Renal Diseases Disorders

Renal Diseases Disorders

Sara M.D. AL-Shammari

Introduction • Patients with kidney disorders are increasingly

encountered in dental practice due to the improvement in the medical care resulting in prolonged life expectancy.

• In order to provide appropriate and safe dental treatment for these patients it is important to have a working knowledge of renal disorders and related problems.

Outline • The Urinary System

– Gross Anatomy

• Functions of the kidney • The nephrone• Hormonal Control of Kidney Function• Assessment of Renal Function• Renal disease

Renal failure Acure renal failure Chronic real failure

nephrotic syndromeRenal dialysisRenal transplant

• Conclusion

• Produce 1-2 liter of urine a day.• Most drug along with other waste products

are execrated by the kidneys • The kidneys receive approximately 25%

cardiac output per minute• The kidneys have an important role in

heamostatis and hormone synthesis

The Urinary system

1 Paired Kidneys

Ureter for each kidney

bladder

Urethra

2

3

4

The Urinary System

Function of the Kidneys• Execrete toxins , nitrogenous wastes

( urea, creatinine, uric acid)Elimination of waste material

Maintanence of blood pressure

• Regulation of (electolyte balance / acid-base balance / calcium balance)Maintanince of the

composition of body fluid

• Erythropioietin secretion • Renin-angiotensin system • Vitamin D synthesis Endocrine

The kidney1) The kidney is a reddish brown, bean-shaped organ 12 centimeters long; it is enclosed in a tough, fibrous capsule.

• 2) Location of the Kidneys – The kidneys are positioned retroperitoneally on either side of

the vertebral column between the twelfth thoracic and third lumbar vertebrae, with the left kidney slightly higher than the right.

3) Kidney Structure - Two distinct regions are found within the kidney: a renal medulla and a renal cortex.- The renal cortex contains the nephrons, the functional units of the kidney.

The Nephron– A kidney contains one million nephrons, each of

which consists of a renal corpuscle and a renal tubule.

vein

artery

afferent arteriole

efferent arteriole

glomerulus

peritubular capillaries

Bowman’s capsule

proximal convoluted tubuledistal convoluted tubule

loop of Henle

collecting duct

• Urine formation is done by thee mechnisim that occurs in the Nephron :

• • 1) glomerular filtration• 2) tubular reabsorption• 3) tubular secretion.

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• 1) glomerular filtration– glomerular filtrate and normally

contains all the major ions, amino acids, glucose, urea, and other substances in approximately the same concentration that exists in the blood plasma

– this ultrafiltrate does not normally contain red blood corpuscles or significant amounts of protein

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2) Tubular Resorption- Most nutrients, water ad essential ions are returned to the blood of the peritubular capillaries

3) Tubular Secretion- Moves additional undesirable molecules into tubule from blood of peritubular capillaries

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Hormonal function of the kidneys

• Synthesis Active form of vitamin D (calcitriol or 1,25 dihydroxy-vitamin D), which regulates absorption of calcium and phosphorus from foods, promoting formation of strong bone.

• Erythropiotin (EPO), which stimulates the bone marrow to produce red blood cells.

• Renin, which regulates blood volume and blood pressure.

Hormonal Control of

Kidney Function

Assessment of Renal Function• Glomerular Filtration Rate (GFR)

– the volume of water filtered from the plasma per unit of time.– Gives a rough measure of the number of functioning nephrons– Normal GFR:

• Men: 130 mL/min./1.73m2• Women: 120 mL/min./1.73m2

– Cannot be measured directly, so we use creatinine and creatinine clearance

– more accurate are inulin clearence or clearance of isotopes.

From the original 1800 g NaCl, only 10 g appears in the urine

UrineWater- 95%Nitrogenous waste:

• urea• uric acid• creatinine

Ions:• sodium• potassium• sulfate• phosphate

Glucose- when present in urine condition called glycosuria (nonpathological) [glucose not normally found in urine]

Indicative of:• Excessive carbohydrate intake• Stress• Diabetes mellitus

Abnormal Constitutes of Urine

Albumin-abnormal in urine; it’s a very large molecule, too large to pass through glomerular membrane > abnormal increase in permeability of membrane

Albuminuria- nonpathological conditions- excessive exertion, pregnancy, overabundant protein intake-- leads to physiologic albuminuria

Pathological condition- kidney trauma due to blows, heavy metals, bacterial toxin


Ketone bodies- normal in urine but in small amts

Ketonuria- find during starvation, using fat stores

Ketonuria is couples w/a finding of glycosuria-- which is usually diagnosed as diabetes mellitus

