The Renal Examination

Overview – The Renal Examination

The renal examination is a vital clinical skill used to assess for signs of acute and chronic kidney disease, electrolyte disturbances, nephrotic or nephritic syndromes, and complications from dialysis or systemic conditions like diabetes and lupus. It includes a top-to-toe inspection approach supported by focused palpation, auscultation, percussion, and relevant bedside investigations such as urine dipstick. The renal examination is essential for identifying red flags like fluid overload, uraemia, nephritic syndrome, and dialysis-related complications.

Preparation

  • Introduction: Introduce yourself, obtain consent, and wash hands.
  • Exposure: Ensure adequate exposure – patient should be in a gown with access to arms, abdomen, legs, and feet.
  • Positioning: Patient supine, head elevated at 45°, and comfortable.

General Inspection

  • Alertness & Orientation: Look for confusion (e.g. uraemic encephalopathy or UTI in elderly)
  • Distress or pain: Renal colic or pyelonephritis
  • Signs of fluid overload: Ascites, peripheral oedema
  • Signs of dehydration: May suggest pre-renal failure
  • Other signs:
    • Facial oedema (nephrotic syndrome)
    • Scars, in-dwelling catheters
    • Uraemic fetor (ammonia smell)
    • Easy bruising (coagulopathy or platelet dysfunction)

Vital Signs

  • Pulse: Tachycardia → infection, anaemia, hypovolaemia
  • Blood Pressure:
    • Hypertension: CKD, nephritic syndrome, polycystic kidney
    • Postural hypotension: Addison’s, diabetic neuropathy, hyponatraemia
  • Respiratory Rate:
  • Temperature: Infection, systemic inflammation

Hands

  • Circulation: Capillary refill time
  • Nails:
    • Mee’s lines (arsenic poisoning)
    • Muehrcke’s lines and leukonychia (nephrotic syndrome)
  • Pallor: Palmar creases (anaemia)
  • Pigmentation: Addison’s
  • Xanthomata: Dyslipidaemia in nephrotic syndrome or diabetes
  • Tophi: Gout from hyperuricaemia
  • Vasculitic lesions: Digital infarcts (glomerulonephritis)

Arms

  • Uraemic tinge/frost (severe hyperuricaemia)
  • Scratch marks (pruritus of CKD)
  • A-V fistula (dialysis access)
  • Scars: Cannula, fistula, previous surgery
  • Asterixis: Uraemia

Face

  • Butterfly malar rash: SLE
  • Periorbital oedema: Nephrotic syndrome
  • Conjunctival pallor: Anaemia
  • Cyanosis: Central or peripheral
  • Mouth:
    • Thrush (diabetes, immunosuppression)
    • Pharyngitis (can lead to post-streptococcal glomerulonephritis)
  • Xanthelasma: Hyperlipidaemia
  • Band keratopathy: Hyperparathyroidism (CKD-related)
  • Fundoscopy: Diabetic or hypertensive retinopathy
  • Gum hypertrophy: Methotrexate (post-transplant meds)

Neck

Chest

  • Signs of pulmonary oedema (CKD or fluid overload)
  • Heart failure signs

Abdomen

Inspection

  • Distension: Ascites (nephrotic, nephritic, or peritoneal dialysis)
  • Dialysis ports
  • Scars or masses

Palpation

  • Renal masses: Polycystic kidney, carcinoma
  • Hepatomegaly: Polycystic liver (associated with PKD)
  • Enlarged bladder (obstruction)
  • Insulin injection sites

Auscultation

  • Renal artery bruits (stenosis)
  • Bowel sounds (should be present)

Percussion

Back

  • Scars
  • Costovertebral angle tenderness: Murphy’s punch sign → pyelonephritis, renal stones
  • Bony tenderness
  • Sacral oedema
Renal Examination: Costovertebral Angle Tenderness
https://epomedicine.com/clinical-medicine/costovertebral-or-renal-angle-tenderness/

Legs and Feet

  • Pitting oedema (nephrotic, nephritic, diabetes, CKD)
  • Scratch marks, uraemic frost
  • Xanthomata, gouty tophi
  • Nail signs: Mee’s lines, leukonychia
  • Peripheral pulses & cap refill
  • Neuropathy screen: As part of diabetic foot exam

Urine Dipstick

  • Haematuria: Nephritic syndrome, pyelonephritis, renal stones
  • Proteinuria: Nephrotic syndrome, glomerulonephritis

Nephrotic vs Nephritic Syndrome

Nephrotic Syndrome (Less serious)

  • Massive proteinuria → hypoalbuminaemia & oedema
  • Periorbital oedema
  • Hyperlipidaemia → xanthomata/xanthelasma
  • Immunosuppression (IgG loss)
  • Hypercoagulability (antithrombin III loss)
  • NO haematuria

Nephritic Syndrome (More serious)

  • Anuria/oliguria (↓GFR)
  • Modest proteinuria (normal albumin)
  • PainLESS haematuria (anaemia)
  • Hypertension
  • Oedema (from low GFR)

Summary – The Renal Examination

The renal examination helps identify clinical signs of nephrotic and nephritic syndromes, uraemia, and complications of chronic kidney disease. It integrates full-body inspection with abdominal and neurological assessments, and includes vital urine dipstick testing. For a broader context, see our Clinical Skills Overview page.

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