The renal patient

Question 1

Clinical signs of the renal patient

Answer 1

• Stigmata:
  ⚬⚬ Arms: arteriovenous fistula(e) – currently working (thrill), being used (thrill and dressings), or failed
  ⚬⚬ Neck: tunneled dialysis line (or previous lines; scars in the root of the neck and over the chest wall)
  ⚬⚬ Abdomen:
• • Flank scar: Nephrectomy (polycystic kidney disease, renal malignancy)
• • Iliac fossa scar: Kidney transplant
• • Peritoneal dialysis – catheter, or scars from previous catheter (insertion is below umbilicus, exit site is lateral to umbilicus)
• Fluid status (leg oedema)

Question 2

Three things to consider in all renal patients

Answer 2

1. Underlying reason for renal failure
2. Current treatment modality
3. Complications of past/current treatment

Question 3

1. Underlying reason for renal failure

Answer 3

• Polycystic kidneys: ADPKD
• Visual impairment, fingerprick marks, injection sites/pump, etc.: diabetes
• Sclerodactyly, typical facies: systemic sclerosis
• Rheumatoid hands, nodules: rheumatoid arthritis
• (Hepato)splenomegaly: amyloidosis
• Other organ transplantation (liver/heart/lungs): calcineurin inhibitor(tacrolimus, ciclosporine) nephrotoxicity
• Ungual fibromata, adenoma sebaceum, polycystic kidneys: tuberous sclerosis

Question 4

2. Current treatment modality

Answer 4

• Haemodialysis: working fistula, tunneled neck lines, arteriovenous grafts
• Peritoneal dialysis: abdominal catheter
• Functioning transplant: no evidence of other current dialysis access (in use)

Question 5

3. Complications of past/current treatment

Answer 5

* Side effects of treatment for the underlying disease: Cushingoid appearance from steroids (glomerulonephritis)
* Side effects of immunosuppressive TTT in transplant patients:
⚬⚬ Fine tremor (tacrolimus)
⚬⚬ Steroid side effects
⚬⚬ Gum hypertrophy (ciclosporin)
⚬⚬ Hypertension (ciclosporin, tacrolimus)
⚬⚬ Skin damage and malignancy (especially ciclosporin and azathioprine)
* Scars from previous access for dialysis, failed transplant(s)

Question 6

Kidney‐pancreas transplantation Consider if:

Answer 6

• Lower midline abdominal incision, with a palpable kidney in an iliac fossa (but no overlying scar)
• Evidence of previous diabetes (e.g. visual impairment)
• Patients are often younger (most commonly transplanted in 30s–40s)

Question 7

Top three causes for renal transplantation

Answer 7

• Glomerulonephritis
• Diabetic nephropathy
• Polycystic kidney disease (ADPKD)

Question 8

Problems following transplantation

Answer 8

1* Rejection: acute or chronic
2* Infection secondary to immunosuppression:
⚬⚬ Pneumocystis carinii
⚬⚬ CMV
3* Increased risk of other pathology:
⚬⚬ Skin malignancy
⚬⚬ Post‐transplant lymphoproliferative disease
⚬⚬ Hypertension and hyperlipidaemia causing cardiovascular disease
4* Immunosuppressant drug side effects/toxicity:
⚬⚬ Ciclosporin nephrotoxicity
5* Recurrence of original disease
6* Chronic graft dysfunction

Question 9

Success of renal transplantation

Answer 9

• 90% 1‐year graft survival
• 50% 10‐year graft survival (better with live‐related donor grafts)