general · review renal physiology ckd and general nephrology review differential diagnosis...
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Reviewed: Page: 1 January 10, 2017 Division of Nephrology
DIVISION OF PEDIATRIC NEPHROLOGY PGY-2 ROTATION PACKAGE
GENERAL:
1. Access to your orientation package and educational materials and resources will be provided prior to the start of
the rotation along with your rotation schedule.
2. The Resident works in the nephrology clinics, consults and in-patient service.
3. Where available, the ERP will meet with the resident on the first day and orientate him/her to the service,
review the expectations of the rotation and discuss individual learning objectives.
a. This will be arranged for 0900 on the first morning of the rotation
4. A further exit interview will take place in the final week of the rotation to review individual resident evaluations.
The Orientation package contains: PGY2 Nephrology Rotation Goals and Objectives, Consult Service Goals and
Objectives, Clinic goals and Objectives, Weekly Meetings and Clinic Schedules, Division of Nephrology Telephone
Directory, and a List of Suggested Reading Material.
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Table of Contents GENERAL: ................................................................................................................................................................................ 1
Appendix “A” ........................................................................................................................................................................... 7
PGY-2 Rotation Goals and Objectives ................................................................................................................................. 7
Appendix “B” ......................................................................................................................................................................... 10
Consult Service Expectations ............................................................................................................................................ 10
General Overview: ........................................................................................................................................................ 10
Consult Team members: ............................................................................................................................................... 10
General: ......................................................................................................................................................................... 10
Clinical Expectations & Responsibilities of the Resident: ............................................................................................. 10
Education: ..................................................................................................................................................................... 13
Appendix “C” ......................................................................................................................................................................... 14
Outpatient Clinic Expectations .......................................................................................................................................... 14
General Overview: ........................................................................................................................................................ 14
Clinical: .......................................................................................................................................................................... 14
Education (in addition to weekly academic rounds) ..................................................................................................... 14
Appendix “D” ........................................................................................................................................................................ 15
Sample Schedule ............................................................................................................................................................... 15
Appendix “E” ......................................................................................................................................................................... 16
Nephrology Telephone Directory ..................................................................................................................................... 16
Appendix “F” ......................................................................................................................................................................... 17
Suggested Reading Material ............................................................................................................................................. 17
Reviewed: Page: 3 January 10, 2017 Division of Nephrology
Topic Objectives Consult Clinic Article
Kidney Function
Principles of Clearance
Calculations of eGFR, Cr Clearance
CKD
Electrolytes Hyponatremia Hypernatremia
Review renal physiology
CKD and
General Nephrology
Review differential diagnosis
Management
Fluid and electrolyte abnormalities
Hypokalemia Hyperkalemia
Review physiology
CKD and
General Nephrology
Review differential diagnosis
Management
Action of Diuretics
Renal Tubular Acidosis (RTA)
Review differential diagnosis
General Nephrology
Management
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Topic Objectives Consult Clinic Article
Proteinuria Hematuria
Nephrotic Syndrome
Define Proteinuria
General Nephrology
Work up for proteinuria and hematuria
Management of Nephrotic Syndrome
Acute Kidney Injury (AKI)
Define AKI
General Nephrology
Work-up (include Urinalysis/Microscopy)
Differential Diagnosis including RPGN and TIN
Glomerular Disorders
Review diagnosis and management of Post Infectious GN
General Nephrology
Review diagnosis and management of HSP
Review indications for a renal biopsy
UTIs
Review evaluation and management
CKD and
General Nephrology
Review recent guidelines
Reviewed: Page: 5 January 10, 2017 Division of Nephrology
Topic Objectives Consult Clinic Article
Obstructive Uropathy
Review normal and abnormal development of the genitourinary tract
CKD
Review evaluation and management of antenatal hydronephrosis, posterior urethral valves and hydronephrosis
Understand imaging techniques such as VCUG, Renal Scan, Renal US,
Urodynamics
Hypertension
Review evaluation and management of elevated blood pressure
CKD, Transplant
and General Nephrology
Review acute and chronic management of hypertension
Review workup of hypertension with indications for more detailed imaging
such as renal angiography
Cystic Kidney Disease Review evaluation and management CKD and
General Nephrology
Calcium and Phosphate
Review evaluation and management of Nephrocalcinosis
Stone CKD and
General Nephrology
Review evaluation and management of stones
Review evaluation and management of hyper/hypocalcemia and rickets
Reviewed: Page: 6 January 10, 2017 Division of Nephrology
Topic Objectives Consult Clinic Article
Basic Principles of RRT
Indications for dialysis
Types of dialysis modalities
Basics of Transplant
Indications for Transplant
CKD and
Transplant
Ethics regarding transplant
Types of transplants and outcomes
Reviewed: Page: 7 January 10, 2017 Division of Nephrology
Appendix “A”
PGY-2 Rotation Goals and Objectives
Medical Expert Skills
To understand renal physiology and pathophysiology.
