Renal Disease

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Renal Disease

• Normal Anatomy
• and
• Physiology

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Renal Normal Anatomy 1. Renal artery and
vein 25 of blood volume passes through the
kidney / minute 2. Cortex / Papillae / Pelvis /
Ureter / Bladder / Urethra
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Kidney Cortex Papilla Pelvis Ureter
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Renal Normal Anatomy 3. Nephron high
pressure glomerular filtration of H2O ions, drugs
and wastes (urea) 4. Tubular reabsorption of
ions / H2O, concentration of urine
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Renal Normal Anatomy 5. Juxtaglomerular
apparatus renin / angiotensin system
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JGA
Nephron PCT DCT Glomerulus Renal artery Renal
vein Loop of Henle Collecting duct
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Renal Normal physiology 1. Control of fluid
volume H20 2. Control of electrolytes Na /
K 3. Control of blood pressure renin /
angiotensin / aldosterone
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• Renal Normal physiology
• Renin / Angiotensin / Aldosterone
• Renin secreted by JGA in response to BP or
• chronic Na depletion
• Renin catalyses the production of angiotensin I
  (a
• decapeptide) from a circulating protein
• 3. Angiotensin converting enzyme (ACE) in the
  lungs
• cleaves off 2 more amino acids to form
• Angiotensin II (an octapeptide)

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• Renal Normal physiology
• Renin / Angiotensin / Aldosterone
• Angiotensin II
• is a potent vasoconstrictor and
• it stimulates the release of aldosterone by the
  
• adrenal cortex
• Aldosterone acts on the collecting tubule to
  increase
• the reabsorption of Na (and, therefore H2O)

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Renal Normal physiology 4. Control of acid /
base balance pH 5. Filtration of the
blood elimination of metabolic wastes 6. Drug
metabolism
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• Renal Normal physiology
• Control of Ca / PO4
• activation of vitamin D
• 8. Red blood cell regulation
• erythropoietin

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Renal failure Definition ESRD (end stage renal
disease) Loss of 50 to 75 of nephrons This
implies a huge amount of reserve within the
system Will have 2 in 2000 patient practice
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• Renal failure Causes
• Diabetes mellitus (34)
• micro and macrovascular disease
• 2. Hypertension (25)
• 3. Chronic glomerulonephritis (16)
• 4. Others (polycystic kidney disease,
• SLE, neoplasms, AIDs, etc)

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• Renal failure Assessment
• Urinalysis protein or blood
• 2. Creatinine increased
• 3. BUN increased
• 4. K increased / Na decreased

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Renal failure Assessment 5. CBC anemia /
thrombocytopenia 6. INR / PTT
increased 7. Creatinine clearance
decreased 8. GFR decreased
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Renal failure Assessment GFR (glomerular
filtration rate) (based on serum
creatinine) Normal 100-150 ml/min
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Renal failure Assessment GFR Normal
100-150 ml/min Renal Insufficiency
50-90 Moderate renal failure 10-50 Severe
renal failure lt 10
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• Renal failure Stages
• Diminished renal reserve
• mild increase in Creatinine and
• 10 to 20 decline in GFR
• Renal Insufficiency increase in
• blood urea nitrogen (BUN) and
• 20 to 50 decline in GFR

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• Renal failure Stages
• Renal failure Uremia
• (gt 50 decline in GFR)
• with loss of
• excretory
• endocrine and
• metabolic function

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• Renal failure Pathophysiology
• Irreversible loss of nephrons
• Kidneys are able to compensate
• until 50 to 75 of nephrons
• are lost
• 3. Initial polyuria followed by uremia

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• Renal failure Pathophysiology
• Uremia is characterized by
• a. Fluid overload hypertension
• b. Congestive heart failure
• c. Pulmonary edema
• d. Urea buildup (azotemia BUN)
• e. Metabolic acidosis ( pH)
• f. Hyponatremia / hyperkalemia

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• Renal failure Pathophysiology
• Uremia is characterized by
• g. Anemia
• h. WBC dysfunction immunity
• i. Platelet factor coagulopathy
• j. Renal osteodystrophy vit D
• secondary hyperparathyroidism

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• Renal failure Management
• Conservative care fluid, K, Na
• protein and phosphate
• 2. Recombinant human erythropoietin
• 3. Treat (optimize) concommitant
• disease diabetes, hypertension
• CHF, infection, etc

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Renal failure Management 4. Avoid nephrotoxic
drugs 5. Peritoneal dialysis (10) hypertonic
solution indwelling catheter frequent
exchanges
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Renal failure Management 6. Hemodialysis
(90) every 2 to 3 days 3 to 4 hours /
session surgical fistula heparin (6 hour ½
life) risk of Hep B / C and HIV 1 year
survival 78 5 year survival 28
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Renal failure Management 7. Kidney
transplant immunosuppression gingival
hyperplasia (cyclosporin and CCBs) chronic
steroid use 1 year survival 87 5 year
survival 76
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• Renal failure Dental concerns
• Monitor blood pressure avoid
• fistula arm
• 2. Assess for anemia
• 3. Increased risk of bleeding (heparin
• effect and thrombocytopenia)
• 4. Increased risk of infection

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Renal failure Dental concerns 5. Drugs avoid
NSAIDs and acetaminophen in high
doses reduce dose of tetracycline,
metronidazole acyclovir penicillins
cephalosporins
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Renal failure Dental concerns 6. Oral
complications xerostomia candidiasis gingival
bleeding / petechiae osteodystrophy 7. ???
Prophy Abs for fistula ???
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Questions????