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 syndrome Renal dialysis Renal transplant Conclusion

The Urinary system

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

Paired Kidneys Ureter for each kidney

bladder Urethra

Function of the Kidneys

Elimination of waste material Maintanence of blood pressure Regulation of (electolyte balance / Maintanince of the composition of body fluid acid-base balance / calcium balance)
Erythropioietin secretion Renin-angiotensin system Vitamin D synthesis

Execrete toxins , nitrogenous wastes ( urea, creatinine, uric acid)

Endocrine

The kidney
1) 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.

efferent arteriole afferent arteriole

glomerulus

artery
peritubular capillaries

Bowmans capsule proximal convoluted tubule distal convoluted tubule collecting duct

vein

loop of Henle

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

Urine

Water- 95% Nitrogenous waste: urea uric acid creatinine Ions: sodium potassium sulfate phosphate

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

Abnormal Constitutes of Urine

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; its a very large molecule, too large to pass through glomerular membrane > abnormal increase in permeability of membrane Albuminuria- nonpathological conditionsexcessive exertion, pregnancy, overabundant protein intake-- leads to physiologic albuminuria Pathological condition- kidney trauma due to blows, heavy metals, bacterial toxin

Abnormal Constitutes of Urine

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

Abnormal Constitutes of Urine

Bile pigmentsBilirubinuria (bile pigment in urine)- liver pathology such as hepatitis or cirrhosis WBCPyuria- 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 Diseases & Disorders

Renal failure
Acute renal failure Chronic renal failure

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

Patients on Dialysis Renal transplant patients

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 AfroCaribbean 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 Disease

Stage 1 2 3 4 5 Description Kidney damage with normal or increased GFR Kidney damage with mildly decreased GFR Moderately decreased GFR Severely decreased GFR Kidney Failure GFR (mL/min/1.73 m2) 90 60-89 30-59 15-29 < 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

 Gavald 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
Gavald C, Bagn JV, Scully C, Silvestre FJ, Milin MA, Jimnez. 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 by hypertension (11%30%) and glomerulonephritis ( 11%-24%)

Renal failure and transplantation activity in the Arab world.

Arab Society of Nephrology and Renal Transplantation M. S. Abomelha Department 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.

Nephrotic syndrome
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

Renal Dialysis

DIALYSIS
Dialysis works on the principles of the diffusion and osmosis of solutes and fluid across a semipermeable 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

 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

Renal failure and transplantation activity in the Arab world.

Arab Society of Nephrology and Renal Transplantation M. S. Abomelha Department of Urology, Armed Forces Hospital Riyadh, Saudi Arabia All the collected data as of 31 December 1992 were analyzed.

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.

Renal failure and transplantation activity in the Arab world.

Arab Society of Nephrology and Renal Transplantation M. S. Abomelha Department of Urology, Armed Forces Hospital Riyadh, Saudi Arabia All the collected data as of 31 December 1992 were analyzed.

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 , kaposis sarcoma

Oral candidiosis

Kaposi Sarcoma following renal transplant

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?