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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 (TD 8.1)
    • Renal System and Urinary Tract
      1. Outline the structural components of the urinary passageways and bladder and describe how micturition is controlled
      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)
      3. Describe the vasculature of the kidney, relating its unique features to the physiology of urine production and nourishment of the nephron (CR1, GEP/CO2)
      4. Describe the structure and microanatomy of the urinary tract, including the bladder.
  • Medical knowledge: PHYSIOLOGY (TD 8.2)
    • Body Fluid Compartments and Water Balance
      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
      2. Distinguish between the terms 'osmolarity' and 'osmolality' and between the terms 'isosmotic' and 'isotonic'. State a normal value for plasma osmolality.
      3. Name the main fluid compartments of the body, commenting on their volumes and predominant cations
      4. Quantify the factors that contribute to the water balance of the body
      5. Explain how total body water and total body sodium are regulated by mechanisms that are sensitive to plasma volume and plasma osmolality
    • Homeostasis
      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
      2. 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
      3. Quantify the factors that contribute to the water balance of the body
      4. Explain how total body water and total body sodium are regulated by mechanisms that are sensitive to plasma volume and plasma osmolality
    • Homeostasis
      1. 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 a dilute or concentrated urine to meet the requirements of water balance. (GEP/CO2)
    • 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
    • Bladder, Urethra and Ureters
      1. Outline the structural components of the urinary passageways and bladder and describe how micturition is controlled
    • Renal Function
      1. Identify the parts of the nephron and describe the role of each component in the physiologic processes involved in urine production (CR1, GEP/CO2)
      2. 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
      3. 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)
      4. Describe the vasculature of the kidney, relating its unique features to the physiology of urine production and nourishment of the nephron (CR1, GEP/CO2)
      5. Relate the structure of the glomerulus to its role in the filtration of blood.
      6. 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 a dilute or concentrated urine to meet the requirements of water balance. (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)
  • Medical knowledge: BIOCHEMISTRY (inc. Metabolism) (TD 8.3)
    • 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)
  • Medical knowledge: PATHOLOGY (TD 8.7)
    • 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
    • General Pathology
      1. Know the methods available for the assessment of acid-base balance in patients. (GEP/CO2)
      2. Know the methods available for the assessment of acid-base balance in patients (MET2)
      3. To understand the pathogenesis and common causes of: a) respiratory acidosis b) respiratory alkalosis c) metabolic acidosis d) metabolic alkalosis (MET2)
      4. To recognise the biochemical changes associated with the above disorders and how the body attempts to compensate (MET2)
    • General Outcomes for Renal Tract Disorders
      1. List the causes of impaired glomerular filtration and the clinical consequences of this.
  • Medical knowledge: CLINICAL FEATURES of DISEASE (TD 8 b)
    • 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
  • Clinical skills: MAKING A DIAGNOSIS and CLINICAL JUDGEMENT (TD 14 e-f)
    • Bladder Dysfunction and Urinary Tract Infection
      1. Distinguish between urge incontinence, stress incontinence, overflow incontinence and leak incontinence (GEP/DGM)
  • Clinical skills: DIAGNOSTIC PROCEDURES (TD 18 a)
    • General Procedures
      1. perform insertion of urinary catheter (MET3A)
• Renal Failure
  • Acute Renal Failure
    1. Classify the causes of acute renal failure into pre-renal, renal and post-renal
    2. Be able to carry out a fluid assessment of a patient ie, know if they are volume deplete or volume expanded
    3. Understand the role of daily weight, lying and standing blood pressure and other clinical signs in the assessment of fluid balance
    4. Outline the systemic effects and pathological changes in the kidney of acute renal failure.
    5. Know the difference between crystalloid, colloid and blood products and the appropriate use of these solutions in managing patients with acute renal failure
    6. Understand the cause and management of the diuretic phase during recovery from acute renal failure
    7. Understand how urinalysis and microscopy can help distinguish the various categories of acute renal failure
    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
    9. Understand prevention and management of life threatening complications of acute renal failure especially: hyperkalaemia; pulmonary oedema and severe uraemia
    10. Understand the methods of blood purification and fluid removal such as peritoneal and haemodialysis, continuous arteriovenous haemofiltration (CAVH) and CAVH / Dialysis
    11. List the causes of acute renal failure
  • Chronic Renal Failure
    1. Be familiar with drugs that are mostly or exclusively renally cleared
    2. Understand the concept of hyperfiltration injury
    3. List the common causes of chronic renal failure
    4. Understand the different locations in the nephron that drugs that act on the kidney work
    5. Describe the pathological changes of chronic renal failure in the kidney
    6. Understand the role of proteinuria in the monitoring of patients with chronic renal failure and its role in progression
    7. Understand the classification of chronic failure into the five classes of Chronic Kidney Disease (CKD)
    8. Describe the effects and management of complications of chronic renal failure such as anaemia; secondary hyperparathyroidism; bone disease and impaired immunity
    9. Be familiar with commonly prescribed nephrotoxic drugs and how to monitor them and patients safely
    10. 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
    11. Understand the importance of blood pressure control in attenuating the progression of chronic renal failure
    12. Understand the different types of ADRs on the kidney
    13. Be aware of the use of drugs blocking the renal angiotensin system in the treatment of chronic renal failure
    14. Be able to dose-adjust important drugs for patients will renal failure
    15. Understand that fluid balance must be assessed clinically rather than by laboratory tests
• 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
    2. Know and understand the diagnostic criteria for nephrotic syndrome
    3. Know the differing diagnostic / treatment approaches to childhood and adult nephrotic syndrome
    4. Know the differential diagnosis for nephrotic syndrome
    5. Know the clinical signs of patients with nephrotic syndrome
    6. Be aware of the factors that indicate poor prognosis with any glomerulonephritis
    7. Know the appropriate investigations of patient with nephrotic syndrome
    8. Know and understand principles that govern the treatment of nephrotic syndrome
    9. Know the association between systemic lupus erythematosus (SLE) and the kidney
    10. Be aware of the concept of rapidly progressive glomerulonephritis and the relevant autoantibodies ie anti-GBM and ANCA and their association with pulmonary haemorrhage
