NEPHROLOGY

DEFINITION:Nephrology is the branch of medicine concerned with the care of patients with kidney disease and disorders of fluid and electrolyte metabolism.

GENERAL OBJECTIVES:On completion of the educational program, the graduate physician will be competent to function as a consultant nephrologist. This requires the physician to be competent in the management of patients with kidney disease, and with disturbances of acid base and fluid and electrolyte metabolism. The nephrologist must also be competent in the management of dialysis and renal transplantation.

SPECIFIC OBJECTIVES:

Medical Expert/Clinical Decision-Maker

• demonstrate diagnostic and therapeutic skills for ethical and effective patient care
• access and apply relevant information to clinical practice
• demonstrate effective consultation services with respect to patient care, education and legal opinions

Knowledge

Each resident will have a basic understanding of physiology, pathophysiology, and pharmacology of all organ systems but in particular, an in-depth understanding of the kidney and urinary tract. The resident must be able to demonstrate both basic and clinical knowledge in the below-listed topic areas. These topic areas are necessarily linked and form a framework for learning and knowledge acquisition. The knowledge components within each topic area include clinical skills, differential diagnosis, diagnostic tests, etiology, pathophysiology, treatment/management issues including preventive health measures, complications of treatment, prognosis and any controversies in the area.

Topics

1. Acute renal failure
2. Chronic renal failure
3. End-stage renal failure including dialysis and transplantation
4. Dysuria/Pyuria/Reflux Nephropathy
5. Edema
6. Hypertension
7. Renal colic
8. Laboratory abnormalities
   1. hyponatremia and hypernatremia
   2. hypokalemia and hyperkalemia
   3. acid-base disturbances
   4. calcium and phosphate disturbances
   5. hypomagnesemia
   6. hematuria
   7. proteinuria
9. Inherited Renal Disorders
   1. cystic
   2. metabolic
   3. tubular
10. Growth, Development, Nutrition

Clinical skills

Residents must acquire the following clinical/technical skills:

1. Mastery in obtaining complete and relevant history and physical examination including urinalysis and integration of findings in the assessment of a patient suspected of a nephrologic problem,
2. Proficiency in the management of a patient with acute/chronic renal disease.
3. Demonstrable skill in dealing with the psychosocial and ethical issues related to patients with renal disease, including the ethical issues of death and grieving.
4. Demonstrate knowledge of indications, risks, interpretations of
   1. urinalysis
   2. renal biopsy including native and transplanted organs
   3. mechanisms of fluid delivery, machine mechanics and physics as they relate to hemodialysis and peritoneal dialysis therapy
   4. central venous access, arterial venous fistulae and graft access
   5. peritoneal access
   6. dialysis prescriptions.
5. Residents must be able to competently and safely perform the following technical procedures:
   1. placement of central venous access (except for pediatric nephrologists in the case of infants and young children where it is permissible to routinely obtain the assistance of a pediatric surgeon)
   2. urinalysis

Communicator

• establish therapeutic relationships with patients/families
• obtain and synthesize relevant history from patients/families/communities
• listen effectively
• discuss appropriate information with patients/families and the health care team

The resident will develop the skills of establishing therapeutic relationships with patients and their families. The resident will be able to obtain and synthesize a relevant history from patients' families or at times communities and to listen effectively to patients. The resident must demonstrate the ability to discuss appropriate health care information with the patient, family and the health care team.

The resident must demonstrate the ability to manage, in an ethical and effective fashion, problems related to the initiation and withdrawal of dialysis, the role of the advanced directive, the management of death from renal failure. In addition, the resident must appreciate the bioethical principles involved with the donation of living related and unrelated organs, as well as cadaveric organs, the application of organ donation allocation algorithms, and the management of genetic counseling for hereditary renal disease.

The resident must demonstrate effective consultation skills with respect to patient care, education and the ability to generate legal opinions and advice to insurance companies.

