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Knowledge objectives for Renal and Urology teaching - Malawi

A DRAFT list of the areas that Malawi medical students are expected to know about, and as a model for a wider curriculum. Compare Edinburgh. Year refers to the time when the subject is encountered in the current Malawi programme.  

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.

For each item, the first statement is the most important.

Anatomy and physiology

Urinary abnormalities

Investigations

Urinary tract obstruction

Intrinsic renal diseases

Age and physiological states

Systemic disorders and the kidney

Renovascular disease

Hypertension

Acute renal failure

Chronic renal failure and ESRD

Renal replacement therapy

Kidney stones

Continence and incontinence 

UTI

Prostate and bladder

Malignancies

Fluid and electrolyte abnormalities

Drugs and the kidney

 

Anatomy and physiology

 		YEAR

Basic anatomy of the urinary tract including vascular supply

Y2
Basic mechanisms of glomerular filtration,tubular resorption and secretion,and handling of solute and water by the kidneys Y2

Mechanisms of bladder filling and emptying and maintenance of continence

  • Recognise normal glomeruli and tubules histologically
  • Detail of some specific transporters and the consequences to them of malfunction and drug therapy
 Y2

Urinary abnormalities

 		YEAR

Haematuria and proteinuria - pathophysiology of each

Basis and sensitivity of stick tests for haematuria and proteinuria

 

 Y3?

Important causes of haematuria

Significance of positive results of screening tests

 

Y3

Appropriate management of haematuria and proteinuria

  • Pathways of tubular protein metabolism
  • differences between glomerular and tubular proteinuria
  • Significance of associated signs of renal disease and of red cell morphology/casts
  • Possible mechanisms for microalbuminuria for cardiovascular risk

 

Y5

Polyuria - common causes, and understanding of mechanisms with examples

Mechanism of urine concentration; effects of ADH

Mechanisms and consequences of osmotic diuresis

  • Molecular detail of action of diabetes insipidus

 Y2

Oliguria - major possible physiological and pathological explanations and how they can be distinguished clinically

  • Biochemical features (incompletely) distinguishing compensatory oliguria from established acute renal failure ('ATN ')

Y2,Y3

 

 

Investigations

 		YEAR

Imaging

Principles and capabilities of major imagining modalitites: unltrsound, CT, pyelography, arteriography.

 

Y5

Risks of intravenous and intra-arterial procedures

  • Understanding of nuclear imaging, MRI
  • Background, prophylaxis, alternatives

 

Other investigations

Estimations of renal function

Capabilities and use of cystoscopy

  • ureteroscopy and other urological techniques

 

Y5

 

 

 

Y2,Y3

Y3,5?

Urinary tract obstruction

 		YEAR

Presentation, (lack of) signs, possible locations and etiologies

 Y2,Y3

Diagnostic and therapeutic approaches to obstruction at different levels

Y5

Intrinsic renal diseases

 		 YEAR

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 - minimal change disease, FSGS, Membranous, diabetes, amyloidosis (but also remembering subacute inflammatory, including SLE)

Post-infectious GN as ‘nephritic syndrome’ archetype – and the range of
presentations and outcomes of inflammatory, haematuric glomerulonephritis

  • Some further details of the incidence,management,outcome of IgA nephropathy as the most common 'nephritic ' disease in Europe, the Americas, the Far East
  • Prognostic factors in glomerular diseases

Crescentic nephritis (RPGN): presentation, importance, occurrence in systemic diseases

  • Short details of major systemic causes; especially small vessel vasculitis, 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

Nephrotoxic drugs (including ART) as one of several toxic causes (include herbal toxicity))

Vesicoureteric reflux, reflux nephropathy, and chronic pyelonephritis: their nature and
interrelationships

  • More detail on each. Some evidence to support assertions about relationships.

 

Y5

 

 

 

Y5

 

 

Y3

 

 

 

 

 

Y5

 

 

 

 

Y5

 

 

 

Y5

 

Y5

 

Y5
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Age and physiological states

 		YEAR

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. Renal failure as a manifestation (also coveved in Obstetrics).

  • The multiple presentations of pre-eclampsia and related diseases.

Y2,Y5

Y4,Y5

Y4,Y5

Systemic disorders

 		YEAR

Haematological

Sickle cell anaemia ­ - how it may affect the kidney (briefly)

HUS/TTP ­ presenting features and complications.  E.coli O157 and D+ HUS.

  • Some understanding of pathogenesis, management and outcome

Infection

Acute renal failure in malaria

Schistosomiasis

  • Bacterial endocarditis and the kidney
  • Reactive amyloidosis

HIV and the kidney

Inflammatory and autoimmune disorders

 

Ways in which systemic diseases can affect the kidney and how to suspect them

  • Some knowledge of important specific causes: Small vessel vasculitis, SLE, Infection

Malignancy

 Myeloma ­ its effects on the kidney via hypercalcaemia and cast nephropathy
  • Further understanding of myeloma kidney
Other tumours: via hypercalcaemia or other mechanisms
  • Membranous nephropathy most commonly implicated

Metabolic

Diabetes mellitus (see glomerular disorders)

 

Y5

Y5

 

 

 

Y3,Y5

Y3

 

Y3,Y5

 

 Y5

 

 

 

Y5

 

Y5

 

 

Y3,Y5

Renovascular disease

 		YEAR

Arterial disease

Renal artery stenosis: principle causes, diagnosis, effects of ACE inhibition; uncertain value of intervention for stenosis alone. 

