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METABOLISM: Renal and Urinary System

Index

• General Outcomes for Renal and Urinary System
• Renal Failure
• Nephrotic Syndrome and Glomerulonephritis
• Renal Replacement Therapies and Transplantation
• Malignancies of the Renal and Urinary System
• Renal Stone Disease and Renal Tract Calcification
• Bladder Dysfunction and Urinary Tract Infection
• Benign Disorders of the Prostate Gland

• General Outcomes for Renal and Urinary System
  • Medical knowledge: ANATOMY
    • Renal System and Urinary Tract
      1. Describe the vasculature of the kidney, relating its unique features to the physiology of urine production and nourishment of the nephron (CR1, GEP/CO2, MET2)
      2. Identify the parts of the nephron and describe the role of each component in the physiologic processes involved in urine production (CR1, GEP/CO2, GEP/CO2, MET2)
      3. Outline the general organisation of the urinary system including the kidney, ureter, bladder and urethra (CR1, GEP/CO2, GEP/CO2, MET2, MET2)
      4. Outline the structural components of the urinary passageways and bladder and describe how micturition is controlled (GEP/CO2, MET2)
      5. Describe the structure and microanatomy of the urinary tract, including the bladder. (GEP/CO2)
  • Medical knowledge: PHYSIOLOGY
    • Homeostasis
      1. Explain how total body water and total body sodium are regulated by mechanisms that are sensitive to plasma volume and plasma osmolality (GEP/CO2, MET2)
      2. Quantify the factors that contribute to the water balance of the body (GEP/CO2, MET2)
      3. State the source, nature and mechanisms of release of ADH. Describe the stimuli for the release of ADH and explain how ADH controls urine volume and osmolality (GEP/CO2, MET2)
      4. Explain how the thick-walled, ascending limb of the loop of Henle plays a key role (in conjunction with ADH) in the production of either dilute or concentrated urine to meet the requirements of water balance (GEP/CO2, MET2)
    • Body Fluid Compartments and Water Balance
      1. Explain how total body water and total body sodium are regulated by mechanisms that are sensitive to plasma volume and plasma osmolality (GEP/CO2, MET2)
      2. Distinguish between the terms 'osmolarity' and 'osmolality' and between the terms 'isosmotic' and 'isotonic'. State a normal value for plasma osmolality. (GEP/CO2, MET2)
      3. Quantify the factors that contribute to the water balance of the body (GEP/CO2, MET2)
      4. Name the main fluid compartments of the body, commenting on their volumes and predominant cations (GEP/CO2, MET2)
      5. Distinguish between the terms water diuresis, osmotic diuresis, diabetes insipidus and diabetes mellitus. State typical values (and normal ranges) for the osmolality and of urine and daily urine production (GEP/CO2, MET2)
    • Renal Function
      1. Describe the vasculature of the kidney, relating its unique features to the physiology of urine production and nourishment of the nephron (CR1, GEP/CO2, MET2)
      2. By means of labelled diagrams, show the changes in volume and osmolality of tubular fluid along the length of the nephron, in the presence or absence of anti-diuretic hormone (ADH) (GEP/CO2, MET2)
      3. Identify the parts of the nephron and describe the role of each component in the physiologic processes involved in urine production (CR1, GEP/CO2, GEP/CO2, MET2)
      4. Explain how the thick-walled, ascending limb of the loop of Henle plays a key role (in conjunction with ADH) in the production of either dilute or concentrated urine to meet the requirements of water balance (GEP/CO2, MET2)
      5. Explain the 'clearance concept' and how this is used to measure glomerular filtration rate (GFR). State the properties of suitable marker substances and show how clearance, and hence GFR, are calculated. State normal values for the GFR (GEP/CO2, MET2, MET2)
      6. Relate the structure of the glomerulus to its role in the filtration of blood. (GEP/CO2)
      7. Identify the components of the juxtaglomerular apparatus and describe its role in regulation of blood and urine volumes and renal homeostasis. (CR1, GEP/CO2, MET2)
      8. Briefly describe the autoregulation of GFR under normal circumstances and the significance of a reduced GFR. (CR1, GEP/CO2, MET2)
    • Bladder, Urethra and Ureters
      1. Outline the structural components of the urinary passageways and bladder and describe how micturition is controlled (GEP/CO2, MET2)
    • Hypothalamus and Pituitary Gland
      1. State the source, nature and mechanisms of release of ADH. Describe the stimuli for the release of ADH and explain how ADH controls urine volume and osmolality (GEP/CO2, MET2)
