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  1. 1. Nephrology Goal Nephrology involves disease of the kidneys, its contiguous collecting system, and its vasculature. The kidneys play a key role in fluid, electrolyte, and acid-base regulation and are affected by a wide range of systemic disorders, drugs, and toxins. The general internist should be competent to evaluate and appropriately refer patients with glomerular disorders, asymptomatic urine abnormalities, tubulointerstitial diseases, renal vascular disease, renal failure, nephrolithiasis, tubular defects, and infections and neoplasms of the kidneys, bladder, and urethra, and should also be able to provide principal treatment for some of these conditions. He or she should be able to manage fluid, electrolyte, and acid-base disorders; understand the ways in which systemic diseases may affect the kidneys; and recognize the potential nephrotoxicity of various therapeutic and diagnostic agents. The general internist must also be familiar with guidelines for pre-dialysis management of patients with renal failure and be able to recognize indications for dialysis and for referral to a nephrologist. The range of competencies in managing renal disease will depend on the availability of a nephrologist to the primary care internist. Although all general internists should know the indications for dialysis, in some cases (for example, if a nephrologist is unavailable), the general internists may be responsible for initiating and maintaining patients on peritoneal dialysis. In most situations, hemodialysis will be the responsibility of a nephrologist, as will renal biopsies and nephrostomy tube placement. Lead Faculty Sean Leavey, MD Objectives 1 0 Patient Care and Medical Knowledge 1 A Resources 1 A Utilize the extensive resources electronic, paper-based, and person-based (physician consult services, social work, nursing, pharmacy, practice management, other allied health professionals) available to help residents taking care of patients with nephrology related problems 1 B Core Knowledge 1 B Demonstrate ability to use the serum creatinine concentration to estimate Glomerular Filtration Rate. Explain the assumption of steady-state concentration. Discuss shortcomings of creatinine-based methods of estimating GFR 1 B Demonstrate ability to interpret a spot protein-to-creatinine ratio and/or a spot albumin-to-creatinine ratio on a random urine sample as a marker of kidney damage and a quantitative measure of proteinuria. Relate this test to 24-hour urine results. 1 B Recognize that 24 hour urine collections for the purposes of
  2. 2. 1.) GFR estimation from creatinine clearance 2.) Diagnosing and following proteinuria are not superior to the spot tests above (in the majority of situations) 1 B Know the patient populations at risk for chronic kidney disease 1 B Discuss risk factors for acute renal failure in out- and in-patient settings 1 B Categorize based on both frequency of occurrence and on dominant pathological site(s) of injury (Pre-renal, Intra-renal [includes vascular, glomerular, tubular and interstitial] and Post-renal) the causes of: • Chronic Kidney Disease • Acute Renal Failure 1 B Define and List the most common causes of: • Nephrotic syndrome • Rapidly progressive glomerulonephritis Define and List the most common causes of: • Isolated hematuria (i.e. without other abnormalities) • Isolated proteinuria (i.e. without other abnormalities) • Hematuria and proteinuria without a decreased GFR 1 B Discuss the physiological concept of clearance and apply this to: Native renal function (GFR) and, Principles governing solute clearance by peritoneal dialysis, intermittent hemodialysis, and continuous renal replacement therapy Principles governing handling of medications by the kidney 1 B Discuss the pathophysiology underlying normal and abnormal proteinuria Define nephrotic-range proteinuria, glomerular proteinuria, tubular proteinuria, Benz-Jones protein 1 B Describe