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Nephrology curriculum standards

Knowledge guide

Knowledge guide 3: Chronic kidney disease (CKD)

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 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
  • Antenatal diagnosis
  • Decreased urine output
  • Growth failure
  • Haematuria
  • Hypertension
  • Incontinence
  • KDIGO – GFR stages G1–G5
  • Nephritic syndrome
  • Nephrotic syndrome
  • Oedema
  • Polyuria
  • Uraemia
Conditions
  • CKD sequalae with complications:
    • acidosis
    • anaemia
    • β2‐microglobulin amyloidosis
    • cardiovascular disease
    • CKD mineral bone disorder (MBD) including:
      • calcium/phosphate/PTH and vitamin D control
    • electrolyte disturbances, including hyperkalaemia and hypocalcaemia
    • hypertension
    • increased risk of infections
    • infectious complications iron stores, erythropoietin, preparation for transplant
    • physiology, and use of, hypoxia inhibitor stabilisers and hepcidin
  • Diabetic kidney disease
  • Environmental chronic kidney disease of unknown aetiology (CKDu)
  • Glomerulonephritis
  • Hyperuricaemia and gout
  • Nephropathy:
    • hypertensive
    • obstructive
    • vascular/renovascular

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 patients 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
  • Extraosseous and vascular calcification:
    • calciphylaxis
    • medial vessel calcification
    • other extraosseous and vascular calcification, including visceral organs
  • Inherited and genetic kidney disease (see KG8)
  • Kidney failure protein energy wasting
  • Kidney hypertension
  • Kidney manifestations of systemic and chronic disease, hepato-renal, and cardio-renal
  • Metabolic acidosis
  • Mineral and bone disorder:
    • kidney osteodystrophy (and related pathophysiology):
      • adynamic bone disease
      • mixed uremic osteodystrophy
      • osteitis fibrosis
      • osteomalacia
      • other kidney osteodystrophy, including low bone mass (osteoporosis)
  • Renal artery stenosis complications

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 patients 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
  • Allergic/interstitial kidney disease
  • Bone–kidney axis and its physiology, including:
    • fetuin
    • fibroblast growth factor 23 (FGF23)
    • klotho
    • parathyroid hormone (PTH)
  • Calcium and phosphate and vitamin D balance
  • Chronic kidney disease of unknown aetiology (CKDu), including Balkan nephropathy
  • Classification and description of CKD – KDIGO stages G1–G5
  • Kidney endocrine functions:
    • erythropoietin (EPO)
    • vasopressin
    • vitamin D3
  • Measurement of kidney function and estimation of glomerular filtration rate (eGFR) using creatinine clearance
  • Nephrotoxins including drugs, contrast, and envenomation
  • Pathophysiology of diabetic nephropathy, its predisposing factors, and available screening methods
  • Pathophysiology of kidney anaemia, and the haematological and biochemical methods to diagnose, assess, and monitor treatment for kidney anaemia
  • Pathophysiology of kidney mineral and bone disease (MBD) including:
    • adynamic mineral and bone disease
    • hyper parathyroid-associated mineral and bone disease
    • osteomalacia
  • Physiology of electrolyte and acid base disturbances
  • Progression and progressive disease predictors (senescence versus disease and predicting progression)
  • The common nephrotoxins causing:
    • AKI – drugs, contrast
    • CKD – environmental, drugs, herbs, e.g. Balkan nephropathy
Imaging
  • CT scan and MRI
  • Kidney angiogram
  • Kidney tract ultrasound
  • Nuclear medicine testing
  • Pyelography
Laboratory studies
  • 24-hour urine electrolyte collection
  • Arterial blood gases (ABGs)
  • Bone studies
  • Creatinine clearance
  • Electrolytes
  • Full blood count (FBC)
  • Glomerular filtration rate (eGFR)
  • Haematuria (urine microscopy and phase contrast microscopy)
  • Kidney function
  • Other labs appropriate to underlying disease – nephrotic state TFTs, lipids
  • Proteinuria
  • PTH
  • Urinalysis
  • Urine microscopy and dipstick analysis
  • Vitamins D and A
Procedures
  • Renal artery angioplasty and stenting
  • Kidney biopsy
  • CARI guidelines identifying the components relevant to patients and their family and/or carers in supporting non-dialysis patients:
    • continuity of care
    • multidisciplinary management with allied health staff, particularly social work and dietetics
    • symptom control
  • Pregnancy in patients with CKD: » perinatal and postnatal support
    • pregnancy outcomes
    • risk and incidence of AKI
  • Post significant AKI screening
  • Prevalence and aetiology of kidney disease in Aboriginal and Torres Strait Islander and Māori peoples
  • Strategies to improve diagnosis and prognosis by opportunistic and at-risk screening and early intervention
  • Impacts and considerations for patients with CKD
    • Common pathological, pharmacological, and sexual health impacts
    • Dermatological complications, such as pruritis
    • Factors that affect progression of kidney failure
    • Fatigue, xerostomia, depression, constipation, insomnia, nausea, vomiting, dyspnoea, and pain
    • Management of patients with CKD in palliative care
    • Nephrotoxicity of environmental and occupational agents, including lead, organic solvents, cadmium, and mercury
    • Nutritional issues facing kidney patients and special dietary regimes prescribed, such as low protein diet in CKD
    • Referral for vascular access where appropriate
    • Transplant preparation
    • Vein preservation
  • Pharmacology and treatment
    • Anti-hypertensive agents
    • Cardiovascular risk factor management
    • Causes of resistance to erythropoietic stimulating agent (ESA) therapy and its investigation
    • CKD mineral and bone disorder (MBD) pharmacology management, including:
      • calcimimetic drugs
      • parathyroidectomy to manage the condition
      • phosphate binders
      • vitamin D preparation
    • Continued immunosuppression therapy for proliferative glomerulonephritis and vasculitis immunosuppressive agents and regimes
    • Diabetic management
    • Drug interactions
    • ESAs and their complications
    • Ethical considerations for treatment equity in different populations
    • Hypertensive medications
    • Immunosuppressive agents
    • Kidney disease and anaemia – erythropoietin and Fe, including hypoxia-inducible factor (HIF) stabilisers and hepcidin
    • Oral and parenteral iron therapy and its complications
    • Patient response to treatment for kidney mineral and bone disease
    • Pharmacology of major drug classes used to treat kidney disease
    • Proteinuria reducing drugs
    • The interrelationship between drug dosing to GFR and age using Cockcroft–Gault equation (CG) or eGFR equation to identify the toxicity of certain agents in CKD
    • Therapeutic drug level monitoring

    • PCH

    • Growth, and the role of nutrition and growth hormone in paediatrics
    • Outcomes of kidney failure in infants and children diagnosed at an early age
    • The principles of bioethics and ethics support available
    • Transition of kidney patients to adult care