ghana college of physicians and surgeons · refer logbook. evaluation format: this will consist of...

Paediatric Nephrology Subspecialty Training- Recommendations

Page1

GHANA COLLEGE OF PHYSICIANS AND SURGEONS

FELLOWSHIP PROGRAMME IN PAEDIATRIC NEPHROLOGY

TRAINING CURRICULUM

FACULTY OF PAEDIATRICS/CHILD HEALTH


Page2

PAEDIATRIC NEPHROLOGY SUBSPECIALTY

PROPOSED CURRICULUM AND RECOMMENDATIONS TO THE GHANA COLLEGE OF

PHYSICIANS AND SURGEONS

1. Preamble

Kidney diseases remain a leading cause of childhood morbidity and acute kidney injury (AKI) is

responsible for over 20% of deaths in children under 5 years old in most developing countries

and in particular in those of sub Saharan Africa. Due to almost nonexistent facilities, most

trainees in general paediatrics are not exposed to in-depth investigations and the appropriate

management of kidney diseases during their training in the sub region. Also the training is

unstructured with less than desired interactions with paediatric nephrologists, limited

opportunity to develop advanced knowledge of acute and chronic paediatric renal diseases

and lack of use of advanced diagnostic and treatment modalities such as renal biopsy and

renal replacement therapy. As a result, training and expertise in this sub-specialty lags behind

significantly compared to the skills, knowledge and experience available in more developed

countries.

2. Philosophy

Our philosophy is that given the strides made in general paediatric practice since the

establishment of the Ghana College, the time is ripe to have sub specialized care in paediatric

renal diseases.

Creating subspecialty training in this field within Ghana and the sub region is now essential

given the occurrence of renal conditions such as nephrotic syndrome, the

glomerulonephritides, hypertension, urinary tract infection and congenital anomalies of the

kidney and urinary tract.

Sub-specialty training in nephrology will improve the quality of care for children with kidney

disease and will promote awareness, facilitate research required for a better understanding of

the local and regional kidney diseases and management protocols. It will produce relevant

data required for the development of local and region-specific public health interventions and

evidence-based policy making that will improve child survival.

This document proposes curriculum and recommendations for the training of paediatricians

who will be recognized as paediatric nephrologists by the Ghana College of Physicians and

Surgeons.


Page3

3. Aims

The aim of this curriculum is to train paediatric nephrology specialists for Ghana and the West

African sub region

Specific objectives

The specific goals of this program include the following;

1. To apply knowledge in basic science of nephrology including embryology to be able to

understand the pathophysiological mechanisms underlying common renal disorders.

2. To have appreciable knowledge of the spectrum of paediatric renal disease in the sub region

in order to correctly diagnose the condition.

3. To have in-depth knowledge of the principles of investigating renal disease with the

advanced tools available in the field - laboratory/diagnostic tests/procedures (including

biopsy and imaging) - and interpretation of these results.

4. To have in-depth knowledge in the principles of management of frequently occurring

paediatric kidney diseases including dialysis therapy.

5. To understand the principles of renal replacement therapy including work-up for kidney

transplantation and transplant immunosuppressant therapy.

6. To acquire the requisite skills in counselling the family of a renal patient including breaking

bad news.

7. To know the principles of palliative care in nephrology and its application in patient care.

8. To develop the attitudes and behaviours expected in good practice of nephrology and integrate these in trainees’ practice.

4. Key Educational Principles

There are a number of educational principles underpinning the Training Program.

These principles are described in this section.

Contents

• Self-directed learning


Page4

• Training, Teaching and Supervision

Self-Directed Learning

Trainees are responsible for ensuring that they meet the various assessment and

progression requirements throughout the training program. Trainees entering the new

training program will be provided with learning and assessment materials that outline

the key training milestones throughout the years of membership and fellowship

residency program.

Training, Teaching and Supervision

To enable Residents to learn it is essential that they are provided with training,

teaching and supervision that is appropriate to their stage of training.

