BRONX-LEBANON HOSPITAL CENTER

Marciela Del Rio, M.D. 

Residents in the Department of Pediatrics at Bronx-Lebanon Hospital Center can elect to do a rotation in Pediatric Nephrology at the Children’s Hospital at Montefiore Medical Center.  Dr. Flynn conducts an outpatient clinic for children and adolescents with renal disease every Friday afternoon. A resident is assigned to this outpatient clinic, and it affords a unique opportunity to understand the outpatient management of renal pathology.

GOALS & OBJECTIVES

The house-officer should gain mastery of the following topics:

Urinary tract infection.

Fluid and electrolyte disorders (including acid/base disturbances and dehydration)

Initial evaluation of hematuria and proteinuria

Conservative management of acute renal failure

Acute glomerulonephritis

The house-officer should become knowledgeable in the following areas:

Congenital anomalies of the genitourinary tract hypertension

Renal disorders in systemic disease

Chronic renal failure

Neoplasms of the kidney

Acute and chronic glomerular diseases

Renal Tubular disorders

Nephrolithiasis

Primary Goals for this Rotation

Hypertension

Understand the general pediatrician's role in diagnosis and management of hypertension in children.

Understand the general pediatrician's role in diagnosis and management of hypertension in children.

Manage a patient with hypertension using a step-wise approach that includes the role of diet, exercise, weight control, and medications.

Identify the indicators for a cardiology or nephrology referral in a child with hypertension.

Prevention, Counseling and Screening

Understand the role of the pediatrician in preventing renal disease, and in counseling and screening individuals at risk for these diseases.

Provide routine prevention counseling about kidney health and disease to all parents and patients, addressing:

Provide routine prevention counseling about kidney health and disease to all parents and patients, addressing normal voiding, toilet training, and attainment of bladder control, female hygiene, urinary tract infections and non-specificity of physical complaints in infants and young children, strategies to assure normal bowel and bladder habits, importance of routinely measuring blood pressures in children, especially overweight children and those with a family history of hypertension.

In conjunction with a specialist, provide specific prevention counseling to parents and patients with renal diseases, addressing need for medication adjustments in patients with impaired renal function, including many over the counter medicines, need for prophylactic medications for certain renal conditions, altered immunization schedule for children with specific renal diseases (e.g., those immunocompromised following renal transplantation, with chronic renal failure, nephritic syndrome, etc.), importance of continued home and office monitoring in children with specific diseases (e.g., blood pressures in children with hypertension or urine protein for children with nephrotic syndrome), risks of contact and other sports in children with a single kidney.

Normal Versus Abnormal

Differentiate between normal and pathological states related to the renal system

Discuss the normal physiological development of the kidneys and bladder, including renal concentrating ability, glomerular filtration and sodium

Handling, normal voiding pattern, urine output, and attainment of bladder control.

Undifferentiated Signs and Symptoms

Evaluate, treat, and/or refer patients with presenting signs and symptoms that may indicate a nephrologic disease process.

Create a strategy to determine if the following presenting signs and symptoms are caused by a renal disease process and determine if the patient needs treating, consultation, or referral.

Fluid and Electrolytes

Understand the physiology of body fluids and electrolytes, abnormalities, and treatment

Discuss the normal physiology of body fluids (water) and salts, including: intracellular versus extracellular component, composition of salt in each (Na, K), intake and output, measured and insensible losses, and normal daily requirements.

Implement maintenance and replacement fluid therapy (either oral or IV) in patients and make changes based on changes in the clinical condition, taking into account fluid and electrolyte deficits, maintenance needs, insensible losses, output and intracellular vs extracellular components.

Interpret acid base laboratory values and discuss the differential diagnosis of metabolic acidosis and alkalosis. Describe your approach to diagnosis and treatment.

Urinary Tract Infection

Appropriately manage and refer, when necessary, patients with urinary tract infections

Discuss findings on clinical history and examination that lead one to suspect a urinary tract infection.

Discuss findings on clinical history and examination that lead one to suspect a urinary tract infection.

Identify indicators for a nephrology or urology consult or referral of a child with a urinary tract infection.

Nephrotic Syndrome

Understand the pediatrician's role in the management of nephrotic syndrome

Discuss findings on clinical history and physical examination that would lead one to suspect nephrotic syndrome.

Discuss the different types of nephrotic syndrome, the current therapy of each, and the need for consistent therapy.

Describe age related differences in the etiology of nephrotic syndrome.

Identify indicators of the need for emergent management and urgent vs. non-urgent nephrology referral of a child with nephrotic syndrome.

Systemic Conditions with Renal Involvement

Understand the pathophysiology and management of common systemic conditions that may present with renal involvement, and seek consultation or referral appropriately

Identify and explain the renal involvement seen in the following systemic conditions:

1.       Henoch-Schonlein purpura

2.       Systemic lupus erythematosus

3.       Sickle cell anemia

4.       Bacteremia and sepsis

5.       Shock

6.       Dehydration

7.       Vasculitis

8.       Diabetes mellitus