the basic metabolic, homeostatic regulatory functions and endocrine functions of the kidney 1 C History-Taking 1 C Elicit history of / distinguish risk factors for acute and chronic renal disease 1 C Demonstrate consistent ability to use history and historical records thoroughly to determine temporal duration of kidney disease 1 C Elicit specific symptoms of a genitourinary systems review 1 C Elicit symptoms of uremia 1 C Elicit symptoms of systemic disease and understand the diagnostic and therapeutic importance of seeking associated renal involvement 1 C Elicit medication history (prescribed and over-the-counter) and completely explore potential contributions and ongoing risks for adverse drug effects 1 C Elicit family history of kidney disease 1 C Elicit symptoms of comorbid conditions and complications related to kidney failure (diabetes, accelerated atherosclerosis, hypertension, anemia, salt and water retention, mineral and bone disease, malnutrition, neuropathy, sexual dysfunction, electrolyte and acid-base disturbance) 1 D Physical Exam 1 D Demonstrate performance of physical exam to accurately assess: • Blood pressure
  3. 3. • Cardiovascular system • Volume status: signs of overload or depletion • Signs of Uremia • Presence of enlarged urinary bladder • Presence of ballotable kidneys and/or kidney transplant • Evidence of atherosclerotic disease • Evidence for cormorbid diseases (including systemic diseases such as SLE and vasculitis) • Evidence of atheroembolic disease • Signs of complications of uremia 1 E Urinalysis 1 E Demonstrate ability to read a urine dipstick 1 E Demonstrate ability to recognize RBCs, WBCs, tubular, transitional and squamous epithelial cells, and bacteria on microscopy of urine sediment. Discuss potential sources of origin of each constituent. 1 E Demonstrate ability to recognize hyaline, granular and cellular casts (red cells, white cells and tubular epithelial cells). Discuss pathophysiology of their formation and source of origin. 1 E Demonstrate an ability to interpret quantitative estimates of proteinuria (dipstick, spot protein-to-creatinine ratio, 24 hour urine collection) Discuss the pathophysiology leading to abnormal proteinuria 1 F Integrate core knowledge, history taking, physical exam, serum chemistries and urinalysis and, plan further diagnostic evaluation 1 F For each of the clinical problems and/or disease processes listed below, describe expected presentations in terms of symptoms, signs, serum chemistries and pattern of urinalysis findings and discuss differential diagnosis: • Pre-renal renal failure • Diabetic nephropathy • Hypertensive nephrosclerosis • Atheroembolic kidney disease • Renovascular disease • Nephritic Syndrome • Nephrotic syndrome • Acute tubular necrosis • Tubulo/interstitial renal diseases • Cystic kidney diseases • Iatrogenic renal toxins (e.g., NSAIDs, contrast dye, etc.) • Renal stone disease • Post-renal renal failure 1 F Demonstrate ability to interpret in the context of varied clinical presentations, and in an integrative manner, measurements of serum electrolytes and osmolarity, arterial blood gas parameters, urine electrolytes and osmolarity. Be able to use these interpretations to assist in formulating differential diagnoses of patients with: • Acute renal failure
  4. 4. • Chronic kidney disease • Clinical disorders of salt and water metabolism • Clinical disorders of major electrolytes (K+, Ca2+, Mg2+, PO42- ) • Clinical acid-base disorders • Renal stone disease 1 F Define the implications for urgency of diagnostic evaluation of a decreased GFR of acute or undetermined duration in contrast to a chronic duration 1 F Define the implications for urgency of diagnostic evaluation of an active urine sediment (white and red cells, granular casts, +/- cellular casts) in the setting of a decreased GFR 1 F Describe the relative merits, indications for, and information gained from diagnostic imaging studies including ultrasound, CT, IVP, conventional