Docstoc

Inpatient Uremia

Document Sample
Inpatient Uremia Powered By Docstoc
					                                 Goals                                                    Instructional Format                  Evaluation              Goal Setting
                                                                                                                                                        Feedback
                                 To learn to provide accurate and effective               Two month inpatient rotations.        Monthly online and      Goals as outlined in
Inpatient consultation service



                                 consultation based on effective data collection and      Fellows assess patients in AM and     oral evaluation of      program materials
                                 construction of appropriate differential diagnoses;      gather data, adjust dialysis          the fellows by the      and modified by
                                 to learn the principals and practice of renal            schedules as needed. Rounds           attending               attending each month
                                 replacement therapy; to develop leadership and           with attending nephrologists as       nephrologists.          based on fellow
                                 management skills appropriate to running an              scheduled.                             Semi-annual            performance.
                                 inpatient dialysis services; to develop skills needed      New consultations received          evaluation of faculty
                                 for effective patient-provider and consultant-           during or after attending rounds      by fellows.
                                 provider communication in care of patients with          are seen as soon as possible; these    Evaluation of
                                 renal disease.                                           may be presented to the               experience by fellows
                                                                                          attending physician after rounds      and faculty in
                                                                                          if necessary. Acute dialysis          rotation with other
                                                                                          treatments are scheduled              experiences.
                                                                                          throughout the day as required.


                                 Goals                                                    Instructional Format                  Evaluation              Goal Setting
                                                                                                                                                        Feedback
                                 To learn the principals and practices currently used     Two month inpatient rotations.        Monthly online and      Learning objectives set
                                 in the management of renal transplantation,              Assessment of inpatients by           oral evaluation of      at onset by attending
Renal Transplantation Service




                                 including: the evaluation of prospective recipients      fellows in AM and as patients         the fellows by the      nephrologist.
                                 and donors, the choice of recipients for deceased        arrive to the hospital; rounds with   attending transplant    Feedback provided by
                                 donor kidneys, the use of induction immune               the transplant nephrologists as       nephrologists.          attending nephrologist
                                 suppression and the pharmacologic, immunologic,          scheduled. Evaluation and                                     and transplant
                                 and clinical basis of the regimen used; the peri-        presentation to attending             Semi-annual             surgeon throughout
                                 operative management of the renal transplant             surgeons in the transplant clinic;    evaluation of faculty   month.
                                 patient with emphasis on the management of peri-         attendance and participation in       by fellows. Regular
                                 operative diabetes, hypertension, and fluids; the        the monthly renal transplant          evaluation of
                                 causes of immediate graft non-function; the              patient evaluation meeting;           experience by fellows
                                 diagnosis and treatment of hyperacute, acute, and        assistance at transplant surgical     and faculty.
                                 chronic rejection; the differential diagnosis of early   procedures as permitted by
                                 transplant dysfunction; the appropriate                  schedule.
                                 management of renal failure post-transplant; and
                                 the recognition, differential diagnosis and
                                 management of infections in the transplant patient.
                      Goals                                                    Instructional Format                 Evaluation              Goal Setting
                                                                                                                                            Feedback
                      To learn the principals and practice of outpatient       Bi-weekly clinical experiences.      Monthly online          Goals are as stated in
                      nephrology, including: the provision of effective and    Nephrology clinics on Mondays        evaluation and          this document and in
                      efficient outpatient consultation; the diagnosis and     from 1 – 5 PM, and on Thursdays      additional oral input   the outline for each
Outpatient Clinic




                      management of chronic renal diseases such as             from 8 AM to noon at the Texas       on an ad hoc basis.     year of the fellowship.
                      diabetic nephropathy, chronic glomerulonephritis         Tech University nephrology clinic.   Clinic chart reviews
                      and the nephrotic syndrome, ADPKD and other                                                   may be instituted.      Feedback is provided
                      hereditary renal disorders, stone disease,                                                                            in the clinic on case by
                      complicated or secondary hypertension; the long                                               Semi-annual             case bases.
                      term management of renal transplant patients; and                                             evaluation of faculty
                      the outpatient care of dialysis patients. In addition,                                        by fellows. Regular
                      the fellow should particularly learn the principals of                                        evaluation of the
                      management applicable to the pre-end stage                                                    experience by fellows
                      patient, including the use of diet and medication in                                          and faculty.
                      the non dialytic management of renal failure.
                      Goals                                                    Instructional Format                 Evaluation           Goal Setting
                                                                                                                                         Feedback
                      The goals of this rotations is the mastery of            Six month rotations for second      Online evaluations    Goals are as set forth
                      principals and the practice of chronic dialysis          year fellows. The fellow rounds     are completed at the in this document and
                      therapy including the prescription and delivery of       on dialysis shifts and reviews data end of each month.    in the formal
                      dialysis treatments, the interpretation of treatment     with and without the attending      Oral evaluations      statements regarding
                      adequacy, the care and management of dialysis            physician. The fellow takes         may be given at any the second year
                      access, the management of anemia, the                    beeper call Monday through          time during the       curriculum. The
Outpatient Dialysis




                      management of renal bone disease, the evaluation         Friday during daytime hours. The month by the             attending
                      and management of nutritional issues, the                fellow rounds once each week        attending physician. nephrologists may set
                      management of hypertension, and the                      with the attending physician on                           specific goals for each
                      management of intradialytic hypotension.                 each dialysis shift. Peritoneal     Semi-annual           month. Feedback is
                                                                               dialysis patients are seen in the   evaluation of faculty supplied regularly
                                                                               clinic and at the dialysis center   by fellows. Regular   during dialysis rounds.
                                                                               with the peritoneal dialysis nurse. evaluation of the
                                                                               The fellow also attends and         experience by fellows
                                                                               contributes to the monthly long     and faculty.
                                                                               and short term care plan
                                                                               meetings and is urged to attend
                                                                               the monthly QI meetings.
                      Goals                                                 Instructional Format                  Evaluation              Goal Setting
                                                                                                                                          Feedback
                      To learn the principals and practice of chronic       One to two month rotation in the      Rotation written        Goals are stated in this
                      peritoneal dialysis treatment, emphasizing the        Red Bud Dialysis Center, during       evaluations will be     document and in the
                      interpretation of tests of treatment adequacy, the    which time the fellow will devote     made by Dr. C.J.        curriculum for the
                      management of peritoneal and tunnel infections,       his/her time to the care of the       Wheeler. Oral           second fellowship year.
                      the management of catheter malfunction, and the       patients in the peritoneal dialysis   evaluation may be       Feedback from the
Peritoneal Dialysis




                      management of anemia, hypertension, bone              clinic. The schedule is set by the    provided during this    dialysis unit staff and
                      disease and nutrition in the peritoneal dialysis      dialysis unit staff.                  month.                  physicians.
                      patient.
                                                                                                                  Semi-annual
                                                                                                                  evaluation of faculty
                                                                                                                  by fellows. Regular
                                                                                                                  evaluation of the
                                                                                                                  experience by fellows
                                                                                                                  and faculty


                      Goals                                                 Instructional Format                  Evaluation              Goal Setting
                                                                                                                                          Feedback
                      To develop experience in the care of patients with    Bimonthly clinic in the               Semi-annual online      The general goals are
                      renal stone disease and to broaden the                Department of Urology. Fellows        evaluations are         set forth in the overall
                      understanding of the pathophysiology of renal stone   see and evaluate patients with        provided. Oral          curriculum. The intent
                      disease. The goal of the rotation is to make the      stone disease and present cases to    evaluations may be      is that the fellows
                      fellow more comfortable with the evaluation and       Urology attendings in the clinic.     given at any time       become competent in
                      care of the renal stone patient, to familiarize the                                         during the month by     the evaluation of renal
Renal Stone Clinic




                      fellow with urological techniques of stone removal                                          the attending           stones and are able to
                      and lithotripsy, and to allow for organized                                                 physician.              outline treatment and
                      longitudinal follow up of intervention in stone                                                                     its limitations.
                      disease.                                                                                    Semi-annual             Feedback is given in
                                                                                                                  evaluation of faculty   conference.
                                                                                                                  by fellows. Regular
                                                                                                                  evaluation of the
                                                                                                                  experience by fellows
                                                                                                                  and faculty.
                      Goals                                                      Instructional Format               Evaluation              Goal Setting
                                                                                                                                            Feedback
                      To learn the histology and pathology of the kidney         Monthly conference. Biopsy        Monthly online           The goals are set forth
Biopsy Conference


                      by reviewing the results of biopsies performed by          findings are presented and slides evaluations are          in the overall
                      the fellows or submitted to the pathology                  are interpreted by conference     provided.                curriculum. The intent
                      department by other physicians.                            participants. Clinical data is                             is that the fellows
                                                                                 presented by the fellows and                               competently interpret
                                                                                 treatment is discussed by staff                            renal biopsies and are
                                                                                 and fellows. The conference takes                          able to outline
                                                                                 place the fourth Thursday of each                          treatment. Feedback
                                                                                 month.                                                     is given in conference.


