Plot the patient’s height and weight on a growth chart. Also attempt to get prior heights and weights.

Children with chronic renal failure will frequently exhibit growth failure. Weight will usually be the first to be effected with height being maintained for a longer time. Head circumference is usually the last to be effected. Growth failure is at least initially associated with decreased caloric intake.

Obtain the patient’s vital signs including the blood pressure.

Refer to nomograms for age to access the percentile for the child’s blood pressure for age. If the child’s blood pressure is above the 95% for age, this would suggest renal disease. Don’t forget to take three extremity blood pressures if the child is being assessed for hypertension for the first time. Remember, patients may have advanced renal failure and normal blood pressures, especially if the failure is associated with obstructive uropathy. The presence of hypertension does not always mean renal disease.

Assess HEENT for optic disc changes of hypertension. Assess for colobomas of the nerve, iris or retina. Colobomas may be associated with renal dysplasia.

Red conjunctiva may be associated with calcium phosphorus deposits in advanced renal failure. Look for skin tags associated with the ear. Their presence is sometimes associated with renal dysplasia.

The chest should be auscultated for decreased breath sounds or pulmonary edema.

A plural effusion can be seen in nephrotic syndrome. Rales or crepitation can indicate fluid accumulating in advanced renal failure. Children with asphyxiating thoracic dysplasia (Jeune syndrome) have constricted thoracic, short limbs and may have either glomerular sclerosis or diffuse cystic dysplasia.

Listen to the heart for murmurs, gallops or friction rubs.

The anemia of renal failure will often produce loud flow murmurs. A gallop could indicate volume overload in advanced renal failure or uremic myocardiopathy. A friction rub may be a sign of uremic pericarditis. It is usually accompanied by fever and chest pain.

Assess the abdomen for ascites.

A fluid wave may be detected by tapping one side of the abdomen, placing a hand in the center and observing the transmitted wave on the contra lateral side of the belly. Ascites may also be assessed by percussing for dullness with the patient on their back and side. A large shift in dullness can represent ascetic fluid.

Assess the abdomen for organomegaly.

Large kidneys are commonly seen in autosomal dominant polycystic kidney disease as one grows older. In the autosomal recessive variety the kidneys are very large in infancy. Sometimes an obstructed kidney may be palpable or an obstructed ureter may be felt on abdominal examination. They may be difficult to distinguish from bowel loops. Hepatic fibrosis is seen in autosomal recessive polycystic kidney disease and may result in an enlarged firm liver. The spleen may be enlarged as a result of hepatic fibrosis. The liver may be also enlarged as the result of volume overload in advanced renal failure.

Asses the abdominal wall musculature.

The absence of abdominal wall musculature likely represents Prune-Belly syndrome especially if there is bilateral undescended testes.

Examine the genitalia.

Ambiguous genitalia may be associated with renal abnormalities. Certain syndromes such as Drash syndrome may exhibit pseudohermaphroditism and progressive renal disease. Severe hypospadias may be associated with renal anomalies. Cryptorchidism is more problematic. If the testes are undescended bilaterally, Prune-Belly syndrome should be considered. There should be absence of the abdominal musculature and very likely significant renal abnormalities. Unilateral cryptorchidism is more problematic. Some series report no association between unilateral undescended testes and renal abnormalities and others report an increase. Remember, the more severe the anomaly and the presence of any associated abnormalities, the more likely a renal abnormality is present.

Exam the patient’s anus.

Imperforate anus is associated with renal abnormalities. VATER is associated with an imperforate anus, esophageal fistula, vertebral anomalies, radial anomalies and renal abnormalities. Anal stenosis may also be associated with renal abnormalities along with other abnormalities (example Fraser syndrome).

Examine the extremities for evidence of renal osteodystrophy.

The presence of rickets is evidence for log-standing renal insufficiency. Exaggeration of the normal genus varum and valgum is evidence of renal osteodystrophy. Clubbing of the nail beds may be seen with renal osteodystrophy. Syndactyly may be part of a syndromic picture associated with renal abnormalities (example Bardet-Biedl syndrome). Polydactyly may be part of syndrome associated with renal anomalies (example Lawrence-Moon-Biedl syndrome). Fanconi anemia has skeletal abnormalities (hypoplastic thumbs, radial abnormalities, brachydactyly) and may have renal anomalies. Nail-patella syndrome (hypoplasia of the patella and nails) is associated with a progressive segmental sclerosis of the glomeruli.

Assess the back for evidence of sacral agenesis (absence of gluteal cleft and flattened buttocks).

The child may have a neurogenic bladder leading to renal insufficiency. A meningomyelocele is associated with a neurogenic bladder.

Patients with advanced renal failure often exhibit dry skin.

They have increased capillary fragility and will exhibit increased bruising. A high calcium phosphorus product may produce subcutaneous soft tissue deposits of calcium which can be painful. Severe hyperparathyroidism and calcium deposition can lead to tissue necrosis. There are characteristic rashes that are associated with diseases that can lead to renal insufficiency. An example would be the butterfly rash associated with lupus.

Neurologic evaluation may reveal weakness or decreased sensation in the lower extremities in patients with neurogenic bladders if there is a chord lesion.

Advanced uremia could result in an overall depression in CNS function. Severe hypertension could lead to an encephalopathic picture and potentially seizures.