PACES23 Renal Cases: Essential Strategies for Complex Presentations

Introduction

Renal cases in the PACES23 format remain one of the most feared scenarios for candidates. The revised PACES23 structure, with its integrated approach to clinical assessment, demands not only accurate physical examination but also a senior-level grasp of management reasoning. Renal patients—whether on haemodialysis, post-transplant, or presenting with subtle signs of glomerular disease—can quickly expose gaps in a candidate's clinical armoury.

This guide unpacks the essential strategies for tackling renal cases in PACES23, drawing on examiner feedback, common pitfalls, and high-yield clinical patterns that repeatedly appear.

Understanding Renal Cases Within the PACES23 Structure

The PACES23 format retains five stations but has refined the emphasis on integrated clinical assessment. Renal cases most commonly surface in:

• Station 1 and 3 (Physical Examination): A patient with an AV fistula, renal transplant, or signs of CKD

• Station 2 (History Taking): A patient presenting with haematuria, recurrent UTIs, or newly detected proteinuria

• Station 5 (Integrated Clinical Assessment): A complex consultation involving dialysis decisions, transplant complications, or conservative management of advanced CKD

Examiners are assessing whether you can move seamlessly from clinical findings to a coherent management plan that reflects a registrar-level thinker—not a medical student reciting textbooks.

High-Yield Renal Presentations in PACES23

1. The Haemodialysis Patient

This is a classic Station 1 or 3 scenario. The patient typically has:

• Arteriovenous fistula (look for the surgical scar and thrill)

• Signs of fluid overload (raised JVP, bibasal crackles, peripheral oedema)

• Evidence of anaemia (pale conjunctiva)

• Possibly nephrectomy scars or evidence of polycystic kidney disease

Key examination pearls:

• Always examine the fistula properly—feel for thrill, listen for bruit

• Check for signs of secondary hyperparathyroidism if CKD is long-standing

• Look for evidence of transplant (abdominal scar, immunosuppression side effects like gum hypertrophy from ciclosporin)

Examiner Tip: When presenting, start with the most obvious positive finding (the fistula), then systematically work through associated signs. Avoid the trap of listing every negative finding—examiners want targeted, relevant observations.

2. Renal Transplant Recipient

This presentation tests your ability to recognise transplant-related complications:

Discussion points examiners love:

• Differentiating acute rejection from calcineurin inhibitor toxicity

• Managing post-transplant infections (CMV, BK virus, PJP)

• Understanding immunosuppression regimens and their monitoring

3. Nephrotic Syndrome

A Station 2 or 5 favourite. The history may reveal:

• Frothy urine, progressive ankle swelling, periorbital puffiness

• Possible underlying cause: diabetes, SLE, malignancy (membranous nephropathy)

• Complications: DVT (renal vein thrombosis), infection (pneumococcal peritonitis)

Critical management points to articulate:

1. Confirm nephrotic syndrome: Proteinuria >3.5g/24h, hypoalbuminaemia, oedema, hyperlipidaemia

2. Investigate the cause: Renal biopsy is essential in adults

3. Manage complications: Anticoagulation for severe nephrotic syndrome, ACE inhibitors/ARBs for proteinuria, diuretics for oedema

4. Address underlying cause: Immunosuppression for minimal change disease, management of secondary causes

Station 5 Consultation Mastery: Renal Scenarios

The PACES23 integrated consultation assessment in Station 5 demands a structured yet fluid approach. Here is a framework specifically designed for renal consultations:

The SOAP-RENAL Framework

S – Summarise the clinical issue in one sentence
O – Outline the key clinical findings and investigations already done
A – Assess the patient's understanding, concerns, and priorities
P – Plan management in a patient-centred manner

Then specifically for renal cases:

R – Renal function trajectory (acute, chronic, acute-on-chronic?)
E – Electrolytes and acid-base status
N – Nephrotoxins to review and stop
A – Access for dialysis if needed (AVF, tunnelled line, PD catheter)
L – Long-term plan (transplant eligibility, conservative care, dialysis modality)

Common Examiner Questions in Renal PACES Cases

Examiners in PACES23 are instructed to probe clinical reasoning. Anticipate these questions:

On Diagnosis

• "What is your differential diagnosis for this patient's renal impairment?"

• "How would you differentiate pre-renal, intrinsic, and post-renal causes?"

• "What specific features in the history suggest the underlying aetiology?"

