Return to Scenario ListShow Learning Points most relevant to Phase 1:

Chronic kidney disease / asymptomatic worsening renal function

Clinical Discipline(s)/Organ System(s)
Genitourinary System, Renal Medicine, Ethics
Progress Test Topic(s)
A 45 year old Māori man is referred to you from by his GP. He was diagnosed with diabetes 15 years ago and routine monitoring of his renal function demonstrates a steadily increasing serum creatinine level. Renal ultrasound reveals small echogenic kidneys. His blood pressure is 150/92 mmHg.
Progress Test-Type Questions:   Question 1 | Question 2 | Question 3 | Question 4
Applied Science for Medicine 
   - Structure and function of the kidney, including its extra-renal functions (e.g. role in red cell formation)
   - Physiology of renal perfusion, ultrafiltration and the nephron
   - Pathological processes affecting the kidney; pathology of diabetic renal disease
   - Effects of hypertension on the kidney and the effect of renal disease on blood pressure
   - Principles of dialysis and haemofiltration
   - Role of the kidney in elimination of drugs and the effect of renal dysfunction on this; pharmacokinetic variability
Clinical and Communication Skills 
   - Elicit a relevant history from a patient with chronic kidney disease, including relevant drug history and co-morbidities
   - Perform a focused examination relevant to renal impairment
   - Assess fluid balance, particularly in relation to hypoalbuminaemia
   - List causes of chronic kidney disease
   - Interpret blood test of renal function, urinalysis and culture, urinary protein/albumin creatinine ratio
   - Indications for renal ultrasound, renal biopsy (including contraindications)
   - Differential diagnosis of microscopic haematuria
   - Measurement and calculation of glomerular filtration rate (GFR), estimated GFR; classification system of severity used in chronic kidney disease
   - Indications for and principles of peritoneal dialysis and haemodialysis; access for both types of dialysis (lines, catheters, fistulae)
   - Pharmacological management of chronic kidney disease and its comorbidities
   - Prescribe for patient with impaired renal function
   - Dietetic input in chronic kidney disease
   - Role of renal transplantation
   - Psychological factors in chronic renal disease; awareness that this patient is high risk for developing depression
   - Recognise and manage associated electrolyte abnormalities namely hyperkalaemia, hypocalcaemia, hypercalcaemia and hyperphosphataemia and understand the underlying pathophysiology i.e. renal failure and relationship to secondary and tertiary hyperparathyroidism
Personal and Professional Skills 
   - Awareness of the impact on the patient of fluid restriction and possible altered body image
   - Breaking bad news, sensitive communication of a chronic incurable diagnosis with patient and whānau
   - Ethics, justice and access to renal replacement therapy
   - Empathy for the change of quality of life for patients receiving renal replacement therapy
   - Awareness of the importance of the multidisciplinary team in management - primary, secondary and tertiary
Hauora Māori 
   - Higher prevalence of chronic kidney disease in Māori and differences in underlying cause
   - Differential access to renal dialysis (peritoneal vs haemodialysis) by ethnicity in New Zealand
   - Awareness of issues relating to organ donation for Māori including fact that Māori have less access to waiting lists for cadaveric transplants, but higher rates of familial transplants
   - Disproportionate impact of chronic condition (such as kidney failure) and its treatment (dialysis) for Māori
   - The role of kaupapa Māori services in the management of long-term conditions
Population Health 
   - Epidemiology, risk factors and prognosis of chronic kidney disease, including trends over time and by ethnic group, impact of ageing population and metabolic syndrome
   - Effectiveness and cost-effectiveness of renal replacement therapy options
   - Provision, audit and monitoring of dialysis and renal transplantation services
Conditions to be considered relating to this scenario
diabetes mellitus, hypertensive nephrosclerosis, renovascular disease, prostatic hypertrophy, nephrolithiasis, analgesic nephropathy, interstitial nephritis, glomerulonephritis
Less common but 'important not to miss'
systemic lupus erythematosus (SLE), vasculitis
myeloma, amyloidosis, scleroderma, nephrocalcinosis, gout, Alport syndrome