Examples of accredited training and teaching in the Training Program include:

Observation of procedures/examinations

Completion of in training assessments in the Curriculum and Training Program

Attendance at formal teaching sessions

Presenting at formal teaching sessions

Participation in clinic rounds and meetings

Participation in quality assurance activities

Participation in journal clubs

Completion of experiential training requirements in the Curriculum and Training

Program

Report writing

Reviewing archived teaching cases

It is essential for trainees to receive appropriate formal supervision during service

work. Formal supervision will enable trainees to learn and accrue accredited training

time.

5. Duration of training: The proposed duration of training will be three years. A detailed

content of training is included in the appendix.


Page5

Entry Point: it is recommended that candidates that are seeking training in this subspecialty

would have passed the Membership examination of the Ghana College of Physicians and

Surgeons in paediatrics or its equivalent.

6. Programme Outline

The period of training will consist of the following rotations:

1. One year general paediatrics to cover the following rotations:

a. General Paediatrics (2 months) b. Paediatric emergency (2 months) c. Neonatology/Neonatal Intensive Care (1 month) d. Haematology/Oncology (1 month) e. Intensive Care Unit, preferably paediatric intensive care (2 months) f. Nephrology (as part of general rotation)-2 months

At the end of this rotation, the trainee would have consolidated his/her knowledge in general

paediatrics and would have acquired the skills in placement of central venous catheter as well

as appreciation of the challenge of oncological emergencies needing renal care.

2. Two years clinical paediatric nephrology posting

At the end this rotation, the trainee should have acquired the requisite competence in the

diagnosis and management of urinary tract infection (including the performance of dip-stick

urinalysis), hypertension, congenital anomaly of the kidney and urinary tract (CAKUT), acute

kidney injury, glomerulonephritis, nephrotic syndrome and chronic kidney disease. Other

competencies include prescription and performance of both modalities of dialysis and the

concept of transplantation medicine. Also, the trainee should have acquired skills in the design

and management of research project.

DETAILS OF THE TWO YEARS OF CLINICAL PAEDIATRIC NEPHROLOGY ROTATION (Also refer to

chat on rotation on Section 15 of this document).

S/He must undertake rotation in the following disciplines:

a) Mandatory rotation in:

i. Haemodialysis Unit for 3 months. At the end of this rotation, the trainee should be

able to acquire the competence of starting the patient on the haemodialysis

machine, manage intradialytic complications and take patients off the machine.


Page6

ii. Radiology rotation for 1 month. At the end of this rotation, the trainee should be

able to perform renal ultrasound and interpret other renal images like CT scan and

MRI.

iii. Microbiology (emphasis on parasitology) for 1 month. At the end of this rotation,

the trainee should be able to acquire the competence in the preparation of urine

specimen for microscopy and recognition of cellular elements in urine.

b) Elective rotation (*Desirable but NOT mandatory) in:

i. Nuclear medicine unit for 1 month. At the end of rotation, the trainee should be

able to understand the principle of nuclear medicine in nephrology and interpret

results.

ii. Transplant medicine for 1 month. At the end of this rotation, the trainee should

have participated in the work up, intra operative and post operative management

of a kidney transplant

*This position may change in future if facilities in the country support such training.

. 7. Faculty

The starting faculty shall consist of the 2 paediatric Nephrologists; Prof Sampson Antwi

(FGCP, FWACP) of SMS-KNUST/KATH and Dr Victoria Adabayeri (FGCP, FWACP) of Korle

bu Teaching Hospital

8. Training Sites*/Requirements

The following criteria will be applied for the selection of clinical training centres.