Collaborator

• consult effectively with other physicians and health care professionals
• contribute effectively to other interdisciplinary team activities

The resident must learn to consult effectively with other physicians and health care professionals, including particularly nurses, dietitians and social workers. The resident must demonstrate the capacity to work effectively in a multi-disciplinary team environment in the management of patients with chronic illnesses such as end-stage renal failure and renal transplant.

Manager

• utilize resources effectively to balance patient care, learning needs, and outside activities
• allocate finite health care resources wisely
• work effectively and efficiently in a health care organization
• utilize information technology to optimize patient care, life-long learning and other activities

Residents must demonstrate the ability to utilize time effectively to balance the requirements for patient care, ongoing learning and outside activities. During their training residents must demonstrate the ability to allocate finite health care resources such as renal transplant organs and dialysis wisely, balancing the requirements of individual patients with the overall community of patients for whose care the resident is responsible.

Health Advocate

• identify the important determinants of health affecting patients
• contribute effectively to improved health of patients and communities
• recognize and respond to those issues where advocacy is appropriate

The resident must be able to identify the important determinants of health affecting the individual patient, and particular problems related to the health care of groups of renal failure patients. If possible, the resident should have the opportunity to develop skills in advocacy where appropriate to improve patient care.

Scholar

• develop, implement and monitor a personal continuing education strategy
• critically appraise sources of medical information
• facilitate learning of patients, housestaff/students and other health professionals
• contribute to development of new knowledge

The resident must learn to develop, implement and monitor a personal strategy for continuing education. The resident must be able to critically appraise sources of medical information and demonstrate the ability to facilitate the learning of patients, house staff/students and other health professionals. The resident must develop the skill of contributing to the development of new knowledge, whether by the performance of quality assurance reviews, case reports or by the performance of original research.

Professional

• deliver highest quality care with integrity, honesty and compassion
• exhibit appropriate personal and interpersonal professional behaviours
• practise medicine ethically consistent with obligations of a physician

Residents must demonstrate the ability to deliver high quality care with integrity, honesty and compassion and to exhibit appropriate personal and interpersonal professional behavior while doing so. The resident must practice medicine ethically consistent with the obligations of a physician and must understand the basic principles of bioethics.

confirmation of completion of training signifying the attainment of consultant competence in nephrology.

ADULT NEPHROLOGY:

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in adult nephrology must be consistent with the specialty training requirements.

Residents must be provided with increasing individual responsibility, under appropriate supervision, according to their level of training, ability and experience.

In addition to offering the components noted in the specialty training requirements all accredited programs in adult nephrology should offer community-based learning experiences.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in nephrology.

In those cases where a university has sufficient resources to provide most of the training in adult nephrology but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

1. Teaching Faculty

There must be at least two qualified teaching staff to supervise the residents and provide teaching in the basic and clinical sciences related to renal diseases. The teaching staff should have an appropriate nucleus of full-time teachers.

2. Number and Variety of Patients

There should be adequate numbers of patients available for teaching to provide experience in the following areas of nephrology:

• general aspects of primary renal diseases;
• renal diseases associated with systemic disorders;
• renal biopsy and its interpretation;
• the management of acute and chronic renal failure, including the necessary skills required to manage peritoneal and hemodialysis;
• the recognition and management of disorders in other organ systems which are associated with disturbed renal function;
• management of fluid, electrolyte and acid-base disorders including those seen in obstetrical, urological and other surgical patients;
• management of all forms of hypertension.

In addition to assuming appropriate and progressive responsibility for the care of patients, residents should take an active part in providing a consultative service.

Pediatric Nephrology

An elective experience in pediatric nephrology should be available for adult nephrology residents.