and MR angiography, MR urography, antegrade and retrograde urography, cystoscopy, and radioisotope studies in investigations of: • Hypertension • Hematuria • Acute renal failure • Chronic Kidney Disease • A patient with a renal cyst, mass or abnormality of the lower urinary tract • Lower urinary tract disease 1 F Describe, in the context of the pretest probabilities for specific renal diseases, the discriminant value and appropriate ordering of the following serologic tests: • Serum complement components • Anti- neutrophil cytoplasmic antibody • Anti- glomerular basement membrane antibody • ANA, anti double-stranded DNA, Anti- cardiolipin antibodies • Hepatitis serologies • Cryoglobulins • Serum Protein Electrophoresis • Urine Immunoelectrophoresis • Serum and urine eosinophils 1 F List the indications for renal biopsy List the risks and relative and absolute contraindications of renal biopsy Discuss the implications for patient choice if there is a low versus high probability for underlying treatable disease Discuss the implications of the possibility of a rapidly progressive yet potentially treatable underlying disease for urgency of biopsy 1 G Effective Patient Management Plans 1 G Be able to coordinate multidisciplinary care and develop management plans based on medical evidence for patients across the full spectrum of diseases and presentations that lead to: • Acute renal failure • Chronic kidney disease Be able to coordinate multidisciplinary care and develop management plans based on medical evidence for patients across the full spectrum of diseases and
  5. 5. presentations that lead to: • Clinical disorders of salt and water metabolism • Clinical disorders of major electrolytes (K+, Ca2+, Mg2+, PO42- ) • Clinical acid-base disorders • Infections of upper and lower urinary tract • Other lower urinary tract disease 1 G Blood Pressure Control Recognize importance of achieving blood pressure control to prevent progression of chronic kidney disease. Know the evidence for this. Identify blood pressure control targets for preventing progressive disease Discuss the role of converting enzyme inhibitors and/or angiotensin receptor blockers in preventing kidney disease progression 1 G Vascular Risk factor reduction Identify chronic kidney disease as an indications for aggressive cardiovascular risk factor reduction 1 G Develop and apply specific skills appropriate to the management of: • Fluid and electrolytes in patients with Acute Renal Failure • Fluid and electrolytes in patients with chronic kidney diseases • Hypertensive urgencies and emergency • Avoidance of unnecessary nephrotoxic exposures • Prophylaxis of radiocontrast associated nephropathy in at-risk patients • Dietary modification in the acute and chronic renal failure • Anemia and iron deficiency in kidney disease • Ca, Phosphorus and parathyroid hormone in kidney disease • Upper and lower urinary tract infection • Nephrolithiasis 1 G Recognize the need for coordinated disease-specific management plans in: • Patients with various glomerulonephritides • Patients with renal vasculitis • Patient with lupus nephritis • Patients with acute interstitial nephritis • Patients with progressive chronic kidney diseases 1 H Dialysis for End-stage renal disease (ESRD) and Acute Renal Failure 1 H Know the appropriate GFR for initiating timely (well enough in advance of anticipated end-stage kidney disease): • Patient education regarding ESRD • Renal replacement modality selection • Transplant evaluation • Vascular access preparation Discuss referral of chronic kidney disease patients to nephrology clinic 1 H Be able to describe: Indications for dialysis acute and chronic Relative advantages / disadvantages of hemodialysis vs. peritoneal dialysis Concept of adequate /optimal dialysis Preferred vascular access for maintenance hemodialysis
