Renal

‫بسم ال الرحمن الرحيم‬ Renal disease Chronic renal failure: irreversible deterioration of function for more than 3 months which means that the disease will not recover and the patient will maintain with degree of chronic . renal failure Also we call it chronic renal insufficiency or chronic renal impairment it depends on the degree of this chronic renal insufficiency this is why we classify chronic renal failure in 5 .stages Stage 1: subnormal creatinine clearance To identify chronic renal failure, serum creatinine level should be duplicated above normal that means serum creatinine level .should be double of the normal to identify it clinically This means that chronic renal failure might be silent, sub clinical, asyptomatic for long and the patient doesn’t know The patient might have chronic renal failure while he is normally behave and if you do some lab investigations As serum creatinine level it might be normal as in pregnant women, ladies. Serum creatinine level might be normal but .actually the actual kidney function is impaired ? How we will identify the actual kidney function By doing creatinine clearance or glomular filtration rate(GFR) this is why we have 4 or 5 classes according to the classification .of chronic renal failure . The 1st one is that serum creatinine level within normal values Creatinine clearance above 50ml\min up to 80ml\min provided that creatinine clearance is around 100+-15or25 for males and females ,of course creatinine clearance is less than the males,for males it depends on muscle mass of body ,age ,gender bcoz of that we can say roughly that creatinine clearance is around 100+-15 and you can do it also 110+-20or 25

Which means that creatinine clearance less than 80 or 85ml\min is chronic renal insufficiency and this will reflect normal serum .creatinine level Serum creatinine level might be normal for pregnant women but .still having insuffency and might be In process Stage 2: it is below 50 and above 25 at that time serum creatinine level showing some increase above upper normal .values not within the range Stage 3: below 25ml and more than 10 ml (Stage 4 : below 10, called (end stage renal disease .At that point the patient needs renal replacement therapy that means the patient is in need for dialysis 1st hemodialysis then peritoneal dialysis and then if he need for kidney transplantation. So chronic renal failure is an irreversible deterioration of kidney function for more than 3 months. Why 3 months? Bcoz sometimes renal failure might be transient and acute, if any body experience hypotensive state or shock state, sever infection ,sever diarrhea ,obstruction might cause acute renal failure. This is might be irreversible within weeks, days up to 6 weeks in some cases it might persist for 8 weeks this is very rare condition. This is why we give also 4 weeks more to say this is established chronic renal impairment and this is what we call chronic renal insufficiency and it is irreversible. What r the functions of kidney ? 1. it has role to remove toxic waste products. 2. to remove the excess water and salts this is why it interfere with blood pressure and the patient will not have edema 3.of course it is a part or portion of hormonal production as erythropoietin and vitamin D . vitamin D3 is the active form of vitamin D that is produced or generated in proximal tubules of kidney by 1αhydroxylase

this is why we have active form of vitamin D3(1α vitamin D3) as well you know that erythropoietin is produced in proximal tubule that has a role in erythropoisis so patients with chronic renal failure with advanced stages will proceed later anemia bcoz of low erythropoisis due to decrease in production of erythropoietin.. 4. kidney has a role in generation of active form of vitamin D and also a role in ca +2 hemostasis 5. also a role in fluid balance and electrolytes particularly Na,k,Cl,Mg azotemia: elevated blood urea nitrogen without symptoms and sometimes .might be associated with increase in serum creatinine level :Uremia There is azotemia, elevation of urea but there is symptoms that are systemic from GIT,CNS,CVS, fluid,skin and even other .organs At end stage renal disease the patient is in need for renal replacement therapy,the kidney cant take over of its .responsibilities and creatinine clearance below 10ml\min Again Chronic renal failure is irreversible deterioration with .azotemia for more than 3 months Creatinine clearance :rate of filtration of creatinine by the (kidney (marker for GFR We have 2 entities of renal failure: acute and chronic Acute renal failure: in most cases it is reversible but sometimes it is not reversible so in this case we call it acute which has a (progress to chronic renal failure.(this is by definition We have 3 main causes of chronic of acute renal failure this is :what we call acute renal failure .Pre renal diseases: cause acute renal failure Parenchymal diseases: these are the acute tubular necrosis, acute .glomerulonephritis as well as in some cases vasculitis

