🩺 Nephrology Posting Guide - GM PG (4 Weeks)

Overall Strategy

• Morning rounds - focus on one patient per day, understand their diagnosis deeply
• Evening - read the concept behind what you saw that day (bedside-to-book approach)
• Weekly goals - each week builds on the previous

📅 WEEK 1 - Foundation: Kidney Physiology + Fluid & Electrolytes

Core Concepts to Master:

• GFR, tubular function (proximal, loop, distal, collecting duct)
• Renin-Angiotensin-Aldosterone System (RAAS)
• Antidiuretic hormone (ADH) and water handling
• Creatinine vs urea as markers - why both matter

• Metabolic acidosis / alkalosis
• Respiratory compensation
• Anion gap calculation and causes (MUDPILES)
• Renal tubular acidosis (RTA Types 1, 2, 4)

Clinical Skill This Week:

• Learn to read a basic urine routine examination properly
• Urine protein, casts (RBC cast = glomerulonephritis, granular cast = ATN), specific gravity

📅 WEEK 2 - AKI & CKD (Most Common Ward Diagnoses)

Acute Kidney Injury (AKI)

• KDIGO staging (Creatinine + Urine output criteria)
• Pre-renal vs Intrinsic vs Post-renal - approach and key differentiators
• Fractional Excretion of Sodium (FENa) - how to calculate, when to use
• Causes: ATN (most common), contrast nephropathy, drugs (NSAIDs, aminoglycosides, vancomycin)
• Indications for emergency dialysis: AEIOU (Acidosis, Electrolytes, Intoxication, Overload, Uremia)

Chronic Kidney Disease (CKD)

• KDIGO staging (GFR + Albuminuria)
• Complications: anemia (EPO deficiency), renal osteodystrophy, hyperkalemia, metabolic acidosis, hypertension, pericarditis
• Management: dietary restrictions, RAAS blockade, phosphate binders, erythropoiesis-stimulating agents
• When to refer for RRT (Renal Replacement Therapy)

Clinical Skills This Week:

• Calculate eGFR using CKD-EPI formula (know the concept, use calculator in practice)
• Spot a uremic patient on rounds - look for pallor, pericardial rub, asterixis, altered sensorium

📅 WEEK 3 - Glomerular Diseases (High Exam Yield)

Framework First:

• Nephrotic syndrome vs Nephritic syndrome - memorize the table below:

Causes to Know:

• Adults: Membranous nephropathy (most common primary), Focal Segmental Glomerulosclerosis (FSGS), Minimal Change Disease (MCD - steroid-sensitive)
• Secondary: Diabetic nephropathy, Amyloidosis, Lupus

• IgA nephropathy (most common GN worldwide)
• Post-infectious GN (low C3, high ASO)
• Lupus nephritis (WHO/ISN classification)
• RPGN - Anti-GBM disease, ANCA vasculitis, Immune complex (crescents on biopsy)

Clinical Skills This Week:

• Look at real biopsy reports in your ward - identify the staining patterns
• Learn immunofluorescence patterns: granular (immune complex), linear (anti-GBM), pauci-immune (ANCA)

📅 WEEK 4 - Dialysis, Hypertension, Systemic Diseases + Revision

Dialysis

• Hemodialysis vs Peritoneal Dialysis - principles, access, indications, complications
• CRRT (Continuous Renal Replacement Therapy) - used in ICU/hemodynamically unstable patients
• Acute complications of HD: hypotension (most common), disequilibrium syndrome, air embolism

Renovascular & Hypertensive Nephropathy

• Renal artery stenosis - causes (atherosclerosis vs FMD), clue: flash pulmonary edema, resistant HTN
• Malignant hypertension - TMA pattern on biopsy (onion-skin)

Systemic Diseases Affecting Kidney

• Diabetic nephropathy - Kimmelstiel-Wilson nodules, microalbuminuria progression
• Lupus nephritis - ISN/RPS classification (Class I-VI)
• Myeloma kidney - cast nephropathy, free light chains
• Amyloidosis - Congo red staining, apple-green birefringence

Revision Week Tasks:

• Go through your ward patients - can you classify each one's diagnosis?
• Practice 3-4 clinical case write-ups (AKI, nephrotic, CKD on dialysis)

📚 Resources to Use

🔑 Key Numbers to Memorize

• Normal GFR: ~90-120 mL/min/1.73m²
• CKD defined as: GFR <60 for >3 months OR markers of damage >3 months
• Nephrotic range proteinuria: >3.5g/day
• FENa <1% = pre-renal; >2% = intrinsic renal
• ESRD dialysis threshold: GFR ~5-10 mL/min (symptomatic)
• Hyperkalemia emergency: K+ >6.5 mEq/L or ECG changes

Daily Habit (15 minutes)

1. What stage of AKI/CKD are they in?
2. What are their electrolytes today - and why?
3. What is their urine output - and what does it tell me?
4. Are there any indications for dialysis today?