 
Atheroemboli ­ - as a possible consequence of investigations and otherwise

 

Y5

Hypertension

 		YEAR

Hypertension

Relationship to renal disease

  • Possible mechanisms
  • That the effect of the kidney in hypertension is frequently paramount.

Risk factors for decline in GFR

  • High incidence of so called ‘hypertensive’ disease in black races may be due to predisposition to specific renal diseases

Malignant hypertension: consequences, treatment, importance of seeking cause

  • Possible causes

Y2,Y5
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Acute renal failure

 		YEAR

Important categories and causes of acute renal failure

Management and natural history of acute tubular necrosis (ATN)

Causes of rapid loss of renal function - likely diseases,how to recognise them,implications for management: Obstruction; Vascular; Intrinsic: RPGN, ATN, Toxic

How to diagnose and manage acute renal failure and oliguria

  • Indications for referral/renal replacement therapy
  • Simple pathophysiology of prerenal oliguria and ATN

Y3

Y3

Y3,Y5

 

Y5

Chronic Renal Failure and End Stage Renal Disease (ESRD)

 		YEAR

Major consequences of CRF

How to suspect and identify it

Elementary understanding of renal anaemia and renal osteodystrophy

Progression of renal impairment regardless of cause of initial injury

Effectiveness of blood pressure control and when proteinuric, ACE inhibitors

  • Role of dietary management

Y3

Y5

Y5

Y5

Y5

 

 

Renal Replacement Therapy

YEAR

An outline understanding of indications for, and issues raised by dialysis and renal transplantation, including resourse implications and ethical questions raised.

Dialysis

Basic principles and a sketchy outline of the practie of each or the major modalities, their chief advantages and disadvantages - PD/HD

Transplant

The various origins of donor organs

Principles and practicalities of brainstem death

Practicalities of renal transplantation (when, where, how)

Consequences of longterm immunosuppression

Y5


 

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Kidney stones

 		YEAR

Presentation, epidemiology, immediate management

Consequences, complications, predisposing factors

Principles and major indications for lithotripsy or other intervention

  • Basic advice and treatment (but not investigations) for recurrent stone formers

Y5

Continence and incontinence

 		YEAR

Terminology and definitions

History, examination and investigations including frequency / volume charts

  • Predisposing factors
  • Management: physiotherapy, anticholinergic medical therapies, surgical interventions
  • Consequences and complications, alternatives

Y2

Y5
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Urinary tract infection

 		YEAR

Symptoms, signs, risk factors

Clinical and laboratory diagnosis; common pathogens

Management of uncomplicated and complicated infection

Who, when, and how to investigate

Y2,Y3

Prostate and bladder

 		YEAR

Epidemiology of prostate and bladder disease (outline)

Pathophysiological mechanisms

Principles of treatment (endocrine, surgical)

  • Some detail on mechanism of hormonal and related treatments for prostatic disease

Common congenital causes of problems with bladder drainage

  • Some knowledge of origin of developmental abnormalities.

Common acquired causes of impaired bladder drainage: neurological, detrusor dysfunction, sphincter problems, obstruction

  • Investigation of bladder outlet obstruction - flow rates and post-void residuals

Y2,Y5

Malignancies of the urinary tract

 		YEAR

Renal cell carcinoma - common presentations, therapeutic approaches

  • Systemic manifestations occasionally produced

Urothelial tract malignancies ­ common presentation and management

  • Risk factors. Staging. Therapy and prognosis.

Prostate cancer - incidence, presentation, natural history, therapies, prognosis

  • Screening and case-finding: controversy over value

Testicular tumours - incidence, presentation

Y2,Y5
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Fluid and electrolyte abnormalities

 		YEAR

Potassium - high and low - Important causes and their differentiation

  • understanding of pathophysiology of hype and hypokalaemia, and therapy

Sodium - high and low - how to diagnose and treat

Calcium - high and low - how to diagnose and treat

  • (in the setting of renal disease and otherwise)

Acid-base balance - its maintenance; role of kidney in maintaining

Interpretation of blood gases (simple in Y2/3, mainly respiratory, more complex later)

Y5

 

 

 

 

Y1, Y2

 Y2/3,Y5?

Drugs and the kidney

 		YEAR

Principles of how diuretics work, their indications, risks, and side-effects.

Adjusting dose in altered renal function, with practical examples

  • examples of other speicifc problems in renal disease

Specific drugs: potential effects of NSAIDs, ACE inhibitors, and anti-retrovirals on renal function

  • explanation for these

Y2,Y3

Y5

 

 

Y5

 

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