                      Goals                                                      Instructional Format               Evaluation              Goal Setting
                                                                                                                                            Feedback
                      The fellows will learn the principals of research,         Monthly conference. Research is    Research is             Goals for the research
Research Conference




                      including its ethics, its designs, the analysis of data,   performed by the fellow            evaluated by the        project are set by the
                      and art of presentation of results.                        throughout the fellowship,         faculty member          faculty involved. The
                                                                                 especially in the second year.     primarily involved.     overall goal is the
                                                                                 Projects are suggested by the      Presentations are       generation of data
                                                                                 fellow or faculty, and the         reviewed in written     worthy of publication
                                                                                 schedule for its performance is    form on a monthly       in a peer reviewed
                                                                                 arranged individually.             basis. Final product    journal. Feedback is
                                                                                 Conference is held Thursdays at    is reviewed by the      individualized.
                                                                                 4PM.                               journal or conference
                                                                                                                    peer review system.

                      Goals                                                      Instructional Format               Evaluation              Goal Setting
                                                                                                                                            Feedback
                      To learn to critically analyze the renal literature, the   Bimonthly conference. Fellows      Monthly online          Goals as stated.
                      appropriate use of statistical analysis, the ethics of     present and critique papers from   evaluations are         Papers may be
                      research, and to expand the fellow’s knowledge             current peer reviewed journal      provided. Individual    specifically selected for
Journal Club




                      base by accessing new developments in nephrology.          each Wednesday at 4 PM.            presentations may       fellows based on a
                                                                                 Faculty, fellows and residents     be evaluated at the     fellow’s need to
                                                                                 take part in the discussion.       time of presentation.   expand in a specific
                                                                                                                                            area. Feedback from
                                                                                                                                            audience.
                       Goals                                                   Instructional Format                  Evaluation                 Goal Setting
                                                                                                                                                Feedback
                       In depth review of renal anatomy, physiology,           Weekly lecture conference.            There is no scheduled      The course outline
                       pathophysiology, histopathology, epidemiology,          Formal presentations by faculty       fellow evaluation for      indicates the topics
                       and treatment.                                          each Tuesday at 8 AM from             this activity. A more      covered, this varies
Didactic Conference




                                                                               September through June.               formal evaluation of       with the semester. The
                                                                               Readings are assigned. The total      the fellows’ learning      overall two year cycles
                                                                               cycle of lectures covers two years.   and quality of the         includes renal
                                                                               One year is predominantly basic       course material may        anatomy, physiology,
                                                                               science and pathophysiologically      be made after an “in       histopathology, and
                                                                               based. The second year is more        service” written           therapeutics. The
                                                                               devoted to the pathology of renal     exam becomes               material should be
                                                                               disease and a number of clinical      available.                 incorporated by fellow
                                                                               topics.                                                          into other activities as
                                                                                                                                                “knowledge base”
                                                                                                                                                Feedback is provided
                                                                                                                                                as this base is utilized
                                                                                                                                                in clinical rotations and
                                                                                                                                                in other conferences

                       Goals                                                   Instructional Format                  Evaluation                 Goal Setting
                                                                                                                                                Feedback
                       Clinically based review of clinical cases and           Case presentation or group data       Evaluation is              General goal is to
                       problems by fellow. Each conference presentation is     presentation and discussion with      presented as               cover clinically
                       based on a clinical encounter or problem specific to    review of literature especially       immediate feedback         applicable aspects of
                       the service on which the fellow is rotating. The        outcomes research, randomized         to presentation and        physiology and
Clinical Conferences




                       services/rotations specifically represented are:        controlled studies, and clinical      answers to questions.      pathophysiology and
                       Transplant, Inpatient Consultation, Outpatient          reviews. KDOQI                        Online evaluation of       to outline the
                       Dialysis, Peritoneal Dialysis, and Clinic. Transplant   recommendations and clinical          performance. The           established and
                       and Consultation problems are generally expected        guidelines from other groups          fellows’ performance       defacto algorithms
                       to be related to specific patients. Dialysis related    should be considered if such          here is used to judge      used by practicing
                       conferences may address general problems the            applicable standards exist.           their ability to utilize   nephrologists in
                       fellow is encountering (i.e. anemia, hypertension,                                            the literature,            analysis of clinical
                       phosphate control, nutrition, catheter infection,                                             integrate current          problems.
                       clearance, etc. , though in these cases a review of                                           literature and             Feedback is
                       center data should be presented).                                                             guidelines into            immediate.
                                                                                                                     clinical practice, and
                                                                                                                     generate new
                                                                                                                     hypotheses.
Nephrology Fellowship Program                                                   Learning Objectives                                    Inpatient Consult Nephrology Services

                 Symptoms                 Diseases/Conditions              Risk Factors                         Systems of Care        Psycho-social               Ethics
                 List symptoms of:        Describe epidemiology,           List risks for development of        List the acute and     Recognize and describe      Describe impact of
                 Hematuria,               pathophysiology, and             ARF in and out of hospital; lists    non acute              impact of chronic           ESRD on society.
                 Proteinuria,             treatment of conditions          risk factors for chronic renal       indications for        dialysis on long term       Appropriately counsel
                 Nephritis, RPGN,         listed in curriculum             disorders, describes impact of       dialysis and           QOL; recognize validity     ESRD patients on end-
Knowledge




                 Nephrosis, ARF and       documents and Tables A           renal failure on survival;           contraindications.     of choosing not to          of-life decisions.
                 CRF, list symptoms of    and B below.                     recognize impact of renal            List indications and   accept dialysis             Provide accurate
                 uremia and their                                          failure on drug metabolism. List     contraindications                                  informed consent.
                 pathogenesis                                              risks incurred in uremia,            for renal biopsy.                                  Describe impact of
                                                                           recognized increased                                                                    renal failure on
                                                                           cardiovascular risks in CRF and                                                         prognosis.
                                                                           ESRD
                 Demonstrate the          List historical data sought in   Demonstrate ability to identify                             Obtain psychiatric          Obtain social history
                 ability to obtain        the various renal disorders.     risk factors during review of                               history to assess patient   that allows culturally
History Taking




                 history relevant to      Accurately elicit history of     records and laboratory data.                                competence.                 sensitive discussion of
                 renal disorders and      medical conditions that          Demonstrate ability to elicit                               Recognize and describe      ethical issues.
                 to uremia.               may impact response to or        historical data from chart for                              importance of family        Recognize situations in
                                          effectiveness of dialysis.       issues affecting response to                                and social support in       which dialysis may be
                                                                           dialysis , survival and prognosis.                          adjustment to dialysis.     futile therapy.
                 List physical findings   Accurately detect signs of:      Accurately demonstrate               Demonstrate
                 sought when              uremia, volume overload;         physical findings that confirm or    findings that
Physical




                 evaluating specific      athero-embolic disease,          deny presence of underlying risk     indicate acute
Exam




                 symptoms elicited by     relevant systemic disorders.     factors for renal diseases.          need for dialysis.
                 history taking.          Assess dialysis access.
                 Perform complete         Insert dialysis catheters,       List patient risk factors that       Demonstrate            Demonstrate ability to      Recognize the
                 urinalysis to confirm    order and manage HD,             alter risk benefit ratio for         ability to analyze     deal with problems of       limitations of therapy
Procedures




                 presence of listed       CVVHD and PD. Perform            diagnostic procedures.               effectiveness of       patient behavior on         and identify those
                 symptoms.                renal biopsies; manage                                                dialysis.              dialysis.                   instances when
                                          complications of dialysis                                                                                                intervention may be
                                          and biopsies. See Table C.                                                                                               therapeutically futile.
                                          Demonstrates self                Acknowledges importance of           Demonstrates           Demonstrates openness       Recognizes and accept
                                          motivated independent            prevention, describes roles of       awareness of team      to patient attitudes        patient reasons to
Attitudes
& Values