To understand the medical management of patients with acute renal failure to end the indications for renal replacement therapy (hemodialysis, peritoneal dialysis, continuous hemofiltration) and understand the basic principles and complications of dialysis.
To learn the medical and complications of acute and chronic renal failure and to understand the general principles of renal transplantation including common complications.
To develop the skills necessary to assess the renal system and fluid balance.
To understand the indications for and information obtained from renal imaging studies (ultrasound, renal nuclear scans, renal angiography) and renal biopsy.
To be able to perform urinalysis, including microscopy.
To develop an approach to the diagnosis and management of disorders affecting the kidneys with particular reference to fluid and electrolyte disorders, acid base disorder, hematuria, proteinuria, inherited and developmental anomalies, nephrotoxicity, renal tubular disorders, acute and chronic renal failure urinary tract infection and hypertension.
To interpret fluid balance records of patients with renal dysfunction and to monitor progression of chronic renal failure.
To develop an approach to the differential diagnosis and management of common clinical problems associated with renal disease.
Demonstrates a good understanding of the basic
scientific and clinical knowledge relevant to resolving common clinical problems and relating it to patient care.
History and physical examinations are complete, accurate and well organized.
Able to select, time, sequence and interpret laboratory tests, being aware of the cost and sensitive to inconvenience and discomfort to patient.
Uses all of the pertinent information to arrive at complete and accurate clinical decisions. Plans for consultation and therapeutic program are complete and accurate.
Recognizes and manages emergency conditions (extremely ill patient) resulting in prompt and appropriate treatment. Remains calm, acts in a timely manner and prioritizes correctly.
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Communicator Skills
To understand the importance to the patients and families of acute and chronic renal disease.
Establishes a therapeutic relationship with patients and their caregivers. Communicates well and at an appropriate level with patients and families
Demonstrates appropriate interviewing skills with patients and families, being able to understand and recognize emotional and personal needs of patients and families. Understands issues involving disabilities, gender, race and culture.
Provides clear and thorough explanations of diagnosis, investigation and management to patients and families.
Establishes good relationships with peers and other health professionals. Effectively provides and receives information. Handles conflict situations well. Receives feedback well.
Prepares written documentation (including patient notes, discharge summaries and patient letters) that is accurate, organized and timely.
Able to verbally present cases in an accurate, complete and organized fashion.
Collaborator Skills
To learn how to work with members of the health care team to support these children and their families.
Interacts effectively with health professionals by recognizing and acknowledging their roles and expertise and is respectful of the professional roles of other team members.
Consults and delegates effectively.
Collaborates effectively and constructively with other members of the health care team.
Manager Skills
To learn to make effective use of information technology, such as methods for searching medical databases, to optimize patient care.
To learn to set realistic priorities and to use time effectively in order to optimize professional performance.
To gain an understanding of the cost-effective use of health care resources, including diagnostic and consulting services
Understands and makes effective use of information technology, such as methods for searching medical databases, to optimize patient care and life-long learning.
