Renal Hybrid Description

This rotation will take place in various outpatient clinics at all 3 sites as well as on the nephrology inpatient consult services. Residents will interact with both fellows and attendings. Making use of these settings has afforded us the opportunity to expose house staff to diverse patient populations, pathologies, diagnostic and interventional modalities, and practice settings.

This rotation is a one to four (4) week structured clinical experience under direct supervision designed for Internal Medicine residents in order accomplish the following goals:

• Enhance the general fund of knowledge of nephrology, acid/base/fluids and electrolytes:
  • Residents will participate in attending rounds and small group lectures/discussions, attend the Nephrology Grand Round lecture series given at noon on Tuesdays, Thursdays, Fridays.
• Provide education in major clinical aspects of nephrology
  • The rotation will provide both an inpatient component and an ambulatory component. All aspects of nephrology will be covered including but not limited to CKD, inpatient and chronic outpatient hemodialysis, peritoneal dialysis, ICU nephrology, AKI, glomerulonephritis, nephrolithiasis, electrolyte disturbances, and renal transplantation. One 4-week block can provide the resident with a well-rounded nephrology experience during their residency. The rotation can be repeated for residents who want an enhanced nephrology exposure.
• Increase interest in nephrology as a potential subspecialty for residents.
  • It is hoped that this exposure to the breadth of nephrology will offer undifferentiated residents an overview of the discipline to inform their consideration of nephrology as a career.

Goals and Objectives for Renal Hybrid Inpatient Consults

Develop an understanding of renal disorders seen in the hospital

PGY-1: Understand the basic principles of assessing and managing common presentations of renal disease and fluid and electrolyte disorders in hospitalized patients

PGY-2: Learn how to manage complex presentations of renal disease in hospitalized patients with renal disorders

PGY-3: Develop advanced processes to recognize and treat complications in hospitalized patients with renal disorders (including transplant) and multiple medical problems

Competency: Patient care, Medical knowledge

Developing diagnosis skills

PGY-1: Learn how to effectively use bedside clinical examination in patients with common renal disorders

PGY-2: Demonstrate subtle bedside clinical findings of renal disorders

PGY-3: Learn how to correlate bedside clinical findings with imaging and other data in patients with renal disorders

Competency: Patient care, Medical knowledge

Understand the differential diagnosis of common renal disorders

PGY-1: Develop a basic differential diagnosis for common clinical scenarios in patients with kidney disease, fluid and electrolyte disorders

PGY-2: Develop an expanded differential diagnosis for common clinical scenarios in patients with kidney disease, fluid and electrolyte disorders

PGY-3: Recognize unusual presentations of common clinical situations in patients with kidney disease, fluid and electrolyte disorders

Competency: Medical knowledge

Learn pharmacological management of common renal disorders

PGY-1: Learn the common medications utilized for the management of renal disorders and fluid and electrolyte disorders

PGY-2: Understand how to manage complicated clinical problems and develop specific therapeutic strategies in patients with renal disorders and fluid/electrolyte disorders

PGY-3: Understand interactions between patient nephrology, fluid, and electrolyte problems and develop advanced strategies to prioritize management

Competency: Patient care

Effectively execute day-to-day management of patients

PGY-1: Learn to manage nephrology patients on a daily basis including a daily assessment and determining progress in clinical problems

PGY-2: Understand how to adjust nephrology patient treatment plans based on patient progress and determine the need for additional assistance such as subspecialty consultation

PGY-3: Recognize how to manage complex nephrology problems and manage both expected and unexpected complications.

Competency: Patient care

Interdisciplinary care and discharge planning

PGY-1: Learn how to communicate effectively with the interdisciplinary care team and anticipate patient needs for discharge and effective follow-up

PGY-2: Recognize the unique needs of nephrology patients and help integrate patient needs with available resources

PGY-3: Learn how to manage advanced situations such as end-of-life decisions, complex transitions of care and advocate for patients when resources are limited

Competency: Patient care, System-based practice

Rational ordering of lab tests and imaging studies

PGY-1: Learn the indications for basic laboratory investigations and imaging in patients with renal disorders

PGY-2: Learn how to interpret laboratory findings and imaging seen in patients with renal disease

PGY-3: Gain advanced knowledge of high value principles in the ordering of laboratory studies and imaging for evaluation of renal disease

Competency: Practice-based learning and improvement, Medical knowledge

Familiarity with the electronic health record and optimization of its use

PGY-1: Develop a basic understanding of The EHR and its core components and how it can be used to care for patients with renal disease

PGY-2: Understand and teach others on how to effectively use the electronic health record in the care of patients with renal disease and renal transplants

PGY-3: Develop an understanding of advanced medical informatics in the care of patients with renal disorders and renal transplant by utilizing additional resources in the EHR

Competency: Systems-based practice

Communication and teamwork

PGY-1: Recognize the core members of the patient care team involved in care of patients with renal disease, to include nurses, patient technicians, physical therapists, occupational therapists, discharge planners and hospital administration personnel

PGY-2: Develop effective and timely communication strategies with the interdisciplinary care team for patients with renal disease

PGY-3: Use advanced communication methods to engage and coordinate care with the interdisciplinary care team for patients with renal disease

