Essential Diagnostic Skills (Read in this order)

1. Urinalysis in the diagnosis of kidney disease - Why read: Urinalysis is your first window into kidney pathology - Key learning: Interpretation of proteinuria, hematuria, casts, crystals - Clinical pearls: - RBC casts support a glomerular bleeding source and require clinical correlation - Dysmorphic RBCs suggest glomerular source - WBC casts suggest pyelonephritis or interstitial inflammation - Time needed: 45-60 minutes - How to study: Review case examples; practice interpreting microscopy images

2. Radiologic assessment of kidney disease - Why read: Imaging often provides diagnosis when labs are ambiguous - Key learning: Understanding ultrasound, CT, MRI findings in different kidney diseases - Clinical pearls: - Increased echogenicity is nonspecific - Hydronephrosis prompts an obstruction assessment but does not prove functional obstruction - “Normal-appearing kidneys” on ultrasound can still have disease on biopsy - Time needed: 60-90 minutes - How to study: Look at images while reading; memorize normal measurements

3. Laboratory evaluation of kidney function - Why read: Creatinine and eGFR are imperfect; understand their limitations - Key learning: How to interpret eGFR, creatinine, BUN; when to use cystatin C - Clinical pearls: - A “normal” creatinine can represent significant kidney dysfunction in elderly/frail - eGFR less reliable during acute changes - BUN:Cr ratio is a contextual clue, confounded by protein intake, catabolism, bleeding, and other factors - Time needed: 45-60 minutes - How to study: Learn equations; practice calculating eGFR by hand

Recognizing and Managing AKI

4. Evaluation of acute kidney injury among hospitalized adult patients - Why read: AKI is common and often managed incorrectly (over-fluiding or under-fluiding) - Key learning: KDIGO staging, differentiation of prerenal vs. intrinsic vs. postrenal AKI - Clinical pearls: - FENa is a contextual clue, especially limited with CKD, diuretics, sepsis, or mixed injury - Seek a credible baseline and use serial creatinine and urine output; a missing prior value does not exclude AKI - Time needed: 60-90 minutes - Key sections: KDIGO staging (memorize), diagnostic approach by type, management principles - How to study: Create a decision tree for AKI classification; practice with case examples

5. Causes of acute interstitial nephritis - Why read: AIN is easily missed and can be reversible if caught early - Key learning: Common medications causing AIN, diagnostic findings, treatment - Clinical pearls: - Urine eosinophils do not reliably confirm or exclude AIN - Antibiotics, PPIs, and NSAIDs are important exposures - Latency varies; a delayed presentation does not exclude medication-related disease - Time needed: 30-45 minutes - How to study: Make a list of AIN-causing drugs; present a case to a colleague

Understanding CKD Across Stages

6. Overview of the management of chronic kidney disease in adults - Why read: This is THE comprehensive management topic — foundational for all CKD patients - Key learning: Staging, complications, slowing progression, preparing for RRT - Clinical pearls: - ACEi/ARB use depends on albuminuria, blood pressure, heart failure indications, tolerance, and pregnancy considerations - For selected nondialysis adults, a systolic target <120 uses standardized office measurement and requires tolerability - Screen for complications at each CKD stage - Time needed: 90-120 minutes - Key sections: Definition and staging, complications, management by stage, progression factors - How to study: Create management checklists for each CKD stage (1-5)

7. Evaluation and diagnosis of diabetic kidney disease - Why read: Diabetic nephropathy is the #1 cause of ESRD in developed countries - Key learning: Early detection (microalbuminuria), differentiation from non-diabetic disease - Clinical pearls: - Moderately increased albuminuria can be an early sign, but DKD may occur without it - Absence of retinopathy does not rule out DKD, particularly in type 2 diabetes - Consider SGLT2i according to kidney function, indication, contraindications, and current guidance - Time needed: 45-60 minutes - How to study: Review criteria for diabetic vs. non-diabetic kidney disease