Demonstrates awareness and makes cost effective use of all forms of pediatric health care resources based on sound judgement, and where possible evidence–based medicine
Demonstrates knowledge of and willingness to be
involved in, cost-containment and quality assurance
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programs.
Sets realistic priorities and uses time effectively in order to optimize professional performance, balancing professional, personal and institutional commitments.
Health Advocate Skills
Demonstrates and promotes active involvement of the family in decision making and care of the child
To work with other health care team members to ensure appropriate support for the patient and family on discharge.
Demonstrates and promotes active involvement of the family in medical decision making and comprehensive care of the child.
Identifies the psychosocial, economic and societal factors that may affect a child’s health and ability to receive care.
Recognizes and responds appropriately in advocacy situations.
Demonstrates that the specialist is an advocate for both the child and family by working with the family to obtain needed services for care and on-going family support.
Scholar Skills
To develop skills to assess and critically appraise evidence based information relevant to the patients’ problems
To develop the ability to present various aspects of nephrology in formal or informal educational settings.
Demonstrates an understanding of a commitment to the need for continuous learning.
Develops and implements an ongoing and effective personal learning strategy with an analysis and evaluation of the relevant medical literature
Is able to critically appraise medical information. Successfully integrates information from a variety of sources.
Is able to present various aspects of nephrology in formal or informal educational settings.
Professional Skills
To appreciate the ethical issues related to kidney transplantation, treating infants with end-stage renal disease.
To practice the skills of professional attitude and behaviour.
Demonstrates honesty and integrity
Demonstrates compassion and empathy
Demonstrates respect for others and diversity
Demonstrates reliability, responsibility and conscientiousness.
Demonstrates an understanding of ethical practice and applies this to one’s work.
Demonstrates self-awareness/knowledge.
Reviewed: Page: 10 January 10, 2017 Division of Nephrology
Appendix “B”
Consult Service Expectations
General Overview:
The consult rotation provides exposure to a wide range of renal disorders. During this rotation, the trainee will be
consulted by medical and surgical inpatient services (including critical care and emergency units), community-based
physicians, and outpatients and/or their caregivers for diagnosis and/or management of acutely ill and stable patients
with renal disease. The trainee is expected to provide excellent clinical care and communicate with referring physicians,
nurses, allied health professionals, and patients/family caregivers at the level of a consultant pediatric nephrologist.
Consult Team members:
1 Nephrology Fellow
1 PGY2 Core Pediatric Resident
Elective medical students or adult nephrology fellow (PGY 5)
1 attending Staff Nephrologist
General:
On consult service with the Fellow the resident will see new consults where possible as triaged by the Fellow or Staff and
accompany the Fellow for rounds with the attending Staff physician. On Thursday morning, nephrology fellows attend
their academic half day lectures, during this time the resident will have an opportunity to hold the pager(s) and answer
outside calls and liaise directly with the attending Staff.
Clinical Expectations & Responsibilities of the Resident:
1. Review with fellows new consults and ongoing consult patients before rounding with Attending Staff
2. See/write concise updated progress notes on follow-up patients. Sick or active patients should have a daily progress note by a member of the team.
3. When appropriate, inform staff of new and follow-up consults that require immediate attention
4. Assist the fellow in arranging a time, starting place, and list of consult patients that need to be seen for rounding with Attending Staff – start with sickest patients and make sure new consults are reviewed.
5. After rounding, make sure that the referring service is informed of the Nephrology recommendations. This should be done prior to discussing with families especially if there is a change in plan.
Seeing new inpatient consults:
1. Obtain the following information when you get a new consult:
Full name of patient
Age of patient
Medical Record number of patient
Location of patient
Reason for consultation
Relevant history
Relevant test results
Current management of the problem
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Urgency of the consult request (as determined by the referring MD)
This should be brief to determine the urgency of the consult to prioritize work
2. Depending on the patient’s clinical status, assign a resident or fellow (or yourself) to see the new consult patient
in a timely manner.
