KIDNEY DISEASES

Dr. Ahmed AL-Baghdadi

 Chronic Renal Failure and Dialysis
Chronic renal disease and end stage renal disease (ESRD)
a worldwide problem that continues to increase.
 Because patients with ESRD have many serious medical problems, dentists must know
how to properly manage them
 Function of kidney
A) FUNCTIONS
 Regulate fluid volume and the acid/base balance of plasma;
 Excrete nitrogenous waste;
 Synthesize
o erythropoietin,
o1,25-dihydroxy-cholecalciferol,
o renin
 Responsible for drug metabolism
B) Kidney : target organ for parathormone and aldosterone.
 RENAL DISEASES
A) types
 acute : bacterial infection, obstruction of urinary tract OR damage renal paranchyma
Chronic----(CRD)
o more likely to present to dental care
o Associated with Progressive disease of kidney resulting in reduced function and can manifest in several organ
systems
o Therefor the dentistry must understand the medical status of the patient and the adverse outcome of the
disease as he may face
a) the resultant anemia, abnormal bleeding, electrolyte and fluid imbalance, hypertension, drug
intolerance, and skeletal abnormalities.
b) In addition, patients who have severe and progressive disease may require artificial filtration of the blood
through dialysis or kidney transplantation.
 CHRONIC RENAL DISEASES
A) DIFINATION
 abnormal kidney function OR structure ≤ 3month with implication on general health of patient
 Due to direct damage nephron( functional& structural unit of kidney)
Damage is rarely repaired but it progress leads to End-stage renal disease (ESRD)
 ESRD refers to bilateral, progressive, chronic deterioration of nephrons which results in uremia & renal
failure(RF) death.
 ESRD manifests when 50% to 75% of the approximately 2 million nephrons lose function
 Under normal physiologic conditions, 25% of circulating blood perfuse the kidney each minute.
 Nephron deterioration in ESRD occurs through successive laboratory and clinical stages.
 rate of progressive and severity depend on underlying cases & contributing factors specially DM & HT
 CHRONIC RENAL DISEASES
B) Stages : depend on GFR ( 100- 150ml/ min) glomerular filtration rate
stage I
 normal GFR Stage V
 75% nephron function
Some degree of kidney damage  GFR less than 15
 Asymptomatic  Result in renal failure
 caused by retention of excretory products, and deterioration in endocrine and
 10-20% loss of kidney function metabolic functions— is called uremia.
Stage II  Sequelae involve multiorgan systems, including cardiovascular,
hematologic, neurologic, endocrine, gastrointestinal, and dermatologic
 Mild manifestations
 mildly decreased GFR
Stage III
 Moderate GFR 30- 59
50 % loss of kidney function
Stage VI
 Severely GFR 15-29