                                          disease specific learning        hypertension, obesity, salt          nature of dialysis     and concerns about          refuse or withdraw
                                                                           intake, phosphate intake in          treatment. Works       renal replacement           from treatment.
                                                                           development of renal disease.        well with team.        therapy.
                 Makes accurate           Demonstrates ability to          Demonstrates ability to teach        Demonstrates           Demonstrates ability to     Demonstrates active
                 diagnoses of renal       care for inpatients with         patients their responsibilities      ability to work        interact sensitively and    investigation of ethical
                 disorders. Recognizes    renal diseases. Participate      with regard to reducing              effectively with       compassionately with        questions and
Behaviors




                 symptoms of uremia,      in clinical conference.          behaviors, i.e., smoking             other disciplines.     patients, family other      willingness to enter into
                 electrolyte disorders,   Demonstrate ability to           cessation, medication and diet       Teaches residents      physicians and other        discussions of ethics.
                 and volume               place acute catheters.           non-compliance, weight loss,         and students.          staff members.              Describes methods to
                 overload and                                              control of fluid intake.                                                                deal with non-
                 appropriately                                                                                                                                     compliant dialysis
                 schedules dialysis.                                                                                                                               patients.
Table A Knowledge of Disease/Condition                                                           Table B Knowledge of                           Table C Procedures for
                                                                                                 Disesase/Condition                             Disease/Condition
Be able to describe:                                                                             Be able to list:                               Be able to perform:
1. Techniques for evaluation of renal structure and function                                     1. The causes of secondary hypertension.       1. Placement of temporary dialysis
2. The approach to the diagnosis and management of acute renal failure in hospital patients      2. All common medications requiring            catheters.
3. The radiographic, sonographic, and nuclear medicine findings in various forms of renal        dose modification in renal insufficiency       2. Renal biopsy of native kidneys.
failure.                                                                                         and renal failure.                             3. Renal biopsy of renal transplants.
4. The metabolic consequences of acute renal failure                                             3. Indications for initiation of dialysis or   4. Evaluation and management of
5. The diagnosis and management of chronic renal disease in the hospitalized patient.            CRRT in acute renal failure.                   patients post procedure or
6. The management of hospitalized patients with acute and chronic renal failure.                 4. The indications for renal biopsy in the     complication.
7. The diagnosis and management of patients with acute glomerulonephritis.                       hospitalized patient with renal disease.       5. Management of dialysis
8. The diagnosis and management of patients with renovascular disease and renal vasculitis.      5. The indications for hemodialysis,           complications.
9. The diagnosis and management of patients with acute and chronic interstitial nephritis.       hemofiltration, and hemoperfusion in           6. Hemodialysis, peritoneal dialysis,
10. The diagnosis and management of disorders of salt and water metabolism.                      ingestion of specific toxins.                  and CRRT in the acute hospital
11. The diagnosis and management of clinical disorders of calcium, potassium, magnesium          6. The components used in dialysis             setting.
and phosphorus.                                                                                  membranes and their relative                   7. Acute venous catheterization for
12. The diagnosis and management of hospitalized patient with diuretic use.                      biocompatibility, and solute and water         purposes of hemodialysis or CRRT.
13. The diagnosis and management of clinical acid base disorders.                                transport characteristics.                     8. Evaluation and management of
14 The approach to, diagnosis of, and techniques for managing disorders of the lower urinary     7. Major drug interactions and dosing          complications or ARF , HD, PD, and
tract.                                                                                           adjustments in ARf.                            CRRT.
15. The choice and use of the various renal replacement techniques and their indications.
16. The use of dietary modification in management and prevention of renal failure.
17. The diagnosis and management of accelerate malignant hypertension in hospitalized            Perform:
patients.                                                                                        1. Placement of catheters for acute
18. The diagnosis and management of hospitalized patients with acute pyelonephritis, and         hemodialysis.
renal abscess with special attention to infections in patients with polycystic kidney disease.   2. Initial assessment and triage of
19. The pathogenesis of uremia.                                                                  patients with acute renal failure and
20. Types, advantages and disadvantages of maintenance hemodialysis, CRRT, and                   chronic dialysis patients with acute
peritoneal dialysis.                                                                             problems.
21. Principals of hemodialysis including machinery, dialysate, anticoagulation, clearance and    3. Dialysis decision making and
complications.                                                                                   management in acute renal failure.
22. Principals of CRRT including machinery, dialysate, anticoagulation, clearance and            4. Management of CRRT methods as
complications.                                                                                   indicated.
23. Principals of peritoneal dialysis including solute and water flux, membrane properties,      5. Accurate urinalysis.
and dialysate composition.                                                                       6. Instruction of residents in the care of
24. Principals of dialysis adequacy in all forms of dialysis and use in determining dialysis     patients with acute and chronic renal
prescriptions.                                                                                   failure.
25. Role of temporary and tunneled catheters for HD and CRRT, access for PD; radiology of        7. Extrapolation of K/DOQI guidelines to
access placement and evaluation.                                                                 the setting of ARF in the hospital.
26. The metabolic consequences of ARF and the management of ARF with dialysis , effects          8. Calculation of KT/V or URR for
and dosing of medications in ARF.                                                                hemodialysis, peritoneal dialysis, and
27. Fluid management in ARF patients; use of dialysis to manage fluids.                          CRRT in the hospital setting.
28. The diagnosis and management of anemia and osteodystrohy in ARF patients.
29. The role of nutritional support and dietary management in ARF patients; the impact of
dialysis on nutritional requirements.
30. Ethical issues of dialysis; including withholding and withdrawing therapy in the hospital
setting; role of social work and ethics committees.
31. Basic principals of financing and personnel management in acute dialysis setting.
Nephrology Fellowship Program                                                   Learning Objectives                                              Transplant Service

                 Symptoms                 Diseases/Conditions           Risk Factors                             Systems of Care         Psycho-social              Ethics
                 List causes of           See Tables A and B on         List risk factors for acute rejection,   List the indications    Describe the impact of     Describe the social
                 decreased kidney         next page and                 chronic rejection, chronic               for dialysis pre and    successful renal           impact of transplant,
Knowledge




                 function, oliguria,      curriculum documents.         transplant nephropathy; recurrent        post kidney             transplant, failure of     the ethics of LRKT,
                 anuria, hematuria                                      disease , recognize major drug           transplant. List the    renal transplant, and      LURKT, non-beating
                 and fever in the                                       interactions and impact of renal         contraindications for   rejection on patient       heart, and altruistic
                 transplant patient.                                    failure on drug dosing.                  renal transplant.       and family.                donation.
                 Elicit symptoms of       List historical data sought   Uncover relevant history of                                      Evaluate issues of         Describe the risks and
                 acute and chronic        in pre-transplant patient     diseases and conditions that may                                 patient compliance,        benefits of
History Taking




                 rejection, infections,   assessment. Accurately        adversely impact on transplant                                   family and social          transplantation for
                 lymphocoele,             elicit history of medical     outcome.                                                         support, and               the individual patient
                 hematoma, and            conditions that may                                                                            psychological disorders    and accurately
                 ureterocoele in the      impact transplantation.                                                                        that may adversely         provide for truly
                 transplant patient.                                                                                                     impact transplant          informed consent.
                                                                                                                                         outcome.
                 List physical findings   Accurately detect signs of    Accurately demonstrate physical          Demonstrate
                 sought when              uremia, volume                findings that confirm or deny            findings that
                 evaluating specific      overload, volume              presence of underlying risk factors      indicate acute need
Physical Exam




                 symptoms elicited by     depletion, infections         for poor transplant outcome.             for dialysis.
                 history taking.          associated with                                                        Demonstrates
                                          transplant, PTLD, and                                                  finding indicating
                                          medications side effects.                                              need for further
                                                                                                                 treatment.
                 Perform complete         Manage complications of       List surgical considerations that        Analyze data and        Demonstrate ability to     Recognize instances
                 urinalysis               renal transplant surgery.     increase chances for post                detects signs of        deal with issues of        when renal
Procedures