Post renal diseases: is related to obstruction, obstructive causes from urinary tract bcoz of prostate in males, stones .,malignancies, obliteration These r the causes of acute renal failure which might progress to chronic renal failure as well .Chronic renal failure obstruction might also be functional Something that Is very imp for patient with acute renal failure (parenchymal acute renal failure) ischemia is one of the main causes as i(dr) mentioned before sever diarrhea,vomiting ,loss of blood,burns these can induce decrease of blood flow bcoz of decrease of effective circulating volume leading ischemia of . nephrons Kidney is supplied from heart in apportion of around 2025%,blood is going directly to the kidney, it takes the most prefused tissue in the body this is why the acute tubular necrosis which is one of the causes of the acute parenchymal kidney disease can be divided into 2 categories: toxic ones and .ischemic ones As doctors we should take care for patients with some degree of renal impairment and ask for creatinine clearance especially in case if we need to give antibiotics especially aminoglycoside which r very toxic and might induce acute tubular necrosis(acute renal failure )which in some cases might be not reversible and .might lead to chronic renal failure ?What r the causes of chronic renal failure The most common cause of chronic renal failure is diabetes Diabetes type 1: up to 45-50% of type 1 might cause chronic renal failure with time ,over 15-25 years these patients might develop chronic renal failure bcoz of diabetic nephropathy which might start early in the course of disease within 5 years after there is some of type 1 these patients might develop .diabetec nephropathy in process For type 2 diabetes also might develop chronic renal failure but in less percentage and this depends on the time of onset of disease also there are another factors involve in the pathogenesis .of chronic renal failure in diabetic patients

Remember type 1 diabetic patients have high incidence of developing diabetic nephropathy up to 45-50% For type 2 it depends on the time of onset of disease If they r young →higher incidence If they r older→less incidence for diabetec nephropathy And to know that these patients are suffering from more than one problem except a part from diabetec nephropathy ,they have retinopathy ,peripheral neuropathy ,microangiopathy and amputation this is why it is imp to look in general to such patients as they have more than one problem but the most sever . form is microangiopathy as well as the end stage renal failure 2nd common cause of chronic renal failure is hypertension In USA it is the second common cause,in UK it is the 1st common cause,in Jordan it is the 1st common cause as well As we have many of our patients having hypertension without knowing the underlined disease this is why we can say that the most common cause of end stage renal failure in our country either hypertension or diabetes or glomerulonephritis which is the 3rd common cause of chronic renal failure in general population in western as well as in our area Polycystic kidney disease or chronic tubulointerstitial :nephritis in general Including obstruction bcoz of stones or pyelonephritis either .bcoz of reflux in children or in adults Polycystic disease is not so common in our area ,it is familial (kidney disease (autosomal dominant 50%of the kids will develop polycystic disease ,in children it is different bcoz of different pathogenesis and different .transmission code Renal artery stenosis is one of the causes of (prerenal) disease .which cause chronic renal failure but it is not common In some countries analgesic nephropathy can be considered as of chronic tubulointersitial nephritis bcoz it induce tubular defect .and later on glomular defect leading to chronic renal failure The analgesics in some western countries particularly in Australia and in northen Europe they have high incidence of

chronic renal failure bcoz of abuse of analgesics and most of these patients are females with headache and with some psychosomatic reflex leading to abuse of analgesics causing .chronic renal failure with time Some of patients might develop chronic renal failure bcoz of .complicated pregnancy Again CRF: IS defined as a permanent reduction in glomerular filtration rate(GFR)sufficient to produce detectable alterations in well-bieng and organ function. This is usually occurs at GFR below 25 ml\min This is why we say that CRF may be silent and serum creatinine .level might be normal except if GFR below 30 or 25 At that moment you can see patients that might have anemia .,pallor ,some general fatigue and so on :Stages of chronic renal failure .Silent – GFR up to 50ml\min .Renal insufficiency- GFR 25 to 50ml\min Renal failure –GFR 5 to 25ml\min .End stage renal failure- GFR less than 5 ml\min : how to manage such patients * Manifestations of CRF r many it depends on the stage of CRF,in advanced stage the patient come with many :many symptoms General weakness , anorexia, fatigue ,vomiting ,nausea and sometimes they might have itching bcoz of Ca phosphorus deposition as well as hyperparathyroidism which also occur in CRF from early stages . also they might have nocturia they used to go to the bath over night 2-3 times bcoz of hyperosmosis that .might leads to polyurea Also patient might have low urine out put so they might come .with edema of lower limbs ,hypertension and pleural effusion

