health and medicine

1. by:Dr. A L A A I B R A H I M I

2.  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)

3. 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

4.  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.

5.  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.

6.  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

7.  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.

9.  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

10.  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

11.  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

13. 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 .

14.  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

15.  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 .

17.  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.

19.  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.

20.  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

21. Dental aspects of
kidney disease

22.  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)

23.  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.)

24.  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.

25.  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.

26.  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.

27.  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.)

28.  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.

30.  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

32.  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.)

33.  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

34.  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.

35.  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.

36.  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)

37.  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.

38. Thank you