3. Clinical Services Specific to Adult Nephrology

The equivalent of at least one year must be spent in clinical work, during which the resident has supervised responsibility for the care of patients with renal disease and experience in the laboratory procedures required to manage these patients.

a.       In-Patient

Clinical training must be based on adequate resources to ensure full training in all areas of adult nephrology. The service must be organized into one or more clinical teaching experiences, each with an adequate number of patients available for teaching and administered by a chief-of-service to whom the senior resident is directly responsible.

b.      Ambulatory

In-patient and out-patient teaching services should be integrated so far as possible, in order to provide continuity of observation of patients both in and out of hospital. Organized clinics or other ambulatory care facilities must be available to provide opportunities for pre-admission investigation and post-discharge follow-up of patients with renal disease. Special clinics, such as might be associated with a home dialysis program, provide an important part of the training.

c.       Consultation

Adequate and well-supervised consultant experience must be available.

d.      Renal Transplantation Facilities

Renal transplantation facilities must be available for the training of residents. If transplantation procedures are not conducted in the teaching hospitals of the parent university, specific arrangements must be made for all residents to obtain experience in the medical aspects of renal transplantation in an accredited residency program in another centre.

e.       Pathology

Facilities must provide training in the interpretation of biopsies, as well as the immunology, biochemistry and microbiology related to renal disease.

f.        Intensive Care Units

Intensive care units organized for teaching are required to provide experience in the collaborative care of severely ill and injured patients presenting with renal disorders.

g.       Emergency Department

There must be systematic supervision of residents to ensure expertise in the initial management of all types of emergencies involving renal disorders. Experience in providing a consultative service is an important feature of such training.

4. Supporting Services — Clinical, Diagnostic, Technical

 .        Liaison with Other Specialties and Subspecialties

There must be liaison with the following clinical teaching services:

1. A department of pathology with provision for the study of renal material.
2. A department of radiology equipped for the performance of specialized techniques applicable to the investigation of renal disease.
3. An active general surgery service providing opportunities for collaborative investigation and management of patients with renal complications encountered in general surgical practice including trauma.
4. An active urology service providing opportunities for collaborative investigation and management of patients with surgical diseases of the urinary system.

a.       Other

The following special facilities and services must be available for the training of residents and closely coordinated with the overall program:

1. Adequate clinical laboratory facilities and personnel under competent medical supervision.
2. Facilities for chronic dialysis of patients with end-stage renal failure.
3. Other diagnostic services, including specialized staff and facilities, in the following areas: radioisotopic diagnosis, scanning, and ultrasonography; microbiology in relation to renal disease; immunology in relation to renal disorders and transplantation.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

Organized Scholarly Activities

The program must provide organized teaching in the basic sciences related to adult nephrology, including the physiology, pathophysiology and pathology of the kidney, renal pharmacology and toxicology; the principles of immunology involved in the mechanisms of renal disease and renal transplantation; and the physiology of dialysis.

The program must include organized scholarly activities such as rounds, journal clubs, research conferences, and seminars, which may be interdisciplinary in nature.

Research Opportunities for Residents

Laboratories for research rotations should meet the following requirements:

1. the director of the laboratory should be a scientist with university rank;
2. the research program of the laboratory and the role of the resident in this program should be clearly defined;
3. there should be adequate space, equipment, technical assistance, and where indicated, animal facilities.

PAEDIATRICS NEPHROLOGY:

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in pediatric nephrology must be consistent with the specialty training requirements.

Residents must be provided with increasing individual responsibility, under appropriate supervision, according to their level of training, ability and experience.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in nephrology.

In those cases where a university has sufficient resources to provide most of the training in pediatric nephrology but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

Learning environments must include experiences that facilitate the acquisition of knowledge, skills and attitudes relating to aspects of age, gender, culture, and ethnicity appropriate to pediatric nephrology.

1. Teaching Faculty

There must be at least two qualified teaching staff to supervise the residents and provide teaching in the basic and clinical sciences related to renal diseases. The teaching staff should have an appropriate nucleus of full-time teachers.