It is imp to have an idea about CRF as doctors to be able to identify the problems of the patient before doing any .practice CRF patients might develop dyspnea ,hypertension with evidence of manifestation of heart failure , pleural effusion and pericardial effusion bcoz of chronic inflammatory process this is why might have dyspnea, chest pain, sever tiredness as they are .trying to do any job This is why CRF is not easy not just CRF in some cases it might . be tetany This is why they might have also electrolyte imbalance ,hyperkalemia also they might develop arrhythmia and the patient might die bcoz of hyperkalemia And might develop hypocalcaemia with tetany and tetany signs If you do Chvostek sign and Trousseau sign there will be carpopedal spasm and twitching of musle of face bcoz of low . Ca This is why we should take care for those patients which might . develop seizure while doing the procedure These patients have bleeding diathesis, so as doctors we have many to do we should look for bleeding diathesis, they have platelets dysfunction and bleeding diathesis as they have low GFR bcoz of urinal toxins affecting both platelets and bone .marrow as well :These patient are anemic bcoz of .Erythropoietin deficiency .Bleeding diathesis Tendency to lose blood through vessels from GIT,hands , nose. This is why they come sometimes with epistaxis(bleeding from (the nose Question from dr nisreen that I coudnt hear Answer: tetanus you can tight the arm for a while by a cough of manometer for 3-5 min you can do it by inducing pressure and

the mean arterial pressure you can judge how is the mean arterial pressure you can do it just the diastolic pressure and just 10 mm mercury above to see if there is carpopedal spasm the .patient will have this And if you by your hand in the masseter muscle you can see the .patient has twitching in this muscle And confirming that by doing APG if there is acidosis and asking for Ca level by confirming the ca is low ,of course don’t .forget for asking about total protein albumin and ca level Ca that is free from the total ca is about 45% and ca that is binded to albumin is about 45-50%, this is why you should .correct ca level to albumin We have 2 signs which is clinically obvious in patient with :tetany Trousseau signs and Chvostek signs For patients with hyperkalemia they might have tachycardia or bradycardia and if you do ECG you can see in some cases big t waves ,wide QRS as in sever form , loss of p waves in some .ECG according to the level of K . It is imp to know at least that these patients might have .electrolyte imbalance :How we manage patients with diabetic nephropathy Blood sugar control that is very difficult to do it Swedish protocol is succeeded to decrease the incidence of diabetic nephropathy from 45-50% in most countries to around .10% by strict controlling blood sugar Of course blood pressure is one of the aggravating factors for .progression of renal diseases .So it is imp to control blood pressure Some patients we used to give them angiotensin converting enzyme inhibitor to decrease the intera-glomular pressure which is the main cause of glomerulosclerosis and loss of nephrons in . these patients .Lipid profile should be within normal values

The manifestation of diabeteic nephropathy started early with protein in the urine , the GFR initially is high this is why serum .creatinine level might be normal :Important notes The diabetic patients have high incidence for developing * .diabetic nephropathy and to end stage renal failure don't look only for serum creatinine level bcoz it is not * . reflecting the reality of kidney function you should know that that in diabetic patients in early * stages(1,2,3) creatinine clearance might be high not only normal, serum creatinine level is normal normal this is why we should always as the incidence of diabetic nephropathy is high in such patients we should do specific laboratory :(investigations (what r these apart from creatinine clearance ,asking for protein in urrine by urine analysis and in most of the cases the lab doesn’t show protein or albumin in the urine so we should ask for microalbuminurea and normaly the albumin in urea less (than 20.( this is general but imp for us diabetic is one of the imp causes for death in our area and it is national and international this is why it is imp problem to detect and to all the complications not only the diabetic neohropathy but also microangiopathy,eye problems (he might become blind),many problems in legs ( he might go to surgeon for amputation bcoz there is negligence and there is misunderstanding of doctors regarding diabetes : diabetes is very clever disease the patient might die bcoz of diabetic nephropathy ,heart problems ,microangiopathy,he might become blind bcoz of ignorance of doctors and all who r working in medicine field . physician, dentist, pharmacist

this is why it is imp to have an idea about diabetic nephropathy .and microangiopathy in diabetic patients All our patient should go for of ophthalmologist, all should do .as they have diabetes at the time of diagnosis of the disease For type 2 you might diagnose diabetes now but it was many . years before but it is incipient not clinically diagnosed Doctors experience that there are many many patients come with advanced stages of diabetic nephropathy with sever form of .retinopathy and they don’t know about themselves This is why at the time of diagnosis of type 2 send the patient to ophthalmologist and send him to doctors for urine detection of microalbumin which is normally less than 20mg \day if it is above 30mg\day for two consecutive readings that means the .patient has diabetec nephropathy You have to control his blood pressure ,it is not you r job to control it, but you have to know that it is imp to control his .blood pressure These patients have increase affinity of Na so increase in water so they develop edema and in most cases they have hypertension and might have metabolic acidosis Most of the cases of diabetes with renal involvement they have .Hyporeninemia hypoaldosteronemia Also they might have hyperkalemia which might be harm for the patient and life threatening in some cases so when you give drugs for patients you should be care that they r susceptible to .have hyperkalemia which is very dangerous for the patient :The effect of CRF on bones . CRF patients also have bone defects Many types of renal osteodystrophy bcoz of low ca absorption and high phosphorus in the blood bcoz of decrease of its .excretion in the urine bcoze of renal failure Phosphorus excreted normally fromfrom kidney Phosphorus normally excreted kidney Ca normally absorbed from gut