RBC-hematuria

Hemoglobinuria- due to fragmentation or hemolysis of RBC; conditions: hemolytic anemia, transfusion reaction, burns or renal disease


Bile pigments-

Bilirubinuria (bile pigment in urine)- liver pathology such as hepatitis or cirrhosis

WBC-

Pyuria- urinary tract infection; indicates inflammation of urinary tract


Renal diseases disorders

Renal diseases disorders

Renal Diseases & Disorders

Congenital Congenital

hydronephrosis Congenital obstruction of

urinary tract Duplicated ureter Horseshoe kidney Polycystic kidney disease Renal dysplasia Unilateral small kidney Multicystic dysplastic

kidney

Acquired Diabetic nephropathy Glomerulonephritis Hydronephrosis is the enlargement

of one or both of the kidneys caused by obstruction of the flow of urine.

Interstitial nephritis Kidney stones Kidney tumors – Wilms tumor,

Renal cell carcinoma Lupus nephritis nephrotic syndrome Pyelonephritis Renal failure

• Renal failure – Acute renal failure– Chronic renal failure

• Nephrotic syndrome• ----------------------------------------• CONDITIONS:

– Patients on Dialysis– Renal transplant patients

Renal Diseases & Disorders

Epidemiology • Renal disease in common within the population • The incidence of CRF increases with age• It is more common in Men, and in those of Asian or Afro-

Caribbean origin.• UK estimates suggest that 8.8% of the population have

symptomatic CKD• 1700 renal transplant in the U.K in 2004.• There are about 20.000 people in the U.K with

functioning renal transplant.• More than 10 percent of people, or more than 20 million,

ages 20 years and older in the United States have CKD

Renal failure• This is said to occur when the kidneys fail to

maintain execratory function n as a result of a reduced Glomerular Filtration rate ( GFR).– It could be acute of chronic

• Renal failure results in :– Fluid retention– Acidosis– Accumulation of metabolites and toxins– Damage to platelets leading to bleeding tendency– Hypertension , anemia, and endocrine effects.

Acute Renal failure Acute renal failure (ARF) is the rapid decline in renal

function that occurs when high levels of uremic toxins (waste products of the body's metabolism) accumulate in the blood.

ARF occurs when the kidneys are unable to excrete (discharge) the daily load of toxins in the urine.

• Rapid decline in the GFR over days to weeks.– GFR <10mL/min, or <25% of normal

• Cr increases by >0.5 mg/dL

Causes of ARF• Pre-renal :

– Poor perfusion:• Renal ischemia, severe burns ( result in shock or

dehydration),renal thrombosis, hypotension , heat stroke, some drugs ( NSAIDs , ACH inhibiters), Chemical or drug poisoning.

• Renal :– Interstitial nephritis, acute glomerulonephritis, tubular

necrosis, ischemia, toxins• Post-renal :

– prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders , bilateral renal calculi ( any thing that causes obstruction )

Symptoms of ARF

• It is a medical emergency which causes :– Decrease urine output (70%)– Edema, esp. lower extremity– Mental changes ( confusion)– Seizure– coma– Heart failure– Nausea, vomiting– Pruritus– Anemia– Tachypenic , brethlessness

Acute Renal Failure Management• Identification of the problem • Treatment of the underlying cause• Careful maintenance of fluid balance• Dialysis where the level of toxins needs

to be reduced.

Chronic kidney Failure• Chronic kidney failure : progressive , irreversiple renal

damage with decline of the glomerular filtration rate, leading to an increase of serum creatinine and blood ureic nitrogen levels ( BUN)

• Is shown by low GFR persisting for more than 3 months• ( A GFR of < 60 for 3 months or more) .• This happens gradually, usually months to years.• CKF : is divided into five stages of increasing severity and GFR

Stages of Chronic Kidney DiseaseStage Description GFR (mL/min/1.73 m2)

1 Kidney damage with normal or increased GFR

≥ 90

2 Kidney damage with mildly decreased GFR

60-89

3 Moderately decreased GFR 30-59

4 Severely decreased GFR 15-29

5 Kidney Failure < 15

Chronic Kidney Failure– Most common causes:

• 40% diabetes Meliutis • 25% hypertension• 12% glomerulonephritis

Other causes : artherosclerosis , fibromuscular displasia , SLE, Myeloma , amyloid , poisining , some drugs,

Laboratory features of CRF:

- CRF is measured by :- 1) falling GFR- 2) rising plasma urea ( BUN : Blood Urea

Nitrogen)- 3) rising creatinine level

Chronic kidney failure features:

- At first: asymtomatic- S&S : depend on the degree of renal malfunction

CNS:• loss of memory • Illusion• slurred speech• Depression• low concentration• headaches• Coma• Epilepsy• These findings can be associated with the

development of metabolic acidosis

GI : - Nauseas- vomiting - peptic ulcers- metallic taste in the mouth

Dermatological: • Pallor• Pruritus / itching • calcium deposition in tissues• Hyperpigmintation

Hematology :• anemia due to decreased erythropoietin production • lymphocytopenia• dysfunction of granulocytes • Suppression of cell-mediated immunity == higher

risk for infection • Hemostasis problems due to abnormal platelet

adhesiveness and decreased vWB factor .• Decreased throboxane • Raised prostacyclin level which result in vasodilation• Prolonged BT.

