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Nephrology curriculum standards

Knowledge guide

LG 17: Acute kidney injury (AKI)

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Advanced Trainees will understand these presentations and conditions.

Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will describe the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the indications for – and how to interpret the results of – these investigations, procedures, and clinical assessments tools.

Advanced Trainees will know how to explain the investigation, procedure, or clinical assessment tool to patients, families, and/or carers.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management.

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Presentations
  • Acidosis
  • Haematuria
  • Hypertension
  • Hypertensive emergency
  • Fluid overload
  • Oligo-anuria
  • Oliguria
  • Proteinuria
  • Sodium, potassium, and calcium disturbances
  • Uraemia
Conditions
  • Nephrotoxins
  • Outflow obstruction
  • Sepsis
  • Reduced perfusion

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a relevant clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations consider the impact of illness and disease on patients19 and their quality of life
Manage
  • provide evidence-based management
    For less common or more complex presentations and conditions the trainee must also seek expert opinions
  • prescribe therapies tailored to patients’ needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
Conditions
  • Abdominal compartment syndromes
  • Atypical haemolytic uraemic syndrome/thrombotic microangiopathy (TMA)
  • Cardio-renal syndromes Congenital anomalies of kidney and urinary tract (CAKUT)
  • Delayed graft function post-kidney transplant
  • Endemic nephropathy
  • Haematology disorders, including monoclonal gammopathy of renal significance (MGRS) (AIM only)
  • Hepato-renal syndrome
  • Infections of the urinary tract and kidney
  • Renal artery dissection:
    • toxicological indications for dialysis drug metabolism, pharmacokinetics in patients with reduced kidney function
  • Renal-vascular disease:
    • renal artery stenosis
  • Rhabdomyolysis and myoglobinuric AKI
  • Tumour lysis syndrome

AIM

  • Myeloma and the kidney

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a relevant clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations consider the impact of illness and disease on patients19 and their quality of life
Manage
  • provide evidence-based management
    For less common or more complex presentations and conditions the trainee must also seek expert opinions
  • prescribe therapies tailored to patients’ needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
  • Pathophysiology of acute tubular injury
    • Hypoxia
    • Inflammatory response
    • Linkages between physiology and pathophysiology
    • Normal physiology – AKI, tubular abnormalities, metabolic acidosis, drug induced acidosis, sodium
    • Tubular factors:
      • proximal tubular injury including apoptosis and necrosis
      • sub-lethal proximal tubular injury
    • Vascular factors:
      • thrombosis
Investigations
  • ADAMTS-13
  • Clinical diagnosis versus biochemical versus biomarkers
  • Contemporary biomarkers (blood and urine) of AKI
  • Current biomarkers for research
  • Full blood count (FBC)
  • Immunology testing, including:
    • antineutrophil cytoplasmic antibodies (ANCA)
    • anti-glomerular basement membrane (anti GBM)
    • antinuclear antibodies (ANA)
    • Anti-DNase B
    • creatine kinase (CK)
    • complement component 3 (C3)
    • complement component 4 (C4)
    • cryoglobulins
    • double stranded NDA (dsDNA)
    • extractable nuclear antigen (ENA)
    • serum electrophoresis (light and heavy) chain
  • KDIGO stages G1–G5
  • Kidney histopathology
  • MRI
  • Nuclear medicine scans
  • Peripheral blood (PB) film (aHUS/TMA)
  • Arterio-venous fistulas of the kidney post biopsy
  • Stool for ST-producing E. coli (STEC)
  • Ultrasound or CT of kidneys, ureters, and bladder (KUB)
  • Urine microscopy
  • Urine albuminuria/proteinuria
  • Urine electrolytes (stone work-up)
Procedures
  • Kidney biopsy
  • AKI following endovascular procedures
  • Haptoglobin and lactate dehydrogenase (LDH) to full blood count for haemolytic uremic syndrome (HUS)
  • Difficult management issues
    • Acidaemia
    • Appropriate fluid prescription
    • Disequilibrium
    • Electrolyte and acid base disturbances
    • High AKI risk groups in the emergency department, including:
      • cardiac arrest
      • CKD
      • heart failure
      • hyponatraemia
      • increased creatinine
      • liver disease
      • myocardial infarction
      • post-trauma
      • sepsis
      • shock
      • toxic ingestions
    • Hyperkalaemia
    • Malignant hypertension or emergent hypertension
    • Uraemia
    • Vascular access complications:
      • bleeding
      • central line-associated bloodstream infections (CLABSI)
      • pneumothorax
  • Nephrotoxicity of medications/drugs and therapies
    • Antibiotics
    • Anti-fungal agents
    • Anti-inflammatories
    • Iodinated contrast (intra-arterial)
    • Nephrotoxic agents, such as:
      • checkpoint inhibitors
      • cisplatin
      • proto-inhibitors
    • Some herbal supplements and natural therapies
    • Toxic alcohols – ethylene glycol, methanol
    • Vascular endothelial growth factor inhibitors
  • Pregnancy
    • Causes of AKI in pregnancy
    • Comorbid medical conditions in patients with pre-existing kidney disease, dialysis, or a kidney transplant during pregnancy, with particular emphasis on risk minimisation
    • Hypertension
    • Nephrotic syndrome in pregnancy
    • Pre-eclampsia and eclampsia
  • Prescribing, therapy, and pharmacology
    • Choice of kidney replacement therapy modality, intensity of solute and volume removal, anticoagulation
    • Choice of vascular access
    • Dialysis and drug metabolism
    • Plasmapheresis or plasma exchange
    • Timing of initiating acute kidney replacement therapy
    • Urgent indications for acute kidney replacement therapy
  • Prevention
    • Primary prevention in high-risk patients (e.g. cardiac surgery)
    • Secondary prevention in patients at risk of recurrent AKI

PCH

  • Choice of modality for acute kidney replacement therapy
  • Definitions and staging of AKI in children and neonates
  • Fluid status evaluation
  • Diarrhoea-associated (D+) haemolytic uremic syndrome and diarrhoea negative (D-) or atypical HUS, and use of biologics
  • Prevention and management of AKI in neonates