Examination of the Renal System

NB Signs of kidney disease are quite non-specific and are usually the result of chronic disease.  In the acute setting, U&Es often describe a more specific representation of kidney function.

  • WIPE (wash hands, introduce self, check patient details, explain and gain consent)
  • General Inspection
    • Is the patient well? Are they breathless? Are they cachexic?  Are they drowsy or confused?
    • Look at the patient’s hands-
      • Do they have a flapping tremor (may indicate hyperuraemia)
      • Is there leukonychia (hypoalbuminaemia in nephrotic syndrome); koilonychia (anaemia associated with nephritic syndrome)?
      • Is the skin turgor normal? (fluid status)
    • Look at the patient’s skin
      • Is it dry? (CKD can cause sweat gland atrophy); any hyperpigmentation or yellow/sallow skin; petechiae/ecchymoses; excoriation (itching due to hyperuraemia)
    • Is there an AV-fistula in the patient’s arm?
    • Check the pulse
    • Check BP (ideally postural but lying only may suffice)
    • Check JVP (fluid overload in nephrotic syndrome)
    • Look at the patient’s face-
      • Are there any signs of uraemia (yellow tinge); periorbital oedema (nephritic syndrome); pallor; corneal arcus/xantholasma (hyperlipidaemia in nephrotic syndrome); dry mucous membranes; butterfly rash (autoimmune disease- SLE)
    • Look at the patients legs for any signs of oedema
  • Chest
    • Examine the chest for any signs of pulmonary oedema (very rarely raised uraemia can also cause pericarditis- so listen to the heart too)
  • Abdomen
    • Inspect for any scars (transplant/operations); drains; abnormalities; ascites
    • Palpate the abdomen as you would for a full abdominal examination i.e. superficial/deep for 9 quadrants; palpate for organomegaly
      • Particularly important to ballot kidneys (with your left hand under the flank, ask the patient to breathe out and press up into the renal angle with left hand whilst pressing down with the right hand; ask the patient to breathe in- as they do you may be able to feel the kidney between your hands and can ballot it with the left)
      • Also important to examine for ascites and any shifting dullness (see abdo exam)
      • Auscultate for renal bruits as well as bowel sounds

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