Sick or unstable patients should be seen within an hour of the request for consultation.
It may be more appropriate for the Fellow to see an unstable patient who requires immediate
intervention (viz. dialysis access and initiation)
Stable patients in ER, PICU, and NICU should be seen within four hours of the request
Stable patients on other inpatient units should be seen within 24 hours’ of request (preferably before the
end of the working day) unless pending tests are required for the full consultative plan.
3. Always try to obtain a urine sample
4. An accurate, concise, written consultation note must be provided. It doesn’t need to be long—2 pages max.
The note must include your impression and suggestions for diagnosis and management.
5. Review new consults with the attending staff within 24 hours of completing the consultation depending on
clinical urgency.
6. Unstable patients should be reviewed with attending staff as soon as possible after completing the initial
assessment (if necessary, before you’ve completed your written note!).
7. Stable patients should be reviewed with attending staff during daily rounds.
8. The referring service should be informed of the Nephrology recommendation(s). Non-urgent recommendations
should be documented clearly in the consult note. Urgent recommendations should be communicated directly
to one of the doctors looking after the patient. The bedside nurse should also be informed by direct
communication of any recommendations that involve monitoring. Effective communication involves providing
parameters for clinical deterioration (e.g. give nifedipine if BP>150/95; call Nephrology if urine output
<0.5cc/kg/hr).
9. If the referring service approves, you may enter recommended tests and/or medications on the patient’s chart.
Those orders can be altered, or removed by the referring service at their discretion. This may be most useful on
surgical services; however, it is important to communicate with the primary team that the orders were placed
and for them to remove the suspension.
Following inpatient consults:
1. All consult patients are expected to be followed so long as they require active management or monitoring by
Nephrology. Sick inpatients followed by Nephrology should be seen at least once a day, preferably before noon.
Reviewed: Page: 12 January 10, 2017 Division of Nephrology
Stable inpatients actively managed or monitored by Nephrology should be seen daily.
2. Concise, updated notes must be recorded in the Progress Notes section of the patient chart. Effective
communication involves discussing any changes in management directly with medical and nursing members of
the referring service. If recommendations are being given, there should ALWAYS be a note to document the
recommendations. The fellow should review notes written by residents to ensure their accuracy.
3. Inpatients no longer requiring active management or monitoring should be “signed off”. If Nephrology follow-up
is required at a later date, those patients should remain on the Consult list as inactive and the date for follow-up
should be recorded until they are discharged from hospital.
4. When an inpatient is to be discharged, the Fellow/Resident should ensure that Nephrology follow-up
arrangements are clearly communicated to the referring service as well as the parent/patient caregiver. If
follow-up involves a future Nephrology clinic visit, the fellow or resident should notify the Clinic Nurse of the
follow-up arrangements. This will ensure that the plan is documented. Follow-up should include the time frame,
and tests needed at that visit.
Consultations involving Renal Replacement Therapy:
1. The Nephrology Service plays an active and important role in managing all inpatients requiring renal
replacement therapy (RRT)
2. Inpatient renal replacement includes hemodialysis (HD) and peritoneal dialysis (PD). Stable patients may receive
hemodialysis in the dialysis unit. Patients too unstable to be dialyzed in the dialysis unit may receive their
treatment on their respective inpatient units.
3. New consultation requests from PICU for RRT must be completed immediately.
4. The Resident/Fellow should review with the Attending Staff as soon as possible all new consults on patients with
severe renal impairment who are likely to require RRT. As consultants, the Nephrology Consult team will advise
the referring service on the choice of modality, access, and dialysis prescription.
5. The Fellow is expected to write the dialysis prescription once the modality is chosen. PD and HD orders can be
located in the order sets folder in Citrix.
6. Dialysis orders should be completed as soon as possible once the decision to dialyze is made.
7. When HD is the chosen modality, the Fellow should notify the dialysis unit immediately so that a nurse and
technician may be assigned. Effective communication involves the Fellow discussing the treatment plan with the
assigned dialysis nurse as early as possible.
