SIU School of Medicine

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Department of Internal Medicine

Chronic Kidney Disease

Rationale

Most of the 20 million people with chronic kidney disease in the United States are not recognized and are not treated. Early detection and early treatment of this problem can prevent or delay adverse outcomes and progression to renal failure.

Knowledge

  • The stages in the progression of chronic kidney disease
  • How to identify patients at risk for chronic kidney disease
    • Autoimmune disorders
    • Repetitive urinary tract infections
    • Stones or anatomical problems of the urinary tract
    • Previous episode of acute renal failure
    • Hypertension
    • Diabetes
    • Loss of Renal Mass
    • Hereditary Kidney Disease
  • The markers of chronic kidney disease
    • Proteinuria
    • Persistently abnormal urine sediment
    • Abnormalities in serum chemistries
    • Abnormalities the urinary tract on ultrasound or CT scans
  • The methods for screening for proteinuria in high risk patients
  • Normal values of glomerular filtration rate and methods for estimation of GFR
  • The increased risk of cardiovascular disease in patients with chronic kidney disease
    • Stroke
    • Peripheral vascular disease
    • Coronary artery disease
    • Congestive heart failure
  • The therapeutic strategies to prevent progression of chronic kidney disease
    • Staging chronic kidney disease
    • Define etiology:
      • Diabetes
      • Glomerular diseases – autoimmune, systemic infections, drugs, neoplasia
      • Vascular diseases – large vessel disease, hypertension, microangiopathy, vasculitis
      • Urinary tract obstruction
      • Tubulointerstial disease – urinary tract infection, stones, drug toxicity, autoimmune, neprocalcinosis
      • Polycystic kidney disease and other hereditary renal disease
      • Diseases in the transplanted kidney – chronic rejection, drug toxicity, transplant glomerulopathy
    • Evaluating and managing co-morbid conditions
      • Glucose control in diabetics
      • Strict blood pressure control (understand target BP in CKD)
      • Use of ace inhibitors and angiotensin receptor blocking agents
      • Avoidance of acute decline in GFR
        • Volume depletion
        • Neprhotoxins
        • Urinary tract obstruction

Skills

Students should demonstrate specific skills, including:

  • History-Taking Skills: Students should be able to obtain, document, and present an age-appropriate medical history, that addresses the important contributors to progression of chronic kidney disease:
    • diabetes and glycemic control
    • hypertension
    • hyperlipidemia
    • body habitus, weight, and exercise
    • diet
    • nicotine use
    • Over-the-counter drug use (NSAIDS)
    • presence of vascular disease
  • Physical Exam Skills: Students should be able to perform a physical exam which includes
    • accurate blood pressure measurement
    • fundoscopic examination and identification of retinal changes of chronic hypertension and diabetes.
    • examination of the carotid arteries, aorta, renal and femoral arteries for bruits
    • cardiac auscultatioin and identification of S3, S4, and the systolic murmur of aortic stenosis
    • examination of the face, presacral region, lower extremities and abdomen for edema and ascites
  • Differential Diagnosis: Students should be able to generate a differential diagnosis for each patient with attention to probabilities based on history, urine findings and exam.
  • Laboratory Interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment
    Laboratory and diagnostic tests should include, when appropriate:
    • Renal U S
    • VA
    • CMP
    • CBC
    • PO4
    • P7H
    • Glycohemmoglobin
    • serologies
      • ANCA
      • ANA
      • compliant
    • SPEP/UPEP
    • renal biopsy
  • Students should be able to define the indications for and interpret (with consultation) the significance of the results of
    • urinalysis
    • renal VS
    • serum chemistries
    • renal biopsy
  • Communication Skills: Students should be able to:
    • communicate the diagnosis, treatment plan, and subsequent follow-up to patients
  • Management Skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes:
    • BP management
    • CKD rise factor modification
    • diabetes management
    • anemia management
    • pre-dialysis educaiton

Attitudes and Professional Behaviors

Students should be able to:

  • appreciate the impact that chronic kidney disease has on a patient’s quality of life, well-being, ability to work, and the family
  • recognize the importance of and demonstrate a commitment to the utilization of other healthcare professions in the treatment and prevention of chronic kidney disease

Resources

  • Clerkship Seminar, “Chronic Kidney Disease,” M. Weaver, MD
  • Internal Medicine Clerkship Guide, Paauw, et al, Mosby 2003, pp 170-174
  • Nephrology Clerkship Information

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