This document discusses the manifestations and complications of renal disease and uremic syndrome. It covers the biochemical disturbances that occur like acidosis, electrolyte abnormalities, and fluid retention. Symptoms affecting various organ systems are described, like gastrointestinal issues, neurological signs, hematological problems, and skeletal disorders. Medical management including conservative therapies focusing on diet, medications, and preparing for dialysis are outlined. The two main types of renal replacement therapy, hemodialysis and peritoneal dialysis, are explained in detail. Oral health considerations for patients undergoing treatment are also noted.

1. RENAL DISEASES
Dr. NIDHI SHARMA

2. MANIFESTATIONS OF UREMIC SYNDROME
Two groups of symptoms
Symptoms related to altered regulatory and excretory
functions (fluid volume, electrolyte abnormalities, acidbase
imbalance, accumulation of nitrogenous waste, and
anemia)
Symptoms affecting the cardiovascular, gastrointestinal,
hematologic, and other systems

3. BIOCHEMICAL DISTURBANCES
Renal failure
Reduced H+ ion
excretion
Reduced plasma
pH
Systemic acidosis
•Anorexia
•Lethargy
•Nausea
•Kussmaul’s breathing

4. BIOCHEMICAL DISTURBANCES
Early stage Polyuria Hypokalemia
Late stage
Kidney function
deterioration
Hyperkalemia –
8mEq/L
(normal – 3.5 to
5.5mEq/L)

5. BIOCHEMICAL DISTURBANCES
Early stage Polyuria Excess sodium excretion
Late stage Oliguria
Sodium
retention
Edema
Hypertension
CHF

6. GASTROINTESTINAL SYMPTOMS
EARLY SYMPTOMS - nausea, vomiting, and anorexia
LATE SYMPTOMS - gastritis, duodenitis, and esophagitis
Mucosal ulceration in the stomach, small intestine, and large intestine
may hemmorhage, resulting in lowered blood pressure and a resultant
lowered GFR
Digestion of hemorrhagic blood may lead to a rapid increase in BUN

7. NEUROLOGIC SIGNS AND SYMPTOMS
Metabolic encephalopathy
Asterixis and myoclonic jerks
Seizures
Impaired vibratory sense and loss of deep tendon reflex
Paresthesia or burning feet => muscle weakness => muscle atrophy =>
paralysis
Dialysis disequilibrium – headache, nausea, irritability => seizures, coma and
death

8. HEMATOLOGIC PROBLEMS
NORMOCYTIC AND NORMOCHROMIC ANAEMIA
Hematocrit level reduces to 20-35%....(normal – 42-54% in males and 37-47% in females)
Causes of anaemia
Inability of diseased kidney to produce erythropoietin which stimulates bone
marrow to produce RBCs
nutritional deficiencies, iron metabolism abnormalities, and circulating uremic
toxins that inhibit erythropoiesis
In dialysis patient, blood sampling and blood loss in hemodialysis tubing and
coils.
Microcytic and hypochromic anaemia d/t overload of aluminium ion and iron deficiency
Pallor, tachycardia, widened pulse pressure, angina pectoris

9. HEMATOLOGIC PROBLEMS
NORMOCYTIC AND NORMOCHROMIC ANAEMIA
Treatment -
recombinant human erythropoietin
Complication – hypertension (erythro – inc Hb – inc blood viscosity - hypertension)
50 to 150 U/kg of body weight IV three times a week produces an increase in
hematocrit
desferoxamine

10. HEMATOLOGIC PROBLEMS
BLEEDING
Causes
Increased prostacycline activity
Increased capillary fragility
Deficiency of factor III
Risk factors
Qualitative platelet defect – dec platelet adhesiveness
Low hematocrit level

11. HEMATOLOGIC PROBLEMS
BLEEDING
Treatment
Dialysis
Cryoprecipitate and DDAVP (l-deamino-8-D-arginine vasopressin)

12. CALCIUM AND SKELETAL DISORDERS
(RENAL OSTEODYSTROPHY)
Skeletal changes that results from chronic renal failure due to altered
Calcium metabolism
Phosphate metabolism
Vitamin D metabolism
Parathyroid activity

13. CALCIUM AND SKELETAL DISORDERS
(RENAL OSTEODYSTROPHY)
Sunlight
7-dehydroxycholestrol
Cholecalciferol (skin)
25-hydroxycholecalciferol (liver)
1,25DHCC 21,25DHCC
(hypocalcemia) (hypercalcemia)
KIDNEY

