July 18th, 2020
Patients with renal or urological disease may present with a wide variety of symptoms, from alterations in their urine to severe pain or systemic symptoms. Patients with chronic kidney disease pose a wide variety of diagnostic and management issues, which may be further complicated by a history of dialysis or renal transplantation.
The first step in the renal history is to identify the main issue that the patient is presenting with.
- Common renal and urinary symptoms include:
- An abnormal amount of urine - increased urinary frequency, polyuria, oliguria / anuria
- Abnormal urine appearance - abnormal colour, haematuria, frothy uria, pyuria
- Urinary incontinence
- Obstructive symptoms - urgency, hesitancy, dribbling, nocturia
- Dysuria (pain on urination)
- Flank pain
- Uraemic symptoms - fatigue, pruritis, anorexia, nausea, restless legs
History of Presenting Complaint
When asking for more information about a patient's symptoms, start by asking general questions such as "could you please tell me more about that", and then narrow down the questions as more information is provided.
- Generally speaking, the following questions are a good starting point for any type of pain, and may be useful in gaining information about other symptoms:
- Site - localised or generalised; unilateral or bilateral
- Onset - sudden or gradual, and what the situation was (e.g. following trauma)
- Character - sharp, dull, burning or pressure-like
- Radiation - e.g. down the arm or across the back
- Associated symptoms - e.g. fevers, nausea / vomiting, bony pain
- Timing - duration of symptoms, frequency of episodes, changes through the day
- Exacerbating & alleviating factors - e.g. exacerbation with exertion and alleviation with rest
- Severity - on a scale of 1 to 10, with 10 being the worst
- In patients with chronic kidney disease, assessment of fluid status is key. Ask about symptoms of fluid overload, such as lower limb swelling, orthopnoea or weight gain. Also ask about symptoms of fluid depletion, such as lightheadedness, thirst, weight loss or oliguria.
Other Key Aspects of HistoryIn patients with acute kidney disease, several features suggest a specific cause of renal failure. These may include:
- Recent infections (recent pharyngitis may suggest post-streptococcal glomerulonephritis; diarrhoea, renal failure and thrombocytopaenia suggests HUS)
- Extended immobility - time spent on the ground (a risk factor for rhabdomyolysis)
- Recent imaging with contrast - when the contrast was given, and what type of contrast (a risk factor for contrast-induced nephropathy)
Past Medical History
Chronic Kidney Disease
- By asking a few questions it is possible to understand the natural history of a patient's chronic kidney disease (CKD).
Ask about the cause of their CKD. Common causes include diabetic nephropathy and hypertensive nephropathy, however other causes include glomerulonephropathies, reflux nephropathy and polycystic kidney disease.
Ask about the stage of their CKD. Patients in earlier stages (CKD I - III) tend to have few symptoms and complications, while patients with CKV IV and V require intensive management of complications.
- Ask about the patient's complications. The pertinent complications of chronic kidney disease are:
- Acidosis (poor clearance of hydrogen ions)
- Fluid overload
- Electrolyte derangements - hyperkalaemia, hyperphosphataemia
- Cardiovascular disease - hypertension, increased cardiovascular / cerebrovascular risk
- Anaemia (EPO deficiency / anaemia of chronic disease)
- Mineral bone disease (mediated by FGF23) - secondary hyperparathyroidism, hyperphosphataemia, hypocalcaemia; tertiary hyperparathyroidism
- Uraemia - encephalopathy, uraemic pericarditis
And finally, ask about the management of the patient's CKD. Initially this involves slowing the progression of disease by treating the cause and using RAAS-blocking medications, while later in the disease this involves treating complications. Patients with end stage renal failure may be on dialysis, or may have had a renal transplant.
Other Renal DiseaseThere are many other renal diseases that patients may report. These include:
- Past acute kidney injury
- Recurrent urinary tract infections
- Renal calculi
- Polycystic kidney disease
- Of particular importance in the renal history is the presence of cardiovascular disease such as ischaemic heart disease, stroke, peripheral vascular disease. Also ask about cardiovascular risk factors such as diabetes, hyperlipidaemia, hypertension.
Hypertension and diabetes are common and important causes of chronic kidney disease, and conversely patients with chronic kidney disease are more likely to pass away due to cardiovascular disease.
Other Important Conditions
- Certain other medical conditions may predispose patients to renal disease. This includes autoimmune conditions such as systemic lupus erythematosus and scleroderma; it also includes conditions associated with an excess of light chains, such as plasma cell myeloma and AL amyloidosis.
Dialysis & Transplant History
- Ask the patient whether they recieve peritoneal dialysis or haemodialysis. Generally start by asking how long the patient has been on dialysis and what the indication for commencing it was (e.g. symptoms).
Peritoneal dialysis (PD) may be performed as continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). Ask about the patient's access (Tenckhoff catheter) and whether they have had any issues with it in the past; ask about how much fluid is removed and how often. Ask about any complications they have had in the past, such as PD peritonitis.
Haemodialysis (HD) may be performed in-centre or at home. Ask about their access (vascath, AV fistula or graft), how often they are dialysed, and their dry weight.
- The workup and management of renal transplant patients is complex and includes physical, psychological and social factors. For a more detailed guide, read our renal transplant history page.
Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.
Identify potentially nephrotoxic medications such as NSAIDs, ACE inhibitors and angiotensin II receptor blockers. Older patients with chronic kidney disease may have been exposed to Bex or Vincent's powders in the early 1900s; these are both NSAIDs which have provided a significant contribution to the chronic kidney disease burden.
Common medications taken by patients with early to mid-stage chronic kidney disease include antihypertensives, diuretics, statins and diabetic medications. Patients with end-stage renal failure are likely to be on erythropoietin, phosphate binders and several other medications.
Patients who have recieved a renal transplant are likely to be on a combination of immunosuppressive agents such as steroids, tacrolimus, mTOR inhibitors, cyclosporin and/or mycophenolate; they also usually take antimicrobials for infective prophylaxis.
Ask about any medical conditions that may be known in the family. In the case of chronic kidney disease, this pertains particularly to autosomal dominant polycystic kidney disease, though other potential inherited causes include Alport syndrome and thin basement membrane disease.
Patients with chronic electrolyte derangements may report a family history of Bartter's, Gitelman's or Liddle's syndrome.
Also ask about a significant family history of vascular disease and other cardiovascular risk factors. This may include ischaemic heart disease, peripheral vascular disease, diabetes, hyperlipidaemia and hypertension.
It is important to understand any patient's social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility, ability to perform activities of daily living, diet and exercise.
In patients requiring dialysis or renal transplant, the social history becomes an even more vital part of decision making. Such patients require a significant level of physical, social and psychological support and it is important to ensure that the patient has these in place prior to considering these interventions. This may include ensuring that they have someone to drop them off to dialysis or to appointments; that they are likely to take their medications regularly; and that they are unlikely to do anything that would put them at risk.
Take a detailed smoking history: identify how many years the patient has smoked for, how many they smoked per day, and how long since they quit (if applicable.
Ask about alcohol intake: how many drinks per week, what type of drinks, and whether they have considered cutting down their intake if heavy.
Finally, ask about recreational drug use, and particularly intravenous drug use. Uncommonly, patients who develop infective endocarditis in the context of IV drug use may develop septic emboli which migrate to the kidneys and cause renal failure.
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