Nephrology curriculum standards

Haemodialysis (HD)

• Blood filtration
• Dialysis system including water treatment, membranes, dialysate fluids, dialysis safety monitors
• Diffusion versus convection
• General principles of haemodialysis (high flux, low flux), haemofiltration, and haemodiafilitration (pre-, mixed- and post-dilution)
• Osmotic versus hydrostatic pressures
• Solute removal – small, middle, and large
• The theory of sodium profiling and ultrafiltration
• Water removal (ultrafiltration)

Peritoneal dialysis (PD)

• Peritoneal membrane anatomy
• Peritoneal membrane solute and fluid transport, including principles of diffusion and convention:
  • fluid kinetics
  • kinetics of peritoneal ultrafiltration
  • large versus small molecule clearance
  • peritoneal surface
  • solute transport by convection
  • solute transport by diffusion
  • three pore model
• Physiology of peritoneal dialysis fluids:
  • biocompatibility issues – neutral pH, low glucose degradation product solutions
  • concentrations of electrolytes – sodium, potassium, magnesium, calcium, and buffers (lactate and bicarbonate)
  • principles of using the osmotic agents – glucose, amino acids, icodextrin
• Types of PD:
  • automated PD (APD), including tidal PD, continuous cycler-assisted peritoneal dialysis (CCPD), continuous flow-through peritoneal dialysis (CFPD), and intermittent peritoneal dialysis (IPD)
  • continuous ambulatory PD (CAPD)

Water

• The means to deliver purified water, the necessary standards, and methods of assessing these
• Toxic water system treatment contaminants
• Treatment (prevention) of water and dialysate problems
• Water treatment and monitoring water quality, including bacterial and endotoxin studies
• Water, dialysate composition, and extracorporeal circuit complication

• Principles of plasma exchange, prescribing considerations, and potential complications of treatment

Complications – vascular and catheter considerations

• Abscess
• Catheter-related bacteraemia (CRB)
• Common sites used for insertion of dialysis central venous catheters (CVCs)
• Fistula aneurysm
• Genesis of access stenosis
• Insertion of temporary vascular access
• Insertion of tunnelled dialysis line
• Options and potential complications of different catheter locking solution
• Preoperative vascular mapping
• Preventative strategies to ensure catheter longevity
• Surface and structural anatomy of the subclavian, jugular, and inguinal regions
• The difference between cuffed/tunnelled and non-tunnelled CVCs, and the different indications for use
• The risk of complications with the site chosen for vascular access
• The surgical methods of creating vascular access

Dialysis machine

• Cross infection control policies and procedures
• Dialyser reprocessing – procedures, issues relating to biocompatibility, infection and economics, biocompatibility issues, composition of dialysis fluid
• Dialyses – membrane types, properties of dialyses
• Different line sizes membranes, dialysers, and options for dialysis fluid composition
• Different profiling programs and online monitoring of small solute clearance and blood volume monitoring

Prescription

• Appropriate dialyser
• Blood flow rates including venous and arterial pressures
• Choice of dialyser size
• Dialysate composition and concentration (i.e., electrolytes)
• Dialysate concentration
• Dialysate flow rate
• Fluid status and ultrafiltration rates
• Haemodiafiltration versus haemodialysis
• Patient-centred goal approach, including target weight and nutritional status
• Solute clearance
• Vascular access

APD machine

• Components of setting up the machine
• PD card and characteristics
• Remote monitoring

Complications of dialysis

• Access failure
• Biochemical abnormalities including hypoalbuminemia and hypercalcaemia
• Catheter dysfunction including types, causes and management
• Catheter malpositioning
• Constipation
• Dialysate leakage through congenital (e.g. patent processus vaginalis) or acquired (e.g. pericatheter or prior incisional site) abdominal wall defects
• Hernias, abdominal wall, or genital oedema
• Long-term complications, e.g. sclerosing peritonitis
• Mechanical complications
• Metabolic abnormalities, including hyperglycaemia
• Peritonitis and peritoneal catheter site infection
• Pleuroperitoneal leak
• Ultrafiltration failure Under dialysis – symptoms burden and dialysis measures
• Understanding the principles, local policies, and prevention
• Weight gain

Prescription

• Adjust prescription to patient centred management
• CAPD/APD – prescribing the appropriate patient-centred type of PD
• Concentration of PD solutions and PD bags
• Number and volume of bags
• Patient-centred factors including surface area, education
• The relative therapeutic and lifestyle differences of all modes of peritoneal dialysis
• Tidal/full exchange
• Understanding incremental versus full dialysis dose