8. Treatment of diabetic kidney disease - Why read: SGLT2 inhibitors and GLP-1 agonists have transformed diabetic kidney disease management - Key learning: SGLT2i are now first-line; GLP-1 agents add benefit - Clinical pearls: - SGLT2i reduce progression even without diabetes (surprising finding) - GLP-1 agents reduce albuminuria and cardiovascular risk - Layer therapies according to the patient’s indications, kidney function, potassium, volume status, and tolerance; the same combination is not appropriate for everyone - Time needed: 45-60 minutes - How to study: Compare outcomes in SGLT2i trials; understand mechanisms

When to Worry: Glomerulonephritis

9. Rapidly progressive glomerulonephritis: A clinical overview and diagnostic approach - Why read: RPGN is a medical emergency; missing it costs kidney function - Key learning: Clinical presentation, diagnostic categories (ANCA, anti-GBM, immune complex), urgency of treatment - Clinical pearls: - RBC casts with rapidly worsening kidney function prompt urgent specialist assessment - There is no fixed four-week diagnostic window - Anti-GBM disease often requires urgent plasma exchange; in ANCA disease, consider it in selected severe kidney presentations or hypoxemic alveolar hemorrhage, not automatically for every hemorrhage - Time needed: 60-90 minutes - Key sections: Clinical presentation, diagnostic approach, treatment by type - How to study: Present a RPGN case; explain when urgent immunosuppression and plasma exchange are appropriate

10. IgA nephropathy: Clinical features and diagnosis - Why read: IgA nephropathy is most common glomerulonephritis worldwide; often presents in young patients - Key learning: Presentation (hematuria, proteinuria), progression patterns, biopsy findings - Clinical pearls: - Hematuria may be intermittent and proteinuria may be present early - Prognosis varies with clinical and biopsy features - Review current IgAN-specific guidance for supportive and disease-targeted treatment - Time needed: 30-45 minutes - How to study: Review pathology photos; understand Oxford classification prognostic factors

11. Membranous nephropathy: Clinical presentation and diagnosis - Why read: Common cause of nephrotic syndrome in adults; prognosis highly variable - Key learning: Clinical features, progression patterns, distinction between primary and secondary - Clinical pearls: - Serologic: Check PLA2R and THSD7A antibodies - Spontaneous remission and progression risk vary; avoid applying a fixed rule of thirds to an individual - Treatment varies by risk stratification - Time needed: 30-45 minutes - How to study: Understand risk factors for progression; know secondary causes (malignancy, infections)

12. Focal segmental glomerulosclerosis (FSGS): Clinical features and diagnosis - Why read: Common cause of nephrotic syndrome; understanding variants guides treatment - Key learning: Primary vs. secondary FSGS, prognosis, treatment - Clinical pearls: - Distinguish primary, genetic, secondary, and undetermined-cause FSGS - Age, family history, nephrotic syndrome, and biopsy findings guide evaluation - Immunosuppression is not routine treatment for genetic or secondary FSGS - Time needed: 30-45 minutes - How to study: Compare primary, genetic, and secondary forms; explain how the cause changes treatment

The Cardiorenal Connection

13. Cardiorenal syndrome: Definition, prevalence, diagnosis and pathophysiology - Why read: Heart failure and kidney disease are inextricably linked; treatment requires understanding both - Key learning: CRS types (1-5), mechanisms, diagnostic approach - Clinical pearls: - Type 1: Acute heart failure → acute kidney injury - Type 2: Chronic heart failure → progressive CKD - Type 5: Systemic disease affecting both (sepsis, cardiorenal-hepatic) - Time needed: 60-90 minutes - Key sections: Pathophysiology, diagnosis, prognostic markers - How to study: Compare medication effects in CHF+CKD scenarios