ACCREDITATION CRITERIA:

a) The Institution must be accredited for the GCPS Fellowship programme in General

Paediatrics

b) There should be a Paediatric Renal Unit with at least one recognized Paediatric

Nephrologist.

c) The paediatric renal unit should have large patient load and wide variety of renal cases in

the out-patient clinic.

d) The paediatric renal unit should have facilities for dialysis (BOTH peritoneal and

haemodialysis)


Page7

*For a start, the Komfo Anokye and the Korle Bu Teaching Hospitals will be designated as

starting centers

Specialty Conferences (Local, Abroad): In the course of training, the resident will be expected

to attend at least one conference each locally and internationally on nephrology.

9. Core Competencies

At the end of the training period, the trainee should have achieved adequate knowledge and

Skills in the following areas:

A. Knowledge

1. Appreciable knowledge in kidney embryogenesis and its related abnormalities 2. Ability to recognize, initiate diagnostic tests and manage common kidney diseases

encountered in Ghana and the sub region such as but not limited to:

Urinary tract infection

Nephrotic syndrome

Glomerulonephritis

Acute kidney injury (including Risk factors and RIFLE/AKIN/KDIGO criteria for diagnosis)

Chronic kidney disease (including Risk factors and K/DOQI/KDIGO classification)

Congenital anomaly of the kidney and urinary tract (CAKUT) including ALL cystic kidney diseases

Parasitic kidney diseases

3. Proficiency in the interpretation of urinalysis, blood test results, radiological investigations and nuclear imaging test as relate to renal disease

4. Proficiency in the determination of fluid requirement and nutritional advice for patient with renal disease.

5. Appreciable knowledge in the principles of:

Peritoneal dialysis

Haemodialysis

Kidney transplant

Immunosuppressant in kidney transplant

B. Skills Clinical Skills

Perform and interpret urinalysis.

Understand the use and limitations of commonly used dipsticks.

Interpret electrolyte and blood gas values.


Page8

Provide emergency treatment of Acute Kidney Injury.

Write prescription for dialysis (peritoneal and haemodialysis)

Interpret kidney ultrasound findings, pyelographic studies, micturiting cystourethrogram, and nuclear imaging studies

Counsel Parents/Guardians of children with kidney disease including breaking bad news

Technical Skills

Obtain urine by appropriate methods including suprapubic tap.

Catheterize the urinary bladder.

Place a peritoneal dialysis catheter

Place a central line

Perform a kidney biopsy

Start a patient on haemodialysis, manage intradialytic complications, and take a patient off haemodialysis

9. Fellow Activities

Specific Activities to be undertaken to achieve the stated objectives include but not limited to

the following:

1. Ward rounds 2. One detailed case presentation by residents during weekly ward rounds 3. Post-ward rounds discussion 4. Reading assignments including journals 5. Tutorial sessions 6. Attendance to special procedure sessions e.g. nephrostomy, vesicostomy, kidney biopsy, PD

intervention (both on and off duty sessions)

7. Regular bedside teaching/tutorials for medical students and residents.

8. Attendance of nephrology update courses and conferences.

10. Research

By the end of the first year, (i.e. at commencement of clinical nephrology rotation in year 2),

trainee should identify an area of research which should be developed fully into a dissertation

to be presented as part fulfillment of the award of certificate in paediatric nephrology. This

research activity will continue throughout the last two years of training even during “out-

station” rotation.

The trainee MUST attend courses in research methodology.

11. Specialty Conferences (Local, Abroad)


Page9

The trainee should attend nephrology conferences (at least one each locally and

internationally) during his/her training.

12. Courses

During his/her training, the trainee MUST attend courses in medical ethics, leadership and

management.

13. Specialty-related journals, websites and links of interest

Resources to help the trainee during his/her training include but not limited to the following:

The pediatric nephrology journal (https://link.springer.com/journal/467)

Kidney International (https://www.elsevier.com/journals/kidney-

international/0085-2538),

Peritoneal dialysis international (www.pdiconnect.com)

14. Assessment/Evaluation Methods

Training Evaluation:

Trainees will be required to keep a log book of renal cases managed (including

multidisciplinary team management) and procedures carried out. Refer Logbook.