  6. 6. The large burden of morbidity accruing from catheter-related infections Relative merits of continuous renal replacement (CVVHD) vs. Intermittent hemodialysis in acute renal failure 1 I Kidney Transplantation 1 I Recognize the need for early kidney transplant evaluation to: • Facilitate early identification of potential living donors • Facilitate preemptive transplantation where possible • Facilitate early activation of suitable patients on cadaveric wait-list (UNOS listing criteria GFR < 20cc/min) 1 I Be able to describe: • Side effects, drug interactions and blood level monitoring of common transplant immunosuppressive drugs • Discuss antibiotic and antiviral prophylaxis post transplant • Differential diagnosis and investigation of increased creatinine in transplant patients and the role of transplant renal biopsy 1 I Recognize the symptoms and signs and discuss the diagnosis, management and prevention of: Acute rejection Cyclosporin nephrotoxicity Chronic allograft nephropathy Cytomegalovirus infection Other opportunistic infections Allograft pyelonephritis Post-transplant lymphoproliferative disease Neoplasia – skin, other Atherosclerotic vascular disease Hypertension Post-transplant bone disease Recurrent kidney disease 1 J Drug Dosing 1 J Be able to access information to guide: Drug dosing adjustments based on GFR Drug interactions in patients with kidney diseases 1 K Procedures 1 K Perform a dipstick urinalysis and prepare urine sediment for microscopy Perform bladder catheterization 1 L 3 0 Practice Based Learning and Improvement 3 A Be able to access and utilize the extensive resources electronic, paper-based, and person-based (physician consult services, social work, nursing, pharmacy, practice management, other allied health professionals) available to help residents taking care of patients with nephrology related problems Be able to access clinical practice guidelines: National Kidney Foundation K/DOQI clinical practice guidelines for standards of care in chronic kidney disease and maintenance dialysis patients Perform independent research for evidence-based practice in response to specific
  7. 7. clinical questions arising from patient-care experiences Engage actively in feedback 3 A Maintain an attitude of healthy skepticism and curiosity, as evidenced by thoughtful questioning, independent study, and critical analysis of published materials. 3 A Develop a willingness and ability to learn from errors and use them to improve individual practice and the health care delivery system. 3 A Utilize information technology to enhance patient education. 3 E 4 0 Interpersonal and Communication Skills 4 A Effectively coordinate multidisciplinary involvement (primary in-patient service, physician consult services, social work, nursing, pharmacy, practice management, other allied health professionals) in patient care Communicate effectively with patients, family members, dieticians, social work, nursing, other physicians, other providers in the care of ESRD patients Coordinate effectively multidisciplinary patient care Accurately describe the risks and benefits of renal replacement therapy for informed consent Discuss the impact of renal replacement therapy on quality of life 4 A Conduct all interviews with patients and their families in a compassionate, culturally-effective, and patient-centered manner. 4 A Complete all dictations, letters, and consultation requests in a timely manner. 4 E 5 0 Professionalism 5 A Discuss ethical principles in clinical practice Describe present approaches to counseling patients on end-of-life decision making in ESRD (including withdrawal from dialysis) 5 A Demonstrate a personal sense of altruism by consistently acting in one’s patients’ best interest. 5 A Know how to inform patients and obtain voluntary consent for the general plan of medical care and specific diagnostic and therapeutic interventions. 5 A Provide meaningful feedback to colleagues and students regarding performance and behavior. 5 E 6 0 Systems Based Practice 6 A Interact with and utilize social workers, nurses, medical assistants, billing coordinators, and referral coordinators to provide effective, comprehensive patient care. 6 A Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and disease management 6 A Review the epidemic growth in end-stage renal disease and describe contributions of diabetes and/or hypertension 6 A Describe individual and societal costs of ESRD 6 A Acknowledge the extent of undiagnosed and inadequately treated chronic kidney disease 6 A Discuss the systematic scope for prevention of ESRD
