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Examining a renal patient
Dr Jack Marjot
Dr Louisa Churcher
Dr Stephanie Bailey
OSCE-Aid Presents:
1. Mode of current / previous renal
replacement
2. Adequacy of renal replacement
3. Complications of renal failure
4. Complications of immunosuppression
5. Clues as to cause of kidney failure
Key Things to Look for in Renal
Examination
Structure of the renal exam
1. WIPER
2. Around the bed
3. Hands, arms
4. Neck, face
5. Chest, abdomen
6. Legs
7. Completion of examination
Structure of the renal exam
1. WIPER
2. Around the bed1. Diabetes monitoring
2. Hearing aid (Alports)
3. Drugs
3. Hands1. Fingerprick
monitoring
2. Cap refill, temperature
3. Asterixis (uraemia)
4. Tremor (ciclosporin)
4. Arms1. AV fistula (inspection,
palpation, auscultation)
2. Bruising, excoriations
3. Raise arm
4. Offer BP
5. Neck1. JVP
2. Tunneled lines
3. Parathyroidectomy scar
6. Face1. Mucous membranes
2. Conjunctival pallor
3. Skin malignancies / cushingoid facies / gum hypertrophy
7. Chest1. Skin turgor
2. Auscultate – pericardial rub
3. Lung bases + sacral oedema
8. Abdomen1. Inspect
– Scars (nephrectomy/RM)
– Tenchkoff catheter / surrounding skin
– Inguinal masses
– Subcut injection sites
2. Palpate– Iliac fossa mass
– Ballot for enlarged native kidneys
3. Percuss– Dull mass in iliac fossa
– Shifting dullness
4. Bruit
9. Legs1. Oedema
Mode of current /
previous renal
replacement
Types of Renal Dialysis
Access
• Temporary neck lines in
the femoral/jugular –
“Vascath”
– Non tunneled
– Temporary approx. 7 days
• Intermediate “Permacath”
– Tunneled line
– Dual lumen usually into RIJ
– Lasts months
• AV fistula
– Takes 4-6 weeks to mature
Fistula
• Location:
– Radiocephalic fistula – scar at the wrist
– Brachiocephalic fistula – scar at elbow crease
• Inspection:
– Skin changes (infection, ischemia of hand [steal syndrome])
– Bandages suggesting recent needling
– Length (rule of 6s)
• Palpation:
– CRT / temp
– Palpable thrill
– Tenderness
– Raise arm
• Fistula should collapses
if no outflow obstruction
• Auscultation:
– Audible bruit
Peritoneal dialysis
• Tenchkoff
catheter
• Scars
Renal transplant
• Transplantation Scars:
– Rutherford Morrison
(reverse hockey stick
usually in RIF).
• Renal transplant:
– Inspection:
• R-M scar
• Smooth mass under scar
– Palpate:
• Able to get above and below
mass
• No movement on respiration
• Tender? Warm? – possible
rejection.
– Percuss:
• Dull to percussion
– Auscultate:
• Possible bruit audible
Adequacy of renal
replacement
HYDRATION STATUS
HYDRATION STATUS
HANDS
– Warm? Capillary refill time? Radial pulse
ARMS
– BP (offer lying-standing)
NECK
– JVP
FACE
– Mucous membranes
– Tongue
HYDRATION STATUS
CHEST
– Skin turgor
– Central refill time
– Palpate the apex beat
– Auscultate heart (heart failure – 3rd
heart
sound)
– Lung bases (pulmonary oedema – bibasal fine
crepitations)
– Sacral oedema
LEGS
– Peripheral oedema
URAEMIA
Features of uraemia
• Asterixis
• Bruising (platelet dysfunction)
• Pruritus / excoriations
• Lemon tinged skin
• Pericarditis:
– Chest pain
– Pericardial rub
– Signs of tamponade; pulses paradoxus, Becks triad
• Confusion / encephalopathy
Complications of renal
failure
Complications of chronic
renal failure
• Fluid overload (as above)
• Uraemia (as above)
• Anaemia
– Conjunctival pallor
• Tertiary hyperparathyroidism
– Parathyroidetomy as indicated by horizontal
scar at base of neck
Complications of
immunosuppression
Complications of
immunosuppression
Malignancy:
• Skin cancer (SCC / BCC / malignant melanoma)
Steroid use:
• Cushingoid appearance (e.g. moon face, buffalo
hump, abdominal striae, purpura)
Stigmata of infection
Ciclosporin:
• Tremor, gum hypertrophy
What’s causing the
kidney disease?