C) Etiology
 DM 44% , HT 28%, Ch. Glomerunephritis 16% & Polycystic diseases 4.5%
 RENAL DISEASES
E) Signs & symptoms
 Patient remains asymptomatic until the GFR drops to below 20 mL/min, the creatinine clearance drops to below
20 mL/min,
 Patients appear ill , leg crumps, insomnia ,lethargic , and dizziness.
 Hematologic s/s:
anemic ( pallor of skin &MM) , hemorrhagic episodes are common, particularly occult gastrointestinal
bleeding
 dermatological s/s:
Hyperpigmentation of skin ( brownish yellow appearance) due to retention of carotene-like pigments
(profound pruritus)
 GIT s/s:
anorexia, nausea, and vomiting, generalized gastroenteritis, and peptic ulcer disease, wt. loss. Uremic syndrome
commonly causes malnutrition and diarrhea
CNS s/s:
mental slowness or depression and become psychotic in later stages. Convulsion is a late finding that may be
directly correlated with the level of azotemia.
CVS s/s :
hypertension, congestive heart failure, and pericarditis
 RENAL DISEASES
E) Laboratory Findings
 General urine exam (GUE)
urinalysis
o Albuminuria
o Creatinine clearance
o GFR
 Serological finding
o serum creatinine & blood urea,
o electrolyte measurements,
o protein electrophoresis
F) Oral Manifestations of Chronic Renal Failure
o Pallor & Pigmentation of oral mucosa
o Petechiae and ecchymosis of oral mucosa
o Xerostomia(dry mouth), halitosis , altered taste(metallic
taste)
o Infections: Candidiasis, periodontitis, Parotid infections
o Dysgeusia ‫عسر الهضم‬
o Enamel defects of developing dentition( hypoplasia &
hypocalcification)
o Osteodystrophy (radiolucent jaw lesions)
o Uremic stomatitis
 RENAL DISEASES
F) Medical manegment
1) CONSERVATIVE CARE
o The goals of treatment are to retard the progress of disease & to preserve the patients quality of life.
o is recommended for stage I & II
o involves decreasing the retention of nitrogenous waste products & controlling hypertension, fluids, and
electrolyte imbalances.
o By dietary modification: including instituting a low- protein diet & limiting fluid, sodium & potassium intake
2) DIALYSIS
o a medical procedure that artificially filters blood Complication of dialysis
o 2 types: peritoneal & hemodialysis o Anemia
o When GFR drops below 30ml/ minute o The risk of hepatitis B, hepatitis C, and (HIV) infections
o Done each 2-3 days depending on need o Infection of the arteriovenous fistula is a possibility and
o Usually 3-4hr is required for each session can result in septicemia, septic emboli, infective
o A-V shunt or fistula , usually placed in forearm endarteritis, and infective endocarditis
o Heparin usually is administered during the procedure to o abnormal bleeding: due to altered platelet aggregation
prevent clotting and decreased platelet factor 3.
o Only about 15% of normal renal function
Medical consideration in dental management of
CKD
1) Patient Under Conservative Care
Antibiotics :
o Patients who have CKD (stages 1-3) and are not receiving dialysis generally have few issues with infection, so
they generally do not require additional antibiotic considerations.
o when invasive procedures are planned for a patient with CKD above stage 3, the dentist should consult with the
physician to assess the need for antibiotics.
o If an orofacial infection occurs, aggressive management is generally necessary.

Bleeding:
o if an invasive procedure is planned, the patient should undergo pretreatment screening for bleeding disorders,
and a platelet count should be obtained
o Local hemostatic agents : (topical thrombin, microfibrillar collagen, absorbable gelatin sponge, suture)
o blood pressure should be closely monitored before and during the procedure
o In patients whose kidney function is deteriorating (GFR mL/min less 50),elective dental care should be delayed
until consultation is obtained
Patients who take large doses of corticosteroids (e.g., 10 mglday )
o may develop adrenal insufficiency.
o To avoid an adrenal crisis in patients on such regimens, the dental clinician should ensure that the usual
corticosteroid dose is taken before surgical procedures and must monitor the patient closely during the
postsurgical phase of care
Medical consideration in dental management of
CKD
2) DRUG CONSIDERATIONS
o dentists should know which drugs to use, which to avoid, and the correct drug dosage
o drugs that are metabolized primarily by the kidney or that are nephrotoxic must be avoided
o Nephrotoxic drugs such as
a) acyclovir,
b) aminoglycosides,
c) aspirin,
d) NSADs ( vasoconstriction& decrease renal perfusion)
e) tetracycline
o Acetaminophen also is nephrotoxic at high doses only(metabolize in liver) , An alternative analgesic is tramadol.
o nitrous oxide and diazepam are antianxiety agents that require little modification for use in patients with ESRD
o Opioid use, if needed, requires dosage adjustment for CKD patients, and meperidine should be avoided ( may
cause seizures in patient with CKD)
Medical consideration in dental management of
CKD
3) PATIENTS RECEIVING DIALYSIS
o peritoneal dialysis presents no additional problems with respect to dental management,
o However, this is not the case with patients who are receiving hemodialysis
o Infective endocarditis occurs in 2% to 9% of patients receiving hemodialysis
o Antibiotics :
 American Heart Associations 2003 guidelines do not include a recommendation for prophylactic antibiotics
before invasive dental procedures are performed on patients with intravascular access devices EXCEPT if
an abscess is being incised and drained
 the use of standard infection control procedures
o heparin
 usually on the day after hemodialysis
 if dental care is necessary the day of hemodialysis ?
 Administering protamine sulfate
o should be aware of other cardiovascular considerations
o the arm that contains the arteriovenous shunt should be protected from application of the blood pressure cuff,
and the introduction of IV medications.
o Patient receiving dialysis is at increased risk of bone fracture
Medical consideration in dental management of
CKD
4) PATIENT WITH RENAL TRANSPLANTATION
Such patient usually
a) Use corticosteroids & AB prophylaxis---- you must take complete drug history
b) Need for management of oral infection
c) Need management for gingival overgrowth of cyclosporine