  • Medical knowledge: BIOCHEMISTRY (inc. Metabolism)
    • Biochemistry - Renal System
      1. By means of labelled diagrams, show the changes in volume and osmolality of tubular fluid along the length of the nephron, in the presence or absence of anti-diuretic hormone (ADH) (GEP/CO2, MET2)
      2. Comment briefly on differences in sodium reabsorption in the proximal tubule, the thick-walled, ascending limb of the loop of Henle and the distal tubule, noting the significance of sodium reabsorption in these regions (GEP/CO2, MET2, MET2)
      3. By reference to the renal reabsorption of glucose, define the terms: 'renal threshold' and 'transport maximum'. What may be the effects of glucose presence in the final urine? (GEP/CO2, MET2, MET2)
    • Sodium Balance
      1. Comment briefly on differences in sodium reabsorption in the proximal tubule, the thick-walled, ascending limb of the loop of Henle and the distal tubule, noting the significance of sodium reabsorption in these regions (GEP/CO2, MET2, MET2)
      2. Compare the reabsorption of sodium, glucose, amino acids and hydrogen carbonate in the proximal tubule of the nephron (GEP/CO2, MET2, MET2)
    • Amino Acids
      1. Compare the reabsorption of sodium, glucose, amino acids and hydrogen carbonate in the proximal tubule of the nephron (GEP/CO2, MET2, MET2)
    • Acid-Base Balance
      1. Compare the reabsorption of sodium, glucose, amino acids and hydrogen carbonate in the proximal tubule of the nephron (GEP/CO2, MET2, MET2)
  • Medical knowledge: PATHOLOGY
    • General Pathology
      1. Know the methods available for the assessment of acid-base balance in patients (MET2, MET2)
      2. To understand the pathogenesis and common causes of: a) respiratory acidosis b) respiratory alkalosis c) metabolic acidosis d) metabolic alkalosis (MET2)
      3. To recognise the biochemical changes associated with the above disorders and how the body attempts to compensate (MET2)
    • Bladder Dysfunction and Urinary Tract Infection
      1. Explain the most common causes for each of the above (MET2)
    • General Outcomes for Renal Tract Disorders
      1. List the causes of impaired glomerular filtration and the clinical consequences of this. (GEP/CO2)
    • Diabetes and Insulin Resistance
      1. Distinguish between the terms water diuresis, osmotic diuresis, diabetes insipidus and diabetes mellitus. State typical values (and normal ranges) for the osmolality and of urine and daily urine production (GEP/CO2, MET2)
  • Medical knowledge: CLINICAL FEATURES of DISEASE
    • Diabetes Insipidus and Hypopnatraemia
      1. Distinguish between the terms water diuresis, osmotic diuresis, diabetes insipidus and diabetes mellitus. State typical values (and normal ranges) for the osmolality and of urine and daily urine production (GEP/CO2, MET2)
  • Medical knowledge: THERAPEUTIC PRINCIPLES
    • Renal Tract Disease
      1. Explain the use of mannitol as a diuretic (MET2)
      2. Explain why diuretics increase potassium excretion, and how this may be reduced (MET2)
      3. Give the primary sites of action of thiazide, loop diuretics and spironolactone, and rank them in order of their efficacy (MET2)
      4. List the major clinical indications of the uses of a diuretic (MET2)
  • Medical knowledge: NUTRITION
    • Diet for Renal Disorders - General
      1. Understand the dietary management of chronic renal failure including the current controversy relating to the possible benefits of protein restriction on rate of decline of renal function (MET3B)
  • Clinical skills: INVESTIGATION
    • Renal and Urological Investigations
      1. Outline the investigations available to distinguish the cause of incontinence in an individual (MET2)
      2. Explain the 'clearance concept' and how this is used to measure glomerular filtration rate (GFR). State the properties of suitable marker substances and show how clearance, and hence GFR, are calculated. State normal values for the GFR (GEP/CO2, MET2, MET2)
  • Clinical skills: DIAGNOSIS and REASONING
    • Bladder Dysfunction and Urinary Tract Infection
      1. Distinguish between urge incontinence, stress incontinence, overflow incontinence and leak incontinence (MET2)
  • Clinical skills: PATIENT MANAGEMENT
    • Bladder Dysfunction and Urinary Tract Infection
      1. Describe treatments available for disorders of micturition (MET2)
• Renal Failure
  • Acute Renal Failure
    1. Be able to carry out a fluid assessment of a patient ie, know if they are volume deplete or volume expanded (MET3B)
    2. Classify the causes of acute renal failure into pre-renal, renal and post-renal (MET3B)
    3. Outline the systemic effects and pathological changes in the kidney of acute renal failure. (MET3B)
