Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Scars |
Hockey-stick |
J-shaped scar in the iliac fossa, curving distally toward midline.
Used in renal transplant. Donor kidney palpable underneath the scar. |
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Peritoneal dialysis |
Small, often multiple, peri-umbilical scars.
Tenkhoff catheter inserted through abdominal wall into peritoneal cavity. |
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Tunnelled cuffed catheter |
Small scar to right upper anterior chest wall. Tunnelled cuffed catheter inserted into subclavian or jugular vein, with tip in right atrium or superior vena cava.
Often used as a temporary measure whilst AV fistula is formed, then removed. |
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Nephrostomy |
Flank scar on either right or left side from insertion of nephrostomy.
Catheter inserted through skin directly into kidney to drain urine. |
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| Arteriovenous Fistula |
Radiocephalic |
Artificial connection between artery-vein, creating easy-access blood vessel.
Sited at the wrist. Radial artery-cephalic vein. O/E: palpable thrill, machinery murmur or bruit on auscultation, needle marks. |
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Brachiocephalic |
Artificial connection between artery-vein, creating easy-access blood vessel.
Sited at the antecubital fossa. Brachial artery-cephalic vein. O/E: palpable thrill, machinery murmur or bruit on auscultation, needle marks. |
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Brachiobasilic |
Artificial connection between artery-vein, creating easy-access blood vessel.
Sited at the upper arm. Brachial artery-basilic vein. Less commonly used. O/E: palpable thrill, machinery murmur or bruit on auscultation, needle marks. |
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| Palpable Flank Mass |
Renal transplant |
Transplant of donor kidney into patient with end-stage renal failure.
Donor kidney placed anteriorly in abdomen and is palpable in iliac fossa. Overlying incision scar e.g., hockey-stick. Patient’s kidney remains in situ. |
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Polycystic kidney Disease (PKD) |
Genetic condition, autosomal dominant > autosomal recessive.
Enlarged kidneys may be palpable on abdominal exam on balloting the flank. Associations: ovarian or hepatic cysts, mitral regurgitation, brain aneurysms. |
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Renal cell carcinoma |
RF: smoking, obesity, hypertension, end-stage renal failure.
May be asymptomatic, may be found incidentally on imaging. May present with haematuria, loin pain or non-specific symptoms of cancer. May be a palpable flank mass. |
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| Miscellaneous |
Chronic kidney disease (CKD) |
RF: older age, diabetes, hypertension, PKD, glomerulonephritis, medications.
Asymptomatic early stages, ↑symptoms with progression or decompensation. Fatigue, pallor, nausea, pruritus, oedema, hypertension, peripheral neuropathy. |
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Immuno-suppressive side effects |
Post renal transplant immunosuppression is required to ↓risk of rejection.
Many immunosuppressants e.g., tacrolimus used long term ↑skin cancer risk. Cyclosporine can cause hypertrophy of the gums. Long-term steroids can cause Cushing’s syndrome & steroid induced diabetes. Tacrolimus can cause a tremor. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient reclining 45° | ||
| Appropriate exposure of abdomen | ||
| General Inspection | Systemic appearance | |
| Body habitus | ||
| Colour | ||
| Obvious scars | ||
| Abdominal distension | ||
| Oedema | ||
| Clues in bed space | ||
| Hands | Tremor | |
| Koilonychia | ||
| Leukonychia | ||
| Radial pulse | ||
| Arms | Blood pressure | |
| Fistula palpation | ||
| Fistula auscultation | ||
| Excoriation | ||
| Bruising | ||
| Face | Skin lesions | |
| Conjunctival pallor | ||
| Cushingoid appearance | ||
| Neck | Jugular venous pressure | |
| Chest | Tunnelled haemodialysis catheter | |
| Abdominal Inspection | Reposition patient lying flat | |
| Scars | ||
| Distension | ||
| Striae | ||
| Visible mass | ||
| Lines or tubes | ||
| Abdominal Palpation | Tenderness | |
| Ballot kidneys | ||
| Palpate for transplanted kidney | ||
| Hepatomegaly | ||
| Abdominal Percussion | Shifting dullness | |
| Hepatomegaly | ||
| Abdominal Auscultation | Right renal artery | |
| Left renal artery | ||
| Back | Lung base auscultation | |
| Sacral oedema | ||
| Legs | Pedal oedema | |
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
“I have been asked to carry out a renal examination. This involves looking at your arms, face, and abdomen for signs of any problems with your kidneys. You can ask me to stop at any time. Are you happy for me to do that?”
Position the patient reclining on the examination couch at 45°; you will ask them to lie flat later in the examination
Ask the patient to expose their abdomen.
General Inspection
Look at the patient and around the bed space for useful signs:
- Systemic appearance (e.g., do they look unwell? Are they confused or agitated?)
- Body habitus – are they overweight (e.g., Cushing’s syndrome, diabetes) or underweight (e.g., cachexia)?
- Colour – are they pale (e.g., anaemia), is there evidence of uraemia (lemon-yellow appearance to the skin)?
- Obvious scars visible from the end of the bed.
- Abdominal distension obvious from the end of the bed.
- Oedema (e.g., pedal, abdominal)
- Clues around the bed space (e.g., dialysis machinery, blood transfusions, vomit bowls, medications)
Hands
Examine both hands together, noting:
- Tremor – flapping tremor (asterixis) may be seen in renal failure; tremor is a side effect of tacrolimus (renal transplant)
- Koilonychia – concave deformity of the nails (anaemia)
- Leuconychia – white discolouration of the nail (hypoalbuminaemia)
- Radial pulse – rate, volume, and character can all give a quick overview of hydration status
Arms
Examine both arms together noting:
- Blood pressure – offer to check blood pressure, never use an arm with a fistula in situ.
