1. RENAL EXAMINATION
Presented by
PANKAJ SINGH RANA

2. GENERAL EXAMINATION
• Decreased level of consciousness: seen in end-stage renal disease (ESRD).
• Pallor: Suggestive of underlying anaemia (e.g. erythropoietin deficiency).
• Shortness of breath: may be due to pulmonary oedema secondary to
advanced renal disease.
• 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: muscle loss that is not entirely reversed with nutritional
supplementation associated with end-stage renal failure due to protein-
energy wasting (PEW).

3. PHYSICAL EXAMINATION
EYES
Conjunctival pallor
• pallor in conjunctiva suggestive of anemia.
• Anaemia is common in patients with chronic renal failure due to erythropoietin deficiency.
Band keratopathy
• Band keratopathy is a corneal disease caused by the deposition of calcium in
the central cornea. In renal patient it is generally seen with chronic hypercalcaemia.
Periorbital oedema
• Periorbital oedema (swelling around the eyes) is a common clinical feature
of nephrotic syndrome (defined by massive proteinuria responsible for hypoalbuminemia,
with resulting hyperlipidemia, edema)

4. Band keratopathy Periorbital oedema

5. FACE
• 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: seen in renal immunosuppression patients (e.g.
squamous cell carcinoma, basal cell carcinoma, herpetic
gingivostomatitis).

6. Uraemic frost Yellowish complexion

7. Hearing aid
• Hearing loss seen in
Alport syndrome. Alport
syndrome is a genetic
disorder characterised
by glomerulonephritis, en
d-stage kidney
disease and hearing loss.

8. MOUTH
Gingival hypertrophy
• Gingival hypertrophy is an increase in the size
of the gingiva seen in gingival disease as well
as certain medications such as ciclosporin.
Uraemic fetor
• Uraemic fetor (foul odour) is a urine-like (i.e.
ammonia) smell of the breath typically
associated with end-stage renal disease.

9. NECK
Jugular venous pressure (JVP) indicate an indirect measure of central
venous pressure. internal jugular vein (IJV) reflects the right atrial
pressure.
Internal jugular vein situated between the earlobe and medial end of
clavicle under medial aspect of sternocleidomastoid muscle.
JVP interpretation
• An elevated JVP indicates increased central venous
pressure secondary to fluid overload commonly seen in chronic
kidney disease patient.

11. HANDS
• Pallor: indicative of underlying anaemia (e.g.
erythropoietin deficiency).
• Gouty tophi: nodular masses of monosodium
urate crystals deposited in the soft tissues of
the body, common in advanced chronic kidney
disease.
• Tremor: seen in patient taking
immunosuppressive medications (e.g.
tacrolimus, ciclosporin) in renal transplant
patients.

12. Nail signs
• Koilonychia: spoon-shaped
nails, associated with iron
deficiency anaemia (e.g.
erythropoietin deficiency).
• Leukonychia: whitening of the
nail bed, associated with
hypoalbuminaemia (e.g. end-
stage renal disease, nephrotic
syndrome).

13. • 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.
• 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.

14. Arms
Arteriovenous fistula
Assess for an arteriovenous (AV) fistula
1. Wrist (radio-cephalic fistula)
2. antecubital fossa (brachio-cephalic or brachio-basilic fistula)
3. synthetic PTFE graft in the antecubital fossa (now commonplace in
haemodialysis).

15. Arteriovenous
fistula
Check functioning of fistula by palpating of
the AV fistula for a thrill and auscultate for
a bruit

16. PERIPHERAL AND SACRAL OEDEMA
Assess the patient’s lower legs and sacrum evidence of pitting
oedema which may suggest hypoalbuminaemia or fluid overload (e.g.
end-stage renal disease, nephrotic syndrome).

17. SYSTEMIC
EXAMINATION

18. INSPECTION
Scars: Scars suggestive of 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.

20. Renal transplant inspection
• Renal transplant patients frequently appear in OSCEs, as they are
stable and have specific clinical signs:
• Abdominal scar: right or left iliac fossa (Rutherford-Morrison scar)
• Palpable mass underneath scar: this is the transplanted kidney
• Signs of previous dialysis: AV fistula, peritoneal dialysis scar

21. PALPATION
LIGHT PALPATION OF 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 superficial masses (e.g. hernias, palpable renal transplant) may
be noted on light palpation.
Renal transplant
• Renal transplant patients frequently appear in OSCEs, as they are stable and have
specific clinical signs:
• Abdominal scar: right or left iliac fossa (Rutherford-Morrison scar)
• Palpable mass underneath scar: this is the transplanted kidney
• Signs of previous dialysis: AV fistula, peritoneal dialysis scar

24. DEEP PALPATION OF ABDOMEN
• Palpate each of the nine abdominal regions again, this time
applying greater pressure to identify any deeper masses.
• If any masses are identified during deep palpation, assess the
following characteristics:
• Location: renal masses are typically palpable in the flank.
• 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 fixed and they’ll move superiorly and
inferiorly with respiration.

26. 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.

28. 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 flank if dullness
is noted it may be related to ascites.
2. Now shift patient to right side and wait for 30 seconds
3. Repeat percussion over the same area.
4. If ascites is present, the area that was previously dull should now be
resonant (i.e. the dullness has shifted).

30. AUSCULTATION
Listen for bruits
• Auscultate over the renal arteries to
identify vascular bruits suggestive of turbulent blood flow:
• 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).