Lec1 ‫عماد سلمان حمودي‬.

‫د‬
Chronic renal
disease
It is a progressive loss of renal function that persists for 3
month or progressive, chronic bilateral deterioration of
nephrons resulting in uremia and renal failure and can lead to
death.

The main function of the kidney;

1. Regulation of body fluid volume and the acid base balance

of the plasma.
2. Synthesize erythropoietin and vitamin D.

3. Excecreation of nitrogenous waste.

4. Responsible for drug metabolism.

Acute renal failure; sudden decline in renal function which is a

medical emergency, it is usually reversible .it may be caused by :

 Renal hypoperfusion in shock or hemorrhage.

 Trauma or glomerular disease or damage caused by drug.

Chronic renal failure (CRF): It is an irreversible, advanced, slowly

progressive renal damage characterized by a low glomerular
filtration rate (GER), for more than 3 months.
Etiology of CRF
The three most common known causes are:

1. Diabetes mellitus.

2. Hypertension.

3. Chronic glomerulonephritis.

Chronic renal disease can be compensated by structural and

functional hypertrophy of surviving nephrons, to a point at which
around 50 % of renal function remains, when chronic renal
insufficiency (CRI) ensues. CRI inevitably progresses to ESRD.

End-stage renal disease (ESRD): Refers to bilateral,

progressive, chronic deterioration of nephrons, the functional unite
of the kidney. The disease results in uremia and can lead to death.
ESRD manifests when 50% to 75% of the approximately 2 million
nephrons lose function. Uremia: It is the resultant clinical
syndrome caused by renal failure, retention of excretory products,
and interference with endocrine and metabolic functions.

Clinical features of CRF and ESRD:

CRF is asymptomatic at first. Symptoms and signs of CRF

depend on the degree of renal malfunction, often with few
symptoms until kidney function has fallen to less than 25% of
normal.

Clinical features of CRF can be summarized in the following table.

Clinical features of chronic renal failure

CARDIOVASCULAR DERMATOLOGICAL
Hypertension Pruritu
Congestive heart s
failure Bruisin
Cardiomyopathy g
Pericarditis Hyperpigmentatio
Accelerated atherosclerosis n Pallor
Uremic frost

GASTROINTESTINAL HEMATOLOGICAL
Anorexia Bleedin
Nausea and vomiting g
Peptic ulcer and gastrointestinal Anemia
bleeding Hepatitis Lymphopenia and leukopenia
Peritonitis Splenornegaly and
hypersplenism

NEUROMUSCULAR IMMUNOLOGICAL
Weakness and lassitude Prone to infections
Drowsiness leading to
coma Headaches
Disturbance of vision
Sensory disturbances – peripheral
neuropathy Seizures METABOLIC
Muscle cramps Nocturia and
polyuria Thirst
Glycosuria
Metabolic
acidosis
Raised serum urea, creatinine, lipids and uric
acid Electrolyte disturbances
Secondary hyperparathyroidism

Laboratory findings:
Several tests, including urinalysis, blood urea nitrogen (BUN),
serum creatinine, creatinine clearance, electrolyte measurements
and protein electrophoresis are used to monitor the progress of
CRF.

In CRF, there will be increase in serum creatinine level (normal

value is 0,6 to 1.20 mg/dL), BUN is above 20mg/dL and there will
be increase in the level of serum potassium and phosphate and
decrease in the serum calcium.
Medical management of CRF and ESRD
The main treatment options are:

 Conservative care.
 Dialysis (peritoneal dialysis or hemodialysis).
 Renal transplant.

Conservative care:
It is the first step which is designed to slow the progression of
renal disease and may be adequate for prolonged periods. It
involves:

 Dietary modification (restricting protein, low phosphate diet

and monitoring fluid, sodium and potassium intake).
 Any treatable associated condition such as diabetes,
hypertension, congestive heart failure, infection, volume
depletion, urinary tract obstruction, secondary
hyperparathyroidism is corrected or controlled.
 The use of vitamin D preparations (e.g. calcitriol) that
decrease serum parathyroid hormone levels (to inhibit bone
resorption).
 Avoidance of nephrotoxic drugs (such as NSAIDs and
tetracyclines) or agents metabolized principally by the kidney
(such as penicillins, cephalosporins and erythromycin).
 The use of recombinant human erythropoietin for treatment
of anemia that occurs in renal failure.