                                          Perform tasks outlined in     transplant renovascular problems,        acute rejection,        patient non-               transplantation is
                                          Table C below.                ureteral stenosis and disruption,        chronic rejection,      compliance. Recognizes     contra-indicated.
                                                                        obstructive uropathy, and                and chronic             psychological impact of
                                                                        lymphocoele                              nephropathy.            steroids.
                                          Demonstrates self             Acknowledges importance of               Demonstrates            Demonstrates openness      Recognizes and
                                          motivated independent         prevention, describes roles of           awareness of team       to patient attitudes       accept patient
Attitudes
& Values




                                          disease specific learning     hypertension, obesity, medication        nature of renal         and concerns about         reasons to refuse
                                                                        compliance, smoking, control of          transplantation.        renal transplantation.     transplantation
                                                                        cholesterol, and diet.                   Works with team.                                   option.
                 Accurately diagnoses     Demonstrates ability to       Demonstrates ability to teach            Demonstrates            Demonstrates ability to    Demonstrates active
                 post transplant          care for inpatients with      patients their responsibilities with     ability to work         interact sensitively and   investigation of
                 complications.           renal transplant.             regard to reducing behaviors, i.e.,      effectively with        compassionately with       ethical questions and
                 Recognizes rejection,    Participate in clinical       smoking cessation, medication            other disciplines.      patients, family other     willingness to enter
Behaviors




                 electrolyte disorders,   conference. Participates      and diet non-compliance, weight          Teaches residents       physicians and other       into discussions of
                 and volume               in monthly transplant         loss, control of fluid intake.           and students.           staff members.             ethics. Demonstrates
                 overload and             conference.                                                                                                               ability to effectively
                 appropriately                                                                                                                                      intervene with non-
                 responds.                                                                                                                                          compliant patients.
Table A Knowledge of Disease/Condition                       Table B Knowledge of Disease/Condition                   Table C Procedures for Disease/Condition
Be able to describe                                          Be able to list:                                         Be able to perform:
1. Normal immune response to infection or other insult.      1. The common causes for acute renal failure in renal    1. Acute venous catheterization to place acute dialysis
2. The immunologic basis of hyperacute, acute and            transplant patients.                                     catheters.
chronic allograft rejection.                                 2. The indications for biopsy of the renal allograft.    2. Renal allograft biopsy.
3. The immunologic basis for methods of                      3. The histopathological criteria for the diagnosis of   3. Evaluation and management of complications in
immunosuppression.                                           acute and chronic rejection.                             renal transplant patients.
4. Immunogenetics and tissue typing, crossmatching and       4. Major drug interactions with immunosuppressive        4. Management of the complications of dialysis in renal
surveillance for panel reactive antibodies.                  medications.                                             transplant patients.
5. The system of organ sharing and allocation.
6. Surgical procedures for cadaveric and living kidney
transplantation.
7. The diagnosis and management of acute renal failure
in hospitalized transplant patients.
8. Radioographic, ultrasound, and nuclear medicine
findings in various causes of acute allograft rejection.
9. The metabolic consequences of ARF in transplant
patients.
10. The major side effects, metabolism, and
complications caused by immunosuppressive
medications.
11. The diagnosis and management of chronic renal
failure in the hospitalized transplant patient.
12. The fluid management of hospitalized transplant
patient with acute or chronic renal failure.
13. The diagnosis and management of transplant
patients with recurrent or de novo glomerulonephritis.
14. The diagnosis and management of hemolytic uremic
syndrome and other microangiopathies in the
hospitalized transplant patient.
15. The diagnosis and management of transplant
patients with PTLD, anemia, polycythemia, and other
hematological disorders.
16. The diagnosis and management of disorders of the
lower urinary tract in renal transplant patients.
17. Dietary modifications appropriate to the care of
renal transplant patients.
18. The diagnosis and management of accelerated or
malignant hypertension in transplant patients.
19. The diagnosis and management of pyelonephritis,
renal abscess, and perirenal abscess in renal transplant
patients.
20. Ethical issues in transplantation.
21. Economic issues for recipients, donors, and providers.
Nephrology Fellowship Program                                                    Learning Objectives                                          Outpatient Dialysis Services
                 Symptoms                 Diseases/Conditions          Risk Factors                          Systems of Care        Psycho-social             Ethics

                 List uremic              See Tables A and B on        Describe impact of ESRD and           List indications for   Describe impact of        Describe the impact
                 symptoms and their       next page and                dialysis on vascular disease,         chronic renal          dialysis on patient and   of dialysis on health
                 pathogenesis. List       curriculum documents.        stroke, infection, and bone           replacement. List      family QOL.               care and society.
                 symptoms of                                           disease. List risks of medications    K/DOQI guidelines                                Describe the issues
Knowledge




                 complications seen                                    used in dialysis patients on blood    for chronic dialysis                             involved in
                 in ESRD, HD and                                       pressure, GI symptoms, bone           care.                                            withdrawal from
                 PD>                                                   disease, and anemia.                                                                   therapy and end-of-
                                                                                                                                                              life decisions.
                 Demonstrate ability      Demonstrate ability to       Demonstrate ability to review         Demonstrate ability    Describe common           Accurately describe
                 to elicit symptoms of    obtain history of medical    records to determine presence of      to interact with       compliance problems       risks and benefits of
History Taking




                 uremia, volume           conditions that require      all conditions impacting the care     primary care           and describe              dialysis and access
                 status, bone disease,    concurrent care and          of the individual dialysis patient.   physicians to ensure   appropriate               procedures.
                 anemia, CAD, and         impact survival or the                                             appropriate overall    interventions. Describe
                 medication side          ability to provide                                                 management of the      attributes needed to
                 effects.                 effective dialysis.                                                dialysis patient.      effectively provide
                                                                                                                                    home self care.
                 List physical findings   Accurately detect signs      Accurately demonstrate physical       Demonstrate
                 sought when              of: uremia, volume           findings that confirm or deny         findings that
                 evaluating specific      overload;, relevant          presence of underlying risk           indicate need for
Physical Exam




                 symptoms elicited by     systemic disorders. Assess   factors for renal diseases.           dialysis, changes in
                 history taking.          dialysis access. Detect                                            treatment protocol.
                                          access infections, steal,
                                          peritonitis and tunnel
                                          infections.
                 Perform assessment       Prescribe dialysis           List risks factors that alter risk    Analyze outcome        Advise patients           Participate in
                 of dialysis therapy      appropriately, monitors      benefit ratios and change long        data including KT/V,   regarding issues of       discussions
                 using on-line real       outcomes and adjusts RX,     term outcomes for dialysis or         PET tests, anemia      compliance to diet,       concerning patient
                 time data. Adjusts       evaluates and manages        transplantation.                      data, nutritional      medication, and           withdrawal,
Procedures




                 therapy                  complications of ESRD                                              data, and bone         treatment attendance.     dismissal, and
                 appropriately.           and dialysis per K/DOQI                                            disease                                          referral for
                                          guidelines. See Table C                                            management data.                                 transplantation.
                                          on next page.                                                      Adjusts RX.
                                          Demonstrates self            Acknowledges importance of            Demonstrates           Demonstrates              Recognizes and
                                          motivated independent        prevention, describes roles of        awareness of team      openness to patient       accept patient
Attitudes &




                                          disease specific learning    hypertension, obesity,                nature of renal        attitudes and concerns    reasons to refuse
Values