On Investigation

• "What investigations would you request, and in what order of priority?"

• "When would you consider a renal biopsy, and what are the contraindications?"

• "How would you interpret a urine dipstick in this context?"

On Management

• "This patient has progressive CKD—how would you prepare them for renal replacement therapy?"

• "What is your approach to managing resistant hypertension in a patient with CKD?"

• "How would you counsel this patient about the different dialysis modalities?"

On Complications

• "What are the long-term complications of this patient's condition?"

• "How would you manage hyperkalaemia in this patient?"

• "What is your approach to renal bone disease?"

The Five Most Common Renal PACES Pitfalls

Pitfall 1: Failing to Examine the Fistula Properly

Many candidates glance at the fistula arm without properly assessing it. Always:

• Feel for the thrill (suggests patent fistula)

• Listen for the bruit

• Assess the quality of the fistula (aneurysmal? infection?)

• Check for steal syndrome (check distal pulses and capillary refill)

Pitfall 2: Missing Polycystic Kidney Disease

Bilateral ballotable masses in the abdomen should immediately raise suspicion. Look for:

• Berry aneurysm history (family history of SAH)

• Hepatic cysts

• Mitral valve prolapse

• Family history (autosomal dominant inheritance)

Pitfall 3: Not Addressing the Patient's Concerns

In Station 5, examiners explicitly assess your communication skills. A patient newly diagnosed with ESRD may have fears about:

• Dialysis impact on lifestyle

• Transplant waiting times

• Financial implications

• Life expectancy

Acknowledge these explicitly—do not launch into a textbook management plan without first exploring the patient's perspective.

Pitfall 4: Inadequate Knowledge of Dialysis Modalities

You should be able to explain to a patient:

Pitfall 5: Neglecting Conservative Management

Not every patient with ESRD is suitable for dialysis. For frail, elderly patients with significant comorbidities, conservative kidney management may be appropriate. Be prepared to discuss this option with sensitivity, including:

• Symptom management (anaemia, fluid overload, pruritus)

• Advance care planning

• Realistic prognostic discussions

• Involvement of the palliative care team

Practical Revision Strategy for Renal PACES Cases

Step 1: Master the Physical Signs

Practise examining:

• AV fistulae (visit your local dialysis unit)

• Renal transplant recipients

• Patients with nephrotic syndrome (oedema assessment)

• CKD patients (looking for stigmata of chronic disease)

Step 2: Know the Key Guidelines

Familiarise yourself with:

• NICE CKD guideline (NG203) – classification, monitoring, and referral criteria

• NICE AKI guideline (NG169) – prevention, recognition, and management

• KDIGO guidelines – international standards for glomerular diseases, CKD-MBD, and anaemia management

• Renal Association clinical practice guidelines – UK-specific recommendations

Step 3: Practise the Consultation

Use structured practice with peers or online simulation tools:

• Rehearse breaking bad news about ESRD diagnosis

• Practise modality choice counselling

• Simulate a family member questioning the decision to pursue conservative management

Recent Updates Relevant to PACES23 Renal Cases

SGLT2 Inhibitors in CKD

The 2023 DAPA-CKD and EMPA-KIDNEY trials have fundamentally changed CKD management. SGLT2 inhibitors are now indicated for CKD regardless of diabetic status (eGFR ≥20 mL/min/1.73m²). Examiners expect candidates to know this.

Finerenone in Diabetic Kidney Disease

The FIDELIO-DKD trial established finerenone (a non-steroidal MRA) as a treatment for DKD with albumuria. This is increasingly tested in postgraduate exams.

Updated Anaemia Management

Roxadustat and other HIF-PHIs are emerging therapies for renal anaemia. While not yet widely available in the NHS, awareness of the evidence base demonstrates up-to-date knowledge.

Final Thoughts

Renal cases in PACES23 reward the candidate who combines precise clinical examination with fluent, patient-centred discussion. The key is not memorising every rare glomerular disease but demonstrating:

1. A systematic approach to examination and presentation

2. A senior-level understanding of dialysis, transplant, and conservative management

3. Genuine empathy when discussing life-changing renal diagnoses

4. Confident handling of examiner questions across diagnosis, investigation, and management

Remember: the examiners are assessing whether you are safe to be a medical registrar. A renal case is your opportunity to demonstrate exactly that.

Good luck with your PACES preparation. Consistent, structured practice is the key to success.