Assessing Renal Patients SHARONDEEP GILL

Overview Chronic Kidney Disease History Examination Fistula Cases Clinical Topics Summary

CKD

GFR 3 months Renal failure: GFR<15 or need for dialysis/transplant Causes Hypertension Diabetes Glomerulonephritis Polycystic Kidney Disease Chronic Obstruction Infection - Chronic Pyelonephritis Medications - Analgesics

CKD Stages Stage 1: normal - eGFR >90 ml/minute/1.73 m 2 with other evidence of chronic kidney damage. Stage 2: mild impairment - eGFR ml/minute/1.73 m 2 with other evidence of chronic kidney damage. Stage 3a: moderate impairment - eGFR ml/minute/1.73 m 2. Stage 3b: moderate impairment - eGFR ml/minute/1.73 m 2. Stage 4: severe impairment - eGFR ml/minute/1.73 m 2. Stage 5: established renal failure (ERF) - eGFR less than 15 ml/minute/1.73 m 2 or on dialysis. -Persistent microalbuminuria, proteinuria or haematuria (after exclusion of other causes - eg, urological disease). -Structural abnormalities of the kidneys, demonstrated on ultrasound scanning or other radiological tests - eg, polycystic kidney disease, reflux nephropathy. -Biopsy-proven chronic glomerulonephritis.

HISTORY

History Normal Hx + Anorexia, nausea, vomiting, fatigue, weakness, pruritus, lethargy, peripheral oedema, dyspnoea, insomnia, muscle cramps, pulmonary oedema, nocturia, polyuria and headache. Hiccups, pericarditis, coma and seizures only in very severe CKD. PMHx: diabetes, hypertension, polycystic kidney disease Dialysis Transplant – functioning? DHx: Diabetic or antihypertensive medications Immunosuppression Steroids FHx: Polycystic kidney disease Diabetes Hypertension

EXAMINATION

Examination WIPER – wash hands, intro, patients name/dob, explain + consent, reposition Inspection Around the bed Nutritional status – wasting? Excoriations Cushing Syndrome Hands Flapping tremor (uraemia) Nails – leukonychia (hypoalbuminaemia in nephrotic syndrome), koilonychia (Fe deficiency anaemia in nephritic syndrome Pulse BP Arms: AV fistula – expose both arms fully, palpate and auscultate

Examination - Fistula Used in haemodialysis Surgical procedure to connect artery side to end with ligation of distal vein Higher pressure and increased flow Use 6-8 weeks post formation Active: palpable thrill, audible bruit, access marks Types: Radio-cephalic, Ulnar-basilic, brachio-cephalic Implications: body image, clothing, avoid trauma, no bp/blood taking Complications: infection, stenosis, thrombosis, bleeding, failure Steal syndrome: distal tissue ischaemia

Examination Head & Neck Eyes – conjunctival pallor Mouth/tongue – gingival hypertrophy (immunosuppression) Neck – JVP, scar (parathroidectomy) Abdo Inspection Distension Scars Hockey stick/Rutherford Morrison Previous peritoneal dialysis Back Palpation – LIF mass Percussion Auscultation (renal bruits) Peripheral oedema

Case 1

Mr AB Age 54

No thrill, no audible bruit 2 x small soft masses either side of umbilicus 10cm firm, non tender mass below scar

Case 2

Mr CD Age 58 No thrill, no audible bruit Well healed scar

Case 3

Mrs EF Age 54 Thrill & bruit, puncture mark

10cm firm, non tender mass below scar

Clinical Topics Causes of CKD Haemodialysis vs Peritoneal Dialysis Indications for haemodialysis Renal Transplant Immunosuppression and its complications Cushing Syndrome Polycystic Kidney Disease Hyperparathyroidism Renal Osteodystrophy

Haemodialysis Indications 1.Persistent hyperkalaemia >7 mmol 2.Acidosis pH <7.2 3.Refractory pulmonary oedema 4.Uraemia causing pericarditis / encephalopathy 5.Posioning / overdose e.g. aspirin

Polycystic Kidney Disease 50% will get ESRF Can also get cysts in liver, pancreas, brain, and arterial blood vessels Autosomal dominant PKD1 mutation on Chrom 16 (85%) PKD2 mutation (15%) Autosomal recessive Tend to present younger May need nephrectomy if severe Associated with: mitral valve prolapse, SAH

Hyperparathyroidism Renal osteodystrophy: 1. Osteoporosis 2. Hyperparathyroidism 3. Osteomalacia 4. Osteosclerosis “pepperpot lesions & rugger jersey spine” – sclerotic end plates and lucent central areas

Resources Levey AS, Coresh J (2012). Chronic Kidney Disease. Lancet 379: BTS Guidelines on Renal Transplant Patient.co.uk OHCM