Prepared by the Education Advisory Committee of the International Society of Nephrology

Goals of Training

At the conclusion of a postgraduate training program in Nephrology, the trainee should be competent to provide an independent consulting and management service for the care of patients with kidney disease, with disordered fluid and electrolyte balance (with or without kidney disease), or with hypertension.

In providing such service, the trainee should have acquired the specialized knowledge and skills detailed below, but also the generic attributes of a consultant physician.

These include attitudes and behaviors consistent with

• high personal and professional ethical standards
• an approach to practice which is centered on patients' needs
• a commitment to provide service and care to patients of all sociocultural and age groups
• acceptance of the need to work with colleagues in a multidisciplinary team
• a willingness to devote time to teaching students and junior colleagues
• a commitment to continuing professional self-education

Syllabus

I. REQUIRED COMPETENCIES

Competencies Regional variations
[examples only]

1. Patient-based Competencies
   Make a clinical assessment and direct the management of a patient presenting with:
   1. disturbed fluid and electrolytes balance, including hypervolemia, hypovolemia, and abnormalities of plasma Na and K concentration
      Including the management of patients with cholera in Asia
   2. disturbed acid-base balance, with a particular emphasis on metabolic acidosis and alkalosis
      Regional inherited forms of renal tubular acidosis in Asia
   3. disturbed bone and mineral metabolism, including abnormalities in plasma Ca, Mg and phosphate, renal osteodystrophy and urinary tract stone disease
      Regional variations in stone etiology
   4. urinary tract infection and/or obstruction Renal tuberculosis
      Schistosomiasis in Africa
   5. tubulointerstitial diseases Chinese herb nephropathy
      Leptospirosis
   6. glomerular disease: including primary glomerular disease presenting as nephritic syndrome, nephrotic syndrome, and asymptomatic hematuria/proteinuria, as well as systemic diseases such as HCV, vasculitis, SLE and amyloidosis
      Parasitic nephropathy in the tropics
      Hemolytic-uremic syndrome in South America
      AIDS nephropathy in Africa
   7. diabetic nephropathy Diabetic nephropathy in indigenous populations
   8. hypertension, particularly when associated with evidence for renal disease or dysfunction
   9. renal functional impairment of uncertain etiology Balkan nephropathy
   10. acute renal failure, including the critically ill patient in an intensive care setting
       Tropical causes of ARF: toxins, venoms, infections
   11. chronic kidney disease, including the management of pre-end stage disease as well as renal replacement therapy (modes of dialysis) for ESRD
   12. a request or indication for renal transplantation, or a functioning renal transplant [to include selection, preparation, post op care, management of immunosuppression, common medical complications, etc]
   13. inherited renal disease
   
   N.B. Experience in relation to each of the above competencies should ideally be acquired in a range of patient groups, including;
   • children
   • pregnant women
   • the elderly
   
    
2. Population-based Competencies
   1. Source and interpret the best available epidemiological evidence to guide the management of a patient presenting with kidney disease
   2. Design a research protocol to ascertain the burden of kidney disease in a national or regional population
   3. Implement a strategy for the prevention of kidney disease in a defined patient population
      Diabetic nephropathy in indigenous populations
      Endemic stone disease
   4. Promote the support by health systems of programs for treating patients with renal disease, and contribute to the cost-effective implementation of such programs
   5. Participate in the management of health services so as to achieve optimal allocation of resources for the care of patients with kidney disease

II. REQUIRED KNOWLEDGE AND SKILLS

Knowledge
Trainees should be able to draw on a comprehensive knowledge base, sufficient to understand clinical problems and support optimum patient care decisions, in the following areas.

