Rotation Contact

Rotation Director – Keisha Gibson, MD (keisha_gibson@med.unc.edu)

First Day Information

Meet at 8:30am in 60172 Women’s Hospital for Renal Rounds. The Nephrology Attending schedule is also available on WebXchange.

Welcome Note

Goals and Objectives

OVERALL EDUCATIONAL GOAL:

To achieve competency in General Pediatrics, the resident completing the elective in Nephrology should be able to (1) suspect, accurately document, and initiate a diagnostic evaluation of frequently encountered symptoms, signs or laboratory abnormalities which may be manifestations of renal and urinary system disease, (2) correct water, electrolyte and acid-base disorders, (3) treat acute urinary tract infections and (4) initiate treatment of potentially life-threatening emergencies such as hyperkalemia and hypertension.

OBJECTIVES:

On completion of the elective, the resident should be able to:

Perform a history and physical examination adequately to detect abnormalities in body fluid homeostasis, hypertension and manifestations of renal disease. (PC)

Demonstrate proficiency in interpreting laboratory studies used to detect renal disease to include: (MK)

Urinalysis, by assessing urine specific gravity, reading the urinary dipstick test (i.e. “multistix”), preparing a wet mount, examining the urine sediment in the microscope, recognizing cells and casts and by interpreting “patterns” of these elements as “normal” or as typical of “urinary tract infection”, “nephrotic syndrome”, “acute glomerulonephritis”, “acute tubular necrosis” or “chronic renal failure”.

Measurement or estimation of glomerular filtration rate (GFR), by using the serum creatinine to estimate, from body
height, and calculate, based on formulas to estimate GFR (i.e. Schwartz) or on actual quantitative urinary excretion, i.e. the creatinine clearance extrapolated to a standard body surface area,) compare the result to age-appropriate normal reference values and to recognize limitations in its interpretation.

Tubular function, by calculating and interpreting the “absolute” and “fractional” excretions of water, sodium potassium,
calcium and protein.

Detect, evaluate and manage states of abnormal body homeostasis to include: (MK, PC, PBL)

Volume depletion by estimating water losses from the clinical examination, calculating water and electrolyte deficits, and developing a plan for replacement of deficits, maintenance fluids, on-going losses and mitigating complications of
dehydration.

Dysnatremia, by suspecting, documenting and discovering its etiology and by developing a judicious plan of treatment.

Acid-base disorders, by suspecting, documenting and discovering the etiologies of both “pure” and “mixed” disorders,
determining the indications for correcting the disorder and by recognizing the potential complications of treatment.

Recognize, evaluate and manage common conditions to include: (MK, PC, PBL)

Urinary tract infection, by suspecting and accurately documenting bacteriuria using the appropriate culture method,
selecting, based on their advantages and limitations, the optimal radiographic techniques to detect vesicoureteral reflux and renal parenchymal abnormalities and by developing a treatment/management plan.

Hematuria, by listing the causes of a “positive” urine dipstick for “blood”, identifying red cells in the sediment, defining its origin as “glomerular” or “non-glomerular”, and by differentiating the causes of each.

Proteinuria, be detecting and accurately quantitating protein excretion, defining its origin as “glomerular” or “nonglomerular”, recognizing the characteristics of “functional” forms of proteinuria and by differentiating the causes of“minimal-moderate” and “nephrotic range” proteinuria.

Nephrotic syndrome, by documenting the clinical features typical of Minimal Change Nephropathy, knowing the indication for and interpreting the response to a trial of glucocorticoid therapy and by anticipating the potential complications of steroid therapy and of the untreated “nephrotic state”.

Voiding dysfunction, by suspecting it and understanding the pathophysiologic basis of the various treatment options.

Circumcision – recognize the indications and contraindications of circumcision. Understand the potential complications of the procedure.

Recognize, initiate management and know the indications for referral of potentially serious conditions, to include: (MK, PC, PBL)

Acute renal failure, by suspecting and documenting, choosing and interpreting clinical and laboratory data to distinguish the three major diagnostic categories (prerenal, renal and post-renal failure), instituting appropriate conservative therapy and by recognizing the indications for acute dialysis.

Hypertension, by distinguishing “emergent”, “urgent” and “non-urgent” presentations, by initiating a diagnostic evaluation and by initiating the management of “emergent” and “urgent” hypertension.

Chronic kidney disease (CKD), by understanding its classification by stage (based on the National Kidney Foundation CKD classification) and recognizing differences in the presentation of patients with glomerular and tubulo-interstitial renal disease and by detecting its complications, anemia, osteodystrophy and growth failure.

Urinary tract obstruction, by suspecting and documenting the congenital uropathies, ureteropelvic junction obstruction,
urethral valves and “prune belly” syndrome.

Undescended testis and Hypospadias, by understanding the basis of the treatment options.

EVALUATION:

Resident

Resident performance is observed daily by an Attending. Evaluation is based on the quality of (1) their assessments of
patients suspected of having renal and urinary tract diseases, (2) their participation in the seminar discussions, and (3) the evaluations they propose for the simulated case presentations.

At the conclusion of the elective, the Resident and Attending complete an evaluation form indicating their estimation of the degree to which the Resident has successfully achieved each of the objectives of the elective.

Elective

The Resident evaluates (1) the effectiveness of the elective experience in providing adequate information and instruction to facilitate achieving each objective, and (2) the performance of each Attending as a teacher.

LEARNING ACTIVITIES OF THE ROTATION:

Patient assessments

Under the direct supervision of an Attending, Residents evaluate children seen in three pediatric nephrology clinics each week in the UNC Hospitals Nephrology Clinics, inpatients admitted to the Pediatric Nephrology Service or children seen in consultation to the medical and surgical specialties (e.g. pediatric surgery and urology) or general inpatient services or outpatient clinics of the UNC Hospitals throughout the period of the elective. These evaluations include taking a history, performing a physical examination, determining the qualitative urine protein, examining the urine sediment, measuring the creatinine clearance and protein excretion and interpreting other diagnostic studies necessary to formulate a differential diagnosis.

Case-Presentations

Residents meet with an Attending each week to discuss simulated case presentations directed to achieving each objective. Residents are expected to (1) review reading material provided in the syllabus, (2) read the simulated case presentation(s), and (3) answer questions stimulated by the case(s) and intended to facilitate the Resident’s self-evaluation of his/her understanding. The format of the seminar is to address specific questions, initiated by the Resident, which insure an understanding of concepts essential to achieve the objective.

Conferences

Each week Residents attend formal conferences devoted to issues in nephropathology and clinical pediatric nephrology. During our weekly inter-disciplinary Pediatric Nephrology Clinical Care Conference, there is formal discussion of patients the Resident assessed in the Nephrology Clinic. The latter involves calculations of creatinine clearance

Readings and Resources

Acid-Base Disturbances

Acute Glomerulonephritis

Acute Kidney Injury

Acute Renal Failure

Chronic Glomerulonephritis

ESRD/Chronic Renal Failure

Dysnatremias

Fluid Management

Hypertension

Isolated Hematuria

Neonatal Nephrology

Nephrotic Syndrome

Proteinuria

Urinalysis

Urinary Tract Anomalies

Urinary Tract Infection

Urolithiasis

Patient Education