Chapter 12 Chronic Kidney Disease and Dialysis

Chapter 12:
Chronic Kidney Disease
and Dialysis
Modified by Kalvin Smith
DHTheory III
State Fair Community College

Chronic Kidney Disease and Dialysis
 Chronic kidney disease (CKD), and its ultimate result,
kidney failure, is a worldwide problem that continues to
increase in prevalence
 CKD is associated with many serious medical problems;
thus, the dentist will need to recognize the clinical status
of patients with this condition, and must be cognizant of
the possible adverse outcomes as well as the principles of
proper management

Chronic Kidney Disease and Dialysis (cont’d)
 Progressive kidney disease can result in reduced renal
function, with effects on multiple organ systems
 Potential manifestations include anemia, abnormal
bleeding, electrolyte and fluid imbalance, hypertension,
drug intolerance, and skeletal abnormalities that can
affect the delivery of dental care
 In addition, patients who have severe and progressive
disease may require artificial filtration of the blood
through dialysis or kidney transplantation

 The kidneys regulate fluid volume, filter waste and toxins,
maintain acid/base balance of plasma, synthesize and
release hormones, are responsible for drug metabolism,
and serve as the target organ for parathormone and
aldosterone
 Under normal physiologic conditions, 25% of the
circulating blood perfuses the kidney each minute
 Blood is filtered through a complex series of tubules and
glomerular capillaries within the nephron, the functional
unit of the kidney

 CKD is defined as abnormalities of kidney structure or
function, present for 3 months or longer, with implications
for health
 It results from direct damage to nephrons or from their
progressive, chronic bilateral deterioration
 CKD results in uremia and kidney failure and can lead to
death
 In CKD, kidney damage is rarely repaired

•The National Kidney Foundation defines a five–stage
classification system for CKD based on the glomerular
filtration rate (GFR)

 With disease progression (stages 2 through 5), nitrogen
products accumulate in the blood, and the kidneys perform
fewer excretory, endocrine, and metabolic functions, with
eventual loss of the ability to maintain normal homeostasis
 The resultant clinical syndrome—caused by renal failure,
retention of excretory products, and interference with
endocrine and metabolic function—is called uremia

Epidemiology
 More than 23 million people in the United States have
some form of kidney disease
 The early stages of CKD (stages 1 to 3) tend to be
asymptomatic and constitute 96.5% of the disease
 Each year, more than 100,000 new cases of kidney failure
are diagnosed, and more than 871,000 people have end-
stage renal disease (ESRD)

Epidemiology (cont’d)
 Approximately 90,000 Americans die annually as a result of
kidney failure; cardiovascular system-related disease is the
cause of death for most
 For example, in 14% of persons with hypertension
without diabetes, 20% of persons with diabetes, and 25%
of persons older than 70 years of age, laboratory findings
are consistent with stage 3 or higher CKD

Etiology
 ESRD is caused by conditions that destroy nephrons
 The four most common known causes of ESRD are
diabetes mellitus (44%), hypertension (28%), chronic
glomerulonephritis (16%), and polycystic kidney disease
(4.5%)
 Other common causes, in decreasing order, are tubular
interstitial nephritis, systemic lupus erythematosus,
neoplasm, obstructive nephropathies, and acquired
immunodeficiency syndrome (AIDS) nephropathy

Image A: Normal kidney
Image B: Patient with chronic glomerulonephritis

Pathophysiology and Complications
 Deterioration and destruction of functioning nephrons are
the underlying pathologic processes for renal failure
 Various diseases affect different segments of the
nephron at first, but the entire nephron eventually is
affected
 Once lost, nephrons are not replaced
 Because of compensatory hypertrophy of the remaining
nephrons, however, normal renal function is maintained
for a time

(cont’d)
 Normal function is maintained until greater than 50% of
nephrons are destroyed
 Subsequently, compensatory mechanisms are
overwhelmed, and the signs and symptoms of uremia
appear
 In terms of morphology, the end-stage kidney is
markedly reduced in size, scarred, and nodular

