🧪 MOCK OSCE · FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min · NEPHROLOGY · CHRONIC KIDNEY DISEASE

Chronic Kidney Disease · Short Case

Candidate task: perform focused examination on a child with suspected chronic kidney disease (CKD) / end-stage kidney disease (ESKD).
Then discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏤ Wash, Warm, Introduce, Position, Expose, Approach ▾

Standard pre‑examination protocol – must be demonstrated:

🖐 Wash hands with sterilizing solution.
🔥 Warm hands and stethoscope.
👋 Introduce yourself to child & parent.
🧍 Position child: supine, then sitting (if possible).
👕 Exposure — fully expose for systematic exam, warm environment.
➡️ Approach from the right side.
✔ CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (≈6 min)
02 General Look (Inspection from end of bed) ▾

Key observations – “Chronic Kidney Disease” clues:

  • Facial appearance: sallow / pale complexion, periorbital puffiness (fluid overload).
  • Growth: short stature, failure to thrive (CKD from infancy).
  • Skin: pallor (anaemia), bruising (uraemic platelet dysfunction), scratch marks (pruritus), xerosis.
  • Respiratory: tachypnoea, Kussmaul breathing (acidosis), pleural effusion (fluid overload).
  • Abdomen: distension (ascites), scars (dialysis catheter, transplant), palpable kidney (polycystic).
  • Extremities: oedema (fluid overload), bony deformities (renal osteodystrophy).
👁 Red flags: severe hypertension, encephalopathy, pericarditis, fluid overload → urgent referral.
03 Systemic Examination (CVS, Resp, Abdomen, Neurological) ▾

Systematic examination – identify aetiology & complications:

  • Cardiovascular: HR, BP (hypertension common), JVP (raised if overload), pericardial rub (uraemic pericarditis).
  • Respiratory: reduced air entry at bases (pleural effusion), crackles (pulmonary oedema), Kussmaul breathing.
  • Abdomen: ascites (shifting dullness, fluid wave), hepatomegaly (congestive), palpable kidneys (polycystic), scars (dialysis/transplant).
  • Neurological: asterixis, confusion, seizures (uraemic encephalopathy), peripheral neuropathy.
  • Musculoskeletal: bone pain, bowing (renal rickets), slipped epiphyses.
🔍 Key: hypertension + anaemia + bone disease + growth failure → CKD.
04 General Physical Exam (Hands → Face → Chest → Abdomen → Limbs) ▾

Systematic examination – identify aetiology & complications:

  • Hands: pallor (anaemia), leukonychia, brown lines (uraemia), peripheral cyanosis.
  • Face: sallow complexion, periorbital puffiness, malar flush (SLE), hirsutism (steroids).
  • Chest: respiratory rate, use of accessory muscles, dullness at bases (effusion), pericardial rub.
  • Abdomen: ascites, organomegaly, shifting dullness, scars (dialysis catheter, transplant), palpable kidneys.
  • Limbs: pitting edema (sacrum, ankles), muscle wasting, bony deformities (knock knees, bow legs).
  • Skin: bruising, scratch marks, xerosis, uraemic frost (rare), striae (steroid).
  • Blood pressure: hypertension (common in CKD, especially glomerular causes).
📏 Anthropometry: weight, length/height, head circumference – plot growth.
05 Developmental Assessment & Associated Signs ▾

Assess:

  • Motor milestones: delayed if chronic illness, weakness (anaemia, electrolyte imbalance).
  • Speech & language: may be delayed (uraemic encephalopathy, hearing loss in Alport syndrome).
  • Feeding: poor appetite, vomiting (uraemia), salt craving (salt-wasting nephropathy).
  • Behaviour: irritability, lethargy, poor school performance (uraemia, anaemia).
  • School performance: may be affected by frequent hospitalisations, cognitive dysfunction (uraemia).
🧠 Red flags: severe hypertension, encephalopathy, pericarditis → urgent referral.

📋 Case Presentation – (fill in during exam)

This is a _____-year-old _____ child, referred for _____ (poor growth / pallor / oedema / hypertension / fatigue). On examination, the child appears _____ (well / unwell / in distress), with _____ (pallor / oedema / growth failure). Weight: _____ percentile, Height: _____ percentile. Blood pressure: _____ (normal / elevated / hypertensive crisis). Cardiovascular: _____ (tachycardia / pericardial rub / normal). Respiratory: _____ (Kussmaul / reduced air entry / crackles). Abdomen: _____ (ascites / hepatomegaly / palpable kidneys / scars). Skin: _____ (pallor / bruising / scratch marks / xerosis). GPE: _____ (bony deformities / oedema / normal). Neurological: _____ (alert / confusion / asterixis / seizures).

2. Viva Discussion (≈4 min)
06 Viva · Differential, Investigations, Management, Follow‑up ▾
🔹 Differential Diagnosis

• Congenital anomalies (CAKUT): renal hypoplasia, dysplasia, obstructive uropathy.
• Glomerulonephritis: FSGS, IgA nephropathy, MPGN, lupus nephritis.
• Cystic kidney disease: ADPKD, ARPKD, nephronophthisis.
• Hereditary nephritis: Alport syndrome.
• Metabolic: cystinosis, primary hyperoxaluria.
• Vascular: HUS, renal artery stenosis.
• Tubulointerstitial: reflux nephropathy, drug-induced.
• Systemic: SLE, vasculitis, diabetes mellitus.