14. Cardiorenal syndrome: Prognosis and treatment - Why read: Treatment differs from isolated CKD or isolated CHF - Key learning: Diuretic use, RAAS inhibitor dosing, novel agents - Clinical pearls: - Treat congestion with an individualized diuretic plan and reassess perfusion and response - Sacubitril/valsartan has outcome evidence in eligible HFrEF; do not generalize that comparison to all heart-failure phenotypes - Sodium-glucose cotransporter inhibitors benefit both organs - Time needed: 45-60 minutes - How to study: Build management algorithms for different CRS types

When Kidneys Fail: RRT Modalities

15. Overview of the hemodialysis apparatus - Why read: Understanding how dialysis works helps you manage dialysis patients - Key learning: Vascular access types, dialyzer characteristics, anticoagulation - Clinical pearls: - Choose AVF, AVG, or catheter within an individualized kidney-replacement life plan - Consider time to use, maturation likelihood, infection risk, heart function, prognosis, and patient preferences - Time needed: 45-60 minutes - How to study: Review vascular anatomy; explain why access selection differs between patients

16. Prescribing and assessing adequate hemodialysis - Why read: Dialysis prescription directly impacts patient survival and quality of life - Key learning: Kt/V, urea reduction ratio, adjusting dialysis dose - Clinical pearls: - For conventional thrice-weekly HD, distinguish prescribed targets from minimum delivered adequacy and account for residual kidney function - Inadequate dialysis linked to higher mortality and morbidity - Can be improved by longer sessions, more frequent sessions, or higher flow rates - Time needed: 45-60 minutes - How to study: Calculate Kt/V for case examples; understand how to adjust prescriptions

17. Prescribing peritoneal dialysis - Why read: PD is a home-treatment option that may support autonomy and preservation of residual kidney function - Key learning: CAPD vs. APD, dosing, adequacy assessment, complications - Clinical pearls: - Modality choice depends on goals, home support, residual function, infection risk, and local resources - Avoid promising superior quality of life, kidney preservation, or cost for every patient - Time needed: 30-45 minutes - How to study: Compare PD vs. HD; understand patient selection factors

18. Acute complications during hemodialysis - Why read: Dialysis sessions can trigger serious complications; knowledge prevents morbidity - Key learning: Hypotension, cramping, arrhythmias, dialysis disequilibrium - Clinical pearls: - Hypotension most common; managed by ultrafiltration goals and fluid removal rate - Dialysis disequilibrium: Headache, nausea, seizures from osmotic shifts - New hypoxemia needs assessment for the specific cause - Time needed: 30-45 minutes - How to study: Make a management flow chart for common complications

Critical Fluid and Electrolyte Management

19. Hyponatremia: Etiology, clinical manifestations, and diagnosis - Why read: Hyponatremia is most common electrolyte disorder; mismanagement causes brain damage - Key learning: Classification by volume status, pathophysiology, diagnostic approach - Clinical pearls: - Symptoms, duration, cause, and osmotic-demyelination risk jointly guide treatment - Severe symptoms may require urgent controlled hypertonic saline - Use a monitored correction plan with risk-specific limits and a response to overcorrection - Time needed: 60-90 minutes - Key sections: Classification, diagnosis by urine osmolality + serum osmolality, treatment

20. Hypernatremia: Etiology, clinical manifestations, and diagnosis - Why read: Hypernatremia carries worse prognosis than hyponatremia - Key learning: Classification, pathophysiology, when diabetes insipidus is involved - Clinical pearls: - Inappropriately dilute polyuria prompts evaluation for vasopressin deficiency or resistance - Testing must be supervised; do not water-deprive an unstable or already hypernatremic patient - Partial disorders can complicate desmopressin responses - Time needed: 45-60 minutes - How to study: Practice interpreting water deprivation test results

