What are the typical history and physical examination findings in an older adult patient with renal failure and a history of hypertension, diabetes, and cardiovascular disease?

History and Physical Examination Findings in Renal Failure

History: Key Elements to Elicit

Primary Etiologic Factors

In an older adult with hypertension, diabetes, and cardiovascular disease, the renal failure is most likely due to diabetic kidney disease, hypertensive nephrosclerosis, or a combination of both. 1, 2

• Diabetes history: Determine type and duration of diabetes, as diabetic kidney disease typically develops after 10 years in type 1 diabetes but may be present at diagnosis in type 2 diabetes, accounting for 30-40% of CKD cases. 2

• Hypertension history: Assess duration and control, as approximately 70% of individuals with elevated serum creatinine have hypertension, and uncontrolled systolic blood pressure can accelerate GFR deterioration to 4-8 mL/min per year. 2, 3

• Cardiovascular disease history: Document history of myocardial infarction, stroke, or peripheral vascular disease, as 46% of CKD patients have atherosclerotic heart disease and the presence of cerebrovascular accident strongly suggests long-standing, poorly controlled hypertension with end-organ damage. 2

Symptoms Indicating Renal Parenchymal Disease

• Urinary symptoms: Ask about urinary tract infections, hematuria, urinary frequency, nocturia, and changes in urine output or color. 4

• Volume status symptoms: Inquire about orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, and weight changes indicating fluid retention. 5

• Uremic symptoms: Screen for altered mental status, confusion, lethargy, nausea, vomiting, pruritus, and metallic taste indicating advanced uremia. 5

Medication and Nephrotoxin Exposure

• Nephrotoxic medications: Document use of NSAIDs, ACE inhibitors, ARBs, diuretics, lithium, calcineurin inhibitors, and aminoglycosides. 2, 4

• Contrast exposure: Review history of cardiac catheterizations, CT scans with contrast, and timing relative to renal function decline. 1

Family History

• Kidney disease: Family history of chronic kidney disease or polycystic kidney disease is highly significant and increases risk substantially. 2, 4

Physical Examination: Critical Findings

Volume Status Assessment (Most Critical)

Determining whether the patient is volume depleted, volume overloaded, or euvolemic fundamentally changes management. 5

Signs of Volume Depletion (Prerenal AKI)

• Orthostatic vital signs: Drop in systolic BP ≥20 mmHg or heart rate increase ≥20 bpm indicates significant volume depletion. 5

• Skin turgor: Assess on forehead or sternum (more reliable in elderly than extremities). 5

• Mucous membranes: Dry oral mucosa and tongue indicate dehydration. 5

• Capillary refill: Prolonged time >3 seconds suggests poor peripheral perfusion. 5

• Jugular venous pressure: Low or absent JVP indicates volume depletion. 5

Signs of Volume Overload

• Elevated JVP: Associated with impaired renal function and worsening outcomes; this is a critical finding. 5

• Peripheral edema: Assess ankles, sacrum, and presacral area (particularly important in bedridden patients). 5

• Pulmonary edema: Bibasilar crackles on lung auscultation indicate pulmonary congestion. 5

• Ascites: Fluid wave or shifting dullness on abdominal examination. 5

Cardiovascular Findings

• Blood pressure: Hypotension (mean arterial pressure <60 mmHg) indicates inadequate renal perfusion and is a significant risk factor for AKI. 5

• Heart rate: Tachycardia represents compensatory response to decreased cardiac output or volume depletion. 5

• Cardiac auscultation: S3 gallop, displaced apical impulse, or irregular rhythm suggest heart failure contributing to renal hypoperfusion. 5

• Pericardial friction rub: Late finding indicating uremic pericarditis requiring urgent dialysis. 5

Findings Specific to Diabetic/Hypertensive Etiology

• Fundoscopic examination: Retinopathy suggests chronic microvascular disease affecting kidneys and indicates diabetic or hypertensive end-organ damage. 5

• Peripheral neuropathy: Loss of sensation in stocking-glove distribution is common in diabetic patients and suggests long-standing disease. 5

Uremic Findings (Advanced Renal Failure)

• Mental status: Confusion, lethargy, or asterixis indicates uremic encephalopathy. 5

• Skin examination: Uremic frost (rare, late finding), pallor from anemia, and excoriations from pruritus. 1, 6

Common Pitfalls to Avoid

• Do not rely on normal-sized kidneys on ultrasound to exclude CKD: Diabetic nephropathy and infiltrative disorders can maintain kidney size despite advanced disease. 2, 4

• Do not skip orthostatic vital signs in elderly patients: This is critical for distinguishing prerenal from intrinsic renal failure. 5

• Do not overlook subtle volume overload: Elevated JVP may be the only finding before peripheral edema develops and is strongly associated with worsening renal function. 5

• Do not assume acute presentation means acute kidney injury: Review historical creatinine values to determine if dysfunction has persisted >3 months, which defines CKD rather than AKI. 2, 4