropathy

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Acute Renal Failure: Atheroembolic

Chronic Renal Failure: Predialysis Care

Acute Renal Failure: Radiocontrast or Drug-Induced Hypertension: Hypertensive Urgency

Chronic Renal Failure: Caring for the Patient on Dialysis Secondary Hypertension

Diabetic Nephropathy

Hypertensive Kidney Disease

Nephrolithiasis

Pyelonephritis

Bladder Outlet Obstruction

Urinary Incontinence

Diuretic Uses

Nephrotic Syndrome

Nutrition for Patients with Chronic Renal Failure Glomerulonephritis

Pharmacologic and Behavioral Measures to Prevent Progression of Renal Disease

Chronic Renal Failure: The Transplantation Patient Polycystic Kidneys

Renal Disease in Pregnancy

Objective #3: Residents must competently perform and interpret the results of all diagnostic and therapeutic medical and invasive procedures considered essential after obtaining informed consent, with confidence and minimal discomfort to patients: Interpretation of urinary sediment

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Ability to Interpret renal function testing

Arterial puncture for blood gas analysis

Medical Knowledge Goal #2: Residents must demonstrate knowledge about established and evolving biomedical, biomedical clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Objective #2: Residents must know and apply the basic and clinical supportive sciences applicable to Nephrology with special attention to: Calculation of Creatinine Clearance The Clinical Assessment of Volume Status

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Calculation of the Fractional Excretion of Sodium Examination and interpretation of urinary sediment Microscopic Examination of Urine

The Pharmacology Including the Mechanism of Action of Diuretics Renal diet: what it consists of and when to initiate it Indications for urinary catheterization

Knowing when to refer or prescribe suppressive antibiotics for Chronic indwelling bladder catheter

Practice-Based Learning and Improvement Goal #3: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Objective #4: Residents must be able to analyze practice experience and perform practice-based improvement activities using a systematic methodology. Screening for and management of chronic kidney disease.

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Interpersonal and Communication Skills Goal #4: Residents must demonstrate interpersonal and communication skills that result in effective exchange of information and collaboration with patients, their families, and health professionals. Objective #2: Residents must use effective listening, nonverbal, questioning, and narrative skills to communicate with patients and families. End of Life issues for patients with end stage renal disease.

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Systems Based Practice Goal #6: Residents must demonstrate both an understanding of the contexts and systems in which health care is provided and the ability to apply this knowledge to improve and optimize patient Objective #4: Residents must demonstrate the ability to use cost-conscious strategies which are evidence-based in prevention, diagnosis, and disease management. Impact of hemodialysis on the health care system.

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Teaching Methods ● Nephrology Clinic: VA and QEC ● Nephrology Selective ● Nephrology Elective Nephrology Reading List 1) Barrett BJ, Parfrey PS. Clinical practice. Preventing nephropathy induced by contrast medium. N Engl J Med. 2006 Jan 26;354(4):379-86. 2) Cohen HT, McGovern FJ. Renal-cell carcinoma. N Engl J Med. 2005 Dec 8;353(23): 2477-90. 3) Halloran PF. Immunosuppressive drugs for kidney transplantation. N Engl J Med. 2004 Dec 23;351(26):2715-29. 4) Schrier RW, Wang W. Acute renal failure and sepsis. N Engl J Med. 2004 Jul 8;351(2):159-69. 5) Kimmel PL. Update in nephrology and hypertension. Ann Intern Med. 2006 Feb 21;144(4):281-5. 6) Barnett A. Prevention of loss of renal function over time in patients with diabetic nephropathy. Am J Med. 2006 May;119(5 Suppl 1):S40-7. 7) Levin A, Stevens LA. Executing change in the management of chronic kidney disease: perspectives on guidelines and practice. Med Clin North Am. 2005 May;89(3):701-9. 8) Pendse S, Singh AK. Complications of chronic kidney disease: anemia, mineral metabolism, and cardiovascular disease. Med Clin North Am. 2005 May;89(3):549-61. 9) Yun EJ, Meng MV, Carroll PR. Evaluation of the patient with hematuria. Med Clin North Am. 2004 Mar;88(2):329-43. 10) Hollander-Rodriguez JC, Calvert JF Jr. Hyperkalemia. Am Fam Physician. 2006 Jan 15;73(2):283-90.

