Checklist

WIPER

• Patient supine. Expose both arms completely, as well as chest and abdomen.

Physiological parameters

General

• Fluid status: shortness of breath, audible crackles, dry mucous membranes, facial oedema, peripheral oedema, cyanosis

• Clinical features of immunosuppression or chronic steroid use

Inspection

Arm fistulas:

• Radiocephalic fistula (wrist)

• Brachiocephalic or brachiobasilic fistulas (antecubital fossa)

• Prosthetic straight or loop grafts (PTFE)

Fistula complications:

• Non-functioning/thrombosed fistulas

• Haematomas or ecchymosis from needling

• Aneurysmal changes: tight or shiny skin

• Hand ischaemia from fistula: steal syndrome or embolization

Neck and chest (subclavian and internal jugular veins):

• Raised JVP (fluid overload)

• Dilated neck veins: central vein stenosis from long-term central dialysis lines

• Temporary non-tunnelled haemodialysis intravenous catheters (VasCath)

• Long-term tunnelled haemodialysis intravenous catheters (PermCath)

Abdomen:

• Peritoneal dialysis (PD) catheter

• Scars: nephrectomy scars in flanks, midline scars for PD catheters, suprapubic catheter scars, iliac fossae scars for renal transplant (Rutherford Morison incision, ‘ hockey-stick ’ incision), laparoscopic scars for nephrectomy (donor)

Leg:

• Prosthetic PTFE loop graft.

Palpation

• Skin turgor: fluid status

• Fistula (if present): thrill or pulse, palpable stenosis

• Pulses (if fistula present): radial, ulnar, brachial, axillary, subclavian

• Abdomen:

• ascites

• peritonitis (if PD catheter present)

• ballotable masses (polycystic kidneys)

•iliac fossa masses (transplanted kidney)

Percussion

• Percuss any iliac fossa mass to confirm it is dull (kidney) rather than cystic.

Auscultate

• Fistula: bruit (continuous ‘ machinery ’ bruit)

• Chest: crackles, effusions (fluid overload)

To complete the examination…

• Examine groins (femoral lines) and lower limbs (fistulas and grafts).