Renal Disease by:Dr. A L A A I B R A H I M I

Fluid & Electrolyte balance (Renin)

Waste removal & excretion of drugs and hormones

Acid-base balance

Vit D metabolism (synthesis of active Vit D)

Stimulation of erythrocyte production(erythropoietin)

Introduction; Kidneys’ Role

Renal failure can be : Acute : come suddenly as (after surgery ,

severe injury or obstruction of renal blood vessels)

Chronic : more common, develops slowly (Chronic renal failure CRF, Chronic kidney disease CKD)

Renal failure leads to :Fluid retention,hypertenion , acidosis ,

accumulation of metabolites & drugs , anemia , bleeding tendency , endocrine defects

Renal Diseases ; Guideline

Pre-renal factors (55%): hypotension (hemorrage or burns) renal thrombosis , sepsis, dehydration, heat stroke or drugs( NSAIDS,fluroquinolones,ACEIs, Clarithromycin to patients on C.Ch blockers.)

Renal factors 15% : nephritis, tubular necrosis, surgery or trauma , overdose of drugs( NSAIDS, gentamicin, paracetamol), toxins, syndromes, chemotherapy)

Post-renal factors :obstructed urine flow.** ARF is a medical emergency , may lead to seizures

& coma . Management often by dialysis.

Acute Renal Failure

Definition: kidney damage or reduction of GFR for 3 or more months. (GFR less than 90ml/min per 1.73m2 + proteinuria or hematuria) .

Historically classified to : vascular , glomerular , tubulointerstetial & obstructive.

Accumulation of wastes leads to other issues.

More common among women but in men it is 50% more likely than women to progress to renal failure.

Chronic kidney disease; facts

Diabetes , hypertension , glomerulonephritis .

Renal diseases ( chronic glomerulonephritis, polycystic renal disease ,renal artery stenosis)

Systemic disease: SLE , Myeloma , Amyloid. Poisoning and Drugs ( long term use of

aspirin & other NSAIDS . Large doses of paracetamol)

Risk factors: cardiovascular disease , obesity , hypercholestrolemia, family history of CKD

Common Causes of CKD..

CKD is usually irreversible and progressive and can lead to end stage kidney disease(renal failure)

Factors that increase the risk of progression: - poorly controlled diabetes & hypertension. - repeated kidney injury( infections , drugs &

toxins ) specially in older people.

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Early CDK often no symptoms Only blood test & urine test help the diagnosis. When kidney function falls below 25% of normal Nocturia and anorexia appear & raised urea in

serum

Later on ::Cardiovascular disease , anemia , bone disease & other features appear

CKD.. Clinical features

Fluid overload Na-K impalance Bone & mineral disease Deficient Vit D3 In advanced disease all body systems

involved Anemia :: -toxic suppression of bone marrow- Lack of erythropoietin- Iron deficiency from blood loss in the gut

CKD.. Clinical features

Purpura & bleeding tendency::- Abnormal platelete production

( thrombopoeitin)- Increased prostaglandin 1 Vasodilatation &

poor platelete aggragation.- diminished factor 3 ( thromboxane)- Defective von –willbrand factor

tendency to infections::- Defective phagocyte function ( reduced IL2 &

increased IL1, IL6 & TNF

Secondary & tertiary Hyperparathyroidism

CKD.. Clinical features

Underlying causes of CKD should be treated where possible , any stress, infection or urinary tract obstruction should be dealt with.

Tratment goal:: to slow or halt the progression of CKD to ESKD & reduce the Cardiovascular risk.

K restriction , salt & water control. Reduce cardiovascular risk: aspirin , smoking

cessation. Symptomatic treatment Drugs alterations: avoid nephrotoxic drugs ,

reduce dosage of renally-cleared drugs .

CKD… Management

CKD is treated through medications & lifestyle changes to slow disease progression

However , for renal failure (ESKD) the only treatment options are : Dilalysis or renal transplant.

