Renal Transplant - Unclear Cause

 

Aim to answer:

• Identify transplant

• Aetiology of underlying cause for transplant

• Adequacy of graft function

• Complications from transplant/immunosuppression

 

Thank you for asking me to examine Harry.

 

My salient findings were with evidence of a renal transplantation. I could/could not ascertain the aetiology of chronic kidney disease with certainty, although there were features ____.

 

On inspection of the abdomen, there was a ____ cm scar in the right iliac fossa / left iliac fossa, with a smooth, firm non-tender mass underneath and overlying dullness to percussion, suggestive of a previous renal transplant. There was / was no bruit suggestive of stenosis in the allograft.

 

On further inspection, there was / was not obvious distension with striae. There was/was no scar suggestive of a previous nephrectomy. There was / was not a scar from a previous Tenchkoff catheter.

 

On further palpation, there were/were not bilateral palpable masses in the subcostal areas. There was/was not associated hepatomegaly with an estimated liver span of ____ on percussion. On percussion, there was / was not shifting dullness, suggesting ascites. Bowel sounds were normal / absent. There was / was not a renal bruit.

​

Further examination was targeted at the underlying aetiology, function of the graft, and complications of the transplant and treatment.

 

There was / was not evidence of previous dialysis dependence with a non-functioning 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. There was / was not palmar crease pallor and small muscle wasting. There were/were not fingertip pin pricks from diabetic testing. There were/were not any vasculitic rashes. There were/were not scratch marks, suggestive of uraemia. There was/was not uraemic flap.

 

The blood pressure was ____.

 

On examination of the face, there was/was not conjunctival pallor. There were/were not any hearing aids (Alports).

 

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 complications of immunosuppression from the renal transplant:

• There was / was not signs of steroid complications, such as a Cushingoid appearance, bruising, skin atrophy, cataracts, or proximal myopathy. 

• There was no tremor, rash or gum hypertrophy from calcineurin inhibitors, or evidence of diabetes.

• There were/were not skin malignancies.

 

In summary, my findings are a functioning renal transplant secondary to polycystic kidney disease with nil current uraemic symptoms fluid overload, or complications of immunosuppression.

 

Other differentials for the underlying aetiology include:

• Diabetes - pinpricks, insulin involvement, metabolic syndrome

• HTN

• Polycystic kidney disease

• Glomerulonephritis (lupus, Wegner’s)

• Alport’s syndrome