    4. Understand the role of daily weight, lying and standing blood pressure and other clinical signs in the assessment of fluid balance (MET3B)
    5. Understand the cause and management of the diuretic phase during recovery from acute renal failure (MET3B)
    6. Know the difference between crystalloid, colloid and blood products and the appropriate use of these solutions in managing patients with acute renal failure (MET3B)
    7. Understand how urinalysis and microscopy can help distinguish the various categories of acute renal failure (MET3B)
    8. Understand the investigation of undifferentiated acute uraemia including the place of renal ultrasonography to exlude obstruction and renal biopsy if there is possibility of vasculitis, interstitial nephritis or crescentic glomerulonephritis (MET3B)
    9. Understand prevention and management of life threatening complications of acute renal failure especially: hyperkalaemia; pulmonary oedema and severe uraemia (MET3B)
    10. Understand the methods of blood purification and fluid removal such as peritoneal and haemodialysis, continuous arteriovenous haemofiltration (CAVH) and CAVH / Dialysis (MET3B)
    11. List the causes of acute renal failure (MET3B)
  • Chronic Renal Failure
    1. Understand the concept of hyperfiltration injury (MET3B)
    2. List the common causes of chronic renal failure (MET3B)
    3. Be familiar with drugs that are mostly or exclusively renally cleared (CSP3)
    4. Describe the pathological changes of chronic renal failure in the kidney (MET3B)
    5. Understand the role of proteinuria in the monitoring of patients with chronic renal failure and its role in progression (MET3B)
    6. Understand the different locations in the nephron that drugs that act on the kidney work (CSP3)
    7. Describe the effects and management of complications of chronic renal failure such as anaemia; secondary hyperparathyroidism; bone disease and impaired immunity (MET3B)
    8. Be familiar with commonly prescribed nephrotoxic drugs and how to monitor them and patients safely (CSP3)
    9. Understand the classification of chronic failure into the five classes of Chronic Kidney Disease (CKD) (MET3B)
    10. Understand the importance of blood pressure control in attenuating the progression of chronic renal failure (MET3B)
    11. Understand the different types of ADRs on the kidney (CSP3)
    12. Understand the dietary management of chronic renal failure including the current controversy relating to the possible benefits of protein restriction on rate of decline of renal function (MET3B)
    13. Be able to dose-adjust important drugs for patients will renal failure (CSP3)
    14. Understand that fluid balance must be assessed clinically rather than by laboratory tests (MET3B)
    15. Be aware of the use of drugs blocking the renal angiotensin system in the treatment of chronic renal failure (MET3B)
• Nephrotic Syndrome and Glomerulonephritis
  • General Outcomes for Nephrotic Syndrome and Glomerulonephritis
    1. Understand the mechanism of action of the different diuretics and where they act in the renal tubule (MET3B)
    2. Know and understand the diagnostic criteria for nephrotic syndrome (MET3B, MET3B)
    3. Know the differing diagnostic / treatment approaches to childhood and adult nephrotic syndrome (MET3B)
    4. Know the differential diagnosis for nephrotic syndrome (MET3B, MET3B)
    5. Be aware of the factors that indicate poor prognosis with any glomerulonephritis (MET3B)
    6. Know the clinical signs of patients with nephrotic syndrome (MET3B, MET3B)
    7. Know the association between systemic lupus erythematosus (SLE) and the kidney (MET3B)
    8. Know the appropriate investigations of patient with nephrotic syndrome (MET3B, MET3B)
    9. Be aware of the concept of rapidly progressive glomerulonephritis and the relevant autoantibodies ie anti-GBM and ANCA and their association with pulmonary haemorrhage (MET3B)
    10. Know and understand principles that govern the treatment of nephrotic syndrome (MET3B, MET3B)
    11. Know the different causes of oedema and explain the pathophysiology of each. (CR1, GEP/CO2, MET3B, MET3B)
    12. Understand the importance of proteinuria, how it is measured and its clinical significance (MET3B)
    13. Describe the pathogenetic mechanisms underlying glomerular injury and the tissue reactions of the glomerulus to injury (MET3B, MET3B)
    14. Define the terms nephrotic syndrome and nephritic syndrome (MET3B, MET3B)
    15. Describe the clinical syndromes associated with glomerulonephritis (MET3B, MET3B)
    16. Outline the clinico-pathological features of the common types of glomerulonephritis (MET3B, MET3B)
• Renal Replacement Therapies and Transplantation