Dialysis : two types: -peritoneal dialysis-hemodialysis

CKD… Management

The peritoneal membrane act as a natural semi-permeable membrane

Dialysis fluid is instilled via a catheter placed near the umbilicus into abdominal cavity or tunneled under the skin from near the sternum.

Advantages: easy to learn , fluid balance is easier , done at home , easy to travel with.

Disadvantages: less efficient than hemodialysis , risk of peritonitis , fluid leakage & hernia .

Peritoneal Dialysis

Is used to remove metabolites & excess water by exposing patient’s blood acroos a semi-permeable membrane to a hypotonic solution.

Carried out at home or as an out pateint. Optimal effects are from 5-7 sessions per week .

(6-8 hours each) but most pts have 2-3 sessions per week (3-6 hrs each)

An arteriovenous festula is usually created surgically above the wrist or by a graft or catheter.

The patient is heparinized during dialysis (to keep the infusion lines & tubes patent)

The patient’s blood is passed through an extra corporeal circulation.

Haemodialysis

Dialysis rehabilitate up to 20% of patients but cannot prevent all complications .

Its associated with adverse effects referred to as dialysis (hangover or washout).includes:

-hypotenion , cramps , febrile reactions , arrhythmias , hemolysis , hypoxaemia.

Other effects include: worsened ischamic heart disease , cardiac valve calcification, amyloidosis & neuropathies.

- Haemodialysis may mechanically damage plateletes creating additional bleeding tendency.

Dialysis effects

Grafts & catheters are at risk of infection. Patients on hemodialysis have a higher risk of

infection due to:-freaquent use of catheters & needles- Compromised immunity- Frequent hospital stays & surgery. so steps & measures should be made to prevent infection

as: hand cleaning , protective equipment , use catheters and other instrument safely , disinfect dialysis station.

We have other methods of filtration as hemofiltration in wich we use a hemofilter and create pressure gradient and hemodiafiltration

Dialysis effects

Dental aspects of kidney disease

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The is correlation between tooth loss & patients with low protein and calorie intake.

Oral disease is common specially periodontitis Oral hygiene measures are important.

Dental treatment is best carried out on the day after dialysis ( maximum effect of dialysis & effect of heparin has diminished)

Dental aspects of CKD

The hematologist should first be consulted about bleeding tendency .

Hemostatis should be ensured if surgical procedures are necessary.

If bleeding prolonged ::- Desmopressin (hemostatis up to 4 hrs)- Cryoprecipitate (peak effect at 4-12 hrs & lasts

up to 36 hrs.)- Conjugated estrogens (take 2-5 days to develop

& persists for 30 days.)

Hemostasis

Infections are poorly controlled in CKD patients (specially if immunosuppressed)

May spread locally or cause septicemia. Periodontitis can perpetuate inflammation in

CKD. TB is more common but extrapulmonary so no

risk to dental staff. Signs of inflammation are masked

infections are difficult to be regognized. Hemodialysis predisposes to blood-borne viral

infections as Hepatitis.

Infections

Odontogenic infections should be treated vigorously.

Vascular access infections are usually caused by skin organisms so patients with most arteriovenous festulas don’t require antimicrobial prophylaxis before dental Tx except:

- pts with renal transplants. - pts with polysistic kidneys(may have mitral valve

prolapse) - pts on PD or HD with prosthetic bridge grafts or

tunneled cuffeded catheters.One regimen :: 400 mg teicoplanin IV during

dialysis.

Infections..

Erythromycin given to CKD patients has been associated with reversible hearing loss.

Tetracyclines can worsen nitrogen retention & acidosis so are best avoided except (doxycycline & minocycline)

Penicillins (except flucloxacillin & phenoxymethylpenicillin) And metronidazole should be given in lower doses since high levels are toxic to CNS.

Nephrotoxic drugs should be avoided. Drugs excreted by the kidneys are prescribed

only after consultation with the renal physician except in emergency.

Drugs

Aspirin and other NSAIDs should be avoided since ::

- they aggrevate GI irritation & bleeding associated with CKD.