                                                                       medication compliance,                transplantation.       about renal               transplantation
                                                                       smoking, control of cholesterol,      Works with team.       transplantation.          option.
                                                                       and diet.
                 Recognizes               Demonstrates ability to      Demonstrates ability to care for      Demonstrates ability   Demonstrates ability      Demonstrates ability
                 electrolyte disorders,   care for inpatients with     chronic dialysis patients, .attends   to work effectively    to interact sensitively   to effectively
Behaviors




                 bone disease,            renal transplant.            monthly care plan and QI              with other             and compassionately       intervene with non-
                 anemia and volume        Participate in clinical      meetings.                             disciplines.           with patients, family     compliant patients.
                 disorders.               conference. Participates                                                                  other physicians and
                                          in monthly transplant                                                                     other staff members.
                                          conference.
Table A Knowledge of Disease/Condition                                Table B Knowledge of                               Table C Procedures for Disease/Condition
                                                                      Disease/Condition
Be able to describe                                                   Be able to list or access:                         Be able to perform:
1. The pathogenesis of uremia.                                        1. The components of hemodialysis                  1. Dialysis prescription and supervision for maintenance
2. Types, advantages and disadvantages of maintenance                 membranes and their relative                       hemodialysis and peritoneal dialysis patients.
hemodialysis,, and peritoneal dialysis.                               biocompatibility, and solute and water flux        2. Evaluation and management of complications in
3. Principals of hemodialysis including hemodynamics, solute          characteristics.                                   ESRD patients.
and water flux, dialysis membrane properties, biocompatibility,       2. Major drug interactions and dosing              3. Management of complications of hemodialysis and
and dialysate composition.                                            adjustments necessary in ESRD , HD, and PD.        peritoneal dialysis.
4. Water treatment and dialysate delivery systems for                 3. National Kidney Foundation K/DOQI
hemodialysis.                                                         guidelines for adequacy of dialysis and
5. Techniques, advantages, and disadvantages of dialyzer reuse.       standards of care for chronic dialysis patients.
6. Principals of peritoneal dialysis including solute and water
flux, membrane properties, and dialysate composition.                 Be able to calculate:
7. Connection and cycling systems in peritoneal dialysis.             1. KT/V, URR, and other clearance values for
8. Principals of dialysis adequacy in all forms of dialysis and use   both hemodialysis and peritoneal dialysis
in determining dialysis prescriptions.                                patients to determine treatment adequacy.
9. Surgical techniques for creation and management including
native fistulae, synthetic grafts, shunts, vein transpositions, and
peritoneal dialysis catheter placement.
10. The radiology of access placement and evaluation of
accesses.
11. The metabolic consequences of ESRD
12. The use and dosing of medications in ESRD,
13. The major complications of ESRD and hemodialysis including
access complications.
14. Fluid management in ESRD patients.
15. The diagnosis and management of anemia in ESRD patients.
16. The diagnosis and management of osteodystrohy in ESRD
patients.
17. The diagnosis and management of cardiovascular disease
and hyperlipidemia in ESRD patients.
18. The approach to and management of disorders of the upper
urinary tract including acquired cystic disease in ESRD patients.
19. The approach to and management of disorders of the lower
urinary tract including cystitis in ESRD patients.
20. The role of nutritional support and dietary management in
ESRD patients.
21. Ethical issues of dialysis and dialysis withdrawal.
22. Role of Medicare dialysis networks, USRDS and voluntary
societies in administration and financing of ESRD care.
Nephrology Fellowship Program                                                   Learning Objectives                                             Outpatient Nephrology Clinics

                 Symptoms                 Diseases/Conditions           Risk Factors                           Systems of Care           Psycho-social               Ethics
                 List symptoms of:        Describe epidemiology,        List risk factors for development of   Outline and describe      Recognize impact of         Describe the impact
                 Hematuria,               pathophysiology, and          proteinuria, hematuria, and            the K/DOQI                renal disease and renal     of chronic renal
                 Proteinuria,             treatment of conditions       chronic renal disease, risk factors    guidelines for chronic    replacement on QOL          disease on health
                 Nephritis, RPGN,         listed in curriculum          for hypertension, risks for renal      renal diseases. List      decisions. Recognize        care and society.
                 Nephrosis, ARF and       documents and in Tables       failure associated with medication     indications for           factors that may lead       Outline current
                 CRF, list symptoms of    A and B on next page.         use. Describe modification of          initiation of             patient to decline or       approaches to
Knowledge




                 uremia and their                                       medication dosage in renal             treatment in acute        withdraw from               counseling patients
                 pathogenesis. List                                     diseases.                              and chronic renal         treatment,, whether for     on end-of life issues
                 symptoms of                                                                                   disease.                  ESRD or other               in renal disease and
                 secondary HTN.                                                                                                          disorders.                  ESRD.
                 Demonstrate the          List historical data sought   Demonstrate ability to accurately                                Obtain psychiatric          Accurately describe
                 ability to obtain        in the various renal          review records for history relevant                              history to assess patient   risks and benefits of
History Taking




                 history relevant to      disorders. Accurately         to chronic and acute renal disease                               competence.                 treatments offered
                 renal disorders and      elicit history of medical     and hypertension.                                                Recognize and describe      for renal disease.
                 HTN and to uremia.       conditions that may                                                                            importance of family        Accurately describe
                                          impact response to or                                                                          and social support in       risks and benefits for
                                          effectiveness of                                                                               adjustment to chronic       renal replacement
                                          treatment.                                                                                     renal disease.              therapies.
                 List physical findings   Accurately detect signs       Accurately demonstrate physical        Demonstrate findings
                 sought when              of: uremia, volume            findings that confirm or deny          that indicate acute
Physical Exam




                 evaluating specific      overload; athrero-            presence of underlying risk factors    need for dialysis.
                 symptoms and             embolic disease, and          for renal diseases, cardiovascular
                 systemic disorders       relevant systemic             diseases, and underlying or
                 elicited by history      disorders. Assess dialysis    complicating systemic diseases..
                 taking.                  access.
                 Perform accurate         Perform tasks outlined in     List patient risk factors that alter   Demonstrate ability       Demonstrate ability to      Recognize the
                 urinalysis.              Table C on next page.         risk benefit ratio for diagnostic      to analyze                deal with problems of       limitations of
Procedures




                                                                        procedures.                            effectiveness of          patient behavior s.         therapy and identify
                                                                                                               treatments.                                           those instances when
                                                                                                                                                                     intervention may be
                                                                                                                                                                     futile or unneeded.
                                          Demonstrates self             Acknowledges importance of             Works well with           Demonstrates openness       Recognizes and
                                          motivated independent         prevention, describes roles of         nursing staff, allied     to patient attitudes        accept patient
Attitudes
& Values




                                          disease specific learning     hypertension, obesity, salt intake,    personnel, dialysis       and concerns about          reasons to refuse or
                                                                        phosphate intake in development        and transplant            renal replacement           withdraw from
                                                                        of renal disease.                      teams.                    therapy.                    treatment.
                 Accurately diagnoses     Demonstrates ability to       Demonstrates ability to teach          Demonstrates ability      Demonstrates ability to     Demonstrates active
Behaviors