    11. Know the different causes of oedema and explain the pathophysiology of each.
    12. Define the terms nephrotic syndrome and nephritic syndrome
    13. Understand the importance of proteinuria, how it is measured and its clinical significance
    14. Describe the pathogenetic mechanisms underlying glomerular injury and the tissue reactions of the glomerulus to injury
    15. Describe the clinical syndromes associated with glomerulonephritis
    16. Outline the clinico-pathological features of the common types of glomerulonephritis
• Renal Replacement Therapies and Transplantation
  • General Outcomes for Renal Replacement Therapies and Transplantation
    1. Understand the principles and practical aspects of peritoneal dialysis in its many forms
    2. Be aware of the limitations, advantages and disadvantages of peritoneal dialysis
    3. Understand the principles and practical aspects of haemodialysis
    4. Be aware of the limitations, advantages and disadvantages of haemodialysis
    5. Describe the MHC / HLA system and its role in the immune response
    6. Understand the principles and practical aspects of haemodialysis and be aware of its limitations, advantages and disadvantages
    7. Describe the basic principles of tissue typing and lymphocytotoxic cross matching
    8. Be aware of the prognosis, advantages and disadvantages of transplantation
    9. Describe the complications associated with antirejection therapy
    10. Understand that transplantation can be a very effective treatment for organ failure
    11. Describe the role of T-cells and B-cells in the immune response
    12. Understand why kidney transplantation is better than dialysis.
    13. Understand the principles and practical aspects of peritoneal dialysis and be aware of its limitations, advantages and disadvantages
    14. Be aware of the mode of action of immunosuppressive drugs commonly used.
    15. Be aware of the prognosis, advantages and disadvantages of renal transplantation
    16. Know that there is a shortage of donated organs
    17. Describe the basic principles of tissue typing and lymphocytotoxic cross matching
    18. Know that that deceased may come from people whose death has been defined by brain stem or circulatory death.
    19. Understand that there is a high refusal rate regarding potential donors and the possible reasons why.
    20. Describe the complications associated with anti-rejection therapy
    21. Describe strategies for increasing the availability of organs
• 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
    2. Discuss the principles of screening for and prevention of malignancies of the prostate
    3. Understand the significance of microscopic and macroscopic haematuria
    4. Understand the pathogenesis of tumours of the renal tract and their risk factors
    5. Be able to describe the investigations available to establish a diagnosis of renal tract malignancy including urine cytology, endoscopy and imaging
    6. Be aware of the prognosis of patients with renal tract tumours
    7. Discuss the pathology of mass lesions of the urinary tract.
    8. Understand the use and limitations of prostate specific antigen (PSA) in the diagnosis and monitoring of prostate cancer
    9. Understand the use of chemotherapy, radiotherapy, hormone and immune therapy in the treatment of renal tract tumours
• 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
    2. Know the metabolic conditions that can result in renal tract calcification
    3. Be aware of the various types of renal tubular acidosis and their biochemical basis
    4. Understand the investigations required to diagnose the underlying predisposition to renal calculi
    5. Discuss the aetiology and pathological consequences of calculi in the kidney and ureter
    6. Understand the role of diet in treating patients with renal calculi
    7. Describe the surgical and non-surgical approaches to treating renal calculi
• 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
    2. Know predisposing factors for urinary tract infections (UTI's) and how to diagnose them
    3. Management of urinary tract infections: criteria of UTI; different categories of patient; choice of antimicrobial (CSP3)
    4. Understand the risk of urinary tract infection in patients with congenital abnormalities of the renal tract
    5. 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
    6. Understand principles of treatment and when prophylaxis may be indicated
    7. Outline the therapeutic options for urinary tract infections
    8. Know the methods for investigating urinary tract infections in children; adult males and females; pregnancy
• 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

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