The document discusses renal failure and chronic kidney disease (CKD). It covers the functions of the kidneys, types of renal failure, causes, symptoms, complications, diagnosis and management of CKD including treatment to slow progression, dialysis options, and kidney transplantation. Risk factors, progression, and secondary issues associated with CKD such as bone disease, anemia, and cardiovascular problems are described. Dental considerations for patients with renal disease are also outlined.

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