14. CALCIUM AND SKELETAL DISORDERS
(RENAL OSTEODYSTROPHY)
Reduced Ca+2 absorption
Increased phosphate retention
Decreased serum calcium level
Increased parathyroid activity
Increased phosphate excretion
Decreased calcium excretion

15. CALCIUM AND SKELETAL DISORDERS
(RENAL OSTEODYSTROPHY)
In some cases, renal osteodystrophy becomes worse during hemodialysis
bone remodeling, osteomalacia, osteitis fibrosa cystica and osteosclerosis
digits, the clavicle, and the acromioclavicular joint
Mottling of the skull, erosion of the distal clavicle and margins of the symphysis pubis, rib
fractures, and necrosis of the femoral head
jaws - bone demineralization, decreased trabeculation, a “ground-glass” appearance, loss
of lamina dura, radiolucent giant cell lesions, and metastatic soft-tissue calcifications

16. CALCIUM AND SKELETAL DISORDERS
(RENAL OSTEODYSTROPHY)
Treatment
Protein restricted diet
Phosphate binders(calcium carbonate)
Vitamin D supplement
Parathyroidectomy

17. CARDIOVASCULAR MANIFESTATIONS
Arterial hypertension
Congestive heart failure
Cardiomyopathy
Arrhythmias
d/t sodium and water retention
Pericarditis d/t metabolic cardiotoxins in case of dialysis patient

18. RESPIRATORY SYMPTOMS
Kussmaul’s respirations - deep sighing breathing seen in response to
metabolic acidosis
Pneumonitis
Uremic lungs result from pulmonary edema associated with fluid and
sodium retention

19. ORAL MANIFESTATIONS
Enlarged (asymptomatic) salivary glands
Decreased salivary flow
Dry mouth (salivary gland infl, dehydration and mouth breathing)
Odor of urea on breath
Metallic taste
Increased calculus formation
Low caries rate
Enamel hypoplasia
Dark brown stains on crowns
Extrinsic (secondary to liquid ferrous sulfate therapy)
Intrinsic (secondary to tetracycline staining)

20. ORAL MANIFESTATIONS
erythemopultaceous
Uremic stomatitis(BUN >150mg/dl)
ulcerative
Uremic frosts

21. ORAL MANIFESTATIONS
Dental malocclusions
Tooth mobility
Pale mucosa with diminished color demarcation between attached gingiva and alveolar mucosa
Low-grade gingival inflammation
Petechiae and ecchymosis
Bleeding from gingiva
Candidal infections
Burning and tenderness of mucosa
Erosive glossitis
Tooth erosion (secondary to regurgitation associated with dialysis)
Teeth tender to percussion

22. RADIOLOGICAL MANIFESTATIONS
Demineralization of bone
Loss of bony trabeculation
Ground-glass appearance
Loss of lamina dura
Giant cell lesions, “brown tumors”
Socket sclerosis
Pulpal narrowing and calcification
Tooth mobility
Arterial and oral calcifications

23. MEDICAL MANAGEMENT OF
CHRONIC RENAL FAILURE
(1) Conservative therapy
(2) Renal replacement therapy

24. CONSERVATIVE THERAPY
Aimed at delaying progressive renal dysfunction
Managing diet, fluid, electrolytes, and calcium-phosphate balance
Prevention and treatment of complications
Dietary regulation of protein (20 to 40g per day) may improve acidosis, azotemia, and
nausea
Restriction of protein reduces
BUN levels
Potassium and phosphate intake and hydrogen ion production
The excretory load of the kidney, thereby reducing glomerular hyperfiltration,
intraglomerular pressure, and secondary injury of nephrons

25. CONSERVATIVE THERAPY
Blood pressure less than 130/85mm Hg
Erythropoietin maintains the Hb level to 10 to 12g/dl
Access for dialysis should be created when the serum creatinine reaches > 4.0 mg/dL
(normal – 0.6 to 1.2mg/dl) or the GFR falls to < 20 mL/min (normal – 100-150ml/min)
Nutritional status is important to avoid protein malnutrition, correct metabolic
acidosis, prevent and treat hyperphosphatemia, administer vitamin supplements, and
guide the initiatiation of dialysis therapy
Specialty evaluation by a nephrologist should be instituted when serum creatinine is >
3.0 mg/dL

26. RENAL REPLACEMENT THERAPY
Serum creatinine levels of > 6 mg/dL in males (4 mg/dL in females) and a GFR < 4
mL/min are the laboratory thresholds that are often used to indicate the need for
dialysis therapy.
There are two major techniques of dialysis :
Hemodialysis
Peritoneal dialysis