  8. 8. Teaching Methods Teaching Rounds Conferences Patient Evaluations Selected Readings Evaluation Learning goals are established with each intern, resident, and fellow by the attending at the beginning of the month. Formative face-to-face feedback to interns, residents, and fellows by attendings occur at mid-month. Each month, the Nephrology attendings complete written evaluations of interns, residents, and fellows and these learners evaluate the Nephrology attendings. Interns, residents, and fellows also evaluate the rotation informally through advisor meetings and contact with CMRs. Resources Electronic • UpToDate. Excellent regularly updated and extensively referenced electronic textbook. All residents have web access to this program. Nephrology section is very complete. • PubMed and UM-Medsearch through Taubman library provide access to MEDLINE database and Best Evidence and Cochrane databases • Full-text access to on-line medical journals through Taubman medical library • Nephrology homepage has online curriculum and conference schedule. • web page of National Kidney Foundation. Excellent source for Clinical Practice Guidelines in chronic kidney disease. • useful university of Michigan transplant resource • extensive nephrology links, news and on-line presentations recorded at national and international nephrology meetings Paper-Based • Traditional medical textbooks. Provide basic background and approach to kidney disease suggestions include: “Approaches to the Diagnosis and Management of Renal and Electrolyte Diseases” in the Kelley Textbook of Internal Medicine, Second Edition, pps 760-872 or “Disorders of the Kidney” in the Kelley Textbook of Internal Medicine, Second Edition, pps 703-759 or the comparable sections in Harrison’s or Cecil's Textbook of Medicine. • Nephrology curriculum reference folder. Multiple excellent review articles and seminal clinical articles in nephrology, arranged with topic index see attached reference list. (available in nephrology library Taubman C, Internal medicine resident library (Sherry Reise), nephrology fellows
  9. 9. room behind hemodialysis unit 7th floor university hospital and in 5b conference room) Person-based Nephrology faculty are uniformly available to meet individually with residents on request to discuss issues, provide career guidance information, research mentoring and advice. Interested residents should discuss with nephrology fellowship program director (Dr. Brosius) support available for attending the annual American Society of Nephrology meetings. Articles in curriculum reference folder: General and Glomerular Disease: Cattran, DC, A Controlled trial of cyclosporine in patients with progressive membranous nephropathy. Kidney International 1995; 47: 1130-1135 Falk RJ, Jennette JC. ANCA Small-Vessel Vasculitis. J AM SOC NEPHROL 1997; 8(2): 314-322 Galla, John. IgA Nephopathy. Kidney International 1995; 47: 377-387 Greenberg A (ed) Glomerular Disease, in Primer in Nephrology, Section 3, San Diego, Academic Press, 1998, pp 127-182 Greenberg A (ed) Structure and Function of the Kidney and Their Clinical Assessment, in Primer in Nephrology, Section 1, San Diego, Academic Press, 1998, pp 3-56 Hricik DE, Chung-Park M, Sedor JR. Medical Progress: Glomerulonephritis. N Engl J Med 1998; 339: 888-899 Jindal, Kailash. Management of Idiopathic Crescentic and Diffuse Proliferative Glomerulonephritis: Evidence Based Recommendations. Kidney International 1999; 55 (Supp 70): S33-S40. Levin, Adeera. Management of