                 renal disorders,         care for inpatients with      patients their responsibilities with   to work effectively       interact sensitively and    investigation of
                 uremia, electrolyte      renal diseases.               regard to reducing behaviors, i.e.,    with other disciplines.   compassionately with        ethical questions and
                 disorders, and           Participate in clinical       smoking cessation, medication          Teaches residents         patients, family other      willingness to enter
                 volume overload.         conference                    and diet non-compliance, weight        and students.             physicians and other        into discussions of
                 Treats appropriately.                                  loss, control of fluid intake.                                   staff members.              ethics.
Table A Knowledge of Disease/Condition                                                               Table B Knowledge of                Table C Procedures for Disease/Condition
                                                                                                     Disease/Condition
Be able to describe:                                                                                 Be able to list:                    Be able to perform:
1. Techniques for evaluation of renal structure and function                                         1. The causes of secondary          1. Native kidney biopsy for diagnosis and
2. The approach to the diagnosis and management of proteinuria, hematuria, and chronic               hypertension.                       management of acute and chronic kidney
kidney disease in outpatients with special attention to treatments to delay or prevent               2. All common medications           diseases.
progression to end stage kidney disease.                                                             requiring dose adjustment in        2. Complete urinalysis.
3. The radiographic, sonographic, and nuclear medicine findings in various forms of chronic and      patients with                       3. Instruction of residents and students in the
acute renal disease in the outpatient setting..                                                      glomerulonephritis, vasculitis,     evaluation and management of
4. The metabolic consequences of chronic renal diseases.                                             proteinuria, hematuria, and         proteinuria, hematuria, hypertension, and
5. Fluid management in outpatients with chronic renal disease.                                       chronic kidney diseases.            chronic renal diseases.
6. The management of hypertension in the outpatient with chronic renal diseases.                     3. Indications for initiations of   4. Evaluation and management of patients
7. The diagnosis and management of patients with acute glomerulonephritis.                           dialysis and transplantation in     with complications post renal biopsy.
8. The diagnosis and management of patients with renovascular disease and renal vasculitis.          chronic and acute renal             5. Counseling of patients receiving biopsy
9. The diagnosis and management of patients with acute and chronic interstitial nephritis.           failure.                            results.
10. The diagnosis and management of disorders of salt and water metabolism.                          4. Indications for initiation of
11. The diagnosis and management of clinical disorders of calcium, potassium, magnesium and          steroids and/or
phosphorus.                                                                                          immunosuppressive drugs in
12. The diagnosis and management of outpatients with diuretic use.                                   patients with
13. The diagnosis and management of clinical acid base disorders.                                    glomerulonephritis and
14 The approach to, diagnosis of, and techniques for managing disorders of the lower urinary         vasculitis..
tract.                                                                                               5. Indications for renal biopsy
15. The choice and use of the various renal replacement techniques and their indications.            in the diagnosis of acute,
16. The use of dietary modification in management in prevention and management of chronic            subacute, and chronic renal
renal diseases..                                                                                     disorders.
17. The diagnosis and management of accelerate malignant hypertension in hospitalized
patients.
18. The diagnosis and management of patients with acute pyelonephritis, and renal abscess
with special attention to infections in patients with renal failure and polycystic kidney disease.
19. The diagnosis and management of outpatients with genetic renal diseases with special
attention to ADPKD.
                         Nephrology Fellowship Year One -- Description

                           UMC Consultation Service                     Renal Transplantation Service            Nephrology Clinic
                           Inpatient renal consultation services that   Inpatient service and outpatient         Outpatient consultative and
Educational Experience




                           also serve as primary service for            transplant clinic (Urology). The         continuity clinic. Fellow performs
                           established transplant patient. Fellow       fellow directs care of new and           new consultation evaluations and
                           performs renal consultations, directs all    established renal transplant patients    directs care of established patients
                           inpatient dialysis and continuous renal      under direction of Nephrology faculty    with glomerular and tubular
                           replacement therapy (CRRT), and              and transplant surgeon. The fellow is    disease, chronic kidney disease,
                           oversees the care of all renal transplant    encouraged to observe and may            and ESRD.
                           patients under the guidance of faculty       assist at transplant surgery.
                           nephrologists.

                           Teaching and management rounds are           Daily rounds on transplant service       Review of patient history, physical
                           performed on a daily basis. Consultations    with attending nephrologist.             findings, and laboratory data.
Teaching Methods




                           are reviewed by responsible faculty          Instruction by transplant surgeons in    Discussion of diagnosis and
                           member. Faculty is available for             clinic. Informal teaching sessions       decision making process. Review
                           immediate support when needed.               conducted as time permits. Review        of recommendations or
                                                                        of findings and discussion of decision   therapeutic decisions. Ad hoc
                                                                        making in clinic. Instruction by         discussion of disease entities,
                                                                        surgical staff as fellow observes        therapeutic options, and overall
                                                                        surgical procedures.                     plan of care.
                          UMC Consultation Service                      Renal Transplantation Service             Nephrology Clinic
                          Patients include ESRD patients admitted       New and established renal transplant      Patients with chronic kidney
                          from a faculty practice of over 170 chronic   patients, a majority of whom have         disease of various stages, ESRD
                          dialysis patients and 250 transplant          diabetes as the cause of renal failure.   patients from faculty practice,
                          patients, new consultations with acute        Any patient transplanted in Lubbock       patients with glomerular and
                          and chronic renal diseases from the           may be transferred to UMC for care        tubular disorders, patients with
                          hospital population. There are significant    of any significant medical or surgical    complicated hypertension issues,
                          numbers of intensive care, burn, and          issues at the request of the primary      and new referral patients. New
                          trauma patients with acute renal failure,     care nephrologists. Other transplant      and established renal transplant
                          and extensive exposure to diabetic            patients are also accepted for            patients from UMC program. 50
                          nephropathy. The overall patient              transfer upon request. All kidney         to 60 % DM nephropathy.
Mix of Diseases




                          population includes significant numbers of    transplant patients in UMC are            Majority with hypertension. 5 –
                          patients with various primary and             placed on this service except for those   10 % polycystic kidney disease, 15
                          secondary kidney diseases due to the          patients admitted to transplant           – 20 % glomerulonephritis
                          tertiary care nature of the hospital.         surgery or Urology who are followed
                                                                        as consults.

                          A broad spectrum of renal disorders is seen   Mean age 55 – 60, 60% male, ~ 50%         Ethnically more than 40%
                          with increased experience with trauma         minority status, > 50% diabetic. The      Mexican American, 10- 15%
                          and burn patients due to hospital activity    catchment area for transplantation        African American. 60% diabetic.
                          in this area. There is a high incidence of    includes the Texas panhandle,             Age range from 14 to 80’s with
Patient Characteristics




                          diabetes, hypertension, and CVD. The          eastern New Mexico, north Texas,          many patients over 70. Gender
                          hospital serves as both a primary and         and the Abilene area.                     ratio near 1:1.
                          tertiary care center with a complex
                          patient population. Mean age 55 – 60,
                          60% male, > 50% minority status
                          Ethnically more than 40% Mexican
                          American, 10- 15% African American.
                     UMC Consultation Service                    Renal Transplantation Service              Nephrology Clinic
                    Inpatient consultation rounds at bedside     Inpatient ward rounds, transplant         New patient referral and
                    and in inpatient dialysis units. Intensive   clinic visits, attendance at surgical     consultation, established patient
                    care unit rounds in multiple units.          procedures                                return clinic visits.
                    Emergency department consultations.
Types of Clinical
Encounters




                    Acute and chronic hemodialysis,              Insertion of dialysis catheters.          Performance of consultations.
                    continuous renal replacement therapies,      Procedures needed for diagnosis of        Urinalysis.
                    peritoneal dialysis. Insertion of acute      infection including lumbar puncture
Procedures




                    dialysis catheters. Biopsy of native         and paracentesis, Observation of
                    kidneys. Performance of consultation.        transplant surgery; possible assistance
                                                                 at transplant surgery. Biopsy of
                                                                 transplant kidneys.
                    Nephrology consult service at UMC.           Transplant service, UMC. Transplant       Nephrology division clinics, Texas
Services




                                                                 clinic, Urology department, Texas         Tech University Health Sciences
                                                                 Tech University Health Sciences           Center.
                                                                 Center.
                    Attached.                                    Attached.                                 Attached.
Reading
Lists
             UMC and CMC Consultation Service            Renal Transplantation Service          Nephrology Clinic
             Online and oral evaluation of the fellows   Online and oral evaluation of the      Online and oral evaluation of the
             by the attending nephrologists.             fellows by the attending nephrologists fellows by the attending
                                                         and transplant surgeon.                nephrologists.
                                                                                                Planned semi-annual audit of
Evaluation
Method of




                                                                                                clinic charts to determine fellow
                                                                                                adherence to K/DOQI care
                                                                                                guidelines.
                         Nephrology Fellowship Year Two -- Description

