Renal examination

As you examine, look for evidence of renal disease aetiology, graft function (if transplant present), and complications of immunosuppression.

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Expose and lie patient flat

General inspection

• Patient: well/unwell, pain/discomfort, muscle wasting/cachexia, cushingoid appearance, confusion/myoclonus (uraemic encephalopathy), excoriations (uraemic pruritus), breathless (fluid overload)
• Around bed: dialysis machine, fluid charts

Hands

• Tremors: postural tremor (calcineurin inhibitor side effect), asterixis (flapping tremor; uraemic encephalopathy)
• Nails: leukonychia (hypoalbuminaemia in nephrotic syndrome), koilonychia (iron deficiency anaemia in nephritic syndrome)
• Fingertips: fingertip capillary glucose monitoring marks (diabetes)
• Pulse: rate and volume (tachycardia and low volume may be due to blood loss)
• Arms: arteriovenous fistula (look for active needle marks to see if it’s being used), bruising (Cushing’s syndrome), blood pressure (may be high due to hypertension, in renal graft rejection, or due a to calcineurin inhibitor), skin lesions (immunosuppression)

Arteriovenous fistula

Koilonychia

Heda and neck

• Face: yellow tinge (uraemia), butterfly rash (SLE), hearing aid (Alport syndrome), collapsed nasal bridge (granulomatosis with polyangiitis)
• Eyes: periorbital oedema (nephrotic syndrome), conjunctival pallor (erythropoietin deficiency), corneal arcus/xanthelasma (hyperlipidaemia in nephrotic syndrome)
• Mouth: mucus membranes (hydration), gingival hypertrophy (immunosuppressive drugs)
• Neck: JVP (fluid overload in nephrotic syndrome), central line scar (from previous renal replacement therapy)

Pale conjunctiva

Xanthelasma

Chest

• Inspection: sternotomy scar (renovascular disease)
• Capillary refill and skin turgor on sternum
• Heart sounds (uraemic pericardial rub)

Sit forwards:

• Lung base auscultation (pulmonary oedema in nephrotic syndrome or fluid overload)
• Inspect back: skin lesions/excisions (immunosuppression)

Abdomen

Inspection

• Distension (5Fs: Fluid, Flatus, Fat, Fetus, Faeces),
• Scars (loin scar, may appear on back; Rutherford Morrison scar in L/RIF from transplanted kidney – see scars)
• Fat hypertrophy/lipodystrophy (insulin injections),
• Peritoneal dialysis scars

Palpation

Check for pain and begin palpation away from painful areas:

• Superficial palpation (for tenderness): you crouch to their level and roll fingers over nine regions while watching the patient’s face. Check for: tenderness, guarding or rebound tenderness (peritonitis).
• Deep palpation (for masses): feel particularly for smooth renal graft in iliac fossae if scar present (tenderness = rejection)
• Kidney palpation: one hand anterior, one posterior. Ask patient to expire as you press up into renal angle with your posterior hand and press down with your anterior hand. As patient breathes in, you may feel it between your hands. Ballot the kidney by flexing the metacarpophalangeal joints of your posterior hand. Do flick, flick, stop and repeat as necessary (palpable = polycystic kidney disease).

Percussion of flank

• Should be resonant (tap all the way across abdomen horizontally)

• If dull, demonstrate one of:

  • Shifting dullness (have patient roll to side and percuss all the way across again)
  • Fluid thrill (have patient press hand firmly on abdominal midline while you tap one side and feel the other; ascites in co-existent liver disease)

Auscultation

• Auscultation for renal bruits (5cm superior and lateral to umbilicus bilaterally; renal artery stenosis)

Renal transplant, AV fistula, PD scars

Peritoneal dialysis (Tenckhoff) catheter

Legs

• Pedal oedema (nephrotic syndrome or fluid overload)

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

To complete

• Thank patient and restore clothing
• Summarise and suggest further investigations you would consider after a full history

Questions

What are the most common causes of end-stage kidney disease?

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What symptoms may you expect in end-stage kidney disease?

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What are the main indications for renal replacement therapy in kidney disease?

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List some complications of chronic kidney disease

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What options are available to patients with end-stage chronic kidney disease?

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Time to try a station

1. Renal transplant
2. We have hundreds of OSCE stations to try

Picture references

Xanthelasma: 2005 Klaus D. Peter; licensed under the Creative Commons 3.0 Germany licence (https://creativecommons.org/licenses/by/3.0/de/deed.en). Sourced from: https://commons.wikimedia.org/wiki/File:Xanthelasma.jpg