- Arteriovenous fistula – note the location, palpate and auscultate the fistula.
- Excoriation – uraemia causes itching (pruritus)
- Bruising – (e.g., long-term steroid use)
A fistula sited in the wrist is a radio-cephalic fistula (radial artery and cephalic vein); whereas a fistula sited in the antecubital fossa is most likely to be a brachio-cephalic fistula (brachial artery and cephalic vein). A brachio-basilic fistula is also found in the antecubital fossa but is less commonly used (brachial artery and basilic vein).
Palpate the fistula for a thrill (turbulent blood flow) by placing your hand on the overlying skin.
Auscultate the fistula for a machinery murmur or bruit (turbulent blood flow).
Face
Examine the patient’s face to assess:
- Skin lesions – use of immunosuppressive medication long-term (e.g., post-renal transplant) increases the risk of skin cancers, including squamous cell carcinoma (SCC) and basal cell carcinoma (BCC).
- Conjunctival pallor – (e.g., anaemia)
- Cushingoid appearance (e.g., moon face, puffiness, redness) – may indicate long-term steroid use.
Neck
Examine the JVP by asking the patient to relax their head against the couch and turn their neck 45° to the left. Look for a visible double pulsation of the internal jugular vein on the left side of the neck.
Measure the distance of this pulsation above the sternal angle. A measurement greater than 3-4 cm is a raised JVP and is an abnormal finding, and may indicate fluid overload secondary to renal failure.
Chest
Inspect the chest for a tunnelled catheter in the right upper anterior chest wall. These are used as a temporary haemodialysis measure whilst awaiting fistula formation, and so a scar may be present from a previous catheter.
Abdominal Inspection
Reposition the patient to lie flat, ensuring this is comfortable for them and checking for pain or breathlessness, which may limit their ability to lie flat.
Perform a closer inspection of the abdomen, looking for:
- Abdominal distension – differentials include the six Fs: Fat, Fluid, Flatus, Faeces, Foetus, Flipping huge mass.
- Scars – hockey-stick (renal transplant); peri-umbilical (peritoneal dialysis); flank (nephrostomy).
- Striae – stretch marks associated with rapid abdominal distension due to ascites or with Cushing’s syndrome.
- Visible mass – flank mass (polycystic kidneys, renal cell carcinoma) or iliac fossa mass (renal transplant).
- Lines or tubes – (e.g., Tenckhoff catheter for peritoneal dialysis, nephrostomy)
Abdominal Palpation
Palpate the abdomen as follows:
- Palpate for tenderness and masses
- Ballot the kidneys
- Palpate for a transplanted kidney
- Palpate for hepatomegaly
Palpate the patient’s abdomen, ensuring that you observe their face during the examination to ascertain if they are experiencing pain or discomfort.
Palpation should be performed with the patient at roughly the same height as your outstretched arms. You may need to adjust the couch or crouch down to the patient’s level.
Check if the patient is in any pain at present. If they are, begin your examination away from the site of their pain.
First, light palpation is performed, checking for discomfort or tenderness in all nine regions of the abdomen.
Next, perform deeper palpation, feeling for any masses in all regions. If any masses are palpated, assess their size, shape, mobility, and character (e.g., fluctuance, pulsatility).
Ballot the kidneys by placing one hand on top of the patient’s abdomen in the right flank and the other hand beneath the patient in the right flank. Push up with your posterior hand and down with your anterior hand. If you can feel the kidney between your hands, this indicates an enlarged kidney and is pathological.
Palpate the liver. Starting in the right iliac fossa (RIF), ask the patient to take deep breaths in and out, and palpate in stages upwards towards the right upper quadrant (RUQ), pressing down on the abdomen in time with the patient’s inspiration.
If hepatomegaly is present (polycystic kidney disease, hepatorenal syndrome), you will feel the edge of the liver pushing against your hand on inspiration.
Abdominal Percussion
Percuss the abdomen for:
- Hepatomegaly
- Shifting dullness (e.g., ascites, peritoneal dialysis)
Percuss the liver for hepatomegaly. Beginning in the RIF, percuss over the abdomen, moving upwards towards the RUQ. A transition from resonant to dull indicates the underlying liver.
Percuss for shifting dullness to assess the presence of fluid by percussing from the umbilicus to the patient’s left flank. Then, ask the patient to roll towards you onto their right side. Wait a few seconds, then percuss the left flank again.
If there is fluid present, the flank will have been dull to percussion when lying flat, as fluid accumulates in the flank, and then resonant once the patient has been repositioned due to the movement of fluid with gravity.
Abdominal Auscultation
Auscultate the abdomen for:
- Renal bruits – auscultate over the left and right renal arteries, located approximately 5 cm superolateral to the umbilicus. A bruit indicates turbulent blood flow through the renal artery (e.g., renal artery stenosis)
Back
Examine the back for signs of fluid overload. Auscultate the lung bases; bilateral basal crackles indicate the presence of oedema.
Examine for sacral oedema by asking the patient to sit up and lean forward, examining the sacral region for any pitting oedema.
Legs
Examine the legs for pedal oedema by inspecting and palpating both legs, and observing the level of the oedema.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings, you may wish to carry out further investigations, including blood gas sampling, blood tests, urine testing, or imaging (e.g., ultrasound or CT scan).
Last updated Aug 2025
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