1. Renal failure  It implies destruction of nephrons and failure of the kidney to maintain hemostasis (failure to excrete waste products or regulate water and electrolytes)  Sudden reduction of volume of urine below 400 ml /day

2. Classification: a) Acute renal failure: is functional impairment of kidney characterized by reduction in glomerular filtration rate developing over few days or weeks a) Acute renal failure: is functional impairment of kidney characterized by reduction in glomerular filtration rate developing over few days or weeksCauses:  Pre-renal causes: poor kidney perfusion as in:  hypovolumic shock  dehydration,  septicemia,  heart failure

3.  Renal:  Acute tubular necrosis secondary to nephrotoxic poisons and severe sepsis  Malignant hypertension  CT diseases: SLE, scleroderma  Glomerulonephritis and pyelonephritis  Vasculitic and obstructive diseases  Myeloma  Hepatorenal syndrome  Post-renal: unilateral or bilateral obstruction

4. b) Chronic renal failure (CRF):  persistent impairment of tubular and glomerular functions of gradual onset that develops over months or years due to chronic progressive disease  it consist of three stages  first or initial stage where there is reduction in the renal reserve  second stage of impaired tubular concentrating the power characterized by polyurea, increased frequency of urination and thirst  final stage where is failure of glomerular function and biochemical changes occurs and symptoms of renal failure manifest

5. Causes of CRF: a) Destructive lesions: –Diabetes (40%) –Hypertension (25%) –Chronic glomerulonephritis (12%) –Chronic pyelonephritis (0.9%) –Polycystic kidney diseases –Others b) Obstructive causes: b) Obstructive causes: –stone –prostate enlargement

6. Clinical features:  The signs & symptoms are due to:  polyurea  Na & Ca depletion  Retention of mg, K, sulfates and phosphates  Acidosis

7.  General : fatigue, malaise and restlessness  Dermatological: itching & scratches, bruising and hyperpigmentation (yellow-green tinge)  CVS: hypertension, pericaraditis, cardiomyopathy, heart failure  GIT: anorexia, nausea, vomiting, ulcerations and bleeding  Neuromuscular: weakness, headache, vision disturbance, tremor and fits, drowsiness leading to coma

8.  Hematological: anemia, bleeding tendencies  Immunological: liability to infection  Metabolic: nocturia, polyurea, thirst, glycosurea, increased urea, creatinine, uric acid and lipids, electrolytes disturbance  Respiratory: dyspnea, oedma and pneumonia  Endocrine: secondary hyperparathyroidism

9. Investigation  Hydrogen retention and acidosis  High potassium level > 6 meq/l  Low calcium ions  High alkaline phosphatase  High blood urea may be more than 200 mg %  High blood creatinine  High uric acid  CBC: anemia

10. Management of end stage renal failure  Renal dialysis  Renal transplantations

11. CRF Oral manifestations:  In children: delayed eruption and enamel hypoplasia  Pale oral mucosa  Ulceration  Uremic stomatitis  Dry mouth  Coated tongue

12.  Metallic taste & smell of urine  Bleeding & delayed healing  Anemia and its complications  Infections: candida  Renal osteodystrophy: loss of lamina dura, osteolytic lesions, brown tumours

13. Management is complicated by:  drug excretion  Infections  Hypertension and its treatments  Cardiac diseases  Bleeding  Hepatitis  Anemia

14. Management is complicated by:  The underlying disease  Consult the physician before dental treatment  No active done for poorly controlled patient  any dental treatment should be carried out in the second day of dialysis when general condition is at its optimal and the effect of heparin is wear off

15. Renal dialysis Indications:  blood urea > 300 mg  creatinine > 10 mg  K > 7.5 mEq  acidosis: pH 7.2 

16. Types of dialysis:  Peritoneal  Hemodialysis

17. Dental management of chronic renal failure patient  Defer surgery until get permission of the physician or surgeon  Elective oral surgery is best undertaken the day after dialysis  All nephrotoxic drugs should be avoided or used in modified doses (NSAID), aminoglycosides  Monitor blood pressure  Use prophylactic antibiotics to prevent infection of A-V shunts

18.  Consider the hepatitis risk (20 %)  Patients are at risk of TB  Manage as appropriate if patient is under steroid therapy  Manage the local side effects of immunosuppression drugs