11/13/24, 7\:09 PM Guide | Renal system examination

Renal system examination

Table of contents

Background

A renal system examination involves looking for clinical clues and signs related to end-stage renal disease (e.g.
catheter, renal transplant), renal failure complications (e.g.
(e.g. tremor, striae, steroid facies) and causes of renal disease (e.g. diabetes, hypertension, polycystic kidney disease).
This OSCE guide provides a generic overview of the potential signs you may identify in a patient with renal disease. The
commonest renal patients you'll come across will be those with polycystic kidney disease, a kidney transplant and/or end-
stage renal disease on dialysis.

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adjust the head of the bed to a 45° angle and ask the patient to lay on the bed.
Adequately expose the patient's abdomen for the examination from the waist up (o
required). Exposure of the patient's lower legs can also be helpful to assess for peripheral oedema.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Clinical signs

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology\:
Decreased level of consciousness\: can be a feature of end-stage renal disease.
Obvious scars\: may provide clues regarding previous abdominal surgery.
Pallor\: a pale colour of the skin that can suggest underlying anaemia (e.g. erythropoietin de
Shortness of breath\: may be due to pulmonary oedema secondary to advanced renal disease. Tachypnoea may also be due
to metabolic acidosis secondary to renal failure.
Oedema\: typically presents as swelling of the limbs (e.g. pedal oedema) and abdomen (i.e. ascites). In the context of a renal
system examination, possible causes could include nephrotic syndrome and end-stage renal disease (due to anuria).
Cachexia\: ongoing muscle loss that is not entirely reversed with nutritional supplementation. Cachexia is commonly
associated with end-stage renal failure due to protein-energy wasting (PEW).
Uraemic complexion\: a yellow colour of the skin caused by uraemia in advanced chronic kidney disease.
Cushingoid appearance\: in the context of a renal system examination this may be due to the use of high dose
corticosteroids for renal transplant immunosuppression or glomerulonephritis.

Objects and equipment

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Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Medical equipment\: examples include supplemental oxygen, intravenous medications, urinary catheters, nephrostomy
drains and haemodialysis/peritoneal dialysis machines.
Mobility aids\: items such as wheelchairs and walking aids give an indication of the patient's current mobility status.
Vital signs\: charts on which vital signs are recorded will give an indication of the patient's current clinical status and how their
physiological parameters have changed over time.
Fluid balance\:
patient appears
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient's recent
medications.
General inspection

Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

Inspection

Inspect the hands for any of the following signs\:
Pallor\: indicative of underlying anaemia (e.g. erythropoietin de
Fingerprick marks\: secondary to repeated capillary blood glucose tests in patients with diabetes.
Gouty tophi\: nodular masses of monosodium urate crystals deposited in the soft tissues of the body, common in advanced
chronic kidney disease.
Tremor\: can be caused by immunosuppressive medications such as ciclosporin in renal transplant patients.
Nail signs
Inspect the nails for any of the following signs\:
Koilonychia\: spoon-shaped nails, associated with iron de
Leukonychia\: whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage renal disease, nephrotic
syndrome).
Splinter haemorrhages\: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include
local trauma, infective endocarditis (e.g. dialysis catheter-associated infections), sepsis, vasculitis and psoriatic nail disease.
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Beau’s lines\: one or more palpable transverse ridges in the nail plate extending across the nail associated, in some cases,
with malnutrition and systemic disease.
Muehrke’s lines\: one or more pale transverse bands (not palpable like Beau's lines) extending all the way across the nail
associated with hypoalbuminaemia.
Lindsay’s half-and-half nails\: white discolouration of the proximal portion of the nail and red/brown discolouration of the
distal portion with a sharp line of demarcation between the halves. Commonly present in haemodialysis patients.
Peripheral pallor [5]
Asterixis (
Asterixis (also known as '
a
secondary to renal failure. CO 2
retention secondary to type 2 respiratory failure and hyperammonemia secondary to liver failure
are also causes of asterixis.
To assess for asterixis\:
1. Ask the patient to stretch their arms out in front of them.
2. Then ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds.
3. Observe for evidence of asterixis during this time period.
Skin turgor
Assess skin turgor by gently pinching a fold of skin (this can be done on the back of the hand), holding for a few seconds and
then releasing the skin. Well-hydrated skin should spring back to its previous position immediately, whereas dehydrated skin
will slowly return to normal (known as decreased skin turgor).
Assessment of skin turgor is useful as part of an overall assessment of hydration.
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Asterixis