8. The Fellow is expected to assess the need for renal replacement therapy in a prompt and efficient manner in all
new and active consult patients with kidney failure on a daily basis. The Fellow should request assistance from
the Attending Staff Nephrologist when there is uncertainty over the need for dialysis. For patients receiving daily
acute HD, the decision to dialyze should be made as early in the day as possible. Effective communication
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involves the Fellow notifying the dialysis unit as well as the referring medical service of the patient’s need for
dialysis once that is established.
Education:
1. The resident should read on key medical expert subjects listed in the goals and objectives for this rotation.
2. The fellow/attending staff also has the opportunity for teaching with the core residents, elective students and
observers. This is one of the main rotations that provide an opportunity for developing management and
teaching skills. The goal of the fellow should be to:
a. Promote scholarly discussions around cases on inpatient rounds
b. Provide bedside teaching to residents
c. Provide formal teaching to residents on key topics such as acute kidney injury, nephrotic syndrome,
HUS, etc.
d. Reviewing cases and written notes with residents provides an excellent opportunity for informal bedside
teaching. Asking questions and engaging in discussions on rounds with the attending staff is another way
to stimulate learning.
Reviewed: Page: 14 January 10, 2017 Division of Nephrology
Appendix “C”
Outpatient Clinic Expectations
General Overview:
The clinic rotation provides exposure to a wide range of renal disorders. During this rotation, the resident alongside
fellow and staff will be reviewing a variety of kidney diseases including glomerular diseases, malformations and urinary
tract disorders, CKD, stones, hypertension and genetics. The resident is expected to provide excellent consultative care
and develop evaluation and management plans. The resident is expected to communicate with referring physicians,
nurses, allied health professionals, and patients/family caregivers at the appropriate PGY-2 level as outlined in Goals and
Objectives (‘Appendix A’).
Clinical:
1. Attend all clinics during the clinic rotation
2. Review clinic list the day before clinic and review clinical history of patients (in particular new patients). Speak
with, our administrative assistant, Lisa to obtain a clinic list for review.
3. Morning clinics start promptly at 0900; afternoon clinics start at 1230-1300.
4. No more than 5-10 minutes should be taken to review the chart in clinic prior to seeing each patient (ideally
review the patient clinic list before clinic)
5. Present in a clear and concise fashion with all the pertinent information relevant to the nephrology consultation
or follow-up. Have all documentation ready to go such as prescriptions, imaging requests and clinic sheet. If the
patient has a complicated history, please make sure that you review the medical problem list.
6. Fill in the return clinic sheet and requisitions for imaging if needed for patients.
7. Detailed notes should be written in EPIC within 24 hours
8. Communicate with the nurse involved in the care of the patient if tests need to be arranged or nursing follow-up
required.