Dialysis:
It is a medical procedure that artificially filters blood. Dialysis
becomes essential if renal function deteriorates to ESRD. The
procedure can be accomplished by peritoneal dialysis or
hemodialysis.
Peritoneal dialysis: A hypertonic solution (2 to 3 L) is instilled into
the peritoneal cavity via a permanent peritoneal catheter. After a
short time, the solution and dissolved solutes (e.g. urea) are
drawn out. Peritoneal dialysis does not require anticoagulation,
relatively low cost, ease of performance and reduced likelihood of
infectious disease transmission. However, it requires more
frequent sessions and is less effective than hemodialysis, and has
higher incidence of complications such as infection, hypoglycemia
and protein loss. Its principal use is for patients in ARF or for those
who require only occasional dialysis.

Hemodialysis: It is the most commonly used for CRF and is

performed at 2-3 day intervals. A permanent and surgically placed
arteriovenous (AV) fistula for large bore cannulation is required,
usually placed in the forearm. Administering heparin prevents
clotting. Patients receiving hemodialysis are at risk for contracting
hepatitis B, hepatitis C and HIV because of multiple blood
exposures. In addition, these patients are at risk for infection of
their AV shunts, which predisposes them to septic emboli,
septicemia, infective endarteritis, and infective endocaditis. Long-
term hemodialysis patients have a higher rate of tuberculosis.

Oral Manifestations of CRF and ESRD:

1. Pallor of the oral mucosa related to anemia.
2. Pigmentation of oral mucosa (red-orange discoloration)
caused by deposition of carotene-like pigments.
3. Xerostomia and parotid infections.
4. Candidiasis.
5. Dysgeusia (an altered or metallic taste that results from a
high urea content).
6. Petechiae and ecchymosis of oral mucosa.
7. Gingival bleeding.
8. Oral lesions, ulcers, lichen planus lesions, hairy tongue and
pyogenic granulomas have all been noted in increased
frequency in patients with CRE.
9. Enamel hypoplasia has been documented in patients with
ESRD whose disease began at an early age.
10. Osteodystrophy (radiolucent jaw lesions ....Central giant cell
granulomas; "brown tumor"). Those lytic bone lesions are the
result of hyperparathyroidism.
11. Uremic stomatitis.
12. There may be gingival enlargement as a result of the
medication used (cyclosporine).

Dental management of patient with CRF or ESRD

UNDER CONSERVATIVE CARE

 Consult with physician regarding physical status and level of control.

 Avoid dental treatment if disease is unstable (poorly controlled
or advanced).
 Screen for bleeding disorder before surgery (bleeding time,
platelet count, hematocrit, hemoglobin).
Hemorrhagic diatheses are attributed primarily to abnormal
platelet aggregation and adhesiveness and decreased platelet
factor 3 which enhances the conversion of prothrombin to
thrombin by activated factor X. Defective platelet production
may play a role. The risk of bleeding diathesis in patients with
uremia dictates that the dentist must have local hemostatic
agents available during surgical procedures (topical thrombin,
microfibrillar collagen, and suture).
 Monitor blood pressure closely.
  Pay meticulous attention to good surgical technique to decrease
the risks of excessive bleeding and infection.
 Avoid nephrotoxic drugs (acetaminophen in high doses,
acyclovir aspirin, NSAIDs, aminoglycosides and tetracycline).
 Adjust dosage of drugs metabolized primarily by the kidney
such as penicillins and cephalosporins.
 Aggressively manage orofacial infections with culture and
sensitivity tests and antibiotics.
 The dentist should consult the physician to assess the need for
antibiotics when invasive procedures are planned.
(Host defense is compromised by nutritional deficiencies and
changes in the production and function of white blood cells.
Accordingly, individuals with CRF and ESRD are more
susceptible to infection).
 Consider hospitalization for severe infection or major procedures.
 Consider corticosteroid supplementation as indicated.
If patients with ESRD who are undergoing dialysis or other
treatment have been taking large doses of corticosteroids (i.e.
10 mg daily of prednisone or equivalent), it is possible that they
may have adrenal hypofunction. To avoid an adrenal crisis, the
dental clinician may need to supplement the patient's
corticosteroid dose before complex dental procedures are
performed.

NOTE: Peritoneal dialysis presents no additional problems in

dental management.