Evaluation format: This will consist of formative assessment and examination;

Formative:

Log book documentation of:

a) Clinical cases discussed

b) Counseling sessions undertaken

c) Out of Station rotation experience

d) Procedures observed and performed

e) Journal reviews/presentations at Grand Round

f) Tutorial sessions

15. *Final assessment will be by Examination to consist of the following:


Page10

100 Objective Questions (1 out of 5) for 2 hours

1 hour subspecialty VIVA (including data interpretation and pictures)

1 hour VIVA in General paediatrics

1 hour Dissertation Defense: This will be an oral defense. The candidate will be

examined by a set of examiners, one of whom would have assessed and approved

the proposal and would have read the dissertation prior to the defense

A Candidate MUST pass all the sessions before a FULL PASS is awarded. A FAIL in Dissertation

ONLY or General Paediatrics VIVA ONLY will be exempted from the other sessions. However,

fresh registration for examination will be required.

*As much as it will be feasible and practicable, an External Examiner should be invited for the

final Examination.

16. Timetable

CHART SHOWING HYPOTHETIC ROTATIONS

Year Mo 1 Mo 2

Mo 3

Mo 4

Mo 5

Mo 6 Mo 7

Mo 8

Mo 9

Mo 10

Mo 11

Mo12

Year 1

General Paediatric rotations

General Paediatrics

Paediatric Nephrology (as part of Gen Paed)

Intensive Care (preferably paediatrics)

Neonatology

Haem/ Onco

Annual Leave

Paediatric Emergency

Annual Leave

Year 2

*Clinical Paediatric Nephrology Rotation-1

Year 3

Haemodialysis Unit Radio logy

Parasi tology

Nuclear Medicine**/ Transplant Medicine**

Clinical Paediatric Nephrology Rotation-2

Annual Leave +

Dissertation Write Up

Final Exams

*Research proposal should be developed at the start of this rotation


Page11

**These two rotations will be Elective and desirable but NOT mandatory

17 Recommended Textbooks:

1. Pediatric Nephrology Textbook by Avner, Harmon, Niaudet, Yoshikawa

2. Clinical Paediatric Nephrology by Webb N and Postlethwaite R

3. Clinical Pediatric Nephrology by Kher KK, Schnaper HW, and Makker SP

18. Criteria for Certification (General Fellowship criteria)

Successful Candidates will be awarded Fellowship in Paediatric Nephrology by the Ghana

College of Physicians and Surgeons

19. Logbook/Portfolio

A logbook for trainees is accompanying this curriculum

20. Appendix (Must include full details of syllabus)

Course Content Genito-urinary embryology

The relationship of abnormal embryogenesis to clinical disorders such as pelvic-ureteric junction obstruction, vesico-ureteric junction obstruction, posterior urethral valve, multicystic dysplastic kidney and other cystic kidney disorders, neurogenic bladder.

Understand the glomerular filtration barrier

Genito-urinary Physiology

Physiology of control of water and electrolytes

Requirements for fluid and electrolytes in health and disease

Management of water and electrolyte imbalance

Kidney autoregulatory mechanisms

Understand the glomerular filtration barrier

In-depth understanding of glomerular injury and the corresponding clinical

syndromes (clinicopathological syndromes)


Page12

Principal tubular transport mechanisms at the 4 tubular segments with respect

to acid-base and electrolyte regulation

Understanding acid-base balance and the concept of anion gap: assessment of acidosis

The physiology of micturition and disorders of micturition including detrusor-sphincter dissynergia (DSD), overactive bladder and neurogenic bladder

Pathophysiology of acute and Chronic kidney disease: renal osteodystrophy: growth in chronic renal disease.

