Nephrology

During this rotation, residents should develop an approach to the following:

Inpatient management of patients with acute-renal failure

1. Develop an approach to the assessment of renal disease (GFR, urinalysis, imaging)

2. Develop a diagnostic approach to the patient with ARF

3. Understand the management of the common causes of ARF

   • Rapidly progressive GN

   • Acute tubular necrosis

   • Obstructive ARF

4. Understand the indications for, and risks of, the renal biopsy

5. Understand the indications for renal replacement therapy

6. Understand the basic principles of hemodialysis and peritoneal dialysis 

Inpatient management of patients with end-stage renal disease

1. Fluid balance; assessment and management

2. Anemia management

3. Electrolyte imbalances (sodium, potassium, calcium, phosphorus)

4. Acidosis and alkalosis

5. Uremia

6. Understand the risks and benefits of renal transplantation

7. Have an approach to drug dosing in patients with ESRD

8. Understand the issues of withdrawal of dialysis and end of life planning

Responsibility of the Ward Service

To ensure this component of the rotation is successful, please note the following expectations:

• The resident is expected to arrive each morning, dressed in a professional manner, at 7:45 a.m in order to attend the mandatory morning report (Monday through Thursday).  As with any other service in this hospital, you are expected to prepare a detailed record of patients’ history and physical findings when they are admitted electively or when you are on duty at night as well as write regular progress notes on these patients.  These notes will be reviewed as part of the evaluation process.  When your patient is discharged, you are expected to fill out the discharge notification to referring physicians so that a copy of this notification can be taken by the patient to the referring physician.  This discharge notification should contain the diagnosis, the medications, and for patients in the Chronic Renal Failure Program, the dialysis orders as well as any follow-up procedures to be performed in the future, antibiotics, x-rays, etc.  You are also responsible for dictating the discharge summary on any patient admitted for > 72 hours.

• You are expected to be the primary provider of care for all patients assigned to you.  This includes decision-making around diagnostic evaluations and treatment options.  It also includes writing all dialysis orders on your patients (this can be discussed with the attending staff if you are unfamiliar with dialysis order writing). 

• Ward rounds are scheduled for Monday mornings from 10:00-12:00 and Thursday mornings from 9:00 to 11:00.  You should be prepared to discuss the current status of the patient in a problem-oriented fashion.

• You are responsible for signing out any acutely patients to the on-call     resident at 1700h.  Please inform the fellow or attending nephrologist of any unstable patients prior to leaving post-call.

• You are responsible for dictating discharge summaries, in a timely fashion, on the patients you discharge.

• You should notify the renal fellow or nephrologist on-call of any admissions to the Nephrology service (call the fellow first when one is on-call).  Night calls are usually for new admissions or problems with fluid management, bleeding, or infections, but can also be for a variety of other reasons.  We would encourage you to contact either the renal fellow or the nephrologist on-call with any concerns.  It is advisable that the resident  on-call checks with the  ward at 10 p.m. for any necessary orders before retiring, to avoid unnecessary phone calls afterwards.

By the end of this rotation, residents will be graded as “progressing as expected” in each of the following and in the Global Rating.  The expected level of performance in the PGY1 year is Interpreter level,  PGY2 is Manager Level, PGY3 is Educator Level (See Program Information - Overall Goals and Objectives). 

1. Medical Expert

• Data Collection and Clinical Reasoning: The resident appropriately collects and synthesizes clinical information to formulate a primary diagnosis and appropriate differential diagnosis.

• Clinical Decision Making: The resident is able to make appropriate and cost-effective investigation and management decisions based on the context of the case and best available evidence.

2. Communicator

• Patient and Family Communication: The resident communicates with and about patients and family in a patient-centered manner.

• Documentation and Verbal Presentation: The resident appropriately documents and verbally presents cases for new admissions, progress notes, handover of care, and discharge summaries (succinctly organized, prioritized, summarized).

3. Collaborator

• Interdisciplinary Team: The resident works well in a team, shares work, and interacts with allied healthcare providers and other consultants effectively.

4. Leader

• Efficiency: The resident prioritizes tasks and manages time effectively.

5. Health Advocate

• Patient Advocacy: The resident advocates for patients by obtaining/expediting investigations, consults, or access to other resources during inpatient care or during transition to the outpatient setting.

6. Scholar

• Personal and Team-based Learning:  The resident demonstrates an effective personal learning strategy (reading around cases, appropriate use of resources) and shares knowledge with other team members.

7. Professional

• Scope of Practice:  The resident is trustworthy and responsible, knows limitations (asks for help appropriately), and responds well to feedback.