Arms

Inspect the arms

Excoriation
Excoriation may indicate pruritis secondary to uraemia (e.g. end-stage renal disease).
Bruising
Bruising may be due to excessive corticosteroid use (e.g. immunosuppression in the context of renal transplant) or platelet
dysfunction secondary to uraemia.
Skin lesions
Inspect for obvious warts or skin cancers which can be associated with immunosuppression (e.g. renal transplant patients).
Arteriovenous
Inspect for an arteriovenous (AV)
brachio-basilic
haemodialysis). If an AV
Visible needle marks over the AV
Palpate the AV
after renal transplantation).

Radial pulse

Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.

Blood pressure

O
Blood pressure should NOT be performed on the side of an AV
Causes of hypertension can include chronic kidney disease, renal transplant rejection, corticosteroid use and tacrolimus or
ciclosporin use for renal transplant immunosuppression.
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Rarely, pulsus paradoxus (change in BP >10mmHg during breathing) can occur due to uraemic cardiac tamponade
(associated with raised jugular venous pressure).
See our blood pressure measurement guide for more details.
Arteriovenous

Face

General

Skin colour and skin lesions
Inspect the patient's complexion and note any skin lesions\:
Yellowish complexion (also known as a uraemic complexion)\: associated with chronic renal failure.
Uraemic frost\: crystallized urea deposits found on the skin of patients with chronic kidney disease who are chronically
uraemic.
Skin lesions\: may develop secondary to immunosuppression (e.g. squamous cell carcinoma, basal cell carcinoma, herpetic
gingivostomatitis).
Cushingoid facial appearance
Inspect the patients face for cushingoid features (i.e. a moon-shaped appearance) caused by treatment with high-dose
corticosteroids (e.g. renal transplant immunosuppression, treatment of glomerulonephritis).
Hypertrichosis
Hypertrichosis refers to the excessive >hair growth over and above the normal for the age, sex and race of an individual.
Hypertrichosis is a side e
Hearing aid
If the patient is wearing a hearing aid, consider Alport syndrome. Alport syndrome is a genetic disorder characterised by
glomerulonephritis, end-stage kidney disease and hearing loss.

Eyes

Conjunctival pallor
Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva for pallor indicative of anaemia.
Anaemia is common in patients with chronic renal failure due to erythropoietic de
Band keratopathy
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Band keratopathy is a corneal disease caused by the deposition of calcium in the central cornea. Symptoms include eye
pain and reduced visual acuity.
Band keratopathy has a wide range of causes, but in the context of a renal system examination chronic hypercalcaemia is the
most likely cause.
Periorbital oedema
Periorbital oedema (swelling around the eyes) is a common clinical feature of nephrotic syndrome.

Mouth

Gingival hypertrophy
Gingival hypertrophy is an increase in the size of the gingiva which can be caused by gingival disease as well as certain
medications such as ciclosporin.
Uraemic fetor
Uraemic fetor is a urine-like (i.e. ammonia) smell of the breath typically associated with end-stage renal disease.
Basal cell carcinoma [12]

Neck

Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal
jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. The
presence of this continuous column of blood means that changes in right atrial pressure are re
atrial pressure results in distension of the IJV).
The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid,
making it di
sternocleidomastoid muscle).
Because of the inability to easily visualise the IJV, it's tempting to use the external jugular vein (EJV) as a proxy for assessment
of central venous pressure during clinical assessment. However, because the EJV typically branches at a right angle from the
subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous
pressure.
See our guide to jugular venous pressure (JVP) for more details.
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Measure the JVP