(cont’d)
 A patient in early renal failure may remain asymptomatic,
but physiologic changes invariably develop as the disease
progresses
 Renal tubular malfunction causes the sodium pump to
lose its effectiveness, and sodium excretion occurs
 Along with sodium, excessive amounts of dilute urine are
excreted, which accounts for the polyuria that is
commonly encountered

(cont’d)
 Patients with advanced renal disease develop uremia, which is
uniformly fatal if not treated
 Failing kidneys are unable to concentrate and filter the intake of
sodium
 This contributes to the drop in urine output, development of fluid
overload, hypertension, and risk for severe electrolyte disturbances
(sodium depletion and hyperkalemia—higher-than-normal levels
of potassium) and cardiac disease
 Approximately half of the deaths occurring annually among
patients with ESRD are the result of cardiovascular system–related
events

(cont’d)
 The buildup of nonprotein nitrogen compounds in the
blood, mainly urea, as a consequence of loss of glomerular
function is called azotemia
 Level of azotemia is measured as blood urea nitrogen
(BUN)
 Acids also accumulate because of tubular impairment

(cont’d)
 The build up of waste products serves as a substrate for the
development of metabolic acidosis, the major result of
which is ammonia retention
 With acidosis superimposed on ESRD, adaptive
mechanisms already are taxed beyond normal levels, and
any increase in demand can lead to serious consequences
 For example, sepsis or a febrile illness can result in
profound acidosis and may be fatal

(cont’d)
 Patients with ESRD demonstrate several hematologic
abnormalities, including anemia, leukocyte and platelet
dysfunction, and coagulopathy
 Anemia, caused by iron deficiency, decreased erythropoietin
production by the kidney, inhibition of red blood cell production,
and hemolysis, bleeding episodes, and shortened red cell survival,
is one of the most familiar manifestations of ESRD
 Most of these effects result from unidentified toxic substances in
uremic plasma and from other factors

(cont’d)
 Host defense is compromised by nutritional deficiencies,
leukocyte dysfunction, depressed cellular immunity, and
hypogammaglobulinemia
 This diminished capacity leads to diminished granulocyte
phagocytosis, and bactericidal activity, making affected
persons more susceptible to infection

(cont’d)
 Hemorrhagic diatheses, characterized by tendency toward
abnormal bleeding and bruising, are common in patients
with ESRD, and are attributed to abnormal platelet
aggregation and adhesiveness, decreased platelet factor 3,
and impaired prothrombin consumption
 Defective platelet production also may play a role
 Platelet factor 3 enhances conversion of prothrombin to
thrombin by activated factor X

(cont’d)
 The cardiovascular system is affected by athero- and
arteriosclerosis and arterial hypertension, the latter due to
sodium chloride (NaCl) retention, fluid overload, and
inappropriately high renin levels
Congestive heart failure and hypertrophy of the left
ventricle, which may compromise coronary artery blood
flow, are relatively common developments
 These complications, along with electrolyte disturbances,
put patients with ESRD at increased risk for sudden death
due to myocardial infarction

(cont’d)
 A variety of bone disorders are seen in ESRD; these are
collectively referred to as renal osteodystrophy
 Decreased kidney function results in decreased 1-α-
hydroxylation of vitamin D, which leads to reduced
intestinal absorption of calcium
 With advanced CKD, renal phosphate excretion drops,
resulting in increased levels of serum phosphorus
 Excess phosphorus causes serum calcium to be deposited
in bone (osteoid), leading to a decreased serum calcium
level and weak bones

(cont’d)
 In response to low serum calcium, the parathyroid glands
are stimulated to secrete parathormone (PTH), which
results in secondary hyperparathyroidism
 PTH has three main functions:
 Inhibiting the tubular reabsorption of phosphorus
 Stimulating renal production of the vitamin D necessary for
calcium metabolism
 Enhancing vitamin D absorption within the intestine
 High levels of PTH are sustained, however, because, in ESRD, the
failing kidney does not synthesize 1,25-dihydroxycholecalciferol,
the active metabolite of vitamin D; so calcium absorption in the
gut is inhibited