Membranoproliferative Glomerulonephritis: Evidence Based Recommendations. Kidney International 1999; 55 (Supp 70): S41-S46 Levy, Andrew S. Measurement of renal function in chronic renal disease. Kidney International 1990; 38: 167-184 Muirhead, Norman. Management of Idiopathic Membranous Nephropathy: Evidence-based recommendations. Kidney International 1999; 55 (Supp 70): S47- S55 ONeill, W. Charles. Sonographic Evaluation of Renal Failure. AJKD 2000; 35:6: 1021-1038 Orth SR and Eberhard R. Medical Progress: The Nephrotic Syndrome. N Engl J Med 1998; 338: 1202-1201 Pollock C, Dysmorphysm of urinary red blood cells—Value in diagnosis. Kidney International 1989; 36: 1045-1049 Remuzzi, Giuseppe; Bertani, Tullio. Mechanisms of Disease: Pathophysiology of Progressive Nephropathies. N Engl J Med 1998; 339: 1448-1456 Rose BD, Post TW, Narins RG. Introduction to Renal Function, in Clinical Physiology of Acid-Base and Electrolyte Disorders, 4th ed, McGraw Hill, New York, 1994
  10. 10. Russo D, Additive Antiproteinuric Effect of Converting Enzyme Inhibitor and Losartan in Normotensive Patients with IgA Nephropathy. Am Journal Kid Dis 1999; 33:851-856 Systemic Disease with Renal Manifestations Cameron, JS. Lupus Nephritis. J AM SOC NEPHROL 1999; 10(2) DeFronzo RA, Renal Function in Patients with Multiple Myeloma. Medicine 1978; 57(2):151-166 Donohoe, John. Scleroderma and the Kidney. Kidney International 1992; 41: 462- 477 Gault MH, Barrett BJ. Analgesic Nephropathy. AM J KIDNEY DIS 1998; 32(3):351-360 Gertz Morie and Kyle, Robert. Primary Systemic Amyloidosis—A Diagnostic Primer. Mayo Clin Proc 1989; 64:1505-1519 Greenberg A (ed)The Kidney in Systemic Disease, in Primer in Nephrology, Section 4, San Diego, Academic Press, 1998, pp 183-246 Hou, Susan. Pregnancy in Chronic Renal Insufficiency and End-Stage Renal Disease. Am J Kidney Dis 1999; 33(2): 235-252 Johnson WJ, Treatment of Renal Failure Associated with Multiple Myeloma: Plasmapheresis, Hemodialysis, and Chemotherapy. Arch Int Med 1990; 150: 863-869 Johnson, RJ, Renal Manifestations of Hepatitis C Virus Infection. Kidney International 1994; 46: 1255-1263 Klotman, Paul. HIV-associated Nephropathy. Kidney International 1999; 56: 1161- 1176 Lewis R and Kamath S. Ascites and Hepatorenal Syndrome: Pathophysiology and Management. Mayo Clinic Proceedings 1996; 71: 874-881 Perneger TV, Risk of Kidney Failure Associated with the Use of Acetaminophen, Aspirin and Nonsteroidal Antiinflammatory Drugs. N Engl J Med 1994; 331(25): 1675-1679 Schwartz, Melvin, Role of Pathology Indices in the Management of Severe Lupus Glomerulonephritis. Kidney International 1992; 42: 743-748 Diabetes and Renal Disease Brancatti FL, Risk of End-stage Renal Disease in Diabetes Mellitus: A Prospective Cohort Study of Men Screened for MRFIT. JAMA 1997; 278: 2069- 2074 Breyer J: Diabetic Nephropathy, in Greenberg A (ed): Primer on Kidney Disease, chp 29. San Diego, Academic Press, 1999, pp215-219 Lewis, EJ. The Effect of Angiotensin-Converting-Enzyme Inhibition of Diabetic Nephropathy. N Engl J Med 1993; 329: 1456-62 The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin dependent diabetes mellitus. N Engl J Med 1993; 329: 977-986
  11. 11. Acid-Base and Electrolyte Disorders Adrogue HJ and Madias NE. Medical Progress: Management of Life-Threatening Acid-Base Disorders: First of Two Parts. N Engl J Med 1998; 338:26-34 Adrogue HJ and Madias NE. Medical Progress: Management of Life-Threatening Acid-Base Disorders: Second of Two Parts. N Engl J Med 1998; 338:107-111 Battle DC, The Use of Urinary Anion Gap in the Diagnosis of Hyperchloremic Metabolic Acidosis. N Engl J Med 1988; 318: 594-9 Brown, RS. Extrarenal potassium homeostasis. Kidney International 1986; 30: 116- 127 Chesney RW and Jones DP. Renal Tubular Syndromes. Current Nephrology 1996: 1-31 DeFronzo RA and Their SO. Pathophysiologic Approach to Hyponatremia. Arch Int Med 1980; 140:897-902 Gennari FJ. Current Concepts: Hypokalemia. N Engl J Med 1998; 339: 