• K1 Basic Renal Sciences
  • K1.1 Anatomy and histology of the normal kidney
  • K1.2 Embryology of the kidney and urinary tract
  • K1.3 Normal fluid and electrolyte homeostasis
  • K1.4 Physiology of glomerular filtration
  • K1.5 Physiology of tubular function
  • K1.6 Renal endocrinology, especially erythropoietin and Vitamin D
  • K1.7 Renal pharmacology, especially diuretic, immunosuppressive and antibiotic agents
  • K1.8 Immunology of infection and transplant rejection
  • K1.9 Molecular biology and genetics relevant to the kidney
• 
  K2 Renal Pathology, Pathophysiology, Immunology and Microbiology
  • K2.1 Patterns of abnormal microscopic structure in the kidney, including the basic histopathology of common renal diseases*
  • K2.2 Pathophysiology of disturbed metabolism of water, sodium, potassium, acid, calcium, magnesium and phosphate, due to renal and extra-renal diseases
  • K2.3 Immunopathology of glomerulonephritis and interstitial nephritis
  • K2.4 Pathogenesis of diabetic nephropathy and other systemic diseases affecting the kidney*
  • K2.5 Microbiology and pathogenesis of urinary tract infection
  • K2.6 Pathophysiology of urinary tract obstruction
  • K2.7 Pathogenesis of essential hypertension and hypertension in renal and endocrine disorders
  • K2.8 Pathophysiology of progressive kidney disease
  • K2.9 Etiological factors and pathogenesis relevant to environmental kidney disease
  • K2.10 Pathophysiology of renal transplant rejection
  *Note that in this and subsequent sections emphasis should be placed on conditions which are common in the region where the trainee is working.
• 
  K3 Clinical Manifestations and Natural History of Kidney Disease and Hypertension
  • K3.1 Patterns of clinical presentation of kidney disease, and the approach to differential diagnosis of common presenting syndromes
  • K3.2 Natural history of specific kidney diseases, both primary (especially glomerulonephritis) and secondary (especially diabetic nephropathy)
  • K3.3 Kidney disease and hypertension in pregnancy
  • K3.4 Pathogenesis of characteristic features of acute and chronic kidney failure
  • K3.5 Endorgan disease and clinical consequences in hypertension
  • K3.6 The short- and long-term course of renal transplantation
• 
  K4 Investigation and Diagnosis of Kidney Disease and Hypertension
  • K4.1 Comprehensive renal function testing: assessing glomerular and tubular function
  • K4.2 Immunological investigations in kidney disease
  • K4.3 Rationale and interpretation of urinalysis, urine microscopy, urine culture and sensitivity testing
  • K4.4 Indications for and interpretation of renal biopsy
  • K4.5 Hormone and cytokine assays in the investigation of kidney disease and hypertension
  • K4.6 Radiological and other imaging modalities in the investigation of kidney disease and hypertension
  • K4.7 Molecular biology in the diagnosis of kidney disease
• 
  K5 Treatment of Kidney Disease and Hypertension
  • K5.1 Nutrition and dietary management of kidney disease, before and after end stage renal failure
  • K5.2 Other non-pharmacological measures in the management of kidney failure
  • K5.3 Drug therapies for kidney disease and its complications
  • K5.4 Non-pharmacological measures and drug therapy of hypertension
  • K5.5 Renal replacement therapy using dialysis: principles of prescribing and monitoring peritoneal dialysis (including CAPD) and hemodialysis
  • K5.6 Renal transplantation: patient selection and preparation, immunosuppressive therapy, acute and long term postoperative management
  • K5.7 Published guidelines for management of common kidney disorders as well as complications of kidney failure
• 
  K6 Clinical Epidemiology, Prevention and Population Health
  • K6.1 The principles of Evidence-Based Medicine: evaluation and application of findings from the clinical research literature
  • K6.2 Epidemiology of disease in populations: outbreaks and trends
  • K6.3 Research-based interventions in populations with kidney disease
  • K6.4 Clinical trial design and implementation
  • K6.5 Basic research methodology, including biostatistics
• 
  K7 Miscellaneous
  • K7.1 Ethical issues in management of patients with ESRD (such as patient selection for dialysis and transplantation, donor selection, resource allocation, etc.)
  • K7.2 Advocacy for cost effective care of patients with kidney disease
  • K7.3 Public education focused on prevention of kidney disease

Skills

Trainees should achieve competence and confidence in performing the following clinical skills (refer also to the Postgraduate Training Guidelines).

• S1 Perform a complete clinical history and physical examination of a patient presenting with kidney disease and/or hypertension (to include digital rectal examination and fundoscopy).
• S2 Integrate all clinical and investigative findings into a coherent diagnosis, with formulation of a differential diagnosis, management plan and prognosis
• S3 Perform a dipstick urinalysis, and fresh urine microscopy to detect cellular elements, crystals and casts
• S4 Perform a transcutaneous renal biopsy, under local anesthetic, on a native or transplanted kidney
• S5 Place temporary intravascular lines for hemodialysis access
• S6 Connect a patient to the hemodialysis circuit [desirable]
• S7 Place an acute peritoneal catheter [optional, as required by conditions]
• S8 Place a Tenchkoff catheter (or equivalent) for commencing CAPD [optional]
• S9 Perform a urinary tract ultrasound examination [desirable]
• S10 Assess and manage a poorly functioning vascular access device (shunt or fistula)

Methods of Learning and Assessment

Depending on local expertise and facilities, the following educational methods may be employed in the implementation and assessment of this curriculum. It is recommended that a range of teaching and learning methodologies be used for maximum enrichment of the training experience.

The overall philosophy of training is that it should empower the trainee to provide competent patient care under supervision, with growing responsibility for independent decision-making.

1. Self-directed learning by use of Library materials (texts and journals) and on-line resources
2. Participation in Journal Clubs or equivalent formats for maintaining familiarity with current trial evidence and new advances
3. Formal teaching by lectures, tutorials or demonstration sessions
4. Case presentations and discussions with supervisor and clinical department members
5. Maintaining a logbook of cases managed and procedures performed
6. Assessment of trainee competence should utilize more than one of the following tools:
   • multiple choice questions
   • modified essay questions (case-based)
   • review of clinical records kept
   • observation of consulting and procedural skills by senior colleague(s)
   • survey of observations of trainee performance made by colleagues, non-medical staff and patients

November 2004