Indications for measurement of glomerular filtration rate, creatinine clearance, protein/creatinine ratio, calcium/creatinine ratio, renal imaging

Emergency treatment of Acute Kidney Injury

Knowledge of current theories regarding epidemiology of urinary reflux and secondary progression of renal damage and its possible prevention

Knowledge of current theories surrounding cyst formation in the kidney

When to suspect neuropathic bladder: role of urodynamic studies.

Presentation of tubular and metabolic disorders including: - renal tubular acidosis - cystinosis and other Fanconi syndromes - hypophosphataemic rickets - Bartter’s and Gitelman syndromes - Tubular disorders leading to hypercalciuria - Liddle syndrome - Pseudohypoaldosteronism disorders - nephrogenic diabetes insipidus.

General

Presentation, investigation and management of urinary tract infection as well as possible complications.

Assessment of common presentations of genito-urinary problems e.g. enuresis, proteinuria, oedema, haematuria, hypertension, oligo-anuria.

Variation of blood pressure with age-diagnosis, investigation and management of hypertension.

Indications in Acute Kidney Injury for peritoneal dialysis and haemodialysis.

Ability to diagnose and manage (in consultation with nephrologist and surgical colleagues)

- Vesico-ureteric junction and pelvic-ureteric junction obstruction

- Duplex – systems

- Ureterocele

- Posterior urethral valves.

- Vesicoureteric reflux


Page13

Ability to liaise with radiologists, obstetrician and surgeon in counselling of mothers with an antenatal diagnosis of a urinary tract malformation in their baby.

Neuropathic Bladder

When to suspect neuropathic bladder: clinical conditions associated with neuropathic bladder

The role of urodynamic studies in assessing bladder dynamics.

Management of bladder and bowel dysfunction in conjunction with the appropriate specialist.

Glomerular Disease

Investigation and management (including indications for biopsy) of the following renal syndromes:

- Haematuria

- Proteinuria

- Nephritic syndrome including post-streptococcal glomerulonephritis.

- Nephrotic syndrome

- Henoch Schonlein Purpura, systemic lupus erythematosis and other systemic vasculitis affecting the kidney.

Acute Presentations Of The Following Renal Disease: Nephrotic syndrome

Definition of nephrotic syndromes including congenital and infantile nephrosis

Know the aetiology, pathophysiology and pathogenesis and their corresponding clinical signs & symptoms

Diagnosis and management of nephrotic syndrome including the available treatment options for steroid resistant nephrotic

Understand the investigations including the indications for renal biopsy.

Understand the complications of the nephrotic state including that resulting from therapy

Know pathological diagnosis that portend poor prognosis

Know the adjunctive therapy in the management of nephrotic syndrome

Assess features in the presentation which suggest serious and significant pathology


Page14

Be able to counsel parents on the challenges of steroid resistant nephrotic syndrome, long term prognosis, and the range of immunosuppressive therapies that may be used

Definition of common terminologies in nephrosis

o remission

o relapse

o steroid resistance

o steroid dependence

o frequently relapsing

NEPHRITIC SYNDROME

Know the definition of nephritic syndrome

Common causes with emphasis on postinfectious glomerulonephritis and rapidly progressive glomerulonephritis

Diagnosis and management including complications to anticipate

HAEMATURIA AND PROTEINURIA

Know the causes of these signs

Understand the investigations that will differentiate between the causes

Differentiate glomerular bleeding from non-glomerular bleed

Know the steps in evaluation of a patient with haematuria

Know the indications for renal biopsy

Know other causes of reddish urine

Know the relationship between qualitative dipstick proteinuria, quantitative proteinuria and urine protein; creatinine ratio

Appreciate the danger persistent proteinuria poses and measures to control it

Hypertension

Definition of hypertension in children

Correct technique of blood pressure measurement

Common aetiology of hypertension according to age

Clinical evaluation of a child with hypertension


Page15

Complications of hypertension including hypertensive encephalopathy and its

management

Non-invasive investigation of hypertension: echocardiography.

Management of acute and chronic hypertension. Nephrolithiasis

Understanding of the aetiology, risk factors, clinical presentation, and investigation needed.