                           University Outpatient Dialysis                    Peritoneal Dialysis                       Nephrology Clinic
                           Fellows supervise hemodialysis patient            Rotation at Redbud Dialysis the           Outpatient consultative and
                           care at the Dialysis Center of Lubbock, an        fellows spend two months specifically     continuity clinic. Fellow performs
                           outpatient dialysis center owned and              seeing peritoneal dialysis patients in    new consultation evaluations and
                           managed by Fresenius Dialysis Services            concert with experienced nursing staff    directs care of patients with
                           and staffed by TTU nephrology faculty.            and faculty. This is one of the largest   glomerular and tubular disease,
                           More than 90% of the patients are seen            peritoneal clinics in Texas.              chronic kidney disease, and ESRD
                           by the fellow and faculty, (10% of patients                                                 care.
                           are followed by private nephrologists
                           associated with the program). There are
                           six dialysis shifts; the fellow rounds with the
                           faculty on about 60 TTS or MWF patients
                           weekly. All aspects of dialysis and general
                           care are discussed, and treatment is
Educational Experience




                           evaluated and adjusted as needed. The
                           fellow attends short and long term care
                           conferences, and may attend QI meetings.
                           The rotations last six months during which
                           the fellow has an opportunity to view the
                           chronic aspects of ESRD patient care.
                           After six months with the patients and
                           faculty on one schedule, the fellow
                           switches to the other set of patients.
                   University Outpatient Dialysis               Peritoneal Dialysis                      Nephrology Clinic
                   Fellows round independently as needed        The fellows see patients with the        Review of patient history, physical
                   and weekly with faculty as scheduled on      nursing staff, and review labs and       findings, and laboratory data.
                   each of the hemodialysis shifts. Patient     findings. Review labs and problems       Discussion of diagnosis and decision
Teaching Methods



                   care is reviewed and decisions are           with attending nephrolgist.              making process. Review of
                   discussed.                                                                            recommendations or therapeutic
                                                                                                         decisions. Ad hoc discussion of
                                                                                                         disease entities, therapeutic
                                                                                                         options, and overall plan of care.

                   All patients have end stage renal failure.   The Redbud unit has more than 60         Patients with chronic kidney
                   The most common diagnoses causing renal      peritoneal dialysis patients. The most   disease of various stages, ESRD
                   failure are diabetes and hypertension,       common diagnoses causing renal           patients from faculty practice,
                   followed by glomerular diseases,             failure are diabetes and                 patients with glomerular and
                   renovascular disease, and cystic/inherited   hypertension, followed by glomerular     tubular disorders, patients with
                   renal disease.                               diseases, renovascular disease, and      complicated hypertension issues,
                                                                cystic/inherited renal disease.          and new referral patients. New
                                                                                                         and established renal transplant
Mix of Diseases




                                                                                                         patients from UMC program. 50
                                                                                                         to 60 % DM nephropathy.
                                                                                                         Majority with hypertension. 5 – 10
                                                                                                         % polycystic kidney disease, 15 – 20
                                                                                                         % glomerulonephritis
                               University Outpatient Dialysis               Peritoneal Dialysis                        Nephrology Clinic
                               The demographic distribution of the          The demographic distribution of the      Ethnically more than 50% Mexican
                               patients reflects the region, with greater   patients reflects the region, with       American, ~ 10% African American.
                               numbers of Mexican-American Hispanics        greater numbers of Mexican-
Patient Characteristics



                               than other regions, and ~ 15 % African       American Hispanics than other
                               American patients. The age distribution is   regions, and ~ 10 % African American
                               typical for dialysis.                        patients. The age distribution is
                                                                            typical for dialysis.




                               Rounds in the outpatient dialysis unit        Scheduled clinic visits with nurses and New patient referral and
Types of Clinical Encounters




                               setting. Occasional visits with peritoneal   faculty in the peritoneal dialysis clinic consultation, established patient
                               dialysis patients. Attendance at QI, short   rotation.                                 return clinic visits.
                               term and long term care plan meetings.




                               Outpatient hemodialysis and peritoneal       Outpatient peritoneal dialysis care.     Performance of consultations.
                               dialysis care.                                                                        Urinalysis.
Procedures
             University Outpatient Dialysis              Peritoneal Dialysis                  Nephrology Clinic
             Dialysis Center of Lubbock                  Redbud Dialysis Center                Nephrology Clinic, Texas Tech
Services

                                                                                               University Health Sciences Center


             Attached                                    Attached                              Attached
Reading
Lists




             Online and oral evaluation by the           Written and oral evaluation by the    Online and oral evaluation of the
             attending nephrologists. Audit of quality   attending nephrologists.              fellows by the attending
             reports to determine adherence to                                                 nephrologists. Plan semi-annual
Evaluation
Method of




             K/DOQI care guidelines. Plan 360 degree                                           audit of clinic charts to determine
             evaluation by dialysis center staff.                                              fellow adherence to K/DOQI care
                                                                                               guidelines
               Nephrology Fellowship Year 1 – Competency Matrix

Year 1         UMC Consultation Service                    Renal Transplant Service                    Nephrology Clinic
               Diagnoses acute kidney injury and defines   Correctly manages immunosuppressive         Appropriately uses imaging
               its cause. Chooses correct treatment for    treatment in the post transplant period     techniques in work up of renal
               patient with acute kidney injury based on   and in chronic transplant patients under    disorders. Orders serological tests
               patient needs. Orders dialysis and CRRT     the guidance of the attending physician.    when indicated and interprets
               treatment correctly, manages their          Diagnoses and treats acute and chronic      results correctly. Recommends
               complications, and adjusts treatment as     rejection and infections in transplant      renal biopsy when indicated and
               needed. Chooses appropriate access          patients, especially CMV and BK virus.      arranges for procedure. Controls
Patient Care




               modality. Recognizes and treats dialysis    Diagnoses lymphocoele, urinoma,             blood pressure and treats
               access infections and access failure in     vascular disorders and ureteral             proteinuria to reduce progression
               chronic dialysis patients (HD and PD).      obstruction in the transplant setting.      of renal disease. Correctly
               Recognizes chronic kidney disease in        Recognizes recurrent FSGS, MPGN, IgA        prescribes phosphate binders,
               previously undiagnosed patients and         nephropathy, and diabetes. Manages          vitamin D, and alkali treatment.
               treats this effectively. Diagnoses and      HTN, diabetes and lipid disorders.          Manages secondary complications
               treats patients with nephrotic syndrome,    Diagnoses and treats steroid related        of CKD. Pays careful attention to
               acute and chronic glomerulonephritis and    complications, including aseptic necrosis   vascular disease in CKD patients.
               rapidly progressive glomerulonephritis,     and osteoporosis. Recognizes post           Helps patients choose best ESRD
               interstitial nephritis and other renal      transplant malignancy and post              care option; arranges for
               disease. Adjusts medication use based on    transplant lymphoproliferative disease.     transplant work up; ensures timely
               kidney function.                            Manages post transplant anemia. Treats      placement of dialysis access.
                                                           CKD in transplants appropriately.
               Demonstrates knowledge of acute and         Demonstrates knowledge of basic             Demonstrates knowledge of the
               chronic kidney diseases and electrolyte     transplant immunology,                      K/DOQI guidelines for chronic renal
               disorders and their treatment as outlined immunosuppressive therapies, transplant       disease. Demonstrates knowledge
               in Table A.                                 surgery complications, causes of renal      of treatment of glomerular and
Knowledge




                                                           dysfunction in post transplant period,      tubular diseases, polycystic
Medical




                                                           acute and chronic rejection and viral and   diseases, and renal diseases
                                                           bacterial infections as outlined in Table   associated with systemic illnesses as
                                                           B.                                          outlined in Table C.
               Researches literature related to individual Adapts to use of newly introduced           Incorporates K/DOQI guidelines
               patient issues as needed. Incorporates      medications and protocols as these are      into practice as these are
               new information in practice. Utilizes Up to developed. Uses literature searches as      developed. Applies latest
Learning
Practice




               Date and search engines as required.        required. Incorporates new information      information about treatment in
Based




                                                           in practice.                                glomerular and interstitial disease.
                         Effectively explains the syndrome of acute      Effectively explains risks and benefits of     Effectively explains the risks of
                         kidney injury and its risks for death and       transplantation and donation,                  early renal disease, and the need
                         chronic kidney disease to patients and          importance of patient compliance, and          for interventions. Clearly outlines
                         families. Explains risks and benefits of        medication side effects to patients. Helps     treatment options. Explains biopsy
Communication Skills
                         dialysis and CRRT treatment. Writes or          patients understand and accept                 risks and benefit. Explains biopsy
                         dictates clear opinions and                     complications such as acne and                 results and their meaning. Writes
Interpersonal and




                         recommendations to referring physicians.        Cushingoid appearance.                         or dictates clear opinions and
                         Explains long term plans for management                                                        recommendations to referring
                         of CKD and ESRD to referring physicians.                                                       physicians. Clearly explains
                                                                                                                        treatments for anemia, renal bone
                                                                                                                        disease, hypertension, and
                                                                                                                        reduction of proteinuria.
                         Bases decisions about the need for dialysis     Demonstrates understanding of                  Is prompt and courteous; keeps
                         on patient welfare and prognosis.               significant ethical issues related to kidney   effective records; responds to
Professionalism and




                         Accepts patient rejection of dialysis or        transplantation, including organ               referring MD; applies best care
                         other treatments while maintaining              allocation issues, donor payment, “non-        options. Recognizes influences of
                         therapeutic relationship. Comports self in      beating heart” donors, xeno-                   physician based issues on ESRD
                         hospital in professional manner.                transplantation, and drug costs.               choice and avoids decisions based
                                                                         Understands issues in donor selection and      on physician rather than patient
Ethics




                                                                         recipient approval and listing process.        benefit.

