Chronic renal failure results in the progressive loss of kidney function over time and can lead to end stage renal disease. The kidneys normally regulate fluid, electrolyte and acid-base balance, excrete waste, and produce hormones. Medical management focuses on slowing disease progression, controlling complications like hypertension, and dialysis to filter the blood when kidney function is severely impaired. Dental management for patients with chronic kidney disease or on dialysis requires precautions due to bleeding risks and considerations for medications that are cleared by the kidneys.

1. Oral Diagnosis-I
Review of chronic renal failure and dialysis
December 24, 2006
Dr. Suresh. C. S. BDS; MDS; MDSc (UK)

2. Chronic Renal Failure & Dialysis
“Overview”
 Kidney regulate fluid volume and acid
base balance of the plasma
 Excrete nitrogenous waste
 Synthesize erythropoietin, 1,25-
dihydroxycholecalciferol & renin
 Drug metabolism
 They are the target organs for
parathormone & aldosterone

3. Chronic Renal Failure & Dialysis
Definition
 End stage renal disease (ESRD) is a
bilateral progressive and chronic
deterioration of nephrons (the
functional unit of the kidney).
 The disease results in uremia and can lead to death.
 ESRD manifests when 50-75% of nephrons lose
function.

4. Chronic Renal Failure & Dialysis
Incidence & Prevalence
 In US, 8 million people have some form of kidney
disease, 360,000 have irreversible ESRD.
 Average dental practice of 2000 patients can expect
to have 2 patients with ESRD.
 ♂>♀.
 Age: 45-65.

5. Chronic Renal Failure & Dialysis
Etiology
 Diabetes mellitus 34%
 Hypertension 25%
 Chronic glomerulonephritis 16%
 Other causes like:
 Systemic lupus erythematosis
 AIDS, Etc

6. Chronic Renal Failure & Dialysis
Signs & Symptoms
 Patient appears ill & anemic
 Hemorrhagic episodes: ecchymosis,
petechiae, purpura and gingival or
mucous membrane bleeding (epistaxis)
 Cardiovascular manifestations include:
 Hypertension
 Congestive heart failure (shortness of breath, dyspnea on
exertion & peripheral edema)
 Pericarditis

7. Chronic Renal Failure & Dialysis
Signs & Symptoms (Cont.)
 Hyperpigmentation of the skin (retention of carotene-
like pigments normally excreted by the kidney)
 Gastrointestinal signs:
 Anorexia
 Nausea
 Vomiting
 Generalized gastroenteritis
 Peptic ulcer disease

8. Chronic Renal Failure & Dialysis
Signs & Symptoms (Cont.)
 Stomatitis manifested by oral
ulceration & candidiasis.
 Parotitis may be seen and a urine
like odor to the breath may be
detected.
 Uremic syndrome commonly causes malnutrition and
diarrhea.

9. Chronic Renal Failure & Dialysis
Medical Management
 The goals of treatment are to retard the progress of
disease and preserve the patient’s quality of life
 A conservative approach
 Involve decreasing the retention of nitrogenous
waste products
 Controling hypertension, fluids & electrolyte
imbalances
 Anemia associated with renal failure usually is
treated with the use of recombinant human
erythropoietin

10. Chronic Renal Failure & Dialysis
Medical Management (Cont.)
 Dialysis
 It is a medical procedure that artificially
filters blood
 It becomes necessary when the number of nephrons
diminishes too much.
 Every 2 or 3 days depending on need
 Usually 3 to 4 hours are required for each session

11. Chronic Renal Failure & Dialysis
Medical Management (Cont.)
 Drugs that are metabolized primarily
by the kidney should be avoided
 Abnormal bleeding is associated with
dialysis
 Bleeding tendency because of altered
platelets aggregation and decreased
platelets factor III
 5 years survival rate is 28%
 An alternative is renal transplantation

12. Chronic Renal Failure & Dialysis
Dental Management
 Patients under conservative care
 Consultation with patient’s physician
 If patient is in advance stages, dental care may
best be provided after physician’s consultation
and in a hospital like setting.
 Because of the potential for bleeding problems:
o Pretreatment screening for bleeding time and platelet
count.
o A hematocrit level and hemoglobin count should be
obtained to assess the status of anemia

13. Chronic Renal Failure & Dialysis
Dental Management (Cont.)
 If an orofacial infection exists, aggressive
management is necessary using culture and
sensitive tests and appropriate antibiotics
 Nephrotoxic drugs should be avoided
 Example: NSAID, Aspirin, and Tetracycline
require special dosage adjustments

14. Chronic Renal Failure & Dialysis
Dental Management (Cont.)
 Patients receiving dialysis
 Patients are at risk for infective endocarditis but the
reason(s) are not yet fully established.
 Infective endocarditis occurs in 2% to 9% of patients
receiving hemodialysis
 40% of patients on dialysis have congestive heart
failure
 Hemodialysis tends to aggravate bleeding tendencies
• Physical destruction of platelets
• Heparin usage

15. Chronic Renal Failure & Dialysis
Oral Complications & Manifestations
 Pallor of the oral mucosa secondary to anemia
 Red-Orange discoloration of the cheeks and
mucosa caused by pruritis and deposition of
carotene-like pigments
 Diminished salivary flow (parotid infections)
 Candidiasis (xerostomia)

16. Chronic Renal Failure & Dialysis
Oral Complications & Manifestations
(Cont.)
 Patients complain of an altered metallic
tastes.
 Uremic stomatitis.
 Petechiae and ecchymosis on the labial
and buccal mucosa, soft palate and
margins of the tongue as well as gingival
bleeding.
 Osseous changes of the jaws.