(cont’d)
 PTH activates tumor necrosis factor and interleukin-1,
which mediate bone remodeling, calcium mobilization
from bones, and increased excretion of phosphorus,
potentially leading to formation of renal and metastatic
calcifications
 The progression of osseous changes is
 Osteomalacia (increased unmineralized bone matrix)
 Osteitis fibrosa (bone resorption with lytic lesions and marrow
fibrosis)
 Osteosclerosis of variable degree (enhanced bone density)

Clinical Presentation
 Although the type and extent of manifestations of renal
failure vary with severity and the particular patient, they
must be recognized in the context of the patient’s overall
physical status
 The effects of renal failure often are widespread and can
involve multiple systems (e.g., more than 40% of patients
with ESRD also have diabetes, and more than 15% have
concurrent hypertension)

Clinical Presentation (cont’d)
 CKD patients may show few clinical symptoms or signs
until the condition progresses to stage 3
 At stage 3 and beyond, patients may complain of a general ill
feeling, fatigue, headaches, nausea, loss of appetite, and weight
loss
 With further progression, anemia, leg cramps, insomnia, and
nocturia often develop
 The anemia produces pallor of the skin and mucous membranes
and contributes to the symptoms of lethargy and dizziness

 Patients with renal failure are more likely to experience bone
pain and to develop gastrointestinal signs and symptoms such
as anorexia, nausea, vomiting, generalized gastroenteritis, and
peptic ulcer disease
 Uremic syndrome commonly causes malnutrition and diarrhea and
patients demonstrate mental slowness or depression and become
psychotic in later stages
 Patients may also exhibit signs of peripheral neuropathy and muscular
hyperactivity (twitching)
 Additional findings may include stomatitis manifested with oral
ulceration and candidiasis, or parotitis

 Because of the bleeding diatheses that accompany ESRD,
hemorrhagic episodes are not uncommon, particularly
occult gastrointestinal bleeding
 In patients who receive dialysis, however, benefits
include improved control of uremia and less severe
bleeding
 Skin manifestations include ecchymoses, petechiae,
purpura, and gingival or mucous membrane bleeding
(e.g., epistaxis)

 Hyperpigmentation of the skin is characterized by a
brownish-yellow appearance, caused by the retention of
carotene-like pigments normally excreted by the kidney
 These pigments also may cause profound pruritus
 An occasional finding is a whitish coating on the skin of
the trunk and arms, produced by residual urea crystals
left when perspiration evaporates (“uremic frost”)

▪ Cardiovascular manifestations of ESRD include
hypertension, congestive heart failure (shortness of breath,
orthopnea, dyspnea on exertion, peripheral edema), and
pericarditis

Laboratory and Diagnostic Findings
 The diagnosis of kidney disease is based on history, physical
evidence, laboratory evaluation, and, in select disorders,
imaging, and biopsy
 Evaluation includes measures of blood pressure, GFR, urinalysis, serum
BUN, serum creatinine, creatinine clearance, and electrolytes
 Urinalysis looks for proteinuria, hematuria, cellular casts, specific gravity,
pH and a range of chemicals
 GFR is the best measure of overall kidney function, and the most
significant protein in the urine is albumin
 Together, urinalysis and GFR are used to determine the severity and
prognosis of CKD

(cont’d)
 The serum creatinine level is a measure of muscle breakdown
and filtration capacity of the nephron
 The creatinine concentration is proportional to the glomerular
filtration and can be measured in serum as well as urine
 The creatinine clearance compares the creatinine
concentrations in blood and urine (in a 24-hour urine
collection)
 BUN is a commonly used index of kidney function, but the
BUN level is not as specific as creatinine clearance or serum
creatinine level