🔹 Investigations – Diagnosis

• Serum creatinine & BUN: elevated; monitor trend.
• eGFR (Schwartz formula): stage CKD.
• Urinalysis: proteinuria, hematuria, casts.
• Spot urine protein/creatinine ratio: quantify proteinuria.
• Renal ultrasound: size, echogenicity, hydronephrosis, cysts.
• Electrolytes, bicarbonate: acidosis, hyperkalemia, sodium wasting.

🔹 Investigations – Aetiology

• Complement C3/C4: low in MPGN, SLE, post-infectious.
• ANA, anti-dsDNA: lupus nephritis.
• ASOT, anti-DNase B: post-streptococcal GN.
• Hepatitis B/C, HIV serology.
• Renal biopsy: if glomerular disease suspected.
• Genetic testing: Alport, polycystic kidney disease, cystinosis.

🔹 Investigations – Exclude Others

• Voiding cystourethrogram (VCUG): reflux, PUV.
• DMSA scan: renal scarring.
• MAG3 renogram: obstruction.
• Chest X-ray: cardiomegaly, effusion.
• Echocardiogram: LVH, pericardial effusion.
• Tuberculosis screen: before immunosuppression.

🔹 Investigations – Rule Out Complications

• Serum calcium, phosphate, PTH, alkaline phosphatase: renal osteodystrophy.
• Haemoglobin, ferritin, transferrin saturation: anaemia of CKD.
• Lipid profile: dyslipidemia.
• ABPM (ambulatory blood pressure monitoring): masked hypertension.
• Growth monitoring: weight, height, BMI, growth velocity.

🔹 Management – Across Organ Systems (URÆMIAS)

Uraemic complications

Monitor for neuropathy, encephalopathy. Treat with dialysis if refractory. Manage pruritus (antihistamines, emollients).

Renal replacement

Dialysis (peritoneal / haemodialysis) when GFR <15 mL/min. Pre-emptive transplantation preferred. Living-related donor best.

Acid-base

Maintain serum bicarbonate ≥22 mEq/L. Use sodium bicarbonate or citrate (Bicitra) 2-3 mEq/kg/day.

Electrolytes & fluids

Manage hyperkalemia (dietary restriction, Kayexalate, calcium resonium). Salt and water balance: restrict if overloaded, supplement if salt-wasting.

Mineral & bone (CKD-MBD)

Phosphate binders (calcium carbonate, sevelamer). Calcitriol / vitamin D analogues. Control PTH (aim 2-3x upper normal).

Intake: nutrition

Optimise calories (100% DRI), protein (100% DRI). Tube feeding if needed. Low-phosphate diet. Vitamin supplements.

Anaemia

Erythropoiesis-stimulating agents (epoetin, darbepoetin). Iron supplementation (oral/IV). Target Hb 11-12 g/dL.

Stature / growth

rhGH if height <25th centile and growth velocity <25th centile. Continue until epiphyseal closure or transplant.

Hypertension / proteinuria

ACE inhibitors (ramipril, lisinopril) or ARBs (losartan). Target BP <50th centile on ABPM (ESCAPE trial).

Immunisations

All standard vaccines. Live vaccines (MMR, varicella) before transplant. Annual influenza, pneumococcal (PPSV-23).

Psychosocial

School support, transition to adult services. Adherence to medications (especially immunosuppressants post-transplant).

Dialysis / transplant

Peritoneal dialysis (APD/CAPD) preferred in young. Haemodialysis for older children. Transplant is treatment of choice.

📈 Prognosis

  • CAKUT: slower progression; may reach ESKD in adolescence/adulthood.
  • Glomerular: faster progression; FSGS has 50% ESRD in 5-10 years.
  • Transplant: 5-year graft survival ~85% (deceased) to 93% (living).
  • Children <10 years: best graft survival; adolescents worst (adherence).
  • Mortality: 30-fold higher than healthy peers; cardiovascular leading cause.
  • Growth: improved with rhGH and steroid-free immunosuppression.

📋 Follow‑up Schedule

  • CKD stages 1-3: 6-monthly to annually (BP, growth, eGFR, urine).
  • CKD stage 4: 3-6 monthly; prepare for RRT.
  • CKD stage 5 / dialysis: monthly to 3-monthly (multidisciplinary).
  • Post-transplant: daily/weekly initially; then monthly to 3-monthly.
  • Transition: to adult nephrology at 16-18 years.
💡 Examiner expectation: logical differential (congenital vs acquired), systematic investigation (blood, urine, imaging), and a management plan following the URÆMIAS framework. Know the ESCAPE trial (intensified BP control), CKD-MBD, anaemia of CKD, and renal replacement therapy options.
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Mock OSCE · Chronic Kidney Disease · Based on Nelson, Wyne‑Harris & Pediatric Clinical Advisor