Polycystic Kidney Disease (without transplant)

 

Need to answer:

• Establish diagnosis 

• Complications (e.g. BP, complications of CKD)

• If on dialysis 

• Adequacy of dialysis

• For extra marks - contraindications to transplant 

 

Thank you for asking me to examine Harry who presented with abdominal fullness.

 

My salient findings were bilateral enlarged kidneys suggestive of polycystic kidney disease. This was / was not associated with features of ESKD.

 

On general inspection, Harry appeared comfortable. He did / did not appear cachectic. He was / was not jaundiced.

 

On inspection of the abdomen, there were / were not surgical scars. There was / was not obvious distension with striae, associated with / without prominent veins. There was / was not a Tenchkoff catheter.

 

On palpation, there were bilateral palpable masses in the subcostal areas. There were palpable upper edges, they moved inferiorly on inspiration, and there was overlying resonance on percussion, and hence I believe these are consistent with bilateral enlarged polycystic kidneys. They were non-tender.

 

There was/was not associated hepatomegaly with an estimated liver span of ____ on percussion. It was non-tender and had a smooth / irregular /cystic edge. I could not appreciate hepatomegaly in the setting of the enlarged cystic kidneys.

 

On percussion, there was / was not shifting dullness, suggesting ascites.

 

Bowel sounds were normal / absent. There was / was not a renal bruit.

 

On further examination to assess the presence and complications of both polycystic and chronic kidney disease:

• There was / was not evidence of dialysis dependence with a fistula, Tenchkoff catheter, or central venous access. There was/was not an active thrill and bruit.

• In the hands, there were / were not Terry’s nails in the hands, suggestive of chronic kidney disease. There was / was not palmar crease pallor and small muscle wasting.

• There were/were not scratch marks, suggestive of uraemia.

• The blood pressure was ____.

• On examination of the face, there was/was not conjunctival pallor. There was/was no parathyroidectomy scar.

• On cardiorespiratory examination, the JVP was _____ above the sternal notch with normal waveforms. There were/were not vesicular breath sounds and peripheral oedema. There was/was not a pericardial rub. There was/was not evidence of extra-renal valvular disease associated with PKD.

• There was/was not gout in the legs, or peripheral neuropathy.

 

In terms of contraindications to renal transplant:

• There was / was no clear evidence of active malignancy, ischaemic heart disease, active vasculitis or infections, although these cannot be ruled out on examination.

 

In summary, Harry presented with abdominal fullness. My findings are consistent with polycystic kidney disease with/without features of end stage kidney disease. The blood pressure was/was not inadequately controlled today. There were/were no uraemic features at present and the patient was/was not fluid overloaded, suggesting adequate renal replacement therapy / nil clinical need for dialysis.

 

If dialysis dependent, I would proceed from here by:

• Confirming the diagnosis of PKD with a family history and ultrasound

• Assessing for complications of chronic kidney disease:

  • FBE - anaemia

  • CMP, PTH levels

  • Iron studies

  • Osteoporotic screen

 

If non-dialysis dependent, I would proceed from here by:

• Confirming the diagnosis of PKD with a family history and ultrasound

• Assessing for chronic kidney disease with an eGFR, and protein creatinine ratio

• Assessing for complications of chronic kidney disease:

  • FBE - anaemia

  • CMP, PTH levels

  • Iron studies

  • Osteoporotic screen

• Assessing for suitable of treatment with a sodium level prior to potential tolvaptan.