The document outlines a comprehensive nephrological assessment, emphasizing the importance of clinical history and physical examination in identifying renal dysfunction. Key components include assessing symptoms related to urinary abnormalities, past medical history, and social factors influencing kidney health, while also considering family history and risk factors for chronic kidney disease. The assessment aims to formulate an appropriate diagnosis and treatment plan to enhance the patient's quality of life.

1. NEPHROLOGICAL ASSESSMENT
BY: MR.J.G SAMBAD
MSC NURSING.
NEPHRO-UROLOGY NURSING
IKDRC-ITS

2. Clinical history: introduction
• In nephrology, as in all branches of medicine, a competent clinical
assessment is crucial. This should incorporate symptoms and signs:
• Arising locally from the kidneys and urinary tract.
• Resulting from impaired salt and water handling.
• Caused by failing renal excretory and metabolic function.
• Relating to a systemic disease, causing or contributing to renal
dysfunction.

3. Con..
Several additional factors need to be considered:
• Asymptomatic patients often require assessment, following the discovery
of an abnormal BP, urinalysis, or GFR.
• Symptoms, signs, and investigation findings are organized into clinically
useful syndromes
• Biochemistry, radiology, and/or histopathology are almost always required
for accurate diagnosis (although a thorough clinical assessment will lessen
over-reliance on expensive and potentially invasive tests).
• Diagnosis is often suggested by treatment, e.g. cessation of a nephrotoxic
drug or restoration of adequate circulatory volume.

4. Past medical history
• Urinary tract problems as a child (e.g. infections, nocturnal enuresis).
• Previously documented renal or urinary tract disease of any kind. Ask
specifically about infections, stone disease, and, in ♂ , prostatic disease.
• Hypertension. When diagnosed? Who is responsible for follow-up? Current
and historical treatment? Level of control? Self-monitoring with home BP
monitor?
• Cardiovascular risk factors or disease (e.g. IHD, CVA, PVD, dyslipidaemia).
• Other relevant systemic disease (e.g. diabetes mellitus, connective tissue
disorder, gout, inflammatory bowel disease, sarcoidosis).
• Insurance or employment medicals can provide invaluable historical
benchmarks. Can they recall a past BP check or providing a urine specimen?
Have they had blood tests in the past?

5. Clinical history: symptoms and social history
Local symptoms of urinary tract disease
• Pain:
• Loin pain.
• Ureteric colic.
• Suprapubic pain.
• Haematuria.
• Change in urine appearance.
• Changes in urine volume:
• Polyuria.
• Oliguria and anuria.

6. Cont..
• Lower urinary tract symptoms (LUTS):
• Obstructive (voiding) symptoms:
— Impaired size or force of the urinary stream.
— Hesitancy or abdominal straining.
— Intermittent or interrupted flow.
— Post-micturition dribble.
— A sensation of incomplete emptying.
— Acute retention of urine.
• Storage (fi lling) symptoms:
— Nocturia.
— Daytime frequency.
— Urgency.
— Urge incontinence.
— Dysuria.

7. Social history
• Smoking: general CV risk in (and progression of) CKD, renovascular disease,
urothelial malignancy ( 7 4-fold risk), pulmonary haemorrhage in
Goodpasture ’ s disease.
• Physical activity.
• Occupational history: risk factors for urothelial malignancy.Hydrocarbon
exposure has been implicated in glomerular disease, particularly anti-GBM
disease.
• Hepatitis and HIV risk factors.
• A patient ’ s understanding of their kidney disease should be evaluated,
and they should be encouraged to be involved in decisions about
their care.

8. Cont..
• Renal diseases are often chronic disorders, incurring appreciable
social morbidity. Factors, such as social isolation, accommodation,
and work situation, are hugely important. In ESRD, social
circumstance will exert an important influence on choice of, and
ability to cope with, a particular dialysis modality. Livelihood may also
be affected — one of the goals of RRT, wherever possible, should be
to keep an individual in employment. Quality of life must never be
forgotten amidst all the blood tests.

9. Review of systems
May provide clues to an underlying systemic condition, such as connective
tissue disorder or vasculitis.
• Skin rashes.
• Photosensitivity.
• Mouth ulcers.
• Painful, stiff, or swollen joints.
• Myalgia.
• Raynaud ’ s phenomenon.
• Fevers.
• Night sweats.
• Thromboembolic episodes.
• Red or painful eyes.
• ENT:
• Sinusitis.
• Rhinitis.
• Epistaxis.
• Hearing loss.
• Sicca symptoms (dry eyes, dry mouth).
• Haemoptysis.
• Hair loss.
• Paraesthesiae.

10. Clinical history: drug, treatment, and family
• Drug and treatment history
• The importance of the drug history cannot be overstated — it will often tell a story
of its own. 2 Ask candidly about compliance.
• Antihypertensive therapy — past and present. Any important tablet intolerances or
side effects.
• Analgesics — ask specifi call about common NSAIDs (by their over-the-counter
names, if necessary). Then ask again.
• Any ‘one-off ’ courses of therapy that may not be mentioned as part of regular
treatment, e.g. recent antibiotics (interstitial nephritis).
• Oral contraceptive ( increase BP).
• Steroids, immunosuppressive agents — type and duration.
• Non-prescription, recreational (cocaine, IVDU), and herbal medicines.
• Current or historical exposure to important nephrotoxic drugs

11. Family history
• Essential hypertension: more common if one or both parents affected.
• Diabetes mellitus (types 1 and 2): more common if close relative affected.
Inherited kidney disease e.g PKD, Alport syndrome, IGA neuropathy etc..