-Their excretion may be delayed & they maybe nephtotoxic (especially in older pts or in cardiac failure)

- they cause Na retention peripheral edema,hypertension.

-Some patients already have peptic ulceration. even cox-2 inhibitors maybe nephrotoxic and are

best avoided. Short –term NSAID use is well tolerated if the

patient is well hydrated , has good renal function & no (heart failure , diabetes or hypertension.)

NSAIDs

Antihistamines & antimuscarinic drugs may cause dry mouth or urinary retetion.

Systemic fluorides should not be given because of doubt about fluoride excretion by damaged kidneys.

Antacids containing magnesium salts should not be given ( may lead to magnesium retention).

Antacids containing( Ca or Aluminum) & colestyramine (used in CKD) interfere with absorption of penicillin & sulfonamides.

Drugs…

In patients undergoing hemodialysis there may be : difficulties (in chewing , swallowing , tasting & speaking) . Increased risk or oral disease & infections

There is no effective treatment for hyposalivation in patients on chronic hemodialysis.

Consideration must be given to the effect on dental care of underlying diseases ( hypertension , diabetes …)

Major surgeries may be complicated by heperkalemia which leads to arrythmias and may cause cardiac arrest.

Dialysis is deffered postoperatively if possible since heparinizaton is required

Considerations

Uremic stomatitis is a rare complication of CKD

Local anesthesia is safe unless there is a severe bleeding tendency.

For conscious sedation , relative analgesia (inhalational sedation)is preffered because the veins of the forearms & saphenous veims are lifelines for pts on hemodialysis.

If its necessary to give IV sedation other veins should be used to avoid fistula infection or thrombophlebitis.

(Midazolam is less risky than diazepam to cause thrombophlebitis.)

Anesthesia & Sedation

GA is contraindicated if hemoglobin is below 10g/dl.

CKS pts are sensitive to myocardial depressant effects of anesthetic agents (may develop hypotension)

Myocardial depression & arrythmias are likely in those with poorly controlled acidosis & hyperkalemia.

Enflurane is metabolised to nephrotoxic ions so should be avoided.

Induction with thiopental the light GA with N2O is the technique of choice

General anesthesia

Most studies show that there is more periodontal disease in CKD patients than controls.

Osseous lesions include; loss of lamina dura , osteoporosis & osteolytic areas.

Secondary hyperparathyroidism may lead to giant cell lesions.

There may be abnormal bone repair after extractions with socket sclerosis pts should be screened carefully for bone disease before implant placement.

Dry mouth , halitosis , metallic taste & purpura may be conspicuous.

Oral health in CKD patients

Salivary glands may swell , salivary flow is reduced & there may be calculus accumulation.

In children with CKD we may see ;; jaw growth retardation , delay of tooth eruption , malocclusion & enamel hypoplasia with brownish discoloration.

Lower caries rate & less periodontal disease have been reported in childreb with CKD.

Oral mucosa may be pale (anemia) & there may be oral ulceration.

Oral health in CKD patients…

Transplantation is recommended for ESRD who are medically suitable , it enhances quality of life.

Transplants (cadeveric or living donor) survival is about 90% -1 year & 70% at 5years.

All transplant recipients require lifelong immunosuppresion to prevent T-cell immune rejection response.

Immunosuppressive regimes include ciclosporin & tacrolimus with or w/out corticosteroids.

Complications include: transplant rejection, risk of ischemic heart disease , nephropathy & infection or malignancy(immunosuppression)

Renal transplantation

Any oral sign of infection should be examined immediately & treated aggressively (immunosuppression)

Careful observation to detect any malignancy. Drug induced gingival overgrowth caused

by(ciclosporin & nifidipine) Oral ulceration due to drugs(sirolimus) & pulp

narrowing as a corticosteroids effect. Other considerations to hematological

abnormaliteis & Cardi vascular & other conditions as CKD patients.

Dental aspects of transplantation

Thank you

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