Assessment

We use the following In-Training Evaluation Report (ITER): 

• Nephrology Wards

Entrustable Professional Activities (EPAs)

This rotation may be done during Transition to Discipline or Foundations. If done during Transition to Discipline (July and August of R1) this is an ideal learning environment for the following EPAs:

• TD1: Performing histories and physical exams, documenting and presenting findings, across clinical settings for initial and subsequent care

• TD2: Identifying and assessing unstable patients, providing initial management, and obtaining help

• TD3: Performing the basic procedures of internal medicine

If done during Foundations (September and onward during R1) this is an ideal learning environment for the following EPAs:

• FD1: Assessing, diagnosing, and initiating management for patients with common acute medical presentations in acute care settings

• FD2: Managing patients admitted to acute care settings with common medical problems and advancing their care plans

• FD3: Consulting specialists and other health professionals, synthesizing recommendations, and integrating these into the care plan

• FD4: Formulating, communicating, and implementing discharge plans for patients with common medical conditions from acute care settings

• FD5: Assessing and providing targeted treatment for unstable patients and consulting as needed

• FD6: Discussing and establishing patients’ goals of care

• FD7: Identifying personal learning needs while caring for patients and addressing those needs

Rotation Supervisor 

Dr. Alan McMahon

alan.mcmahon@ualberta.ca

Medical Education Program Coordinator 

mednneph@ualberta.ca

During this rotation, residents should develop an approach to the following:

Inpatient management of patients with acute renal failure

1. Develop a diagnostic approach to the patient with ARF

2. Understand the prevention and management of the common causes of ARF

   • Post operative ARF

   • Obstructive ARF

   • Cardiogenic-prerenal ARF

   • Rhabdomyolysis

   • Contrast nephropathy

3. Perioperative Management of patients with end stage renal disease

4. Understand the principles of perioperative volume management

5. Understand the principles perioperative electrolyte management

6. Understand the basics of dialysis order writing in the perioperative patient

7. Approach to acid base abnormalities

8. Develop an approach to metabolic acidosis and alkalosis

Outpatient management of chronic kidney disease

1. Understand the general management strategies to slow progression in CKD

2. Understand the management of atherosclerotic renal disease

3. Understand the management of diabetic nephropathy

4. Know the natural history, complications, and management of polycystic renal disease. Understand the causes, natural history, treatment options, and complications of nephrotic syndrome.

Responsibilities of the Consult Service

The consult service provides a very different experience from that of the ward. Here, you will have the opportunity to learn the approach and management of most of the common renal disorders, with particular emphasis on acute-renal failure, proteinuria and nephrotic syndrome, and systemic disorders in acutely-ill patients. In addition to the in-patient consult service, you will also have the opportunity to attend weekly outpatient clinics during your rotation. This clinic experience has been designed to provide you with the opportunity to learn some of the clinical aspects of nephrology not seen on the ward, such as patients with mild to moderate renal failure on conservative therapy, glomerulonephritis, renal calculi, and hypertension. Some of the patients attending these clinics have been followed in excess of 10 to 20 years. 

• While on the Consult service, you will make rounds with the attending staff at a time convenient to both of you. This is not a busy service, with an average of one to two new consults per day. You will follow them daily and keep pertinent progress notes. Some of these patients may have renal failure and you will write dialysis orders on them if they require dialysis. 

• You are also expected to write dialysis orders on all the consult patients under your care who are undergoing acute or chronic hemo/peritoneal dialysis. 

• You may also be asked to see patients referred to Nephrology in the Emergency Room by the casualty officer. 

• While on Nephrology Consults, the resident will promptly attend all clinics to which he/she has been assigned.

By the end of this rotation, residents will be graded as “progressing as expected” in each of the following and in the Global Rating.  The expected level of performance in the PGY1 year is Interpreter level,  PGY2 is Manager Level, PGY3 is Educator Level (See Program Information - Overall Goals and Objectives). 

1. Medical Expert

• Data Collection and Clinical Reasoning: The resident appropriately collects and synthesizes clinical information to formulate a primary diagnosis and appropriate differential diagnosis.

• Clinical Decision Making: The resident is able to make appropriate and cost-effective investigation and management decisions based on the context of the case and best available evidence.

2. Communicator

• Patient and Family Communication: The resident communicates with and about patients and family in a patient-centered manner.

• Documentation and Verbal Presentation: The resident appropriately documents and verbally presents cases for new admissions, progress notes, handover of care, and discharge summaries (succinctly organized, prioritized, summarized).

3. Collaborator

• Interdisciplinary Team: The resident works well in a team, shares work, and interacts with allied healthcare providers and other consultants effectively.

4. Leader

• Efficiency: The resident prioritizes tasks and manages time effectively.

5. Health Advocate

• Patient Advocacy: The resident advocates for patients by obtaining/expediting investigations, consults, or access to other resources during inpatient care or during transition to the outpatient setting.

6. Scholar

• Personal and Team-based Learning:  The resident demonstrates an effective personal learning strategy (reading around cases, appropriate use of resources) and shares knowledge with other team members.

7. Professional

• Scope of Practice:  The resident is trustworthy and responsible, knows limitations (asks for help appropriately), and responds well to feedback.

Assessment

We use the following In-Training Evaluation Report (ITER):

• Nephrology Consults 

Entrustable Professional Activities (EPAs)

This rotation is done during Core of the Discipline and is an ideal learning environment for the following EPAs:

• CD1: Assessing, diagnosing and managing patients with complex or atypical acute medical presentations

• CD2: Assessing, diagnosing, and managing patients with complex chronic diseases

• CD3: Providing internal medicine consultation to other clinical services

• CD7: Discussing serious and/or complex aspects of care with patients, families, and caregivers

  • Breaking Bad News - requiring dialysis

• CD8: Caring for patients who have experienced a patient safety incident (adverse event)

• CD10: Implementing health promotion strategies in patients with or at risk for disease

  • E.g. Vascular risk reduction, 

  • Counselling on Immunocompromised state for Renal transplants

Rotation Supervisor 

Dr. Alan McMahon

alan.mcmahon@ualberta.ca

Medical Education Program Coordinator 

mednneph@ualberta.ca