1. Position the patient in a semi-recumbent position (at 45°).
2. Ask the patient to turn their head slightly to the left.
3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of
the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the
sternocleidomastoid. The IJV has a double waveform pulsation, which helps to di
carotid artery.
4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV
(in healthy individuals, this should be no greater than 3 cm).
JVP interpretation
An elevated JVP indicates increased central venous pressure secondary to
disease become anuric and often develop

Other things to look for in the neck

Inspect for the presence of an indwelling dialysis catheter at the base of the neck or on the anterior aspect of the chest
wall (also note any scars in these locations suggestive previous dialysis catheter insertion).
Inspect for a small horizontal scar at the base of the neck suggestive of a previous parathyroidectomy (performed for renal
hyperparathyroidism).
Observe the JVP

Chest

Inspection

Excoriation
Excoriation may indicate pruritis secondary to uraemia (e.g. end-stage renal disease).
Bruising
Bruising may be due to excessive corticosteroid use (e.g. immunosuppression in the context of renal transplant) or platelet
dysfunction secondary to uraemia.
Skin lesions
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Inspect for obvious warts or skin cancers which can be associated with immunosuppression (e.g. renal transplant patients).

Percussion

Percussion of the chest involves listening to the volume and pitch of percussion notes across the chest to identify underlying
pathology. Correct technique is essential to generating e
Percussion technique
1. Place your non-dominant hand on the patient’s chest wall.
2. Position your middle
3. With your dominant hand’s middle
swinging movement of the wrist.
4. The striking
Areas to percuss
Percuss the following areas of the chest, comparing side to side as you progress\:
Supraclavicular region\: lung apices
Infraclavicular region
Anterior chest wall\: percuss over 3-4 locations bilaterally
Axilla
Posterior chest wall\: percuss over 3-4 locations bilaterally including the lung bases
Interpretation
A stony dull percussion note is indicative of pleural e
renal disease) or nephrotic syndrome (hypoalbuminaemia).
Percuss the lung

Palpate

Apex beat
Palpate the apex beat with your
In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line. Ask the patient to lift their
breast to allow palpation of the appropriate area if relevant.
Displacement of the apex beat from its usual location can occur due to ventricular hypertrophy.
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Palpate the apex beat

Auscultate the heart

A systematic routine will ensure you remember all the steps whilst giving you several chances to listen to each valve area. Your
routine should avoid excess repetition whilst each step should ‘build’ upon the information gathered by the previous steps.
Ask the patient to lift their breast to allow auscultation of the appropriate area if relevant.
1. Palpate the carotid pulse to determine the
2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope whilst continuing to palpate the
carotid pulse\:
Mitral valve\: 5th intercostal space in the midclavicular line.
Tricuspid valve\: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve\: 2nd intercostal space at the left sternal edge.
Aortic valve\: 2nd intercostal space at the right sternal edge.
3. Repeat auscultation across the four valves with the bell of the stethoscope.
Interpretation
The presence of a gallop rhythm (additional S3 and S4 heart sounds) is associated with heart failure.
A friction rub may be noted in uraemic pericarditis.
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Auscultate the mitral valve

Auscultate the lung bases

Auscultate the lung
Coarse crackles are suggestive of pulmonary oedema (e.g.
nephrotic syndrome).
Absent air entry and stony dullness on percussion are suggestive of an underlying pleural e
Auscultate lung bases
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Abdomen

Position the patient lying
subsequent palpation.
Inspect the patient's abdomen for signs suggestive of renal pathology\:
Scars\: many di
examples).
Peritoneal dialysis catheter\: a tube inserted into the abdomen for peritoneal dialysis
Abdominal distension\: may be caused by an intrabdominal mass (e.g. polycystic kidneys), ascites (e.g. secondary to
nephrotic syndrome) or indwelling peritoneal dialysis
Nephrostomy tube(s)\: a catheter inserted through the
urinary drainage in the context of obstruction (e.g. secondary to malignancy).
Striae (stretch marks)\: caused by tearing during the rapid growth or overstretching of skin (e.g. ascites, intrabdominal
malignancy, Cushing's syndrome, obesity, pregnancy).
Scars relevant to renal pathology
Rutherford-Morrison (‘hockey-stick’) scar\: suggestive of a previous renal transplant.
Bilateral iliac fossae scars\: suggestive of a simultaneous pancreas-kidney transplant (for a patient with type 1
diabetes).
Umbilical scar\: suggestive of previous peritoneal dialysis catheter insertion.
Flank scar\: suggestive of a previous nephrectomy.
Lipodystrophy marks\: caused by repeated insulin injection in diabetic patients.
Inspect the abdomen

Preparation

Before beginning abdominal palpation\:
The patient should already be positioned lying
Ask the patient if they are aware of any areas of abdominal pain (if present, examine these areas last).
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Kneel beside the patient to carry out palpation and observe their face throughout the examination for signs of discomfort.

