By the end of the nephrology rotation, IR trainees should be comfortable with causes/management of renal failure, fluid management in patients with renal failure, indications for emergent dialysis, indications for long-term dialysis, general pearls in managing a patient with CKD and basic management of acid-base disturbances. Trainees should also be comfortable with interpreting lab results, identifying electrolyte abnormalities, and how to manage them. The following list of clinical goals is intended to provide benchmarks for IR trainees on the clinical nephrology rotation.

Inpatient Rounds

The nephrology service is typically composed of interns, junior/senior residents, a surgical fellow, and attendings. Try to be an integral part of the team. Select a couple new patients or continue to follow the patients that you have observed in the clinic or operating room. You can certainly ask the upper level resident or fellow for guidance on this. Learn to manage their primary and secondary conditions while they are in the hospital setting. Be it central venous access or visceral angiography for a bleed, these patients often require the services of interventional radiology (see below).

Diagnostic Imaging

The resident’s core diagnostic radiology skills will be very useful and may frequently be called upon throughout the rotation. You will be considered the expert radiologist on the service and often be called upon before the finalized read is back. During inpatient rounds, you may be the first to review the images on your patients from the list before any attending has a chance to. This is a great time to learn and build upon your ultrasound and cross-sectional imaging knowledge. This encourages you to think on your feet and formulate an opinion on the spot, which is a great skill to develop. Furthermore, this experience will improve your clinical judgment as you observe how nephrologists decide when an imaging study is indicated or needed, how they respond to radiologists interpretations and dictation styles, and how our reports affect patient management and their course in the hospital. Moreover, this will help you better understand the importance of being judicious with contrast in patients with underlying renal insufficiency.

Relevance to Interventional Radiology

There are a number of interventional procedures that aid in the care and management of nephrology patients. You may be called upon to perform or expound upon these procedures and having a basic understanding of their indications/contraindications and having the basic skills to perform these tasks is crucial. Become familiar with the following common interventional procedures that you may encounter:

  • Tunneled hemodialysis catheter placement
  • Nephrostomy tube placement
  • AV fistulogram + intervention
  • Prostatic artery embolization
  • Renal artery angioplasty and stenting

Specific Rotation Goals and Objectives

  • History taking and physical examination
    • Practice and refine the physical exam and medical history skills learned during internship year (PGY-1)
  • Clinical Knowledge
    • Acute Renal failure
      • Know the different etiologies of pre-renal acute renal failure and how to manage them
      • Know the different etiologies of intra-renal causes of acute renal failure and how to manage them
      • Know the different etiologies of post-renal causes of acute renal failure and how to manage them
      • Be able to diagnose acute renal failure and the specific cause using laboratory findings (BUN/Cr, electrolyte abnormalities, urine output, urinalysis, vital signs, etc.)
    • Chronic Kidney Disease
      • Identify the most common causes of chronic kidney disease (HTN, DM, etc.)
      • Know the sequelae of CKD (anemia, HTN, electrolyte abnormalities, hyperparathyroidism, etc.)
      • Identify the indications for emergent dialysis
      • Identify the indications for long-term dialysis
    • Acid-Base Disturbances
      • Be able to recognize, using an ABG and laboratory findings, metabolic acidosis/alkalosis, respiratory acidosis/alkalosis
        • Recognize the appropriate compensatory changes for each disturbance
      • Known common causes of each disturbance and the initial management
      • Be able to calculate an anion gap in patients with metabolic acidosis
      • Know when to use serum osmolarity gap
    • Urinalysis
      • Identify UA findings in:
        • UTI/Pyelonephritis
        • Nephrotic syndromes
        • Nephritic syndromes
      • Identify abnormal findings on a simple urine dipstick
      • Identify causes of oliguria/anuria
      • Know how to use Fractional excretion of Na (FENa) to guide diagnosis of renal failure
    • Electrolytes
      • Identify electrolyte abnormalities and common causes:
        • Hyperkalemia
        • Hypokalemia
        • Hypercalcemia
        • Hypocalcemia
        • Hyperphosphatemia
        • Hypophosphatemia
        • Hypernatremia
        • Hyponatremia
      • Recognize the ‘red-flag’ sequelae for each electrolyte disturbance and know how to manage these complications (i.e. Peaked T-waves in hyperkalemia, QT prolongation in hypocalcemia, etc.)
      • Know the common clinical pearls in the correction of each electrolyte disturbance (i.e. avoid rapid correction of Na in patient with hyponatremia)
    • Fluid management
      • Know the commonly used fluids (0.9% NaCl, 0.45% NaCl, 3.0% NaCl, LR, D5W)
      • Identify the electrolyte composition of each
      • Know the common indications and contraindications for each
      • Know the commonly used infusion rates and hydration status indicators
      • Know how to assess a patient’s fluid status using physical exam, Chem 7, UA, ultrasound
      • Know how to manage fluids in a euvolemic patient
      • Hypervolemia
        • Identify the most common causes of hypervolemia
        • Know the fluid management and hydration goals in a hypervolemic patient
      • Hypovolemia
        • Identify the most common causes of hypovolemia
        • Know the fluid management and hydration goals in a hypovolemic patient
    • Care of a dialysis patient
      • Know the dialysis options available (HD, PD, etc.)
      • Know how to assess the volume status of a dialysis patient
      • Know when emergent dialysis is indicated
      • Understand the mechanics and physics behind dialysis
      • Understand the goal with dialysis
      • Be able to perform a full cardiovascular and respiratory exam on a dialysis patient
    • Care of an AV Fistula
      • Be able to identify the various types of AV fistulas
      • Be able to palpate a bruit in fistula
      • Recognize the patency rates for each type of fistula
      • Identify the common causes of fistula failures and resulting sequelae
      • Recognize the role of IR in the care of a AV fistula