(cont’d)
▪ Other tests used to assess and monitor kidney disease
include determinations of serum electrolytes involved in
acid-base regulation and calcium and phosphorus
metabolism, complete blood count, PTH levels, bone
density measures, and urine immunoeletrophoresis

Medical Management
 Conservative care
 A conservative approach to CKD treatment is recommended for
stage 1 and stage 2
 This care involves decreasing the retention of nitrogenous waste
products and controlling hypertension, fluids, and electrolyte
imbalances
 This is done through dietary modifications (low-protein diet;
maintaining fluid, sodium, and potassium intake)
 Comorbid conditions, such as diabetes, hypertension, and
congestive heart failure, are corrected or controlled during the
earliest stage possible

Medical Management (cont’d)
 Anemia, malnutrition, and bone disease (e.g.,
hyperparathyroidism) typically are managed beginning in
stage 3
 By stage 4, care by a nephrologist is recommended, and
preparations for renal replacement therapy begin
 In stage 5, or when uremic features appear or intractable
fluid overload occurs, dialysis is started

 Dialysis
 This medical procedure, which artificially filters blood,
becomes necessary when the number of nephrons
diminishes to the point that azotemia is unpreventable or
uncontrollable
 It becomes important when the GFR drops below 30
mL/minute/1.73 m2
 The procedure can be accomplished by peritoneal dialysis
or hemodialysis

 Peritoneal dialysis may be provided as continuous cyclic
peritoneal dialysis (CCPD) or chronic ambulatory peritoneal
dialysis (CAPD)
 With both modalities, a hypertonic solution is instilled
into the peritoneal cavity through a permanent
peritoneal catheter, then drawn out
 CCPD, also known as automated peritoneal dialysis
(APD), uses a machine to perform 3 to 5 dialysate
exchanges while the patient sleeps

Continuous Cyclic Peritoneal Dialysis

 CAPD, performed manually, is a more commonly used
method that requires shorter exchange periods of 30 to 45
minutes, 4 to 5 times per day
 The catheter is sealed, and every 3 to 6 hours the
dialysate is allowed to drain into a bag strapped to the
patient, and new dialysate is instilled by gravity
 CAPD allows the patient more freedom than CCPD,
however, both methods allow patients to perform routine
functions of everyday life between exchanges

Chronic Ambulatory Peritoneal Dialysis

 Advantages of peritoneal dialysis are its relatively low
initial cost, ease of performance, reduced likelihood of
infectious disease transmission, and absence of
requirement for anticoagulation
 Disadvantages include the need for frequent sessions,
risk of peritonitis, frequent association with abdominal
hernia, and significantly lower effectiveness than that for
hemodialysis
 Its principal use is in patients in acute renal failure or in
those who require only occasional dialysis

 Most dialysis patients (80%) in the United States receive
hemodialysis
 Hemodialysis is the method of choice when azotemia
occurs and dialysis is needed on a long-term basis
 Treatments are performed every 2 or 3 days, and usually 3
to 4 hours is required for each session

 More than 80% of the people who receive hemodialysis in
the U.S. do so through a permanent and surgically created
arteriovenous graft or fistula, usually placed in the forearm
 Patients are “plugged in” to the hemodialysis machine at
the fistula or graft site, and blood is passed through the
machine, filtered, and returned to the patient
 Heparin usually is administered during the procedure to
prevent clotting

 Dialysis provides only about 15% of normal renal function,
and complications develop as result of the procedure
 Improper serum calcium blood levels contribute to
muscle tetany and oversecretion of parathyroid hormone
 Dialysis-related amyloidosis is common in persons on
dialysis for more then 5 years
 Anemia is a common feature of renal failure and dialysis
and is treated with recombinant human erythropoietin

 The risk of hepatitis B, hepatitis C, and human
immunodeficiency virus (HIV) infections is increased
because dialyzers usually are disinfected, not sterilized,
between uses
 Although all three viruses constitute a reservoir of
potential infection, only hepatitis B virus and hepatitis C
virus have been reported to be transmitted nosocomially
in dialysis centers in the United States