12. Clinical history: additional factors
• Decreased libido and impotence are extremely common in both ♂ and ♀
with CKD.
• Irregular menses and subfertility are frequently encountered in ♀.
Amenorrhoea is common in ESRD.
• Previous pregnancies and any complications (UTI, proteinuria, i BP, pre-
eclampsia). Miscarriages, terminations? Were infants healthy and born at
term?
• In CKD, maternal and fetal outcomes are importantly related to GFR,
degree of proteinuria, and BP.
• Cytotoxic drugs used in the treatment of glomerular disease can l
premature menopause in ♀ or infertility in ♂ . This may influence treatment
in a ♀ of childbearing age. Pre-treatment sperm banking can be offered in ♂ .
• Risk factors for sexually transmitted disease when appropriate (HIV,
hepatitis B and C can all cause glomerular disease).

13. Dietary history
• Changes in appetite and weight. Dietary habits (alcohol, vegan, ethnic
diet, protein or creatine supplements). Dietary advice is an important
part of the management of many renal disorders ( i BP, AKI, CKD, the
nephrotic syndrome, stone disease, dialysis).

14. Ethnicity and renal disease
IgA nephropathy: Caucasians and certain Asian populations (China,
Japan, and Singapore).
• Diabetic nephropathy: black, Mexican American, Pima Indian (a native
American tribe in Southern Arizona, beloved of epidemiologists and
geneticists). An increasing problem in the immigrant Asian population
in the UK.
• SLE: Asian and black patients (and more aggressive disease).
• Hypertension and hypertensive renal failure: black patients.
• In the UK, the incidence of end-stage renal disease (ESRD) is 7 3 x
higher in South Asian and black patients than in Caucasians.

15. Physical examination/clinical assessment
• General inspection
• Short stature
• (CKD in childhood)
• Weight
• Pallor
• Brown-yellow skin hue
• ‘Sallow’ complexion
• Hearing aid/hearing impairment
• (Alport’s syndrome)
• SVC obstruction
• Evidence of past or present
• haemodialysis access
• (e.g. tunnelled lines,
• scars from previous
• dialysis lines, AV fistula)

16. Mouth
• Fetor
• Oral hygiene (SBE)
• Gum hypertrophy
• (ciclosporin)
• Oral candida
• (immunosuppression)

17. Face
• Periorbital oedema

18. Hands
• Metabolic flap
• (severe uraemia)
• Shortening of distal
• phalanges + pseudoclubbing
• (severe hyperparathyroidism)
• Raynaud’s
• Sclerodactyly
• Calcinosis
• Systemic
• sclerosis

19. Forearms
• Myopathy
• Bony tenderness
• (hyperparathyroidism)
• Dialysis access (past or present)

20. Nails
• Brittle
• Leuconychia
• Splinters (SBE)
• Transverse ridge

21. Skin
• Dry
• Scratch marks
• Bruising
• (uraemic bleeding tendency)
• Vasculitic rash
• Subcutaneous nodules
• (soft tissue calcification)
• Uraemic frost
• (severe uraemia)
• Transplant patient:
• cutaneous malignancies

22. Neurological
• Conscious level
• Mental state
• Myoclonic jerks
• Seizures
• Tetany
• (hypocalcaemia)
• Peripheral neuropathy

23. Cardiorespiratory
• Respiratory pattern
• (? Acidosis)
• Blood pressure
• JVP
• Oedema
• Carotid bruits
• Apex beat
• Heart sounds
• Pericardial rub
• Lung fluids
• Pulmonary oedema
• Effusion

24. Musculoskeletal
• Bony deformity
• Joint inflammation
• Osteoarthritis (? NSAIDs)

25. Ophthalmic
• Dry, red, or painful eyes
• (iritis, episcleritis)
• Corneal calcification

26. Retina
• Hypertension
• Diabetes mellitus
• Vasculitis
• Cholesterol emboli

27. Abdomen
• Scars
• ? Tenckhoff catheter
• Ascites
• Palpation:
• Loin tenderness
• Palpable kidney(s)
• Palpable bladder
• Transplant kidney
• (right or left iliac fossa)
• Abdominal bruit
• Rectal (prostate)
• Pelvic exam

28. Legs
• Peripheral pulses
• Oedema
• Femoral bruits
• Restless legs

29. Palpating the kidneys
• The kidneys are generally only palpable in very thin patients.
• The right kidney is more accessible than the left. Place the left hand
posteriorly in the loin and the right hand on the abdomen lateral to
the umbilicus.
• On deep inspiration, the lower pole may be palpable by pushing the
right hand gently inwards and upwards.
• The normal kidney surface usually feels firm and smooth. ‘Balloting’
the kidney refers to palpation whilst pushing up firmly from behind.
Using this technique, it may be possible to gently‘bounce ’ an
enlarged kidney back and forth between the hands.