‫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 20-
25%,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 normally
Phosphorus excreted excreted
normally fromfrom kidney
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,