 Infection of the arteriovenous fistula is always a possibility,
and can result in septicemia, septic emboli, infective
endarteritis, and infective endocarditis
 Staphylococcus aureus is the most common cause of vascular
access infection and related bacteremia in these patients
 A related concern is risk for infection and antibiotic
resistance
 Rates of tuberculosis and of vancomycin- and methicillin-resistant
infections are higher among patients maintained on long-term
hemodialysis than in the general public

 Patients with ESRD have bleeding tendencies secondary to
altered platelet aggregation and decreased platelet factor 3
 Hemodialysis is associated with the additional problem of
platelet destruction by mechanical trauma of the procedure
 The process of hemodialysis may activate prostaglandin I2
(prostacyclin), which can reduce platelet aggregation
 An alternative to long-term dialysis is renal transplantation,
but also is associated with a significant number of issues of its
own

Dental Management
 Identification
 The National Kidney Foundation’s guidelines recommend
that high-risk groups (i.e., patients with diabetes and
hypertension) be screened for CKD
 Medical referrals should be made for screening when
diabetes, hypertension, and other known risk factors are
present
 A patient with signs and symptoms of kidney disease, but
has not been assessed should be referred to a physician
for diagnosis and treatment

Dental Management (cont’d)
 Risk Assessment
 With CKD graded below stage 3, problems generally do
not arise in the provision of outpatient dental care if the
patient’s disease is well controlled and conservative
medical care provided
 With CKD of stage 4 or higher, consultation with the patient’s
physician is suggested before dental care is provided
 If the patient is in the advanced stages of renal failure or has
another comorbid condition, or if electrolyte imbalance is present,
deferral of treatment may be required until the status of the
patient has been ascertained and the CKD is adequately controlled

 Recommendations
 In developing recommendations for dental patients who
have kidney disease, the dentist must consider the type
and degree of kidney dysfunction, the medical care being
provided, and the dental procedure planned

 Antibiotics
 When invasive procedures are planned for a patient with
CKD above stage 3, the dentist should consult with the
physician to assess the need for antibiotics
 Alterations in drug dosage may be needed, depending on
the amount of renal function retained
 If an orofacial infection occurs, aggressive management
with the use of culture and sensitivity testing and
appropriate antibiotics is necessary

 Bleeding
 Due to the potential for bleeding problems, a patient facing an
invasive procedure should undergo pretreatment screening and
platelet count should be obtained
 Hematocrit level and hemoglobin count should be obtained for
assessment of anemia and abnormal values discussed with the
physician
 Few problems are encountered with nonhemorrhagic dental
procedures when the hematocrit level is above 25%. If bleeding is
anticipated, hematocrit levels can be raised with use of
erythropoietin

 Blood Pressure
 If dental treatment is to be provided on an outpatient
basis, blood pressure should be closely monitored before
and during the procedure
 Good control of blood pressure will benefit both kidney and overall
health
 If an invasive procedure is planned, the patient should undergo
pretreatment screening for bleeding disorders, and a platelet
count should be obtained
 Hematocrit level and hemoglobin count also should be obtained
for assessment of the status of anemia

 Capacity toTolerate Care
 For patients whose kidney function is deteriorating,
elective dental care should be delayed until consultation
is obtained, and the patient is medically stable
 Patients who take large doses of corticosteroids, as often
prescribed for medical management of ESRD, may develop
adrenal insufficiency
 To avoid an adrenal crisis in patients on such regimens, the dental
clinician should ensure that the usual corticosteroid dose is taken
before surgical procedures and will need to monitor the patient
closely during the postsurgical phase of care

 Drug Considerations
 A major concern in the treatment of a patient with ESRD is the
potential for adverse effects from drugs prescribed by the health
care provider
 Dentists should know which drugs to use, which to avoid, and the
correct dosage for the patient’s situation
 Some drugs are excreted primarily by the kidney and certain
agents are inherently nephrotoxic
 As a general rule, drugs excreted by the kidney are eliminated two-
fold less efficiently when the GFR drops to 50 mL/minute and thus
may reach toxic levels at lower GFR

