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Case ID: 1
Created: 15 October 2006

Examine this gentleman's abdomen.

MRCP Kidney Transplantation Scar



     I have discussed about this case in my previous issue. This case is always a popular case MRCP PACES station 1. You notice that there are two vertical surgical scars over this gentleman's flanks. If you have a general inspection before you touching this gentleman's abdomen, you would have an idea what you are dealing with.

MRCP Kidney Transplantation-Moon Face

Yes, you are seeing a patient with kidney transplantation. You are expecting to find the following physical signs during your physical examination,

arrow two vague masses in the flanks( he underwent two kidney transplantations before)
arrowthe masses (transplanted kidneys)are dull on percussion ( superficial and not retro-peritoneal as in normal kidneys)

arrowthe masses are not tender on palpation and there is no bruits heard ( always check for possibilities of renal artery stenosis in a post transplanted kidney).
arrowCushingnoid features as evidenced by moon face, truncal obesity and bruises. ( such as below photo)
arrowsigns to suggest side effects of cyclosporin such as hypertrichosis and gingival hypertrophy.

However, you should try to find the following after you find that he has previous kidney transplantation,

arrowthe possible cause of his end stage renal disease, therefore you must look hard for polycystic kidney and suggest to examiners that you would like to look at his fundus for diabetic retinopathy as well as hypertensive changes ( remember that cyclosporin also causes hypertension)

arrowwhether the transplanted kidney is functioning well ( therefore suggest to examiners that you would like to look at this patient's urine output and check for any haematuria)

arrowlook beyond for other possible complications of medications ( immunosuppressants patient is currently on) such as cataract, osteoporosis ( spine tenderness), proximal myopathy ( secondary to long term steroid) etc

MRCP Kidney Transplantation- Bruises

Common questions examiners would ask you,

1) What are common problems patients face after kidney transplantation? ( Remember to divide that into acute and chronic complications.)
2) What are the possible causes if patient develops chronic kidney disease after kidney transplantataion. ( Remember that common causes include de novo glomerular disease, cyclosporin toxicity, renal artery stenosis and graft rejection).
3) What are the causes of kidney failure where patients might have normal size kidneys when they have end stage renal failure? ( Classical examples are polycystic kideney disease, diabetes nephropathy and amyloidosis!)


This gentleman has two previous kidney transplantations and currently not dialysis dependent .

Extra points:

1) Common side effects of Calcineurin Inhibitor ( such as cyclosporin and tacrolimus) are

arrow Nephrotoxicity
arrowGastrointestinal such as hepatic dysfunction ( include raised liver enzymes,jaundice and gall stone), anorexia, nausea and vomitting.
arrowCosmetic-hypertrichosis ( excessive hair growth),gingival hyperplasia.
arrowHyperlipidemia, glucose intolerance ( more in tacrolimus)
arrowNeurotoxicity- coarse tremor,headache, insomnia,dysesthesias
arrowInfection and malignancy
arrowHyperuricemia and gout

Case ID: 2
Created: 15 October 2006

Station 4: You are the SHO in charge of Nephrology Ward.

Subject: Mr Lee, 52-year old

Kindly see Mr Lee who has recently been diagnosed to have end stage renal disease with a creatinine level of 1000. He has background history of diabetes mellitus for the past 15 years which is poorly controlled. He was admitted to your ward 4 days due to ureamic symptoms and urgent haemodialysis was done for him. Currently he is well and waiting to see you to discuss about further plan.You are asked by your consultant to discuss about long term renal replacement therapy with him. His latest FBS in the ward was 12 mmol and HbA1C=10%. His Blood Pressure was 150/90 during the morning round.

You have 14 min until the patient leaves the room followed by 1 min for reflection before the discussion with the examiners.


  A popular question in MRCP PACES station 4. You are expected to discuss long term renal replacement therapy with Mr Lee. Before you proceed, you must remember that there are three possible ways available namely Haemodialysis, CAPD ( Continuous Ambulatory Peritoneal Dialysis) and Kidney Transplantation.

However, before you start your formal discussion with Mr Lee, remember to do the following,
arrow ask about his current condition ," How do you feel today?"
arrow the reason he was admitted four days ago.
arrow how much does he know about his condition " What do you know about your condition? Did anyone inform you?"
arrow how much does he know about kidney failure and the reasons behind urgent haemodialysis was done for him.
arrow general knowledge about kidney functions and possible ways renal replacement therapy can be done.

During you MRCP PACES examination, you must know the basic knowledge a patient know about his condition before you try to explain his illness. In this scenario, briefly talk about how haemodialysis and CAPD is being done. Try to explain to Mr Lee as well about the pros and cons about each technique available and their limitations ( such as in CAPD, patients may need to have adequate visual acuity to handle himself the CAPD). You must explore the option of kidney transplantation as well to Mr Lee and warn him about the problems he might face in future with all the immunosuppressants.However, remember to talk about a few other related issues with Mr Lee as well such as,

arrowhis diabetic control and tell him about importance of sugar control towards progression of kidney disease.
arrowtalk about his diest and warm him about diet modification due to his kideny function. You might want to refer him to see a dietician.
arrowhis Blood Presssure control

Remember that counseling is always not an easy station in MRCP PACES, look beyond your problems and discuss according to your scenario. Such as in this case, you certainly would be very interested to know about Mr Lee's social history, financial support ( such as insurance coverage) and impact of the disease towards Mr Lee's daily life ( discuss about depression as well if possible).

Summarize your discussion with Mr Lee and present to the examiners, your examiners will like to know what problems you encounter during your counseling with Mr Lee ( such as poor social or financial support, etc....)


1) Handbook of Kidney Transplantation, Gabrieal M. Danovitch
2) Kidney Patient Guide Website

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