This document provides guidance on performing a renal system examination, including inspection of the general appearance, hands, arms, face, eyes, mouth, and neck. Signs of potential underlying renal pathology are described for each body system, such as pallor indicating anemia, edema suggesting nephrotic syndrome, and arteriovenous fistulas indicating hemodialysis. The examination also involves assessing vital signs, skin turgor, nail changes, and neurological signs like asterixis.

1. Renal System Examination
Mr. Shashi Prakash
M.Sc. Nursing II Year
CON, ILBS, New Delhi

2. Introduction
• Wash your hands and don PPE if appropriate.
• 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.
• 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.

3. 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 corticosteroids for renal
transplant immunosuppression or glomerulonephritis.

4. 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.

10. 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.
• Tremor: can be caused by immunosuppressive medications (e.g. tacrolimus, ciclosporin) in renal transplant
patients.

11. 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 in haemodialysis patients.

20. 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:
1. Ask the patient to stretch their arms out in front of them.
2. Then ask them to cock their hands backwards at the wrist joint and hold the position
for 30 seconds.
3. Observe for evidence of asterixis during this time period.

21. 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.

23. 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, or has previously received, 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).

24. Arms
• 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 an 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.

27. Face
• General
• 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: 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 characterized by glomerulonephritis, end-stage
kidney disease and hearing loss.

28. 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.

29. 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 (i.e. ammonia) smell of the
breath typically associated with end-stage renal disease.

38. 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, resulting in a continuous column of blood. The presence of this continuous column of blood
means that changes in right atrial pressure are reflected in the IJV (e.g. raised right atrial pressure
results in distension of the IJV).
• 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, it’s tempting to use the external jugular vein (EJV)
as a proxy for assessment of central venous pressure during clinical assessment. However, 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.

41. 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 IJV, running between the medial end of the clavicle and the
ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just
above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The
IJV 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 pulsation point of the IJV (in healthy individuals, this should be no greater
than 3 cm).

42. 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 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).

45. 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).

46. 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.

47. 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).

52. 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.

54. Auscultate the heart
• A 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.

59. Auscultate the lung
• 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.

61. 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: many different types of abdominal scars can provide clues about the patient’s surgical history (see below for
examples).
• Peritoneal dialysis catheter: a tube inserted into the abdomen for peritoneal dialysis
• 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 peritoneal 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).

62. Abdomen
• 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: caused by repeated insulin injection in diabetic patients.

68. 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, palpable renal transplant) may be noted on light
palpation.

69. 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
• If the transplanted kidney is working effectively, no other signs of end-stage renal disease will be
present. However, you may find clues as to the underlying cause of their renal failure (e.g. large
palpable native kidneys suggesting polycystic kidney disease).
• Patients may have more than one transplanted kidney in their abdomen if they have undergone
multiple transplants.

70. 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.

73. 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.

74. 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.

76. 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).

79. 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).

81. Cont.…
• 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).

83. To complete this examination…
• Explain to the patient that the examination is now finished.
• Thank the patient for their time.
• Dispose of PPE appropriately and wash your hands.
• Summarise your findings.

84. Further assessments and investigations
• Blood pressure measurement: if 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).

100. Thankyou