                         Schedules dialysis with attention to nurse      Takes an active role in transplant related     Develops understanding of
                         staffing, including avoidance of admission      meetings, interacts with transplant office     interactions of specialty and
                         by arranging outpatient treatments.             to allow continuity of care. Uses              primary care clinics regarding care
                         Arranges appointments after discharge as        cardiovascular, dermatology, orthopedic,       of chronic kidney disease patients.
Systems Based Practice




                         needed. Assures continuity of care by           pulmonary, infectious disease, and             Replies to consults in a manner
                         interactions with dialysis units and clinics.   endocrine consultation as needed.              that guides care by primary
                         Plans for access placement in new ESRD          Develops skills needed to utilize the          physician. Prepares patients for
                         patients. Understands and uses PD as a          computerized data base to analyze              ESRD treatment and avoids need
                         bridge to transplant or HD via                  current trends in patient outcomes.            for emergent or urgent institution
                         permanent access. Avoids use of                 Actively participates with transplant          of dialysis. Arranges for access
                         permanent catheters whenever possible.          surgeon and nephrologists in decisions         placement in sufficient time to
                                                                         regarding immunosuppression.                   allow fistula maturation to occur.
                     Nephrology Fellowship Year 2 – Competency Matrix

Year 2              University Associated Dialysis               Peritoneal Dialysis                           Nephrology Clinic
                    Provides safe and effective hemodialysis     Provides safe and effective care of           Appropriately uses imaging
                    treatment in the outpatient setting.         peritoneal dialysis patients, including       techniques and serological tests
                    Orders and manages dialysis treatment so     adequate peritoneal clearance, glycemic       and interprets results correctly.
                    that K/DOQI treatment goals are              control, volume and blood pressure            Recommends and arranges renal
                    achieved, including dialysis adequacy        control, iron, anemia, albumin and            biopsy when indicated. Controls
                    (KT/V), anemia, iron balance, Ca, Phos,      electrolyte control. Treats peritonitis and   BP, and treats proteinuria.
                    Ca x Phos, PTH, K, bicarbonate, albumin,     catheter infections effectively.              Correctly prescribes phosphate
                    blood pressure, and treatment                                                              binders, vitamin D, and alkali
                    compliance targets. Addresses acute                                                        treatment. Manages all secondary
                    medical problems on dialysis effectively.                                                  complications of CKD. Addresses
Patient Care




                    Monitors access issues and arranges for                                                    vascular disease in CKD patients.
                    correction of problems.                                                                    Helps patients choose best ESRD
                                                                                                               care option; arranges for
                                                                                                               transplant work up; ensures timely
                                                                                                               placement of dialysis access.
                    Demonstrates knowledge of hemodialysis       Demonstrates knowledge of peritoneal          Demonstrates knowledge of the
                    techniques and kinetics, the principles of   dialysis including PET tests, weekly          K/DOQI guidelines for chronic renal
                    renal bone disease and its treatment, and    clearance, residual function, and             disease. Demonstrates knowledge
                    the causes and treatment of anemia in        membrane transport characteristics.           of treatment of glomerular and
Medical Knowledge




                    the dialysis patient. Demonstrates           Demonstrates knowledge of nutritional         tubular diseases, polycystic
                    understanding of nutritional needs of        needs of PD patients.                         diseases, and renal diseases
                    dialysis patients and renal dietary                                                        associated with systemic illnesses.
                    interventions. Demonstrates
                    understanding of issues of vascular access
                    and importance of monitoring access as
                    well as access choice.
                    Alters treatment plans in response to        Alters treatment plans in response to         Incorporates new K/DOQI
                    patient outcomes with regard to targets.     patient outcomes with regard to targets.      guidelines into practice as these
Practice Based




                    Adapts to use of bone disease and            Adapts to use of bone disease and             are developed. Applies new
                    anemia algorithms. Changes prescribing       anemia algorithms. Changes prescribing        information about treatment in
Learning




                    practices as needed to achieve unit          practices as needed to achieve unit           glomerular and interstitial disease.
                    therapeutic goals for adequacy, anemia,      therapeutic goals for adequacy, anemia,
                    bone disease and nutrition.                  bone disease and nutrition.
                         Effectively explains importance of              Effectively explains importance of              Effectively explains the risks of
                         treatment compliance, nutritional               treatment compliance, nutritional               early renal disease, and the need
Communication Skills     recommendations, and proper dialysis            recommendations, and proper dialysis            for interventions. Clearly outlines
                         access to patients and caregivers.              access to patients and caregivers.              treatment options. Explains biopsy
Interpersonal and

                                                                                                                         risks and benefit. Explains biopsy
                                                                                                                         results and their meaning. Writes
                                                                                                                         or dictates clear opinions and
                                                                                                                         recommendations to referring
                                                                                                                         physicians.


                         Interacts effectively with dieticians, social   Interacts effectively with dieticians, social   Is prompt and courteous; keeps
                         workers, nurses and technicians during          workers, nurses and technicians during          effective records; responds to
Professionalism and




                         rounds and meetings to ensure care is safe      rounds and meetings to ensure care is           referring MD; applies best care
                         and appropriate. Rounds on patients in          safe and appropriate. Rounds on                 options. Recognizes influences of
                         timely and efficient manner, answering          patients in timely and efficient manner,        physician based issues on ESRD
                         patient questions, and addressing issues.       answering patient questions, and                choice and avoids decisions based
                         Is courteous, discreet, and appropriate at      addressing issues. Is courteous, discreet,      on physician rather than patient
Ethics




                         all times.                                      and appropriate at all times.                   benefit.

                         Exhibits knowledge of governmental,             Exhibits knowledge of governmental,             Understands the problems
                         corporate, and unit guidelines and              corporate, and unit guidelines and              interactions of specialty and
                         regulations. Works with dieticians and          regulations. Works with dieticians and          primary care clinics regarding care
                         nurses in applying algorithms to achieve        nurses in applying algorithms to achieve        of chronic kidney disease patients.
                         bone disease and anemia guidelines.             bone disease and anemia guidelines.             Develops plans to increase
                         Attends care plan and QI meetings as            Attends care plan and QI meetings as            attention to CKD and early
Systems Based Practice




                         invited, participates in decisions regarding    invited, participates in decisions              intervention. Replies to consults in
                         long and short term patient plans, and          regarding long and short term patient           a manner that guides care by
                         reviews issues affecting water treatment,       plans, and reviews issues affecting safety      primary physician. Stresses
                         safety, and unit goal setting. Develops         and unit goal setting. Develops                 preparation for ESRD treatment
                         understanding of governmental                   understanding of governmental                   and avoids emergent or urgent
                         regulations and organizational guidelines       regulations and organizational guidelines       institution of dialysis. Arranges for
                         for dialysis care and dialysis unit             for dialysis care and dialysis unit             access placement in sufficient time
                         management.                                     management.                                     to allow fistula maturation to
                                                                                                                         occur.

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:41
posted:5/17/2011
language:English
pages:27