Systems Based Practice

  • Take on new patients and consultations with the goal of assigning team resources to address them in an appropriate and timely manner
  • Be able to coordinate care within the team over multiple patients and multiple problems of varying urgency (i.e. be able to triage effectively)
  • Coordinate hospital and physician resources in regards to transferring patients who are critically ill from other institutions
  • Complete full consult notes and progress notes every day on the patients that you are covering in a detailed and accurate format that is easily translatable to other services
  • Be an active, effective and efficient team member by effectively transferring care between duty hours completely and responsibly

Practice-Based Learning and Improvement

  • Shows appropriate use of consultation with medical and non-medical services, including special diagnostic studies
  • Uses evidence from the medical literature to answer clinical questions
  • Identifies areas for potential improvement in personal delivery of care
  • Maintains a positive attitude towards learning, including attendance and participation on patient rounds and conferences, and evidence of reading or other methods of gaining knowledge
  • Participates actively in teaching others, including students, residents, and faculty
  • Serve as a radiology advisor/liaison to the team when called upon
  • Educate the team regarding imaging utilization, radiation concerns and
  • Develop the clinical skills necessary to successfully manage a patient throughout the peri-procedural course, to help facilitate improved non-procedural interventional radiology patient care during your career.

Patient Care

  • Review past and current imaging on all patients you are involved with.
  • Perform procedures within the level of your knowledge under supervision.
  • Assist in the admission and discharge of patients when appropriate.
  • Assist in consults when appropriate.

Interpersonal and Communications Skills

  • Presents a patient effectively and efficiently
  • Communicates with patients and concerned others effectively
  • Writes accurate and complete entries in the medical record
  • Works constructively as part of a team
  • Exchanges information effectively and efficiently during rounds that reflects pertinent issues and problems, current therapeutic plans, and expected complications and issues
  • Establish therapeutic and empathetic relationships with patients and their families

Professionalism

  • Remember you are a guest in another specialties’ practice. Be prompt, present
  • Take on progressive amounts of responsibilities during your rotation and live up
  • Dress code: White coat and business casual attire is expected in the outpatient clinic. Scrubs under white coat may be acceptable on the floor depending on your attending. Scrubs alone are acceptable during procedures.