RECEIVING HEMODIALYSIS
 Same as conservative care recommendations.
 Consult with physician about the risk of infective endarteritis or
endocarditis.
In hemodialysis patients, a surgically created AV fistula may be
susceptible to infection (endarteritis) and may become a source
of bacteremia, resulting in infective endocarditis. Infective
endocarditis
 in patients undergoing hemadialysis occurs even when
preexisting cardiac defects are absent.
For patients undergoing hemodialysis who do not have known
cardiac risk factors, the American Heart Association (AHA) does
not recommend antibiotic prophylaxis (low risk); however, the
managing physician may be consulted regarding the need for
antibiotic prophylaxis.
According the AHA, patients on hemodialysis who have known
cardiac risk factors are at increased risk for infective
endocarditis when invasive dental procedures are performed
and thus need antibiotic prophylaxis.

 Avoid blood pressure cuff and IV medications in arm with shunt.

An inflated BP cuff or tourniquet may collapse the shunt and
render it useless. Likewise, the complication of phlebitis from IV
medications can produce a clot that may jeopardize the shunt.

 Avoid dental care on day of treatment (especially within first 6

hours afterward); best to treat on day after.
Hemodialysis tends to aggravate bleeding tendencies through
physical destruction of platelets and the use of heparin.
Therefore, determination of the status of hemostasis is
important before oral surgery is performed. Screening tests
include activated partial thromboplastin time (aPTT), and
platelet count.
Note: if immediate care is necessary; administer protamine
sulfate (usually done by physician) which will block the
anticoagulant effect of heparin.

 Consider corticosteroid supplementation as indicated.

 Assess status of liver function and presence of opportunistic

infection in these patients because of increased risk for carrier
state of hepatitis B and C viruses and HIV.
Accordingly, all patients should be treated with the use of
standard infection control procedures.
Renal Transplant
Transplantation is now strongly recommended for all patients with
ESRD who are medically suitable. A successful kidney transplant
offers enhanced quality and duration of life and is more effective
(medically and economically) than chronic dialysis. Transplants
can be from cadaveric or living donors.

General management:

All kidney transplant recipients require life-long

immunosuppression to prevent graft rejection. These include IV
induction of antirejection agents and maintenance immunotherapy.
Induction therapy consists of a short course of intensive treatment
with IV antilymphocyte antibody. Patients then need to be
immunosuppressed usually with a corticosteroid plus a steroid-
sparing drug such as azathioprine (cytotoxic drug) or now more
commonly cyclosporin.

In addition to immunosuppressive medications, the patients

receive a bladder injection of antibiotic solution by means of foley
catheter and a second generation cephalosporin.
Acyclovir and nystatin usually are given for the first 3 months to
prevent herpes simplex virus (HSV), cytomegalovirus (CMV), and
Candida infection.

Dental aspects:
 Immunosuppression: Increases risk of infection.
 Excessive bleeding which is caused by adverse effects of
immunosuppressant drugs that cause bone marrow
suppression (such as azathioprine) with resultant leucopenia,
thrombocytopenia and anemia. (Cyclosporine also cause
bleeding problems because of its effects on the liver).
 Gingival hyperplasia caused by cyclosporine.
 Increased incidence of cancer like lip squamous cell
carcinoma, Kaposi's sarcoma and lymphoma. Cancer is a
complication of intense immunosuppression perse and is not
related to the use of any particular agent.
  Adrenal gland suppression caused by corticosteroids.
 Poor wound healing, osteoporosis, diabetes mellitus,
hypertension and increased risk of infection (all of
them are adverse effects of corticosteroids).

Dental management:
Immediate postoperative period (6 months):

1. Consultation with physician(s).

2. Avoid routine dental treatment.
3. Continue oral hygiene procedures.
4. Provide emergency dental care as needed (eliminate infection).

Stable graft period:

1. Consultation with physician(s).

2. Maintain effective oral hygiene procedures.
3. Initiate active recall program every 3 to 6 months.
4. Treat all new dental diseases.
5. Use universal precautions in controlling infection.
6. Have staff vaccinated against hepatitis B virus (HBV).
7. Avoid infection
 Medical consultation regarding the need for antibiotic prophylaxis.
 Screening tests (WBC count, total and differential).
8. Avoid excessive bleeding;
 Screening tests (bleeding time, INR, Aptt, platelet count).
 Special precausions for suturing, hemostatic agent use.
9. Avoid renal toxic
drugs. 10.Steriod
supplementation.
11.Monitor blood pressure and refer for medical evaluation if
patient taking cyclosporine or prednisolone and the blood
pressure is high.