Clinical examination and cases Abdo

Question 1

What signs are visible? What is the diagnosis?

Answer 1

Rutherford Morrison scar - kidney transplant
AV fistula, signs of peritoneal dialysis.
this person has had previous ESRD and had a kidney transplant

Question 2

What might be the aetiology behind this patients signs?

Answer 2

Diabetic nephropathy
Hypertensive nephropathy
Adult polycystic kidney disease
Vasculitis or Drug induced
Alport’s syndrome
Tuberous Sclerosis

Question 3

What are the signs? Diagnosis?

Answer 3

There is a rutherford morrison scar suggesting renal transplant.
Finger prick marks, abdominal lipodystrophy and dermopathy suggestive of insulin dependant diabetes.
AV fistula indicating previous dialysis
Faint neck scar - suggesting previous thyroid or parathyroid surgery

this is a diabetic patient who has progressed to end stage renal disease requiring dialysis then renal transplant, the neck scar suggest surgery due to tertiary parathyroidism due to end stage renal disease.

Question 4

What is tested for in the renal transplant donor and recipient screening process?

Answer 4

• HLA
• cross match
• infection screen
• urine - MC&S, protein-creatinine ration

Question 5

What infections are screened for pre renal transplant

Answer 5

• HIV,
• hepatitis,
• B/C,
• CMV/EBV,
• human T lympocytic virus,
• varicella zoster virus,
• sympilis,
• toxoplasma

Question 6

What are the types of transplant rejection?

Answer 6

• Hyper-acute rejection (immediate): thrombosis and occlusion of graft vessels during surgery
• Acute rejection (weeks to months): deterioration in renal function ± flu-like symptoms and graft tenderness
• Chronic rejection (months to years): gradual deterioration in renal function

Question 7

Complication that can arise from renal transplant

Answer 7

Peri operative
Bleeding
Damage to other structures
Damage to transplant organ
Post operative
* Immediate - bleeding
* medium to long - opportunistic infections and sepsis
* wound closure failure and dehiscence plus other surgical site problems
* Paralytic ileus
* renal graft thrombosis
Rejection
* Hyper acutre (immediate)
* Acute (weeks to months)
* chronic (months to years)

Question 8

In this patient, what are some other signs you might look for that could occur due to their current medication/treatment?

Answer 8

signs of immunomodulatory therapy
* Steroids - Cushings signs e.g. round face, striae, bruised skin.
* cyclosporin gum hypertrophy
* Tacrolimus - tremor
* Skin cancer removal scars.

Question 9

What is shown in the image?

Answer 9

Tenckhoff catheter - for peritoneal dialysis

Question 10

differentials

Answer 10

Nephrectomy
* Renal cancer
* Trauma
* PCKD - some cases develop large painful cysts on one kidney so have it removed
* Recurrent kidney infections
* Donor for transplant

Question 11

Patient has this and on the other side the kidney is ballotable, diagnosis?

Answer 11

Polycystic kidney disease

Question 12

patient has this scar, how are you going to manage them?

Answer 12

MDT GP, dietician, OT, PT, Specialist renal physician, specialist renal nurses.
* control hypertension
* treat any aneamia
* P04 binds
* Renal Diet
* Vit D supplementation
* Managment of secondary or teritary hyperparathyroidism
* Regular follow with transplant team
* Regular monitoring of kidney function to assess for rejection
* Immunomodulatory therapy

Question 13

Patient has this scar, how will you investigate

Answer 13

preusmed kidney transplant (rutherford morrison)
Bedside
* Abdo exam
* Cardio exam - tacrolimus and ciclosporin can cause hypertension and hyperglycaemia. Tacrolimus can also cause hyperlipidaemia. Patients must be monitored for accelerated cardiovascular disease.
* Check skin for signs of malignancy due to immunosupression
* Cap blood glucose
* Urine - protein to creatinine ration, haematuria, microscopy for casts
Bloods
* FBC, U&Es, Ca, PTH, Viral markers for CMV, Hep C
* Glucose, HBA1C if diabetic
* If not already conducted could perform bloods to delineate cause of transplation e.g. electrophoresis, AI screen, complement.
* Imaging US KUB
* Renal biopsy if thinking rejection.

Question 14

What immunomodulatory therapies would a renal tranplant patient have?

Answer 14

Example regime
initial: ciclosporin/tacrolimus with a monoclonal antibody
maintenance: ciclosporin/tacrolimus with MMF or sirolimus
add steroids if more than one steroid responsive acute rejection episode

Question 15

What are the causes of hepatomegaly?

Answer 15

• Three Cs
  Cirrhosis, cancer and congestive cardiac failure
  Others
• Infection - Hepatitis,
  Inflammation - PBC, AI hepatitis
  Infiltrative - Amyloid/myeloproliferative disorders