 Drug Considerations (continued)
 Nephrotoxic drugs (acyclovir, aspirin, aminoglycosides, nonsteroidal
antiinflammatory drugs [NSAIDs], tetracycline) should generally be
avoided in patients with renal impairment
 NSAIDs inhibit prostaglandin synthesis resulting in vasoconstriction and
reduced renal perfusion
 Acetaminophen also is nephrotoxic and may cause renal tubular necrosis
at high doses, but probably safer than aspirin when used for a short
period
 Tetracyclines, except for doxycycline, worsen renal impairment by
inhibiting protein synthesis, and have been associated with kidney
deterioration in the dental setting

 Drug frequency and dosage adjustments are required during
advanced CKD for reasons besides nephrotoxicity and renal
metabolism:
 1) A low serum albumin value reduces the number of binding sites
for circulating drugs, thereby enhancing drug effects
 2) Uremia can modify hepatic metabolism of drugs (increasing or
decreasing clearance)
 3) Antacids can affect acid-base or electrolyte balance, further
complicating uremic effects on electrolyte balance

 4) Larger initial doses may be required in the presence of
substantial edema or ascites, but smaller initial doses may be
required if dehydration or severe debilitation is present
 5) Aspirin and other NSAIDs potentiate uremic platelet defects, so
these antiplatelet agents may need to be avoided if invasive
procedures are performed
 Antianxiety agents nitrous oxide and diazepam require little
modification for use in patients with ESRD; the hematocrit or
hemoglobin concentration should be measured before intravenous
sedation to ensure adequate oxygenation

 Drugs that depress the central nervous system (barbiturates,
narcotics) are best avoided in the presence of uremia because the
blood-brain barrier may not be intact, creating excessive sedation
may result
 Opioid use, if needed, requires dosage adjustment for CKD
patients, and meperidine should be avoided in patients with CKD
as its metabolite can accumulate, leading to seizures
 When the hemoglobin concentration is below 10 g/100 mL, general
anesthesia is not recommended for patients with ESRD

Questions to Ask the Patient
 What stage of CKD do you
have?
 What medications are you
taking?
 Do you have any other serious
medical conditions?
 Are you on dialysis?
 If so, what type of dialysis?
 Do you need a premed?
 If you do not know, can we
call your doctor to find
out?

Oral Complications and Manifestations
 A common sign of chronic renal failure is pallor of the oral
mucosa related to anemia
 Red-orange discoloration of the cheeks and mucosa,
caused by pruritus and deposition of carotene-like
pigments, appears when renal filtration is decreased
 Salivary flow may be diminished, resulting in xerostomia
and parotid infections
 Candidiasis is more frequent when salivary flow is
diminished

(cont’d)
 Additional signs of chronic renal failure
 Patients frequently complain of an altered or metallic
taste
 Saliva is altered in composition, has a higher pH, and may
have a characteristic ammonia-like odor, which results
from a high urea content
 Poor oral hygiene, gingivitis, and periodontal disease are
more common in patients with stage 3 or higher CKD

(cont’d)
 Uremic stomatitis is a rare condition generally associated
with acute renal failure
 Early changes typically include red, burning mucosa covered with
gray exudates and later by frank ulceration
 Adherent white patches called uremic frost, caused by urea crystal
deposition, are more common on the skin but may be seen on the
oral mucosa
 Bleeding tendencies are evident as petechiae and ecchymoses on
the labial and buccal mucosa, soft palate, and margins of the
tongue, as in gingival bleeding

(cont’d)
 Tooth-specific changes also may be seen
 Enamel hypoplasia and hypocalcification is evident when ESRD
begins at an early age
 In the developing dentition, red-brown discoloration and a slight
delay in eruption have been reported
 Tooth erosion from persistent vomiting may be seen
 Pulp narrowing or obliteration has been documented
 Caries, however, is not a feature because salivary urea inhibits the
metabolic end products of bacterial plaque and increases the
buffering capacity of saliva, thus preventing a drop in PH sufficient
to attain cariogenic levels

