Renal

Disorders
Monira jameel Alasbahi

1 B. D. S. in Faculty of dentistry
Master degree
in Oral medicine, Pathology & Radiology department
Sana’a University – Yemen
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CONTANTS
1. Kidney Structure.

2. Kidney Function.

3. Classification of Renal Disease .

4. Diagnostic Procedures in Renal

Disease.

5. Oral Manifestations of Renal Disease.

6. Radiographic manifestations.

7. Medical Management .

8. Oral Health Considerations.

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Kidney Structure

 The human kidneys are bean-shaped organs located in the retro

peritoneum at the level of the waist.

 Each adult kidney weighs approximately 160 g and measures 10 to 15

cm in length.

 Coronal sectioning of the kidney reveals two distinct regions: an outer

region, or cortex, and an inner region known as the medulla.

 The kidney’s functional unit is the nephron and each kidney is made up
of approximately one million nephrons.
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6 Kidney Function

 Each day, the kidneys excrete approximately 1.5 to 2.5 L of urine.

 Removal of toxic and waste products from the blood remains their
major role.

 Modulation of salt and water excretion.

 The kidneys are also essential for the production of hormones such
as:

1. Vitamin D .

2. Erythropoietin .
7 Major Functions of the Kidneys
❖ Excretory functions :
1- Excretion of nitrogenous end products of protein metabolism (e.g.,
creatinine, uric acid, urea)

2- Maintenance of blood pressure by altering Na+ excretion .

3- Maintenance of plasma electrolyte concentration within normal range.

4- Maintenance of plasma osmolality by altering water excretion

5- Maintenance of plasma pH by eliminating excess H+.

6- Provision of route of excretion for most drugs.

8 Major Functions of the Kidneys
❖ No excretory functions:
 Degradation of polypeptide hormones.

 Insulin.

 Glucagon.

 Growth hormone.

 Antidiuretic hormone .

 Activation of hormones Erythropoietin (stimulates erythrocyte production by

bone marrow).

 Prostaglandins (vasodilators that act locally to prevent renal ischemia).

 Renin (important in regulation of blood pressure).

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Classification of Renal Disease

1. Fluids, Electrolytes, and pH Homeostasis.

2. Renal Failure:

❖ Acute Renal Failure.

❖ Chronic Renal Failure.

❖ End stage of renal Failure (Uremia).

3. Drug Therapy in Renal Failure.

4. Hemodialysis.

5. Renal Transplants .
10 Diagnostic Procedures in
Renal Disease
 Blood tests (Serum creatinine ,blood urea
nitrogen test).

 Urinalysis.

 Biopsy.

 Ultrasound.

 X Rays.
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 Signs and symptoms of renal
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failure and uremia
13 Oral Manifestations of Renal
Disease
1. Enlargement salivary glands.
2. Decreased salivary flow.
3. Dry mouth.
4. Odor of urea on breath.
5. Metallic taste.
6. Increased calculus formation.
7. Enamel hypoplasia.
8. Dark and brown stains on crowns.
9. Pale mucosa.
10.Erosive glossitis.
 11.Gingival inflammation (Gingivitis).
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12.Petechiae and ecchymosis.

13.Pigmentation of oral mucosa.

14.Bleeding from gingiva.

15.Candidal infections.

16.Burning and tenderness of mucosa.

17.Tooth erosion.

18.Uremic stomatitis.

19.Delayed healing.

20.Osteodystrophy (radiolucent jaw

lesions).
15 Radiographic manifestations
1. Demineralization of bone.

2. Loss of bony trabeculation.

3. Ground glass appearance.

4. Loss of lamina Dura.

5. Giant cell lesions (brown Tumors).

6. Socket sclerosis.

7. Pulpal narrowing.

8. Tooth mobility.

9. Arterial and oral calcifications.

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Medical Management
 Drug treatment: Aminoglycoside (gentamicin), antimicrobial (penicillin), analgesic
(acetaminophen), narcotic (codeine, morphine), sedative (diazepam),
antihistaminic (chlorpheniramine), lidocaine .