2. Number and Variety of Patients

There should be adequate numbers of patients available for teaching to provide experience in the following areas of nephrology:

• general aspects of primary renal diseases;
• renal diseases associated with systemic disorders;
• renal biopsy and its interpretation;
• the management of acute and chronic renal failure, including the necessary skills required to manage peritoneal and hemodialysis;
• the recognition and management of disorders in other organ systems which are associated with disturbed renal function;
• management of fluid, electrolyte and acid-base disorders including those seen in neonates, urological and other surgical patients;
• management of all forms of hypertension.

In addition to assuming appropriate and progressive responsibility for the care of patients, residents should take an active part in providing a consultative service.

3. Clinical Services Specific to Pediatric Nephrology

The equivalent of at least one year must be spent in clinical work, during which the resident has supervised responsibility for the care of patients with renal disease and experience in the laboratory procedures required to manage these patients.

a.       In-Patient

Clinical training must be based on adequate resources to ensure full training in all areas of pediatric nephrology. The service must be organized into one or more clinical teaching services, each with an adequate number of patients available for teaching and administered by a chief-of-service to whom the senior resident is directly responsible.

b.      Ambulatory

In-patient and out-patient teaching services should be integrated so far as possible, in order to provide continuity of observation of patients both in and out of hospital. Organized clinics or other ambulatory care facilities must be available to provide opportunities for pre-admission investigation and post-discharge follow-up of patients with renal disease.

c.       Consultation

Adequate and well-supervised consultant experience must be available.

d.      Renal Transplantation Facilities

Renal transplantation facilities in children must be available for the training of residents. If transplantation procedures are not conducted in the teaching hospitals of the parent university, specific arrangements must be made for all residents to obtain experience in the medical aspects of renal transplantation in an accredited residency program in another centre.

e.       Pathology

Facilities must provide training in the interpretation of biopsies, as well as the immunology and microbiology related to renal disease.

f.        Intensive Care Units

Intensive care units organized for teaching are required to provide experience in the collaborative care of severely ill and injured patients presenting with renal disorders.

g.       Emergency Departments

There must be systematic supervision of residents to ensure expertise in the initial management of all types of emergencies involving renal disorders. Experience in providing a consultative service is an important feature of such training.

4. Supporting Services — Clinical, Diagnostic, Technical

 .        Liaison with Other Specialties and Subspecialties

There must be liaison with the following clinical teaching services:

1. A department of pathology with provision for the study of renal material.
2. A department of radiology equipped for the performance of specialized techniques applicable to the investigation of renal disease.
3. An active pediatric general surgery service providing opportunities for collaborative investigation and management of patients with renal complications encountered in general surgical practice including trauma.
4. An active urology service providing opportunities for collaborative investigation and management of patients with surgical diseases of the urinary system.

a.       Other

The following special facilities and services must be available for the training of residents and closely coordinated with the overall program:

1. Adequate clinical laboratory facilities and personnel under competent medical supervision.
2. Facilities for chronic dialysis of patients with end-stage renal failure.
3. Other diagnostic services, including specialized staff and facilities, in the following areas: radioisotopic diagnosis, scanning, and ultrasonography; microbiology in relation to renal disease; immunology in relation to renal disorders and transplantation.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

Organized Scholarly Activities

The program must provide organized teaching in the basic sciences related to pediatric nephrology, including the physiology, pathophysiology and pathology of the kidney, embryology, genetics, renal pharmacology and toxicology; the principles of immunology involved in the mechanisms of renal disease and renal transplantation; and the physiology of dialysis.

The program must include organized scholarly activities such as rounds, journal clubs, research conferences, and seminars, which may be interdisciplinary in nature.

Research Opportunities for Residents

Laboratories for research rotations should meet the following requirements:

• the director of the laboratory should be a scientist with university rank;
• the research program of the laboratory and the role of the resident in this program should be clearly defined;
• there should be adequate space, equipment, technical assistance, and where indicated, animal facilities.

SPECIALTY REQUIREMENTS:

1. Certification in internal medicine or pediatrics .

2. Approved residency in nephrology.Approved residency in adult or pediatric Nephrology

PROGRAMS (WITH TRAINING REQUIREMENTS):

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.