9. Follow-up on outstanding results and review with the attending physicians.
10. Communicate with families’ the results and plan of management.
Education (in addition to weekly academic rounds)
Self-learning around cases seen in clinic
Discussion with attending staff around cases seen
Identify opportunity for quality improvement or protocol development
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Appendix “D”
Sample Schedule
DAY TIME ACTIVITY LOCATION
Monday 1230-1630 Dr. Chanchlani’s Clinic 2G clinic
Tuesday 0900-1300 Dialysis and Transplant Clinic 2G Clinic
1400-1500 CKD Meeting 4N42
Wednesday
0800-0900 Nephro-Uro Rounds (2nd and 4th weeks) 3H40
0900-1300 Dr. Arora’s Clinic 2G Clinic
1300-1700 Fellow Clinic 2G Clinic
Thursday 0800-0900 Grand Rounds MDCL 3320
1400-1500 Nephrology Journal Club MDCL 2221
Friday 0900-1300
Dr. Belostotsky’s Clinic (Stone Clinic-1st Friday monthly)
2G Clinic
1300-1700 Chronic Kidney Disease (CKD) Clinic 2G Clinic
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Appendix “E”
Nephrology Telephone Directory
Name Role Extension Email Location
Dr. Steven Arora Division Head Ext. 73680 [email protected] 3A53
Dr. Rahul Chanchlani Education Resource Person Ext. 77569 [email protected] 3A51
Dr. Vladimir Belostotsky Pediatric Nephrologist Ext. 75661 [email protected] 3A55
Naif Abdulmajed Fellow Pager: 6076 [email protected]
Lisa Svoboda Administrative Assistant Ext. 75635 [email protected] 3A Pediatrics
Susannah Jenkins Nurse Practitioner Ext. 72294 [email protected] 1C
Jackie Wasson CKD Nurse Ext. 73855 [email protected] 1C
Marian Girodat Dialysis Nurse
Dr. Arora’s Clinic Nurse Ext. 73888 [email protected] 3C-Room 18
Stefanie Gunjilac Dr. Belostotsky’s Clinic Nurse Dr. Chanchlani’s Clinic Nurse
Ext 76091 [email protected] 1C
Jenny Reay Social Worker Ext. 76085 [email protected] 1C
Sindy Ng Dietician Ext. 77235 [email protected] 1C
Reviewed: Page: 17 January 10, 2017 Division of Nephrology
Appendix “F”
Suggested Reading Material
Manual of Pediatric Nephrology
Acute Renal Injury
Autosomal Dominant Polycystic Kidney Disease
Bartter and Gitelman-like Syndromes, Salt-losing Tubulopathies with Loop or DCT Defects
Clinical and Molecular Insights into Tuberous Sclerosis Complex Renal Disease
Clinical Practice Guideline for the Diagnosis and Management of Initial UTI
Continuous Renal Replacement Therapy for Acute Kidney Injury
Controversy in UTI Management in Children
Cystic Kidney Disease: A Primer
Diagnosis Evaluation and Treatment of High Blood Pressure in Children and Adolescents
Evaluation of Renal Disease
Fluid Management in Adults and Children-Core Curriculum
Focal Segmental Glomerulosclerosis
Genetic Forms of Nephrogenic Diabetes Insipidus
Glomerular Diseases
Glomerulonephritis
HSP Nephritis
Hematuria
Hypercalciuria
Hypertension
Hypertension in Infancy: Diagnosis, Management and Outcome
Immunosuppressive Medications
Kidney Transplantation
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Kidney Transplantation in Children
Maintenance Fluid Therapy: What it is and what it is not
Management of Acute Hyperkalaemia in Neonates and Children
Management of high blood pressure in children and adolescents
Management of Nocturnal Enuresis
Measuring and Estimating Glomerular Filtration Rate in Children
Neonatal Hypertension
Neonatal Hypertension Diagnosis and Management
Nephrocalcinosis and Urolithiasis in Children
Nephrotic Syndrome
New Guidelines for the Diagnosis and Management of UTI
Nocturnal Enuresis
Onco-Nephrology: Tumor Lysis Syndrome
Pathogenesis diagnosis and management of hyperkalemia
Pathophysiology of Renal Tubular Acidosis Core Curriculum
Perspectives of Edema in Childhood Nephrotic Syndrome
Podocyte Disorder Core Curriculum
Practical Consensus Guidelines for the Management of Enuresis
Proteinuria
Renal Diseases associated with Hematuria in Children and Adolescents
Renal Physiology for the Clinician
Renal Transplantation in Infants
Renal Tubular Acidosis
Shiga-toxin-producing Escherichia Coli and Haemolytic uraemic syndrome
Sodium Hypernatremia
Sodium Hyponatremia
Syndrome of Inappropriate Antiduresis
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Tuberous Sclerosis Complex Renal Disease
Urinalysis: A comprehensive Review
Urinalysis: Case Presentations for the Primary Care Physician
Urinary Tract Infection in Children
Urinary Tract Obstruction
Vesicoureteric Reflux in Children