27. HEMODIALYSIS
Removal of nitrogenous and toxic products of
metabolism from the blood by means of a hemodialyzer
system
Exchange occurs between the patient’s plasma and
dialysate across a semipermeable membrane that allows
uremic toxins to diffuse out of the plasma while
retaining the formed elements and protein composition
of blood
consists of a dialyzer, dialysate production unit, roller
blood pump, heparin infusion pump, and various devices
to monitor the conductivity, temperature, flow rate, and
pressure of dialysate and to detect blood leaks and
arterial and venous pressures
three times per week, with each treatment lasting
approximately 3 to 4 hours

28. HEMODIALYSIS

29. HEMODIALYSIS
Vascular access for hemodialysis can be created by a shunt or external cannula system or by
an arteriovenous fistula
classic construction is a side-to-side anastomosis between the radial artery and the cephalic
vein at the forearm
Growth alterations may be seen in very young renal disease patients, particularly if they are
maintained on hemodialysis due to the poor caloric intake and the uremic state

30. PERITONEAL DIALYSIS
Access to the body is achieved via a catheter through the
abdominal wall into the peritoneum
One to two liters of dialysate is placed in the peritoneal cavity
Substances diffuse across the semipermeable peritoneal
membrane into the dialysate
Peritoneal membrane has greater permeability for high-
molecular-weight species
Tenckhoff catheter is used which is a permanent
intraperitoneal catheter that has two polyester felt cuffs into
which tissue growth occurs. If used with a sterile technique, it
permits virtually infection-free long-term access to the
peritoneum
In chronic ambulatory peritoneal dialysis (CAPD), 2L of dialysis
fluid is instilled into the peritoneal cavity, allowed to remain
for 30 minutes, and then drained out. This is repeated every 8
to 12 hours, 5 to 7 days per week

31. PERITONEAL DIALYSIS
continuous cyclic peritoneal dialysis (CCPD) - 2L of dialysate is exchanged every 6 to 8 hours
around the clock, 7 days per week
Advantages
No need of heparinization
No risk of air embolism and blood leak
Disadvantage
pain
intra-abdominal hemorrhage, bowel infarction
Inadequate drainage, leakage, and peritonitis

32. HEMOFILTRATION
In acute renal failure
Prediluting the blood with an electrolyte solution similar to plasma
Ultra filtering it under high hydraulic pressures
No dialysis solution is needed

33. ORAL HEALTH CONSIDERATIONS
Before treatment
Determine dialysis schedule and treat on day after dialysis.
Consult with patient’s nephrologist for recent laboratory tests and discussion of antibiotic prophylaxis.
Identify arm with vascular access and type; notate in chart and avoid taking blood pressure
measurement/injection of medication on this arm.
Evaluate patient for hypertension/hypotension.
Institute preoperative hemostatic aids (DDAVP, conjugated estrogen) when appropriate.
Determine underlying cause of renal failure (underlying disease may affect provision of care).
Obtain routine annual dental radiographs to establish presence and follow manifestations of renal
osteodystrophy.
Consider routine serology for HBV, HCV, and HIV antibody.
Consider antibiotic prophylaxis when appropriate.
Consider sedative premedication for patients with hypertension.

34. ORAL HEALTH CONSIDERATIONS
During treatment
Perform a thorough history and physical examination for presence of oral
manifestations.
Aggressively eliminate potential sources of infection/bacteremia.
Use adjunctive hemostatic aids during oral/periodontal surgical procedures.
Maintain patient in a comfortable uncramped position in the dental chair.
Allow patient to walk or stand intermittently during long procedures.

35. ORAL HEALTH CONSIDERATIONS
After treatment
Use postsurgical hemostatic agents.
Encourage meticulous home care.
Institute therapy for xerostomia when appropriate.
Consider use of postoperative antibiotics for traumatic procedures.
Avoid use of respiratory-depressant drugs in presence of severe anemia.
Adjust dosages of postoperative medications according to extent of renal
failure.
Ensure routine recall maintenance.

36. Drugs to Limit or Avoid When Treating
Dialysis Patients
Indication
Magnesium content
Potassium content
Sodium content
Acidifying effects
Catabolic effects
Nephrotoxicity
Alkalosis effect
Drugs
Antacids & Laxatives
IV fluids & Salt substitutes & Massive
penicillin therapy (1.7 mEq/million U)
Carbenicillin (4.7 mEq/g) & Alka Seltzer (23
mEq tablet) & IV fluid
Ascorbic acid & Ammonium chloride &
NSAIDS
Tetracyclines & Steroids
Phenacetin & Ketorolac & Cephalosporins
Absorbed antacids & Carbenicillin &
Penicillin