Ca normally absorbed from gut Ca homeostasis depends on 2 factors: (vitamin D and PTH) and 2organs r involved the kidney and gut . This is why bones r the part where Ca stored Hyperparathyroidism as we have low ca absorption bcoz of low active form of vitamin D which is metabolized in kidney and it has a role to absorb Ca from the gut it is now decreased at the same time they have high phosphorus bcoz of decrease of phosphorus excretion this will accumulate further in decreasing .of Ca level in the blood : Two causes of low ca in blood .low absorption bcoz of hypo vitamin d.1 high phosphorus which binded to ca and causing low ca and.2 .also accumulate further decrease in ca level It has effect on parathyroid gland stimulating PTH level High PTH level which might accumulate and increasing to compensate This PTH has action on the bone leading to resorbtion of* bone ,transferring ca from bone to the circulation(plasma) leading to osteopenia that is part of it osteoporosis and also part of it is osteitis fibrosa cystica which is hyperparathyroidism features This is why if you look to the patient bones and do x ray of the* hand you will see destruction of distal phalanges and subperiosteal resorbtion And u will see widening in medulla and very thining in cortex* *. with resorbtion and also they will be susceptible to farctures Also there will be sever osteopenia* * And if you do x ray you will see pepper-salt appearance Children also will have rickets bcoz of low vitamin D while they have growth retardation as well as for adults they have osteomalacia

And this can be identified clinically or radiologically but also you can see looser zones whis is psudofractures( this is very (imp If you do panorama x ray for oral cavity there is destruction of* bone and some times there is decrease in osteopoesis Of some bone especially some of vertebrae this is why we have a rugger jersey appearance of vertebrae They r also fragile bones which r prone to fractures so for us as Dentist the dr think we will see CRF patients who have many abnormalities as part of the disease bcoz of low Ca and .osteopoesis The osteoid occupying all the space and there is no* mineralization of these osteoid *The patient teeth r not looking healthy x-rays have many problems so the physician send the patients* to dentists to give their opinions as part of their investigations .in kidney transplant Uremic syndrome usually they have all these manifestations usually they have advanced renal failure this is why we need to dialysis them Actually they r susceptible for infections ,they have anemia and sometimes they have hyperurecemia bcoz uric acid is excreated . through kidney bcoz of decrease of GFR they have high retention of uric acid . also as well they have hyperphosphatemia our treatment is concentrated on hypertension control, metabolic acidosis , anemia with erythropoietin , renal osteodystrophy this is why we give Ca carbonate with replacement therapy with 1α which is active form of vitamin D3 this is why all patients r taking combination of Ca carbonate with 1α part of our . management to their renal osteodystrophy

our patient might need dialysis as they reach end stage renal . failure we have 2 available modulaties for renal replacement : therapy : hemodialysis through fistula or shunt or permanent or temporary catheter :peritoneal dialysis through inserting catheter inside abdomen and filling the .abdomen with fluid Transplantation is the last and most proper ideal type of renal .replacement therapy

The end

:Done by Mays Hatamleh

:‫بما انه هادي اول محاضرة إلي حابه اوجه تحية‬ ,‫جميلة‬,‫ رزان‬,‫ اسراء عبد الغني‬, ‫لحلى صاحبتين ةةةة ةةةةةة‬ ‫ة ةةةة‬,‫ةةةةة‬,‫ةةة‬,‫ربى‬,‫مرام‬,‫هبة‬,‫شهد‬ ,‫فكرية‬,‫لمياء‬,(‫أسعد‬,‫فاطمة)علبان‬,‫ةةةةةة‬ ‫اروى‬, ‫ ديمة‬,‫رونزا‬,‫ نور بني هاني‬, ‫ اماني‬, ‫سكينة‬,‫ غادة‬,‫رهام‬,‫أسيل‬,‫ميمنة‬ .‫نسرين‬,‫نور جيوسي‬,(‫طعامنة‬, ‫جمانة)محيسن‬,