Knowledge objectives for Renal and Urology teaching

A detailed list of the areas that Year 4 Edinburgh medical students are expected to know about. Nephrology and Urology are broad-ranging subjects for which fine detail is mostly a post-graduate concern. Therefore we assign most importance to recognition of disease, and to assessing its significance and urgency. There is a danger that the potential scope of study beyond that may seem enormous. We have therefore been unusually detailed in describing our knowledge objectives below.

Anatomy and physiology

Basic anatomy of the urinary tract including vascular supply Recognise normal glomeruli and tubules histologically Basic mechanisms of glomerular filtration,tubular resorption and secretion,and handling of solute and water by the kidneys Detail of some specific transporters and the consequences to them of malfunction and drug therapy Mechanisms of bladder filling and emptying and maintenance of continence

Urinary abnormalities

Haematuria and proteinuria - pathophysiology of each Basis and sensitivity of stick tests for haematuria and proteinuria Pathways of tubular protein metabolism differences between glomerular and tubular proteinuria Important causes of haematuria Significance of positive results of screening tests Significance of associated signs of renal disease and of red cell morphology/casts Possible mechanisms for microalbuminuria,and its significance beyond renal disease Appropriate management of haematuria and proteinuria Polyuria - possible mechanisms with examples Mechanism of urine concentration; effects of ADH Some detail of diabetes insipidus;mechanisms,consequences. Mechanisms and consequences of osmotic diuresis Oliguria - major possible physiological and pathological explanations and how they can be distinguished clinically Features (incompletely)distinguishing compensatory oliguria from established acute renal failure ('ATN ')

Investigations

Imaging Principles and capabilities of major imaging modalities:ultrasound,CT,pyelography,arteriography Understanding of nuclear imaging,MRI Risks of intravenous and intra-arterial procedures Background,prophylaxis,alternatives Other investigations Estimation of renal function Capabilities and use of cystoscopy ureteroscopy also

Urinary tract obstruction

Presentation, (lack of) signs, possible locations and etiologies Diagnostic and therapeutic approaches to obstruction at different levels

Intrinsic renal diseases

Glomerular diseases Glomerulonephritis ­ range of clinical presentations; generic features Cell types (3),mechanisms of injury. Basis of differences between inflammatory and non-inflammatory glomerulopathies. Nephrotic syndrome ­ presentation, diagnosis, major complications, principles of management Short details of 5 important causes,primary and secondary - minimal change disease, FSGS, Membranous, diabetes mellitus, amyloidosis (but also remembering subacute inflammatory, including SLE) IgA nephropathy as the most common example of inflammatory glomerulonephritis;its range of presentations and outcomes. Some further details of the incidence,management,outcome of IgA nephropathy. Prognostic factors in IgA disease (most also true for other glomerular diseases) Other glomerulonephritis Post-streptococcal nephritis as the archetypal 'nephritic ' illness. Crescentic nephritis (RPGN): presentation, importance, occurrence in systemic diseases Short details of major systemic causes;especially small vessel vasculitis but also SLE (see 'systemic diseases and the kidney ') Diabetic nephropathy: presentation and prevention Some detail on incidence,association,prevention,management Inherited diseases: Alport syndrome (primary features only) Benign familial haematuria ' ­ in concept only   Tubulointerstitial diseases Presentation and characteristic urinary and other features Principal manifestations that may characterise tubular disorders (eg concentrating ability,salt-losing,acidosis,aminoaciduria) Polycystic kidney disease ­ presentation and major features of ADPKD That there are other causes of renal cysts, ± examples a little detail of ADPKD genetics, complications, prognosis, management Acute tubulointerstitial nephritis : important features of causation, presentation, and treatment of allergic AIN Some alternative causes or mechanisms of damage (infection,toxins,immune) Chronic TIN ­ outline knowledge of two important causes: Myeloma and Reflux nephropathy (q.v.) Vesicoureteric reflux, reflux nephropathy, and chronic pyelonephritis: their nature and interrelationships Little detail on each. Some evidence to support assertions about relationships.

Age and physiological states

Age ­ Age-associated changes in renal function Pregnancy: physiological changes and their effects on common tests (BP, blood tests). Recognition and immediate management of pre-eclampsia and eclampsia.Risk factors for pre- eclampsia The multiple presentations of pre-eclampsia and related diseases. Minimal knowledge of effect of pregnancy on pre-existing hypertension and renal disease.

Systemic disorders

Haematological Sickle cell anaemia ­ awareness that it may affect the kidney How (very briefly) HUS/TTP ­ presenting features and complications Basic understanding of pathogenesis,management and outcome of E.coli-associated HUS Infection Outline knowledge that chronic or subacute infections may cause secondary glomerulonephritis (other than by post-infectious glomerulonephritis). Bacterial endocarditis and the kidney Reactive amyloidosis.   Inflammatory and autoimmune disorders The ways in which systemic inflammatory diseases can affect the kidney Some knowledge of important causes: Small vessel vasculitis, SLE, Infection   Malignancy Myeloma ­ its effects on the kidney via hypercalcaemia and cast nephropathy Further understanding of myeloma kidney Understanding of nature of some other B cell dyscrasias (eg MGUS,amyloidosis, cryoglobulinaemia) - see Haematology Other tumours:via hypercalcaemia or other mechanisms Membranous nephropathy most commonly implicated   Metabolic Diabetes mellitus (see glomerular disorders)

Renovascular disease

Arterial disease Renal artery stenosis: principle causes,diagnosis,effects of ACE inhibition Best treatments ­ and uncertainty of Atheroemboli ­ as a possible consequence of investigations and otherwise.Major features. Major risk factors,treatment

Hypertension

Hypertension Relationship to renal disease Possible mechanisms That the effect of the kidney in hypertension is frequently paramount. Risk factors for decline in GFR Uncertainty that much renal failure is due to hypertension in the absence of pre-existing renal disease Malignant hypertension: consequences, treatment, importance of seeking cause Possible causes

Acute renal failure

Important categories and causes of acute renal failure Management and natural history of acute tubular necrosis (ATN) Simple pathophysiology of prerenal oliguria and ATN Causes of rapid loss of renal function - likely diseases,how to recognise them,implications for management: Obstruction; Vascular; Intrinsic: RPGN, ATN, Toxic Indications for referral/renal replacement therapy

Chronic Renal Failure and End Stage Renal Disease (ESRD)

Major consequences of CRF How to suspect and identify CRF Outline understanding of:anaemia,bone disease,non-specific effects Effects and practicalities of Epo administration Basic approach to prevention and treatment of osteodystrophy Progression of renal impairment regardless of cause of initial injury Preventive therapies and their effectiveness Role of dietary management

Renal replacement therapy

Patients with end stage renal failure managed by renal replacement therapy are increasingly commonly encountered. Although this used to be regarded as entirely the province of specialists, all doctors now need to be familiar with the outline of these conditions and of the therapeutic, sociological and ethical questions raised. Dialysis Basic principles and a sketchy outline of the practice of each of the major modalities, their chief advantages and disadvantages - PD/ HD/ haemofiltration Major causes of morbidity and mortality in the ESRF population Requirements for dialysis by each modality Transplantation The various origins of donor organs Principles and practicalities of brainstem death Practicalities of renal transplantation (when, where, how) Effects on quality of life and lifespan Pancreatic transplantation (outline and hazards of) Advantages and disadvantages Effects on quality of life and lifespan Consequences of longterm immunosuppression Basic mechanisms of action of major drugs A little detail of the mechanisms behind susceptibility to infections,cancer

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