CKD for dental

Management of patient with

kidney diseasesHANAN SHANAB

OMFS Resident

idneyK

• Excretion.. Of body waste.

• Homeostasis..regulate

– fluid and electrolytes blance.

– acid-base balance.

Function

Function

• Body natural Filter.

• Endocrine function.

– calcitrol, erythropoietin and

renin.

Kidney

Disease

There are two general types of

serious kidney disease:

Acute renal failureChronic kidney disease (CKD)

A- Acute Renal failure:

• It is a reversible rapid damage and deterioration of kidney function that

occurs suddenly.

B- Chronic Kidney Disease

– glomerular filtration rate (GFR) < 60 ml/min/1.73 m2.

– evidence of renal damage (micro- or macroalbuminuria, persistent

hematuria, radiological anomalies)

during a period of more than 3 months

Mahmud Juma Abdalla Abdel HAMID, Claus Dieter DUMMER, Lourenço Schmidt PINTO: Systemic Conditions, Oral Findings and Dental Management of Chronic Renal Failure Patients: General Considerations and Case Report; Brazz Dent J (2006) 17(2): 166-170

increase of serum creatinine and blood ureic nitrogen levels.

Chronic kidney disease (CKD) is generally caused

by long-term diseases, such as

Mahmud Juma Abdalla Abdel HAMID, Claus Dieter DUMMER, Lourenço Schmidt PINTO: Systemic Conditions, Oral Findings and Dental Management of Chronic Renal Failure Patients: General Considerations and Case Report; Brazz Dent J (2006) 17(2): 166-170

20-64 y/o

65 y/o

College of Dental Hygienists of Ontario, CDHO Advisory Kidney Disease and Kidney Failure, 2010-07-15

Stages of Chronic Kidney Disease(

CKD)

END STAGE RENAL

DISEASE (ESRD)

Patients with ESRD can rely on kidney replacement therapeutic modalities such as:

• Hemodialysis (HD),

• Peritoneal dialysis (PD). or

• Renal transplantation.

National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC)A service of the National Institute of Diabetes and Digestive and Kidney

Diseases (NIDDk), National Institutes of Health (NIH).

Peritoneal Dialysis

Peritoneal Dialysis

• Advantages:

– less costly

– The ability to undertake treatment without visiting a medical facility.

• Complication:

– peritonitis

Hemodialysis

• Disadvantages:

– Required hospital care.

– Risk for viral transmission (HIV,

Hep B& C)

Hemodialysis

• Complications:

– If patients do not adhere to the restriction in fluid intake,

– (chronic) fluid overload may occur, resulting in:

• hypertension,

• acute pulmonary edema,

• congestive heart failure and

• consequently death.

Renal Transplant

• Acute and chronic rejection

remains a major clinical

hurdle despite recent

advances in

immunosuppressive

strategies especially 3-6

months post- transplant.

Bv Ciancio G, Burke GW, Jorge D, Rosen A, Miller J. Immunosuppresive treatment options in renal transplantation. Minerva Urol Nefrol 2005; 57: 141-149

Complications

– long term use of immunosuppressive medication can lead to side effects

like:

• gingival overgrowth,

• opportunistic infections.

• cancer.

Clin

ica

l M

an

ife

sta

tio

n

Oral Manifestation

– high urea concentration

in saliva

Altered taste – (metallic)

– ammonia-like smell 1/3 hemodialysis pt.

– Xerostomia

500 ml/day

– Periodontal problem

– Loose and painful teeth.

– Sensitivity to percussion and mastication,

– tooth mobility and malocclusion.

– enamel abnormalities, altered eruptions.

– Calculus,

– Pale gingivae (anemia)

– No caries..

– Uremic frost (crystals deposits more in skin than oral mucosa).

– Stomatitis (in sever RF).

– Oral mucosa & gingival bleeding. (thrombocytopenia)

– Drug-induced gingival

hyperplasia.(cyclosporine, & Ca channel blocker).

Lee and Gisser 1978; bradford et al 1990

• Infections:

Candida, CMV & HSV

R Proctor; N Kumar; A Stein; D Moles; S Porter “Oral and Dental Aspects of Chronic Renal Failure’’ Journal of Dental Research; Mar 2005; 84, 3; Health & Medical Complete pg. 199

In CRF Classical triad:– 1.loss of lamina dura,– 2.Demineralized bone ( ground glass appearance)– 3.Localized maxillary and mandibular radiolucent lesions, central giant cell

granuloma ‘brown tumor’

Renal Osteodystrophy

Chronic renal failure

Decrease glomerular

function

Decrease 1,25(OH)2D3

Increase serum

phosphate

Decrease serum

Calcium

Increase the PTH secretion

Renal OsteodystrophyOsteomalacia, Osteitis Fibrosa Cystica, Osteosclerosis

Osteitis Fibrosa Cystica

Management During Dental Treatment:

Patient under conservative care

Patient on dialysis

History and Physical Ex

History of DM, Related bony

disorders,

Medication..?..