Competency: Professionalism, Interpersonal and communication skills

Nephrology EMR Resources

Please review the following video prior to starting inpatient nephrology hybrid rotation to assistance with Epic Environment and Pre-Charting: 

Inpatient Epic Environment Set-Up and Pre-Charting Tips

The following video contains tips on who to set up Epic in the outpatient environment for success in renal clinic at Parkland and CUH: 

1. Outpatient Epic Environment Setup
2. Outpatient Epic Encounter Navigation

Primary Literature in Nephrology

1. Hypertension in Chronic Kidney Disease
   1. Klahr S, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. NEJM. 1994; 330: 877-84.
   2. The GISEN Group (Gruppo Italiano di Studi Epidemiologici in Nefrologia). Randomised placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of terminal renal failure in proteinuric, non-diabetic nephropathy (REIN). Lancet. 1997; 349: 1857-63.
   3. Wright JT, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002; 288: 2421-31.
   4. Ruggenenti P, et al. Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. Lancet. 2005; 365: 939-46.
   5. Hou FF, et al. Efficacy and safety of benazepril for advanced chronic renal insufficiency. NEJM. 2006; 354: 131-40.
2. Renal Osteodystrophy
   1. Suki, et al. Effects of sevelamer and calcium-based phosphate binders on mortality in hemodialysis patients (DCOR). KI. 2007; 72: 1130-7.
3. Anemia in Chronic Kidney Disease
   1. Besarab A, et al. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin (US Normal Hematocrit Study). NEJM. 1998; 339: 584-90.
   2. Singh AK, et al. Correction of anemia with epoetin alfa in chronic kidney disease (CHOIR). NEJM. 2006; 355: 2085-98.
   3. Pfeffer MA, et al. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease (TREAT). NEJM. 2009; 361: 2019-32.
4. Management of Dyslipidemia in Chronic Kidney Disease
   1. Waner C, et al. Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis (4D Study). NEJM. 2005; 353: 238-48.
   2. Fellstrom BC, et al. Rosuvastatin and cardiovascular events in patients undergoing hemodialysis (AURORA). NEJM. 2009; 360: 1395-407.
   3. Biagent, C, et al. The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial. Lancet. 2011; 2181-92.
5. Hemodialysis and Hemodialysis Access
   1. Eknoyan G, et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis (HEMO). NEJM. 2002; 347: 2010-19.
6. Peritoneal Dialysis and Peritonitis
   1. Paniagua R, et al. Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial. JASN. 2002; 13: 1307-20.
7. Acute Renal Failure and Critical Care Nephrology
   1. Vinsonneau C, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet. 2006; 368: 379-85.
   2. Parienti JJ, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA. 2008; 299: 2413-22.
8. Diabetic Nephropathy
   1. Lewis EJ, et al. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. NEJM. 1993; 329: 1456-62.
   2. Estacio RO, et al. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes (ABCD). Diabetes Care. 2000; 23: B54-64.
   3. Lewis EJ, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes (IDNT). NEJM. 2001; 345: 851-60.
   4. Brenner BM, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy (RENAAL). NEJM. 2001; 345: 861-9.
9. Lupus Nephritis
   1. Appel, et al. Mycophenolate versus cyclophosphamide for induction treatment of lupus nephritis (ALMS). JASN. 2009; 20: 1103-12.
   2. Dooley, MA, et al. Mycophenolate versus Azathioprine as Maintenance Therapy for Lupus Nephritis. NEJM. 2011; 365:1886-95.
10. IgA Nephropathy
    1. Pozzi, et al. Corticosteroids in IgA nephropathy: a randomized controlled trial. Lancett. 1999; 353: 883-7.
11. Minimal Change/FSGS
    1. Cattran DC, et al. A randomized trial of cyclosporine in patients with steroid-resistant focal segmental glomerulosclerosis. North America Nephrotic Syndrome Study Group. KI. 1999; 56: 220-6.
12. Membranous
    1. Ponticelli C, et al. A 10-year follow-up of a randomized study with methylprednisolone and chlorambucil in membranous nephropathy. KI. 1995; 48: 1600-4.
13. ANCA Vasculitis and Anti-GBM
    1. Jayne, et al. A randomized trial of maintenance therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies (CYAZAREM). NEJM. 2003; 349: 36-44.
    2. Jayne, et al. Randomized trial of plasma exchange or high-dosage methylprednisolone as adjunctive therapy for severe renal vasculitis (MEPEX). JASN. 2007; 18: 2180-8.
14. Other Glomerular Diseases
    1. Myeloma Kidney
       1. Clark WF, et al. Plasma exchange when myeloma presents as acute renal failure: a randomized, controlled trial. Ann Intern Med. 2005; 143: 777-84.
    2. TTP
       1. Rock GA, et al. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic pupura. Canadian Apheresis Study Group. NEJM. 1991; 325: 393-7.
15. Transplantation
    1. European Multicentre Trial Group. Cyclosporin in cadaveric renal transplantation: one-year follow-up of a multicentre trial. Lancet 1983. 2: 986-9.
    2. Ekberg H, et al. Reduced exposure to calcineurin inhibitors in renal transplantation (ELITE-SYMPHONY Study). NEJM. 2007; 357: 2562-75.

Evaluations

Evaluations of the resident will be completed by the Nephrology attending at the completion of the rotation.