Metabolic :• Changes in bone metabolism are common

caused by secondary hyperparathyroidism– Which results from a high phosphorus serum

level (due to decreased renal clearance) and low serum calcium and calcitriol levels (due to decreased hydroxylation of 25-hydroxyvitamin D3 in the kidneys) .

• These lead to :– Renal osteadystrophy

CVS:• The aggravation of renal disease can

lead : – congestive heart failure associated to

pulmonary edema, ascites, arrhythmias, arteriosclerosis, myocardiopathy and pericarditis .

• Severe chronic renal disease can also cause hypertension due to fluid overload .

Oral menifistaiton

• Oral Ulceration , stomatitis , xerostomia • Candidias• Salivary gland swollen and reduce salivary

output .eg: Parotitis• Fetor ( ammonia- containing breath)• Lytic leisions in the jaw • loss of lamina dura• abnormal bone remodeling after extraction

• Gavaldá et al. examined the oral mucosa of 105 individuals with chronic renal failure and noted several mucosal lesions, uremic stomatitis and Candida infections in 37% of these patients

• Gavaldá C, Bagán JV, Scully C, Silvestre FJ, Milián• MA, Jiménez. Renal hemodialysis patients: oral• , salivary, dental and periodontal findings in• 105 adult cases. Oral Dis 1999-5:299-203.

INCIDENCE, PREVALENCE, AND TREATMENT OF END-STAGE RENAL DISEASE IN THE MIDDLE EAST Omar Abboud , 2006 , Ethnicity & Disease, Volume 16, Spring 2006

Diabetes mellitus is the most frequently reported cause of ESRD in almost all countries, accounting for 20%–40% of the cases, followed byhypertension (11%–30%) and glomerulonephritis ( 11%-24%)

Renal failure and transplantation activity in the Arab world. Arab Society of Nephrology and Renal Transplantation

M. S. AbomelhaDepartment of Urology, Armed Forces Hospital Riyadh, Saudi Arabia All the collected data as of 31 December 1992 were analyzed.

Oral manifestation of CRF in children

• Jaw growth usually retarded• enamel hypoplasia• delayed tooth eruption pattern• Malocclusion • Low caries rate • Pale oral mucosa• Oral ulceration

Management:• Blood pressure control• Diabetic control• Dietary protein restriction• Phosphorus lowering drugs/ Calcium

replacement–Most patients have some degree of

hyperparathyroidism• Erythropoietin replacement ( Epoietin )

–Start when Hgb < 10 g/dL• Bicarbonate therapy for acidosis• Avoid nephrotoxic drugs• Dialysis?

Local anesthesia and General anesthesia

• LA: is safe UNLESS there is severe bleeding tendency .

• GA :– CRF is complicated by anemia , which is a contraindication

for GA it the Hb is less than 10 g/dl.– CRF are highly sensitive to the the myocardial depressant

effects of anesthetic agent.– Risk of myocardial depression and cardiac dysrhythmia is

poorly controlled cases of metabolic acidosis and hyperkalemia

– Enflurane : nephrotoxic , better use isoflurane or sevoflurane or even NO2

Dental manegment of CRF:• AB prophylaxis considered if the procedure may

cause bacteremia.• Oral hyegine important• Best treated under LA• corticosteriod may be prescribed to these pt. ==

adrenal crisis• Check BP amd maintaine good hemostatis after

the surgical procedure .• Good suction to prevent blood swallowing • Impaired drug execretion• Consultation with the nephrologists is a advised

Drugs:• Many drugs are execreted

by the kidneys---failure to execrete result in toxicity.

• Any drug that is considered nephrotoxic should be avoided.