Aetiology of ESRF
• Diabetes:
– Diabetic paraphernalia around bed
– Diabetic finger prick marks
– Subcut insulin injection sites
• HTN:
– Blood pressure
– Antihypertensives on drug chart
– Fundoscopy
• PCKD:
– Balottable kidneys
– Hepatomegaly from liver cysts
– Nephrectomy scar
– Look for III nerve palsy (PCA aneurysm)
• Vasculitis:
– Skin lesions or rheumatological disease
• Alports syndrome:
– Hearing aid
To finish…
Things to say to the
examiner…
• Urine dip:
– Blood (nephritic syndrome)
– Protein (nephrotic syndrome)
• Urine for MC&S
• Bloods:
– U&Es, FBC, rheumatology/autoimmune
screen
• Fluid balance
• Blood pressure
• Ultrasound scan
RECAP…
Structure of the renal exam
1. WIPER
2. Around the bed1. Diabetes monitoring
2. Hearing aid (Alports)
3. Drugs
3. Hands1. Fingerprick
monitoring
2. Cap refill, temperature
3. Asterixis (uraemia)
4. Tremor (ciclosporin)
4. Arms1. AV fistula (inspection,
palpation, auscultation)
2. Bruising, excoriations
3. Raise arm
4. Offer BP
5. Neck1. JVP
2. Tunneled lines
3. Parathyroidectomy scar
6. Face1. Mucous membranes
2. Conjunctival pallor
3. Skin malignancies / cushingoid facies / gum hypertrophy
7. Chest1. Skin turgor
2. Auscultate – pericardial rub
3. Lung bases + sacral oedema
8. Abdomen1. Inspect
– Scars (nephrectomy/RM)
– Tenchkoff catheter /
surrounding skin
– Inguinal masses
– Subcut injection sites
2. Palpate– Iliac fossa mass
– Ballot for enlarged native kidneys
3. Percuss – Dull mass in iliac fossa
– Shifting dullness
4. Bruit
9. Legs1. Oedema
Presentation…
Present your findings…
I have examined Mrs Smith…
1.Mode of current / previous renal replacement
• She also has a Rutherford-Morrison scar overlying the right lower
quadrant, with a smooth, non-tender palpable mass underlying it.
This is consistent with a renal transplant.
• I note she has a non-functioning right brachiocephalic fistula,
suggesting that haemodialysis was her previous mode of RRT
2.Adequacy of renal replacement
• She is clinically euvolaemic and has no stigmata of uraemia. Of
note, I cannot hear a pericardial rub.
3.Complications of renal failure
• She has no stigmata of anaemia
4.Complications of immunosuppression
• I have not identified any complications of immunosuppression,
such as infection or skin cancer. She does not appear
Cushingoid.
5.Clues as to cause of kidney failure
• I note a blood sugar monitoring kit at the bedside, fingerprick
marks and abdominal sites of insulin injection. This may suggest
diabetic nephropathy as the underlying cause of her renal failure.
In summary...
• Approach exam in standard peripheral to
central way (around bed > hands > arms etc...)
• Whilst looking for signs of:
1. Mode of current / previous renal replacement
2. Adequacy of renal replacement
3. Complications of renal failure
4. Complications of immunosuppression
5. Clues as to cause of kidney failure
COMMON QUESTIONS
What are the complications of
a fistula?
• Bleeding
• Stenosis
• Aneurysm
• Steal syndrome from ischemia
• High output cardiac failure
Complications of renal
transplantation?
• Surgical complications:
– bleeding, post op complications
• Medical
– rejection (acute/chronic)
– delayed graft function
– malignancy
– infection due to immunosuppression
– cardiovascular disease
What are the different types of
dialysis?
What are the indications for
acute dialysis?
• Refractory pulmonary oedema
• Persistent hyperkalaemia
• Refractory metabolic acidosis
• Uraemic pericarditis
• Uraemic encephalopathy
Renal screen bloods –
vasculitic/autoimmune
• Serum / urine protein electrophoresis
• dsDNA, ANA
• Serum complement
• cANCA, pANCA
• Anti-GBM
• Hep B, Hep C, HIV, syphilis