 Hemodialysis: To remove nitrogenous and toxic products of metabolism from

blood by means of a dialysis system .

 Peritoneal dialysis: In it, 1–2 liters of dialysate are placed in the peritoneal cavity
to remain there for varying intervals of time. Main advantages of this includes no
risk of air embolism and blood leak .

 Kidney transplantation: It involves surgical removal of a kidney from a donor and

implantation into a receptor.
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Renal
disorders
22 Fluids, Electrolytes, and pH
Homeostasis
 The first clinical sign of diminished renal function is a decreased ability to
concentrate the urine.

 With advancing nephron destruction, water and electrolyte regulation becomes

increasingly more difficult.

 As a result of this inability to conserve water, dehydration ensues. With early

renal insufficiency, sodium is also lost in the urine.

 As renal disease progresses, volume overload leading to hypertension and

congestive heart failure.

 When glomerular filtration becomes markedly diminished, the distal tubule can
no longer secrete sufficient potassium, leading to hyperkalemia.
23 Renal Failure
 Occurs due to many conditions like acute, chronic ,
Hemolytic uremic condition, nephrosclerosis, diabetes.

 Clinical symptoms :
 are many, gastrointestinal, neurological (paralysis),
normocytic and normochromic anemia, congestive heart
failure, pallor, hyperpigmentation, renal osteodystrophy,
secondary hyperparathyroidism.
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Acute Rénal Failure
 Acute and reversible deterioration of renal function which develops
over a period of days or rarely weeks and results in uremia .

 Causes of acute renal failure:

1. Hypovolemia.

2. Hypotension.

3. Reduced cardiac output and heart failure.

4. Obstruction of renal arteries or veins.

5. Obstruction of the kidney or lower urinary tract.

25 Chronic Renal Failure
❑ Is the irreversible deterioration in renal function which results from a metabolic and
endocrine functions of the kidney which leads to the development of the clinical
syndrome of uremia.

 Causes of chronic renal failure:

1. Diabetes mellitus.

2. Hypertension.

3. Chronic glomerulonephritis.

4. Pyelonephritis or other infection.

5. Obstruction of urinary tract.

6. Hereditary lesions.

7. Vascular disorders.

8. Medications or toxic agents.

 End stage of renal Failure
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(Uremia)
 Two groups of symptoms are present in patients with uremic syndrome:

1. Symptoms related to altered regulatory and excretory functions (fluid volume,

electrolyte abnormalities, acid-base imbalance, accumulation of nitrogenous waste,
and anemia).

2. Group of clinical symptoms affecting the cardiovascular, gastrointestinal,

hematologic, and other systems.

3. Uremia It is a clinical condition caused by the retention of urinary constituents in the

blood.
  Points to remember for uremia Retention of
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urinary constituents in the blood:
1. Headache.

2. Itching.

3. Nausea.

4. Convulsions and eventually coma.

5. Urinous odor in breath.

6. Unpleasant taste and dryness of mouth.

7. Erythematous.

8. Pseudomembranous stomatitis.

9. Oral candidiasis.
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Drug Therapy in Renal Failure
 Renal patients are often on multiple drugs to manage both the renal disease and
its complications.

 Drugs that are metabolized by the kidneys should be avoided or used with
caution.

 Antifungal agents:
 Amphotericin, Fluconazole, Miconazole, Aminoglycosides ,Gentamicin .

 Avoid if possible Tobramycin, Streptomycin.

 Other antimicrobials:
 Penicillin G, Erythromycin, Ampicillin, Amoxicillin.

 Avoid Carbenicillin, Clindamycin, Metronidazole, Vancomycin ,Tetracycline,

Doxycycline .
  Analgesics :
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 Acetaminophen Acetylsalicylic acid .

 Avoid Ibuprofen .

 Narcotics:

 Codeine Meperidine, Morphine ,Pentazocine.

 Hypnotics:
 barbiturates, tranquilizers Chlordiazepoxide, Diazepam,Flurazepam, Methaqualone ,
Phenobarbital .