Nephrotic syndrome• Damaged glomerulus, large amount of protein in

the blood enters the urine.• It is characterized by proteinuria,

hypoalbuminemia, hyperlipidemia and edema which is generalized

• low serum albumin, and high cholesterol• Incresed level of circulatery factor VIII leads to

hyper-coagulability and possible thrombosis.• Causes:

– Minimal change disease, Diabetic nephropathy , SLE.

http://en.wikipedia.org/wiki/Proteinuria

http://en.wikipedia.org/wiki/Hypoalbuminemia

http://en.wikipedia.org/wiki/Hyperlipidemia

http://en.wikipedia.org/wiki/Edema

• Manegment : – patients may be on Heparin to prevent

thrompoemboletic complications..– Corticosteroids and immunusuprresant ( cyclosporin)– Low salt , high protein diet– Prophylactic Antibiotics for procedures likely to cause

bacteremia.

• Dental aspects:– Long term corticosteroid therapy is the main problem

( adrenal crisis ) – Susceptible to infections– May need antibiotic prophylaxis

Nephrotic syndrome

Renal Dialysis

DIALYSIS Dialysis works on the principles of the diffusion

and osmosis of solutes and fluid across a semi-permeable membrane.

Blood flows by one side of a semi-permeable membrane, and a dialysate or fluid flows by the opposite side.

Smaller solutes and fluid pass through the membrane.

The concentrations of undesired solutes are high in the blood, but low or absent in the the dialysate

For another solute, bicarbonate, dialysis solution level is set at a slightly higher level than in normal blood, to encourage diffusion of bicarbonate into the blood, to neutralise the metabolic acidosis that is often present in these patients

2 types

Hemodialysis

Peritoneal dialysis

Hemodialysis• 3-4 times a week• Takes 2-4 hours • Machine filters blood an returns it to body

Hemodialysis Machine

Types of Access• Temporary site• AV fistula

– Surgeon constructs by combining an artery and a vein

– 3 to 6 months to mature

• AV graft– Man-made tube inserted by a surgeon to connect

artery and vein– 2 to 6 weeks to mature

Temporary Catheter

The A-V fistula should not be used for venopuncture or IV sedation

Peritoneal dialysis

- The process uses the patient's peritoneum in the abdomen as a semi-peameable membrane across which fluids and dissolved substances are exchanged from the blood

http://en.wikipedia.org/wiki/Peritoneum



Dental consideration:• Patients undergoing dialysis are exposed to a large

number of blood transfusions and are therefore at a higher risk of contracting hepatitis B and C, HIV.

• Patients who are dialysed , will be heparinized . Also some platelets will be destroyed during dialysis

• The best time for dental treament is the day after the dialysis

• Prophylactic antibiotic .• Consultation with the nephrologists is a advised

KIDNEY TRANSPLANTATION

Kidney transplant

• Renal transplant is recommended for ESRD.

• Better quality and duration of life than chronic dialysis

• Renal graft survival rate:– 1st year 90%– 5 years 70%

• Cadaveric or living donors.



Dental management :• Before kidney transplant:

– Aggressive Dental treatment of these patients should preferably be carried out before the transplant.

Dental management :• After kidney transplant:

– Elective dental treatment sould be defered for at least 6 months..

– Post-kindey transplant pts are immunosuppressed to prevent rejection.

– Signs of infection could be masked .– Steroids used as immunosuppressant.– Cyclosporine also used as immunosuppressant– Cyclosporine causes gingival hyperplasia – Antibiotic prophylaxis should be considered at least two

years after the transplant .

Dental management :• After kidney transplant:

– Patients may have history of : oral candidiosis, oral viral infections ( herpes, EBV, CMV).

– There is an increase chance of malignancy due to immunosuppressant ( lymphomas , basal cell carcinoma, squamous cell carcinoma) , hairy lukoplakia , kaposi’s sarcoma

Kaposi Sarcoma following renal transplant

Oral candidiosis

Conclusion • Renal disease impact dental treatment• The timing of the treatment may be

affected in patients with renal impairment

• Co-operation with the physician is necessary in such patients

Refrences :• Medical problems in dentistry 5th edition .crisbian scully .• Essential human diseases for dentists. Chris sprout• A clinical guide to general medicine and surgery for dental practitioners.

BDJ books• Clinical dentistry . Churchil pocket book • Systemic Conditions, Oral Findings and Dental , Management of Chronic

Renal Failure Patients, General Considerations and Case , Report . Mahmud Juma Abdalla Braz Dent J (2006) 17(2): 166-170

• INCIDENCE, PREVALENCE, AND TREATMENT OF END-STAGE RENAL DISEASE IN THE MIDDLE EAST. Ommar abboud , Ethnicity & Disease, Volume 16, Spring 2006

• Dental management in renal failure: Patients on dialysis . Alba Jover Cerver Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.

• Renal failure and transplantation activity in the Arab world. Arab Society of Nephrology and Renal Transplantation .M. S. Abomel. Nephrol Dial Transplant (1996) 11: 28-29

Thank you ,, Qs?

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Renal Diseases Disorders