Light palpation of the abdomen

Lightly palpate each of the nine abdominal regions, assessing for clinical signs suggestive of renal disease\:
Tenderness\: note the abdominal region(s) involved and the severity of the pain.
Masses\: large or super
Renal transplant
Renal transplant patients frequently appear in OSCEs, as they are stable and have speci
Abdominal scar\: right or left iliac fossa (Rutherford-Morrison scar)
Palpable mass underneath scar\: this is the transplanted kidney
Signs of previous dialysis\: AV
If the transplanted kidney is working e
may
kidney disease).
Patients may have more than one transplanted kidney in their abdomen if they have undergone multiple transplants.

Deep palpation of the abdomen

Palpate each of the nine abdominal regions again, this time applying greater pressure to identify any deeper masses. Warn
the patient this may feel uncomfortable and ask them to let you know if they want you to stop. You should also carefully
monitor the patient's face for evidence of discomfort (as they may not vocalise this).
If any masses are identi
Location\: renal masses are typically palpable in the
Size and shape\: assess the approximate size and shape of the mass.
Consistency\: assess the consistency of the mass (e.g. enlarged polycystic kidneys may be irregular in their consistency).
Mobility\: renal masses will be
Perform light abdominal palpation
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Ballot the kidneys

1. Place your left hand behind the patient's back, below the ribs and underneath the right
2. Then place your right hand on the anterior abdominal wall just below the right costal margin in the right
3. Push your
4. Ask the patient to take a deep breath and as they do this feel for the lower pole of the kidney moving down between your

5. If a kidney is ballotable, describe its size and consistency.
6. Repeat this process on the opposite side to ballot the left kidney.
In healthy individuals, the kidneys are not usually ballotable, however, in patients with a low body mass index, the inferior pole
can sometimes be palpated during inspiration.
Causes of enlarged kidneys
Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.
A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.
Ballot the kidneys

Percussion

Shifting dullness
Percussion can also be used to assess for the presence of ascites by identifying shifting dullness\:
1. Percuss from the umbilical region to the patient's left
in the
2. Whilst keeping your
side (towards you for stability).
3. Keep the patient on their right side for 30 seconds and then repeat percussion over the same area.
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4. If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).
Assess for shifting dullness

Auscultation

Listen for bruits
Auscultate over the renal arteries to identify vascular bruits suggestive of turbulent blood
Auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side.
A bruit in this location may be associated with renal artery stenosis (a possible cause of hypertension and renal failure).
Auscultate for renal artery bruits
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Peripheral and sacral oedema

Assess the patient's lower legs and sacrum evidence of pitting oedema which may suggest hypoalbuminaemia (e.g. end-
stage renal disease, nephrotic syndrome).
Assess sacral oedema

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your

Further assessments and investigations

Blood pressure measurement\: if not already performed (do not perform on the side of an arteriovenous
Fundoscopy\: to assess for evidence of retinopathy (e.g. diabetic, hypertensive).
Urinalysis\: to screen for urinary tract infection and to assess for haematuria/proteinuria which is associated with glomerular
disease.
24-hour urine collection\: to assess various urinary compounds and assist in the calculation of protein-creatinine and/or
albumin-creatinine ratio.
Urine culture\: if a urinary tract infection is suspected.
U&Es\: to assess renal function.
Bicarbonate\: to assess for evidence of acidaemia.
Bone pro

Reviewers

Dr Ian Logan
Consultant Nephrologist
Dr Paul Callan
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Consultant Cardiologist

References

Source\: geekymedics.com
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