LABS

Complete Blood Count

Liver Function Test Urea & Electrolyte

Patient under conservative care

1- Consult with the physician

regarding physical status if:

Positive findings in patient history or lab

Patient under conservative care

3- Screening for bleeding disorders

2- Monitor blood pressure.

Patient under conservative care

4- Pay meticulous attention to good

surgical technique and accepted oral

hygiene.

To avoid infections, periodontitis and

xerostomia related complication.

Patient under conservative care

5- Avoid nephrotoxic drugs (

acetamenophen in high doses, acycolovir,

aspirin, NSAID).

6- Adjust the dose of drugs metabolized by

kidney.

Drug administration require adjustment during uremia for reasons beside nephrotoxicity and renal metabolism:

• 1. low serum albumin value reduces the number of binding sites, increasing

toxicity.

• 2.uremia can modify hepatic metabolism of drugs ( increase or decrease)

the clearance.

• 3. Antacid may complicate uremic effect.

• 4. ASA & NSAID potentiate uremic platelet defects so these antiplatelets

must be avoided.

Drug administration require adjustment during uremia for reasons beside nephrotoxicity and renal metabolism:

Alba Jover Cerveró, José V. Bagán, Yolanda Jiménez Soriano, Rafael Poveda Roda ‘’Dental management in renal failure: Patients on dialysis’’

Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.

Alba Jover Cerveró, José V. Bagán, Yolanda Jiménez Soriano, Rafael Poveda Roda ‘’Dental management in renal failure: Patients on dialysis’’

Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.

Alba Jover Cerveró, José V. Bagán, Yolanda Jiménez Soriano, Rafael Poveda Roda ‘’Dental management in renal failure: Patients on dialysis’’

Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.

Patient under conservative care

7- Aggressive managing orofacial

infections with culture and sensitivity

tests and appropriate Antibiotic (avoid

nephrotoxic).

8- consider hospitalization for sever

infection or major procedure.

HEMODIALYSIS

If patient on dialysis

• 1. same as conservative care

recommendation.

• 2. consult with the physician

about the risk of bacterial

endocarditis.

Can take OralNon-Allergic to penicillin

– Amoxicillin

• Adult dose: 2 g PO

• Pediatric dose: 50 mg/kg

PO

Allergic to penicillin

– Clindamycin

• Adult dose: 600 mg PO

• Pediatric dose: 20 mg/kg PO

– Cephalexin or other first- or

second-generation oral

cephalosporin in equivalent dose

anaphylaxis)

• Adult dose: 2 g PO

• Pediatric dose: 50 mg/kg PO

– Azithromycin or clarithromycin

• Adult dose: 500 mg PO

• Pediatric dose: 15 mg/kg PO

Can’t take OralNon- Allergic to penicillin

– Ampicillin

• Adult dose: 2 g IV/IM

• Pediatric dose: 50 mg/kg

IV/IM

Allergic to penicillin

– Clindamycin

• Adult dose: 600 mg IV

• Pediatric dose: 20 mg/kg

IV

– Cefazolin or ceftriaxone

anaphylaxis)

• Adult dose: 1 g IV/IM

• Pediatric dose: 50 mg/kg

IV/IM

• 3. consider corticosteroid

supplementation as indication.

Avoid adrenal crisis

•They are taking large doses

of corticosteroids (10 mg

daily of prednisone or

equivalent).

If patient on dialysis

• 4. Dosage adjustment in accordance with advice from patient’s physician.

If patient on dialysis

If patient on dialysis

• 5. beware of ArterioVenous (AV)

fistula or shunt.

– Susceptible to infection

(endarteritis), become a source

of bacteremia, resulting in

infective endocarditis (2-9%) .

AVOID

If patient on dialysis

• 6- Dentist must be aware of pt’s drugs

and dental precaution measures that are

appropriate

• Because approximately 40% of pt. on

dialysis patients have CHF & 9% may

die from cardiac complication each

year.

– So pt. is taking antihypertension,

Anticoagulant& Drugs for CHF

• 7. Assess liver function and screen it for opportunistic infection.

– Increase risk for carrier state of Hep B and C ,and HIV

If patient on dialysis

• 8. determine the hemostasis status is

important

They have tendencies to bleed from the

physical destruction of platelets &

using of heparin.

If patient on dialysis

Bleeding Precaution

• 1. timing of dental treatment

– Avoid the day of the dialysis ( fatigue ,

bleeding tendencies (heparin 3-6 hrs

activity), fluid overload

– Choose the day after the dialysis to

provide a time for clot retention.

• 2. primary closure and hemostatic agents

Bleeding Precaution

• 3. contacting the nephrologist

when necessary &requesting

the heparin dose to be reduced

or eliminated during the 1st

hemodialysis session after the

surgical procedures.

• 4. request protamine sulfate to be

given when immediate care is

necessary as antidote for the heparin.

thanx

Thank you

grateful

merci

Thank you

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