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11) Needham E. Management of acute renal failure. Am Fam Physician. 2005 Nov 1;72(9):1739-46. 12) Thorp ML. Diabetic nephropathy: common questions. Am Fam Physician. 2005 Jul 1;72(1):96-9. 13) Tryggvason K, Patrakka J, Wartiovaara J. Hereditary proteinuria syndromes and mechanisms of proteinuria. N Engl J Med. 2006 Mar 30;354(13):1387-401. 14) Pastan S and Bailey J. Medical progress: dialysis therapy. N Engl J Med. 1998; 338(20): 1428 – 1437. 15) Halloran PF. Drug therapy: immunosuppressive drugs for kidney transplantation. N Engl J Med. 2004; 351: 2715 – 2729. 16) McGee S, Abernathy WB, Simel DL. The rational clinical examination: is this patient hypovolemic? JAMA. 1999; 281: 1022 – 1029. 17) Rizk D and Chapman AB. Core curriculum in nephrology: cystic and inherited kidney diseases. Am J Kid Dis 2003; 42 (6):1305 – 1317. 18) Adler SG and Salant DJ. Core curriculum in nephrology: an outline of essential topics in glomerular pathophysiology, diagnosis, and treatment for nephrology trainees. Am J Kid Dis 2003; 42(2): 395 – 418. 19) O’Neill WC and Baumgarten DA. Core curriculum in nephrology: imaging. Am J Kid Dis 2003; 42(3): 601 – 604. 20) Teitelbaum I and Burkard J. Core curriculum in nephrology: peritoneal dialysis. Am J Kid Dis 2003; 42(5): 1082 – 1096. 21) Fogo AB. Core curriculum in nephrology: approach to renal biopsy. Am J Kid Dis 2003; 42(4): 826 – 836. 22) Provenzano R and Nissenson AR. Core curriculum in nephrology: economics of clinical nephrology practice. Am J Kid Dis 2004; 44(1): 168 – 178. 23) Moss AH, Holley JL, Davison SN, et al. Core curriculum in nephrology: palliative care. Am J Kid Dis 2004; 43(1): 172 – 185. 185 24) Davis CL. Core curriculum in nephrology: transplant: immunology and treatment of rejection. Am J Kid Dis 2004; 43(6): 1116 – 1134. 25) Hricik DE. Core curriculum in nephrology: nonimmunologic complications of kidney transplantation. Am J Kid Dis 2004; 43(6): 1135 – 1137. 26) Warnock DG and Textor SC. Core curriculum in nephrology: hypertension. Am J Kid Dis 2004; 44(2): 369 – 375. 27) Dursun B and Edelson CL. Core curriculum in nephrology: acute renal failure. Am J Kid Dis 2005; 45(3). 28) Moe SM. Core curriculum in nephrology: disorders of calcium, phosphorus, and magnesium. Am J Kid Dis 2005; 45(1): 213 – 218. 29) O’Connor AS and Schelling JR. Core curriculum in nephrology: diabetes and the kidney. Am J Kid Dis 2005; 46(4): 766 – 773. 30) Wiggins J. Core curriculum in nephrology: geriatrics. Am J Kid Dis 2005; 46(1): 147 – 158. 31) Ikizler TA and Schulman G. Core curriculum in nephrology: hemodialysis: techniques and prescription. Am J Kid Dis 2005; 46(5): 976 – 981.

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32) Himmelfarb J. Core curriculum in nephrology: hemodialysis complications. Am J Kid Dis 2005; 45(6): 1122 – 1131. 33) Wasserstein AG. Core curriculum in nephrology: nephrolithiasis. Am J Kid Dis 2005; 45(2): 422 – 428. 34) Wiseman AC and Linas S. Core curriculum in nephrology: disorders of potassium and acid-base balance. Am J Kid Dis 2005; 45(5): 941 – 949. 35) Perazella MA and Parikh C. Core curriculum in nephrology: pharmacology. Am J Kid Dis 2005; 46(6): 1129 – 1139. 36) Ellison DH. Core curriculum in nephrology: disorders of sodium and water. Am J Kid Dis 2005; 46(2): 356 – 361. 37) Braden GL, O’Shea MH, and Mulhern JG. Core curriculum in nephrology: tubulointerstitial diseases. Am J Kid Dis 2005; 46(3): 560 – 572. 38) Rosner MH and Bolton WK. Core curriculum in nephrology: renal function testing. Am J Kid Dis 2006; 47(1): 174 – 183. Yale Ambulatory Care Curriculum.

Revised by Kelly M. Wachi, MD 2007 Reviewed and Approved by Curriculum Task Force February 6, 2007 Approved by Curriculum Committee April 2, 2007 Revised by Ronald Ng, MD 2010 Reviewed and Approved by Curriculum Task Force February 2, 2010 Approved by Curriculum Committee March 1, 2010

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