451-458 Greenberg A (ed) Acid Base, Fluid, and Electrolyte Disorders, in Primer in Nephrology, Section 2, San Diego, Academic Press, 1998, pp 57-126 Hamm LL. Renal Handling of Citrate. Kidney International 1990; 38:728-735 Harrington JT and Cohen JJ. Clinical Disorders of Urine Concentration and Dilution. Arch Int Med 1973;131:810-825 Narins RG and Emmett M. Simple and Mixed Acid Base Disorders: A Practical Approach. Medicine 1980; 59(3): 161-187 Oster JR and Epstein M. Acid-Base Aspects of Ketoacidosis. Am J Nephrol 1984; 4: 137-151 Rimmer JM, Gennari FJ. Metabolic Alkalosis. J Intensive Care Med 1987;2:137-150 Rose, BD. New approach to disturbances in the plasma sodium concentration. AJM 1986; 81:1023-1040 Sherman RA and Eisinger RP. The Use (and Misuse) of Urinary Sodium and Chloride Measurements. JAMA 1982; 247:3121-4 Swartz RD, Correction of Postoperative Metabolic Alkalosis and Renal Failure by Hemodialysis. Annals of Internal Medicine 1977; 86:52-55 Acute Renal Failure: Pathophysiology and Treatment Anderson RJ, Nonoliguric Acute Renal Failure. N Engl J Med 1977; 296: 1134-1138 Belenfant X, Meyrier A, and Jacquot C. Supportive Treatment improves Survival In Multivisceral Cholesterol Crystal Embolism. Am J Kidney Dis 1999; 33:840-850 Conger JD. Interventions in Acute Renal Failure: What Are the Data? AM J KIDNEY DIS 1995; 26:565-576 Denton M, Chertow GM, and Brady HR. “Renal Dose” Dopamine for the Treatment of Acute Renal Failure: Scientific Rationale, Experimental Studies, and Clinical Trials. Kidney International 1996; 49:4-14 Klahr S and Miller SB. Acute Oliguria. N Engl J Med 1998; 338:671-675 Mehta RL. Continuous Renal Replacement Therapies in the Acute Renal Failure Setting: Current Concepts. Advances in Renal Replacement Therapy 1997; 4:81- 92
  12. 12. Miller TR, Urinary Diagnostic Indices in Acute Renal Failure: A Prospective Study. Ann Int Med 1978; 89: 47-50 Nolan CR and Anderson RJ. Hospital –Acquired Acute Renal Failure. J AM SOC NEPHROL 1998; 9:710-8 Ravi T, Pascual M, Binventre JV. Medical Progress: Acute Renal Failure. N Engl J Med 1996; 334:1448-1460 Rudnick MR, Contrast Media-Associated Nephrotoxicity. Seminars in Nephrology 1997; 17:15-26 Solomon R, Effects of Mannitol, and Furosemide on Acute Decreases in Renal Function Induced by Radiocontrast Agents. N Engl J Med 1994;331:1416-20 Swartz RD, Messana JM, Orzol S, Port FK. Comparing Continuous Hemofiltration with Hemodialysis in Patients with Severe Acute Renal Failure. Am J Kidney Dis 1999; 34:424-432 Chronic Renal Failure and Progression Burgess, Ellen. Conservative treatment to slow deterioration of renal function: Evidence-based recommendations. Kidney International 1999; 55 (Supp 70): S17-S25 Epstein, FH. Pregancy And Renal Disease. New England J Med 1996; Editorials: 277-278 Giatras, Ioannis, Effect of Angiotensin –Converting Enzyme Inhibitors of the Progression of Non-diabetic Renal Disease: A Meta-Analysis of Randomized Trials. Annals of Int Med 1997; 127: 337-345 Greenberg A (ed) Chronic Renal Failure and Its Therapy, in Primer in Nephrology, Section 10, San Diego, Academic Press, 1998, pp 403-490 Hou, Susan. Pregnancy in chronic Renal Insufficiency and End-Stage Renal Disease. AJKD 1999; 33(02):235-252 Jungers, Paul Pregnancy in Renal Disease. Kidney International 1997; 52:871- 885 Klahr, S, The Effects of Dietary Protein Restriction and Blood Pressure Control on the Progression of Chronic Renal Disease. New Engl J Med 1994; 330(13): 877-884 Maschio, Giuseppe, Effect of the Angiotensin-Converting-Enzyme Inhibitor Benazepril on the Progression of Chronic Renal Insufficiency. N Engl J Med 1996; 334: 939-45 ESRD and Renal Replacement Therapy: General, Outcomes, Vascular Access, Complications Beathard GA. Management of Bacteremia Associated with Tunneled-Cuffed Hemodialysis Catheters. J AM SOC NEPHROL 1999; 10:1045-1049 Beathard GA. Thrombolysis Versus Surgery for the Treatment of Thrombosed Dialysis Access Grafts. J AM SOC NEPHROL 1995; 6:1619-1624 Besarab A, The Effects of Normal as Compared with Low Hematocrit Values in Patients with Cardiac Disease Who are Receiving Hemodialysis and Epoetin. N Engl J Med 1998; 339:584-590