 Antihistamines:
 Chlorpheniramine (Chlortrimeton), Diphenhydramine (Benadryl)

 Corticosteroids:
 Cortisone Hydrocortisone Prednisone

 Neurologic agents:
 Phenytoin (Dilantin), Lidocaine.
30 Drugs to Limit or Avoid When
Treating Dialysis Patients
 Magnesium content .

 Potassium content .

 Penicillin therapy.

 Sodium content .

 Ascorbic acid.

 Ammonium chloride (in cough syrup).

 Nonsteroidal anti-inflammatory agents Catabolic effects Tetracycline .

 Steroids Nephrotoxicity .
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Hemodialysis
 Hemodialysis is the removal of nitrogenous and toxic products of

metabolism from the blood by means of a hem dialyzer system.

 Exchange occurs between the patient’s plasma and dialysate (the

electrolyte composition of which mimics that of extracellular fluid) that

allows uremic toxins to diffuse out of the plasma while retaining the

formed elements and protein composition of blood.

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Dental Considerations for
Renal Dialysis
1. Antibiotic prophylaxis: Dialysis patients are at risk for uremic (chemical trauma) .

2. Do not measure blood pressure in the arm with a shunt.

3. Patients may have failing platelet function due to renal failure and concomitant
uremia.

4. Penicillins are acceptable for short-term use (several days) but not for long-term use,
due to high potassium levels.

5. Nephrotoxic medications (e.g., aminoglycosides, tetracyclines, and cephalosporins)

should be avoided.

6. Ideally, dental appointments should occur on the day following dialysis. Patients are
usually tired after dialysis.

7. There is a higher incidence of hepatitis B and C and anemia.

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Renal Transplants

 In order to prolong life in patients with end stage renal failure, renal

transplantation is done.

 It involves surgical removal of kidney from living first degree relative

such as sibling, parent, child or a recently expired source.

 Kidney transplant patient usually receives a continuous regimen of

immunosuppressive medication to ensure graft survival.

 Clinical Features :
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 Majority of clinical manifestation occur secondary to immunosuppressive
drugs.

 Buffalo hump: Steroids are responsible for cushingoid effect,

characterized by rapidly acquired adiposity about the upper portion of the
body, mooning of face.

 Infection: There is increase in susceptibility to fungal infection due to

decreased migration and impaired phagocytic function of leukocytes and
macrophages .

 Hepatic dysfunction: Cyclosporine can cause hepatic dysfunction

because metabolism occurs exclusively in the liver.
35 Dental Considerations for
Renal Transplant
1. Patients are on life long immunosuppressive therapy.

2. Although steroid prophylaxis may be considered for adrenal

insufficiency, antibiotic prophylaxis for dental procedures.

3. Watch for gingival overgrowth if the patient is taking cyclosporine.

4. Oral infection should be treated aggressively and may require

hospitalization for IV antibiotics and closer monitoring of infection

(airway, etc.).
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Oral Health Considerations
1. Before treatment Determine dialysis schedule and treat on day after dialysis.

2. Consult with the patient’s nephrologist for recent laboratory tests and
discussion of antibiotic prophylaxis.

3. Identify arm with vascular access and type; notate in chart and avoid taking
blood pressure measurement/injection of medication on this arm.

4. Evaluate patient for hypertension/hypotension.

5. Obtain routine annual dental radiographs to establish presence and follow

manifestations of renal osteodystrophy.

6. Consider routine serology for HBV, HCV, and HIV antibody. Consider antibiotic
prophylaxis when appropriate.

7. Consider sedative premedication for patients with hypertension.

 8. During treatment Perform a thorough history and physical examination for the
37 presence of oral manifestations.

9. Aggressively eliminate potential sources of infection/bacteremia.

10. Use adjunctive hemostatic aids during oral/periodontal surgical procedures(After

treatment Use postsurgical hemostatic agents).

11. Maintain the patient in a comfortable position in the dental chair.

12. Allow the patient to walk or stand intermittently during long procedures.

13. Institute therapy for xerostomia when appropriate.

14. Consider use of postoperative antibiotics for traumatic procedures.

15. Adjust dosages of postoperative medications according to the extent of renal

failure.

16. Ensure routine recall maintenance.

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Thank you