Medical and surgical treatments. Tubular and Metabolic Dysfunction

Presentation of tubular and metabolic disorders including:

- Renal tubular acidosis.

- Cystinosis and other Fanconi syndromes

- Hypophosphataemic rickets.

- Bartter’s and Gitelman syndromes

- Tubular disorders leading to hypercalciuria

- Liddle syndrome

- Pseudohypoaldosteronism disordersNephrogenic diabetes insipidus,

Understanding when to refer to specialist investigation and advice on treatment. Acute Kidney Injury

Pathophysiology and pathogenesis of Acute Kidney Injury

Common causes of Acute Kidney Injury in children including haemolytic uraemic

syndrome

Diagnosis and management of a child in Acute Kidney Injury including the

associated complications

Ability to define the 3 levels of Acute Kidney Injury:

o Pre-renal

o Intrinsic

o Post-renal

Ability to differentiate pre-renal AKI from Intrinsic AKI

Understand the methods to correct fluid and biochemical abnormalities seen in

renal failure


Page16

Know the indications for dialysis. Appropriate initial investigation and management

Basic knowledge of the principles underlying peritoneal and haemodialysis, plasmapheresis

Chronic kidney disease

Definition of chronic kidney disease

K/DOQI classification of chronic kidney disease

Common causes of Chronic kidney disease in children including congenital

anomalies of the kidney and urinary tract

Essential features of Chronic kidney disease and how to differentiate between

chronic and Acute Kidney Injury

Measures to slow down progression of renal injury to end stage renal failure

Forms of renal replacement therapy and their indications

Understanding of the factors involved in failure to thrive in Chronic kidney disease.

Dietary advice for a child in Chronic kidney disease

Ideally but not absolutely essential: Exposure to the care of the renal transplant recipient, including pre-, peri- and post-transplant management of patients

1.Understanding the basics of Transplantation indications, workup and immunology and management of the transplant patient

a. Short-term and long-term complications of renal transplantation including opportunistic infections, post-transplant lymphoproliferative disease, growth and cardiovascular disease

b. Working knowledge of immunological tests such as HLA-matching, and lymphocyte cross-matching

2. Multi-disciplinary Approach to Care

The importance of a team approach in the management of nephrological disorders and to understand its advantages and limitations.

Planning handover to adult services.

B. Skills Clinical Skills

Perform and interpret urinalysis.

Understand the use and limitations of commonly used dipsticks.


Page17

Interpretation of electrolyte and blood gas values.

Emergency treatment of Acute Kidney Injury.

Priscription for dialysis (peritoneal and haemodialysis)

Interpretation of kidney ultrasound findings, pyelographic studies, micturiting cystourethrogram, and nuclear imaging studies

Technical Skills

Obtain urine by appropriate methods including suprapubic tap.

Catherterisation of the bladder.

Ability to place a peritoneal dialysis catheter

Ability to place a central line

Ability to perform a kidney biopsy

Ability to start a patient on haemodialysis, manage intradialytic complications, and take a patient off haemodialysis

Attitude Understanding the psychological stresses associated with end stage renal failure and its management.

Particular Problems

Ability to recognize, initiate diagnostic tests and outline the management of:

Renal abnormalities detected in fetal life.

Hypospadias.

Undescended testes and retractile testes.

Vulvo-vaginitis and discharge.

Reflux and reflux nephropathy.

Obstructive uropathy.

Acute urinary obstruction.

Henoch Schonlein purpura.

Nephrotic Syndrome.

Haemolytic uraemic sysndome.

Acute glomerulonephritis.

Familial nephritides.

Renal calculi: hypercalciuria.

Renal causes of rickets.

Renal tumours.

Renal tubular disorders.

Pre-end stage renal failure.

Contraindications for circumcision.

ghana college of physicians and surgeons · refer logbook. evaluation format: this will consist of...

Documents