Renal System Examination – OSCE Guide


A renal system examination involves looking for clinical clues and signs related to end-stage renal disease (e.g. fistula, dialysis catheter, renal transplant), renal failure complications (e.g. fluid overload, uraemia), transplant immunosuppression side effects (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

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the examination will involve using patient-friendly language.

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.

Wash your hands.

Adequately expose the patient’s abdomen for the examination from the waist up (offer a blanket to allow exposure only when 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 deficiency).
  • 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 steroids for renal transplant immunosuppression or glomerulonephritis.

Objects and equipment

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: fluid balance charts will give an indication of the patient’s current fluid status which may be relevant if a patient appears fluid overloaded or dehydrated.
  • Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications.
  • General inspection
    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 deficiency).
  • 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.

Nail signs

Inspect the nails for any of the following 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).
  • 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.
  • 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 haemodialysis patients.
  • Peripheral pallor
    Peripheral pallor 5

Asterixis (flapping tremor)

Asterixis (also known as ‘flapping tremor’) is a type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands. In the context of a renal system examination, the most likely underlying cause is uraemia secondary to renal failure. CO2 retention secondary to type 2 respiratory failure and hyperammonemia secondary to liver failure are also causes of asterixis.

To assess for asterixis:

  • Ask the patient to stretch their arms out in front of them.
  • Then ask them to cock their hands backwards at the wrist joint and hold the position for 30 seconds.
  • 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.

  • Asterixis
    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 fistula

Inspect for an arteriovenous (AV) fistula in the wrist (radio-cephalic fistula) and antecubital fossa (brachio-cephalic or brachio-basilic fistula) or the presence of a synthetic PTFE graft in the antecubital fossa (now commonplace in haemodialysis). If an AV fistula is present it indicates that the patient is receiving haemodialysis.

Visible needle marks over the AV fistula indicates recent use.

Palpate the AV fistula for a thrill and auscultate for a bruit (both absent if the fistula is thrombosed or surgically ligated such as 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 fingers aligned longitudinally over the course of the artery.

Once you have located the radial pulse, assess the rate and rhythm.

Blood pressure

Offer to measure the patient’s blood pressure:

  • Blood pressure should NOT be performed on the side of the AV fistula if present.
  • Causes of hypertension can include chronic kidney disease, renal transplant rejection, corticosteroid use and tacrolimus or ciclosporin use for renal transplant immunosuppression.
  • Rarely, pulsus paradoxus (change in BP >10mmHg during breathing) can occur due to uraemic cardiac tamponade (associated with low jugular venous pressure).
  • See our blood pressure measurement guide for more details.
  • Arteriovenous fistula
    Arteriovenous fistula 11

Face

General

Skin colour and skin lesions

Inspect the patient’s complexion and note any skin lesion:

  • Yellowish complexion (also known as a uraemic complexion): associated with chronic renal failure.
  • Uraemic frost: crystallized urea deposits found on the skin of patient’s 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 effect of ciclosporin treatment for renal transplant immunosuppression.

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 deficiency.

Band keratopathy

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 smell of the breath typically associated with end-stage renal disease.

  • Basal cell carcinoma
    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. The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid, making it difficult to visualise (its double waveform pulsation is, however, sometimes visible due to transmission through the sternocleidomastoid muscle). Because of the inability to easily visualise the IJV, the external jugular vein (EJV) is used as a proxy for assessment of central venous pressure during clinical assessment. It should be noted that 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. The instructions below are for measuring the level of the EJV.

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 EJV, which runs from the angle of the mandible to the middle of the clavicle superficial to the sternocleidomastoid muscle. The EJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery.

4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the EJV (in healthy individuals, this should be no greater than 4cm).

JVP interpretation

An elevated JVP indicates increased central venous pressure secondary to fluid overload. Patients with end-stage renal disease become anuric and often develop fluid overload, resulting in a raised JVP.

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
    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

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 effective percussion notes.

Percussion technique

1. Place your non-dominant hand on the patient’s chest wall.

2. Position your middle finger over the area you want to percuss, firmly pressed against the chest wall.

3. With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s middle finger using a swinging movement of the wrist.

4. The striking finger should be removed quickly, otherwise, you may muffle the resulting percussion note.

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 effusion which may occur in patients with fluid overload (e.g. end-stage renal disease) or nephrotic syndrome (hypoalbuminaemia).

  • Percuss the lung fields

Palpate

Apex beat

Palpate the apex beat with your fingers placed horizontally across the chest.

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.

  • Palpate the apex beat
    Palpate the apex beat

Auscultate the heart

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 first heart sound.

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.

  • Auscultate the mitral valve
    Auscultate the mitral valve

Auscultate the lung bases

Auscultate the lung fields posteriorly:

  • Coarse crackles are suggestive of pulmonary oedema (e.g. fluid overload in end-stage renal disease, hypoalbuminaemia in nephrotic syndrome).
  • Absent air entry and stony dullness on percussion are suggestive of an underlying pleural effusion.
  • Auscultate the posterior lung fields
    Auscultate the posterior lung fields

Abdomen

Position the patient lying flat on the bed, with their arms by their sides and legs uncrossed for abdominal inspection and subsequent palpation.

Inspect the patient’s abdomen for signs suggestive of renal pathology:

  • Scars: there are many different types of abdominal scars that can provide clues as to the patient’s past surgical history (see below for examples).
  • Abdominal distension: may be caused by an intrabdominal mass (e.g. polycystic kidneys), ascites (e.g. secondary to nephrotic syndrome) or indwelling peritoneal dialysis fluid (look for a peripheral dialysis catheter).
  • Nephrostomy tube(s): a catheter inserted through the flank musculature and into the renal pelvis enabling diversion of 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 from insulin injections in diabetic patients.
  • Inspect the abdomen
    Inspect the abdomen

Preparation

Before beginning abdominal palpation:

  • The patient should already be positioned lying flat on the bed.
  • Ask the patient if they are aware of any areas of abdominal pain (if present, examine these areas last).
  • 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 superficial masses (e.g. hernias) may be noted on light palpation.

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 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.
  • Abdominal palpation
    Perform light abdominal palpation

Ballot the kidneys

1. Place your left hand behind the patient’s back, below the ribs and underneath the right flank.

2. Then place your right hand on the anterior abdominal wall just below the right costal margin in the right flank.

3. Push your fingers together, pressing upwards with your left hand and downwards with your right hand.

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 fingers. This bimanual method of kidney palpation is known as balloting.

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
    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 flank. If dullness is noted, this may suggest the presence of ascitic fluid in the flank.

2. Whilst keeping your fingers over the area at which the percussion note became dull, ask the patient to roll onto their right side (towards you for stability).

3. Keep the patient on their right side for 30 seconds and then 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).

  • Shifting dullness
    Assess for shifting dullness

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).
  • Renal artery bruit
    Auscultate for renal artery bruits

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
    Assess sacral oedema

To complete this examination

Explain to the patient that the examination is now finished.

Thank the patient for their time.

Wash your hands.

Summarise your findings.

Further assessments and investigations

  • Blood pressure measurementif not already performed (do not perform on the side of an arteriovenous fistula).
  • 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 profile: to assess the levels of calcium, phosphate and PTH (to screen for secondary and tertiary hyperparathyroidism).

Reviewers

Dr Ian Logan

Consultant Nephrologist 

Dr Paul Callan

Consultant Cardiologist


References

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