(cont’d)
 Specific osseous changes of the jaws accompany chronic renal
failure
 The most classically described osseous change is the triad of
loss of lamina dura, demineralized bone (resulting in a
“ground glass” appearance), and localized radiolucent jaw
lesions (central giant cell granulomas, also called brown
tumors), the last from secondary hyperparathyroidism
 Other osseous findings include widened trabeculations, loss
of cortication, calcified extraction sites (so-called socket
sclerosis), and metastatic calcifications within the skull

(cont’d)
 Patients with CKD who take calcium channel blocker
hypotensive medication and renal transplant recipients
who are taking cyclosporine may exhibit gingival
enlargement
 The clinical presentation is similar to that caused by phenytoin
(Dilantin)

Treatment Planning Modifications
 Persons with CKD often exhibit evidence of poor oral
hygiene and other unmet dental needs
 Oral hygiene instruction and frequent recall appointments are key
for maintenance of oral health
 Meticulous oral hygiene, frequent professional prophylaxis, and
antiplaque measures also will help to reduce the effect of drug-
induced gingival enlargement in transplant recipients taking
cyclosporine
 Once an acceptable level of oral hygiene has been established, no
contraindication exists to routine dental care, provided that proper
attention is paid to the systemic health of the patient

Patient Receiving Dialysis
 Risk Assessment
 In assessing risk for dental patients with kidney disease who
receive dialysis, the dentist must consider the type of dialysis,
degree of kidney dysfunction, comorbidities, oral health status and
the procedure planned
 Although the risk factors for infective endocarditis in this setting
have not been fully established, altered host defenses, altered
cardiac output and mechanical stresses, and bacterial seeding and
growth on the shunt are recognized as important
 Infective endocarditis occurs in 2% to 9% of patients receiving
hemodialysis

Patient Receiving Dialysis (cont’d)
 Antibiotics
 On the basis of an apparently low risk, the American
Heart Association (AHA) 2003 guidelines do not include a
recommendation for prophylactic antibiotics before
invasive dental procedures are performed on patients
with intravascular access devices to prevent endarteritis
or infective endocarditis, except if an abscess is being
incised and drained

 Risk of Infection
 Patients who are dependent on long-term dialysis, especially those
with diabetes, are prone to infection
 Rates of tuberculosis and vancomycin- and methicillin-resistant
infections are higher among such patients than in the general
public
 Efforts should be directed at identifying orofacial manifestations of
these infections and eliminating oral sources of infection
 Patients with active tuberculosis should not receive dialysis until
the disease is rendered inactive

 Risk of Infection (continued)
 Patients who undergo hemodialysis also can benefit from periodic
testing for hepatitis viruses and HIV
 Vaccination (hepatitis) or antiviral agents (HIV) can be
administered to reduce the risk of complications with these
diseases
 A negative test result in the past is not predictive of a carrier state
 Patients may have acquired the disease since they were last
tested, or they may be carriers of other infectious viruses (e.g.,
Epstein-Barr virus, cytomegalovirus) that can cause hepatic injury
or immune deficiency

 Risk of Infection (continued)
 Use of standard infection control procedures is warranted for
dental procedures performed in all patients
 Patients who are carriers of hepatitis viruses from infection during
hemodialysis may have altered hepatic function
 Liver function should be assessed before hemorrhagic procedures
are performed

 Bleeding
 Hemodialysis tends to aggravate bleeding tendencies through
physical destruction of platelets and the associated use of heparin
 Determination of the status of hemostasis is important before oral
surgery is performed
 Screening tests, such as the activated partial thromboplastin time
(aPTT) and platelet count, should be ordered
 Patients at higher risk are those with elevated values on these tests
and a history of gastrointestinal bleeding

