Nephrology curriculum standards: Knowledge guide 1: Clinical sciences

Knowledge guide

Knowledge guide 1: Clinical sciences

Epidemiology, Pathophysiology, and Clinical sciences

Advanced Trainees will describe the principles of the foundational sciences.

For the statistical and epidemiological concepts listed, trainees should be able to describe the underlying rationale, the indications for using one test or method over another, and the calculations required to generate descriptive statistics.

View

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.

View

Important specific issues

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

View

Clinical sciences
- Acid–base regulation and its link to the respiratory system Community presentations, including incidental diagnosis of structural kidney disease
- Embryology of kidney and urogenital development
- Kidney autoregulation and how it changes with acute kidney injury (AKI)
- Normal physiology and homeostasis and pathophysiology of electrolytes
  - sodium, potassium, calcium, magnesium, chloride, and phosphate balances, and water balance
- Normal urine composition
- Physiology of calcium, phosphate, bone, and mineral metabolism Physiology of tubular disorders Physiology of water, electrolyte, and acid–base abnormalities
- Process of fluid and electrolyte regulation
- Process of hormonal regulation:
  - aldosterone and its link to the endocrine system
  - antidiuretic hormone (ADH)
  - renin-angiotensin system (RAS)
- Structure and function of the kidney system and prostate
- The role of the kidney in regulation of erythropoiesis and causes of anaemia in people with kidney disease

PCH

Anatomy, development, and physiology

Factors that contribute to impaired growth in children with kidney disorders and chronic kidney disease (CKD)
Neurodevelopmental outcomes in children with kidney disease
Normal blood pressure in children
Physiology of the developing nephron
Physiology of the developing nephron, including tubular and glomerular maturation with age, including changes in:
- homeostasis, fluid and electrolyte requirements
- glomerular filtration rate (GFR)
- urine protein excretion

The development and anatomy of the urinary tract

Embryological, histological, clinical, and radiological features of kidney dysplasia and developmental abnormalities of the kidney
Epidemiology and microbiology of urinary tract infections (UTIs) and the role of host defence mechanisms
Genital abnormalities and their association with kidney disease
Physiology of normal micturition and acquisition of bladder control, along with potential barriers to this
Syndromes associated with kidney disease
The pathophysiology of the neuropathic bladder

Clinical study design
- Clinical trials
- Consumer engagement
- Evidence based medicine (EBM) in nephrology
- Good Clinical Practice (GCP)
- Implementability and implementation
- Pragmatic versus explanatory
- Systematic reviews
- Trial registration
- Trials networks and guideline groups
Determinants of health
- Prevalence of kidney disease in Indigenous populations
- Socioeconomic determinants of health
Health economics
- Resource allocation for the provision of dialysis and needs that are important to patients, such as transportation
- Resource allocation for transplantation
Measures of treatment efficacy and interpretation of study results
- Clinical outcomes
- Core outcomes
- Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment
- Patient reported experience measures (PREMs)
- Patient-reported outcome measures (PROMS) in studies, including Standardised Outcomes in Nephrology (SONG) initiative
- Surrogate outcomes
Pharmacology
- Immunological kidney injury from drugs – different types of AKI
- Influence of drugs on eGFR [angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARBS), sodium-glucose transport protein 2 (SGLT2)]
- Modification of drug dose according to eGFR
- Nephrotoxicity
Pharmacokinetics
- Altered drug-protein binding and metabolism in kidney disease, such as insulin
Pharmacodynamics
- Altered volume of distribution in patient with kidney disease, such as nephrotic syndrome and other low albumin states
Population statistics
- Complications
- Cost to community of kidney failure, including treatment with dialysis, transplantation, or conservative kidney management, and non-dialysis CKD
- Epidemiology – incidence, prevalence Quality of life

Formulae used to estimate GFR, and their limitations
Kinetic eGFR calculation for situations in which eGFR is unreliable (non-steady state)
Measurement techniques, including:
- cystatin C
- diethylene triamine pentaacetic acid (DTPA)
- dimercaptosuccinic acid scan (DMSA)
- ethylenediaminetetraacetic acid (EDTA)
- mercapto acetyl tri glycine scan (MAG-3)
Normal appearance and common features of the kidney
Pathological features of kidneys shown by imaging modalities
Single photon emission computed tomography (SPECT) and PET scans for vasculitis
Tests to measure electrolytes, such as:
- blood tests – serum creatinine, eGFR, blood urea nitrogen (BUN)
- imaging – CT scan, MRI, including strengths and shortcomings of imaging modalities
- urine tests – urinalysis, urine protein, microalbuminuria, albuminto-creatinine ratio (ACR), creatinine clearance
The implications of interpreting glomerular filtration rate
The limitations of eGFR

PCH

Paediatric-specific kidney function tests

Developmental abnormalities on antenatal imaging and provide counselling as needed
Imaging modalities used in adults, plus:
- dimercaptosuccinic acid scan
- MAG-3 and pyelograms for assessment of obstruction
- micturating cystourethrogram

Laboratory tests
- Biomarkers of acute and chronic kidney injury
- Blood analyses including acid–base, electrolytes, and hormone measurements
- eGFR and its limitations
- Microurine interpretation – bacteria, cells, casts, other biomarkers
- Patterns of abnormalities in the above tests, including glomerulonephritis, tubulointerstitial disease, and kidney failure
- Traditional and non-traditional CVS risk markers
- Urine dipstick test – its characteristics in normal and pathophysiological states, such as solutes, protein, and bacteria, including patient factors that may impact (age and gender)

PCH

Paediatric-specific laboratory tests

eGFR in children
Urine collections methods and their application in the setting of UTIs

Evidence-based clinical practice
- Consistency
- Continuous quality improvement
- Critical appraisal
- Directness
- Evaluating certainty of evidence
- GRADE assessment
- Other bias, such as publication, commercial bias
- Precision
- Risk of bias
- Understanding enablers of, and barriers to, implementation

Health needs of specific patient groups
- CKD in patients with diabetes
- Indigenous populations

Management considerations
- Acquired and genetic podocyte and tubular disorders that lead to acid–base disorders
- Antenatal and postnatal assessment of kidney morphology and function, including physiological changes that occur during childhood
- Changes in acid–base metabolism and volume homeostasis in pregnancy
- Changes in the anatomy and function of the kidneys in normal pregnancy Postnatal changes in kidney tubular function and GFR

Prescribing
- Aminoglycosides
- Drugs that should be withheld in AKI or in sick day plans (SADMANS acronym)
- Effects of commonly prescribed kidney drugs on nephron function, such as diuretics, sodium-glucose cotransporter-2 (SGLT2) inhibitors, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor antagonists
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Trimethoprim
Considerations for prescribing:
- » adjustment of drug dosage in prescribing therapies
- » mechanisms of action and side effect profiles of immunosuppressive agents (calcineurin inhibitors [CNI], mechanistic target of rapamycin [mTOR], cyclophosphamide, steroids, biologic agents), commonly used agents associated with kidney injury