  • General Outcomes for Renal Replacement Therapies and Transplantation
    1. Be aware of the prognosis, advantages and disadvantages of transplantation (MET2)
    2. Describe the MHC / HLA system and its role in the immune response (MET3B)
    3. Understand the principles and practical aspects of haemodialysis and be aware of its limitations, advantages and disadvantages (MET3B)
    4. Describe the basic principles of tissue typing and lymphocytotoxic cross matching (MET2)
    5. Describe the complications associated with antirejection therapy (MET2)
    6. Be aware of the limitations, advantages and disadvantages of haaemodialysis (MET2)
    7. Understand the principles and practical aspects of peritoneal dialysis in its many forms (MET2)
    8. Be aware of the limitations, advantages and disadvantages of peritoneal dialysis (MET2)
    9. Understand the principles and practical aspects of haemodialysis (MET2)
    10. Understand the principles and practical aspects of peritoneal dialysis and be aware of its limitations, advantages and disadvantages (MET3B)
    11. Describe the role of T-cells and B-cells in the immune response (MET3B)
    12. Be aware of the mode of action of immunosuppressive drugs commonly used. (MET3B)
    13. Be aware of the prognosis, advantages and disadvantages of renal transplantation (MET3B)
    14. Describe the basic principles of tissue typing and lymphocytotoxic cross matching (MET3B)
    15. Describe the complications associated with anti-rejection therapy (MET3B)
• Malignancies of the Renal and Urinary System
  • Malignancies of the Renal and Urinary System - General
    1. Describe the clinical features of patients with renal tract tumours (MET3B)
    2. Understand the significance of microscopic and macroscopic haematuria (MET3B)
    3. Discuss the principles of screening for and prevention of malignancies of the prostate (HD2)
    4. Understand the pathogenesis of tumours of the renal tract and their risk factors (MET3B)
    5. Be able to describe the investigations available to establish a diagnosis of renal tract malignancy including urine cytology, endoscopy and imaging (MET3B)
    6. Understand the surgical approach to treating renal tract tumours (MET3B)
    7. Discuss the pathology of mass lesions of the urinary tract. (GEP/CO2)
    8. Be aware of the prognosis of patients with renal tract tumours (MET3B)
    9. Understand the use of prostate specific antigen (PSA) in the diagnosis and monitoring of prostate cancer (MET3B)
    10. Understand the use of chemotherapy, radiotherapy, hormone and immune therapy in the treatment of renal tract tumours (MET3B)
• Renal Stone Disease and Renal Tract Calcification
  • General Outcomes for Renal Stone Disease and Renal Tract Calcification
    1. Describe the clinical features of patients with renal calculi (MET3B)
    2. Know the metabolic conditions that can result in renal tract calcification (MET3B)
    3. Discuss the aetiology and pathological consequences of calculi in the kidney and ureter (MET3B)
    4. Be aware of the various types of renal tubular acidosis and their biochemical basis (MET3B)
    5. Understand the investigations required to diagnose the underlying predisposition to renal calculi (MET3B)
    6. Understand the role of diet in treating patients with renal calculi (MET3B)
    7. Describe the surgical and non-surgical approaches to treating renal calculi (MET3B)
• Bladder Dysfunction and Urinary Tract Infection
  • General Outcomes for Urinary Tract Infection
    1. Understand that urinary tract infections (UTI's) are a common cause for prescribing antimicrobials (MET3B)
    2. Know predisposing factors for urinary tract infections (UTI's) and how to diagnose them (MET3B)
    3. Understand that clinical significance and duration of treatment of UTI's varies depending on the group of patients treated eg children; pregnant women; non-pregnant sexually active women; young men; elderly and people with abnormal urinary tracts (MET3B)
    4. Management of urinary tract infections: criteria of UTI; different categories of patient; choice of antimicrobial (CSP3)
    5. Understand the risk of urinary tract infection in patients with congenital abnormalities of the renal tract (MET3B)
    6. Understand principles of treatment and when prophylaxis may be indicated (MET3B)
    7. Know the methods for investigating urinary tract infections in children; adult males and females; pregnancy (MET3B)
    8. Outline the therapeutic options for urinary tract infections (MET3B)
• Benign Disorders of the Prostate Gland
  • Benign Disorders of the Prostate Gland - General
    1. Know important drugs that are used for bladder and prostate disease (CSP3)

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