 Reducing serious bleeding
 Provide dental treatment at the optimum time, usually on the day
after hemodialysis, because on the day of dialysis, patients
typically are fatigued and may have a tendency to bleed.
 Heparin’s effect lasts for 3 to 6 hours after infusion, and delay of
treatment is prudent until that medication is eliminated from the
bloodstream
 Obtain primary closure and, as needed, using pressure and local
hemostatic agents

 Reducing Serious Bleeding (continued)
 Perform major surgical procedures on the day after the end of the
week of hemodialysis treatment to provide additional time for clot
retention before dialysis is resumed
 Contacting the nephrologist to request that the heparin dose be
reduced or eliminated during the first hemodialysis session after
the surgical procedure
 Administer protamine sulfate (usually by a physician) to block the
anticoagulant effects of heparin if dental care is necessary the day
of hemodialysis

 Blood Pressure
 The clinician should be aware of other cardiovascular
considerations in patients undergoing hemodialysis
 The arm that contains the arteriovenous shunt should be protected
from application of the blood pressure cuff, blood drawing, and the
introduction of intravenous medications
 An inflated blood pressure cuff or tourniquet may potentially
collapse the shunt, rendering it useless
 The complication of phlebitis from intravenous medications can
produce a clot that may jeopardize the shunt

 Capacity toTolerate Care
 Comorbid conditions, such as cardiovascular disease and diabetes,
are common in patients receiving dialysis
 Approximately 40% of patients on dialysis have congestive heart
failure, and 39% of them die of cardiovascular complications each
year
 Dental care must be provided only when the patient is medically
stable, and treatment should be planned with an understanding of
the required medications and the appropriate dental precautionary
measures

 Drug Considerations
 The dentist should be aware that hemodialysis removes some
drugs from the circulating blood, which may shorten the
duration of effectiveness
 The chance that a given drug will be dialyzed is governed by
four factors: 1. molecular weight and size, 2. degree of protein
binding, 3. volume of drug distribution, 4. endogenous drug
clearance
 Drugs removed during hemodialysis are those with low
capacities for binding to plasma proteins. However, uremia
may greatly alter the normal degree of protein binding

 Drugs with high lipid affinity exhibit high tissue binding
and are not available for dialysis removal. Also, efficient
liver clearing of a drug greatly reduces the effect of
dialysis treatment
 In general, dosing of drugs should be tailored to occur
after dialysis to ensure active drug levels are reached
until the next dosing, and dosage amounts and intervals
should be adjusted in accordance with current evidence
and advice from the patient’s physician

 Hemodialysis reverses many of the severe oral pathologic
changes associated with ESRD
Uremic odor, dry mouth, taste change, and tongue and mucosal
pain are signs and symptoms that persist in many of these patients
Petechiae, ecchymoses, higher plaque and calculus indices, and
lower levels of salivary secretion are common among patients
undergoing hemodialysis Secondary hyperparathyroidism along
with the associated osseous changes in the jaws have been
reported in up to 30% of patients receiving hemodialysis

Patient with Renal Transplant
 There are approximately 190,000 ESRD patients who have
a functioning transplanted kidney
 Patients who have a transplanted kidney may require
special management precautions, including the need for
corticosteroids or antibiotic prophylaxis and the need for
management of oral infection and gingival overgrowth
caused by cyclosporine therapy

Recommendations for Patients with CKD
and/or Patients Receiving Dialysis
▪ Patients with CKD often exhibit poor oral hygiene, low salivary flow,
and unmet dental needs.Thus, it is important for them to have the
following:
 Frequent recall appointments for oral hygiene inspection and prophylaxis
 Meticulous oral hygiene at home
 Electric toothbrush, fluoride toothpaste, floss/Waterpik
 Chlorhexidine or triclosan rinses
▪ Antiplaque measures, reduce effects of gingival enlargement
 Biotene rinses
▪ Dry mouth occurs with CKD and renal dialysis

Chapter 12 Chronic Kidney Disease and Dialysis

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Chapter 12 Chronic Kidney Disease and Dialysis

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