  13. 13. Burkart JM. Microbiology and Therapy of Peritonitis in Continuous Peritoneal Dialysis. In Up To Date v. 10.3, 2002 Eschbach JW, Correction of the Anemia of End-Stage Renal Disease with Recombinant Human Erythropoietin. N Engl J Med 1987; 316:73-78 Felsenfeld AJ. Considerations for the Treatment for Secondary Hyperparathyroidism in Renal Failure. J AM SOC NEPHROL 1997; 8:993-1004 Herzog CA, Ma JZ, and Collins AJ. Poor Long-Term Survival After Acute Myocardial Infarction Among Patients On Long-Term Hemodialysis. N Engl J Med 1998;339:799-805 Hollett MD, Complications of Continuous Ambulatory Peritoneal Dialysis: Evaluation with CT Peritoneography. AJR 1992; 159:983-989 Ifudu O. Care of Patients Undergoing Hemodialysis. N Engl J Med 1998; 339:1054- 1062 Llach F. Hyperphosphatemia in End-Stage Renal Disease Patients: Pathophysiological Consequences. Kidney International 1999; 56(supp 73): S31- S37) Macdougall IC, A Randomized Controlled Study of Iron Supplementation in Patients Treated with Erythropoietin. Kidney International 1996; 50: 1694-1699 Marcus RG, Messana JM, Swartz RD. Peritoneal Dialysis in End-Stage Renal Disease Patients with Preexisting Chronic Liver Disease. Am J Med 1992; 93:35- 40 Pastan S and Bailey J. Dialysis Therapy. N Engl J Med 1998; 338: 1428-1437 Popovich RP, Continuous Ambulatory Peritoneal Dialysis. Ann Int Med 1978; 88:449-456 Port FK. Morbidity and Mortality in Dialysis Patients. Kidney International 1994; 46:1728-1737 Slatopolsky E, Brown A, Dusso A. Pathogenesis of Secondary Hyperparathyroidism. Kidney International 1999; 56(supp73): S14-S19 Swartz RD, Successful Use of Cuffed Central Venous Hemodialysis Catheters Inserted Percutaneously. J AM SOC NEPHROL 1994; 4:1719-1725 Swartz RD. Chronic Peritoneal Dialysis: Mechanical and Infectious Complications. Nephron 1985; 40: 29-37 US Renal Data System 1999 Annual Report. Incidence and Prevalence of ESRD. American Journal of Kidney Diseases. 1999; 34(2 Suppl 1):S40-50 Valji K, Hand Ischemia in Patients with Hemodialysis Access Grafts: Angiographic Diagnosis and Treatment. Radiology 1995; 196: 697-701 Wolfe RA, A Critical Examination of Trends in Outcomes over the Last Decade. Am J Kidney Dis 1998; 32(supp 4): S9-S15 Transplant Anonymous. VII: Renal Transplantation: Access and Outcomes. AM J KIDNEY DIS 1999; Supp1: S95-S101 Fishman JA and Rubin RH. Infection in Organ Transplant Recipients. N Engl J Med 1998; 338:1741-1751 Jani A and Pavlakis M. After Kidney Transplantation: Options for Tailoring Immunosuppression. Nephrology Rounds 1998; 2: 1-7
  14. 14. Kasiske B: Evaluation of Prospective Renal transplant Recipients, in Greenberg A (ed): Primer on Kidney Disease, chp 74. San Diego, Academic Press, 1999, pp477-481 Norman D: Renal Transplantation: Immunosuppression and Postoperative Management, in Greenberg A (ed): Primer on Kidney Disease, chp 75. San Diego, Academic Press, 1999, pp482-490 Sayegh MH and Carpenter CB. Differential Diagnosis of Renal Allograft Dysfunction. In Up to Date v. 10.3, 2002 Silkensen JR: Long term Complications in Kidney Transplantation. J Am Soc Neph 2000; 11(3): 582-588 Terasaki PI, High Survival Rates of Kidney Transplants from Spousal and Living Unrelated Donors. N Engl J Med 1995; 333:333-6 Veenstra DL, Incidence and Long-Term Cost of Steroid-Related Side Effects after Renal Transplantation. AM J KIDNEY DIS 1999; 33:829-839 Schedule Monday Tuesday Wednesday Thursday Friday AM PM University hospital: ½ month on in-patient nephrology consult service ½ month in nephrology clinics (attend 6-7 clinics per week including general nephrology, transplant nephrology and dialysis clinic exposure) Veterans hospital: integrate in-patient consult at Veterans hospital with out-patient clinic time in VA and University hospital nephrology clinics