21. Hypokalemia: Treatment - Why read: Hypokalemia causes cardiac arrhythmias; treatment requires thoughtfulness about replacement rate and route - Key learning: Calculating deficits, oral vs. IV replacement, monitoring - Clinical pearls: - Each 1 g KCl = 13.4 mEq K+ - Refractory hypokalemia often due to magnesium depletion - Must replete magnesium for potassium to normalize - Time needed: 30-45 minutes - How to study: Calculate replacement amounts for case examples

22. Hyperkalemia: Causes, clinical features, diagnosis, and treatment - Why read: Hyperkalemia with ECG changes is a medical emergency; treatment has narrow margins - Key learning: “ABCs” approach: Antagonize (calcium), Shift (insulin/glucose), Remove (diuretics/dialysis) - Clinical pearls: - ECG findings are variable; dangerous hyperkalemia may occur without a predictable sequence or striking ECG changes - Calcium gluconate acts immediately but doesn’t lower K+ - Insulin + dextrose shifts K+ intracellular (onset 10-20 mins) - Time needed: 45-60 minutes - Key sections: Causes, treatment algorithms, monitoring - How to study: Review the local emergency protocol, including urgent treatment when indicated, repeat potassium, and glucose monitoring after insulin

Nephrology Beyond the Mainstream

23. Acute kidney injury in the critically ill patient - Why read: ICU patients have complex AKI; context matters for management - Key learning: Multifactorial AKI, when to dialyze, nutritional support - Clinical pearls: - Often combination of prerenal + intrinsic + toxic insults - CRRT often preferred over IHD in hemodynamically unstable - Nutritional needs change with dialysis; coordinate with nutrition - Time needed: 45-60 minutes - How to study: Review ICU case examples; understand CRRT indications

24. Contrast-induced acute kidney injury - Why read: AKI after contrast has multiple possible causes; association alone does not establish contrast causation - Key learning: Pathophysiology, prevention strategies, management - Clinical pearls: - Balance diagnostic benefit against patient-specific risk - Consider prophylactic isotonic fluid for appropriate high-risk patients while assessing heart failure and volume status - Metformin and laboratory follow-up depend on AKI, kidney function, route, and current radiology policy; they are not universal requirements - Time needed: 30 minutes - How to study: Create pre/post-contrast orders for your institution

Topics for Specific Patient Encounters

Beyond the main reading: - Pregnancy and kidney disease (preeclampsia, gestational hypertension) - Kidney disease in cancer patients (onco-nephrology) - Medication dosing in kidney disease (pharmacokinetics) - Kidney transplant evaluation and management - Nephrolithiasis (kidney stones): Prevention and treatment - Polycystic kidney disease (genetic counseling, management) - Vasculitis and ANCA-associated disease - Systemic lupus erythematosus and lupus nephritis

Read these topics when you encounter patients with these conditions.

How to Get Maximum Value from Reading

General Principles:

1. Read actively, not passively
   • Keep notes while reading
   • Write down definitions and key concepts
   • Create your own diagrams and algorithms
2. Connect to patients you’ve seen
   • After each topic, recall a patient encounter
   • Ask: “Does this explain what I saw?”
   • Discuss cases with faculty and colleagues
3. Build your own resource library
   • Favorite images and diagrams
   • Most useful algorithms
   • Key references for common conditions
4. Practice clinical reasoning
   • Present cases to colleagues
   • Ask “What would you do?” before reading answers
   • Explain your clinical reasoning to a student
5. Focus on clinical applicability
   • Every concept should connect to patient care
   • Ask “When will I use this knowledge?”
   • Prioritize common conditions over rare diseases

2-Week Rotation

Must-read (Sections A & B): Topics 1, 2, 4, 5 Time commitment: ~4 hours

4-Week Rotation

Add (Sections C & D): Topics 3, 6, 7, 9 Time commitment: ~8 hours total

6-Week Rotation

Add (Sections E & F): Topics 13, 14, 15, 16 Time commitment: ~12 hours total

8-Week Rotation

Add (Sections G & H): Topics 19, 20, 21, 22 Time commitment: ~16 hours total