Renal Disease

1. Case Presentation: Winfrey Latifa Renal Disease

2. 35 yr. old African-American female Presents for extraction of several periodontally involved teeth “Episodes” of kidney problems resulting in trips to ER In ER, BP extremely high and BUN and creatine levels high Often weak, fatigued, nauseated White plaques in mouth Heavy smoker Urinates many times a day Not allowed to donate blood or take certain medications Case Presentation: Winfrey Latifa

3. Kidney Functions • Fluid volume • pH of plasma • Excrete nitrogen waste • Synthesize erythropoietin & renin • Drug metabolism

4. Complications From Renal Failure • Anemia • Abnormal bleeding • Electrolyte and fluid imbalance • Hypertension • Skeletal abnormalities • Drug intolerance

5. End Stage Renal Disease (ESRD) • Chronic deterioration of nephrons • Uremia . . . potentially death • Stages • Diminished renal reserve(asymptomatic):creatinine levels & GFR • Renal insufficiency: further GFR w/ Nitrogen products in blood • Renal failure: excretory, metabolic & endocrine fx completely fail with sequelae effecting cardiovascular, hematologic, endocrine, GI, & neuromuscular systems

6. Etiology & Prevalence of ERSD • Caused by any disease that destroys Nephrons • 360,000 have ERSD in US ~ 1.3 per 10,000 • Diabetes + Hypertension= high risk factors • Men, Africans, Native Americans & Asian Americans

7. 35 yr. old African-American female Presents for extraction of several periodontally involved teeth “Episodes” of kidney problems resulting in trips to ER In ER, BP extremely high and BUN and creatine levels high Often weak, fatigued, nauseated White plaques in mouth Heavy smoker Urinates many times a day Not allowed to donate blood or take certain medications Case Presentation: Winfrey Latifa

8. Clinical Features of Chronic Renal Failure • Cardiovascular • Hypertension • Congestive Heart Failure • Cardiomyopathy • Pericarditis • Atherosclerosis • Gastrointestinal • Anorexia • Nausea • Ulcers and GI bleeding • Hepatitis • Peritonitis

9. Clinical Features of Chronic Renal Failure • Neuromuscular • Weakness • Drowsiness • Headaches • Disturbances of vision • Peripheral neuropathy • Seizures • Muscle Cramps • Dermatological • Pruritus • Bruising • Uremic frost

10. Clinical Features of Chronic Renal Failure • Hematological • Bleeding • Anemia • Lymphopenia and leukopenia • Splenomegaly • Immunological • Prone to infections • Metabolic • Nocturia and polyuria • Thirst • Glycosuria • Metabolic acidosis • Raised serum urea, creatinine, lipids and uric acid • Electrolyte disturbances • Hyperparathyroidism

11. Physical Evaluation • Need to IDENTIFY and ASSESS the patients underlying conditions:

12. Physical Evaluation • “at those times her blood pressure , which is not usually too high, has been extremely high”

13. Physical Evaluation • “at those times her blood pressure , which is not usually too high, has been extremely high” • Assess level of cardiovascular complications • Related cardiovascular disease is most common cause of death in ESRD patients • Blood pressure must be monitored

14. Physical Evaluation • “at those times her blood pressure , which is not usually too high, has been extremely high” • Assess level of cardiovascular complications • Related cardiovascular disease is most common cause of death in ESRD patients • Blood pressure must be monitored • “BUN andcreatinine levels havebeen high”

15. Physical Evaluation • “at those times her blood pressure , which is not usually too high, has been extremely high” • Assess level of cardiovascular complications • Related cardiovascular disease is most common cause of death in ESRD patients • Blood pressure must be monitored • “BUN andcreatinine levels havebeen high” • Assess loss of glomerular function • Should obtain total blood analysis to assess any other hematologic complications (Porath territory) • Bleeding problems • Anemia

16. Physical Evaluation • “often quite weak/fatigued and has nausea a lot”

17. Physical Evaluation • “often quite weak/fatigued and has nausea a lot” • Assess patients state of metabolic acidosis • Hyperventilation is an important indicator of acidosis • Profound acidosis can be fatal

18. Physical Evaluation • “often quite weak/fatigued and has nausea a lot” • Assess patients state of metabolic acidosis • Hyperventilation is an important indicator of acidosis • Profound acidosis can be fatal • “presents with white plaques which scrape off”

19. Physical Evaluation • “often quite weak/fatigued and has nausea a lot” • Assess patients state of metabolic acidosis • Hyperventilation is an important indicator of acidosis • Profound acidosis can be fatal • “presents with white plaques which scrape off” • Assess patients oral candidiasis • Oral infection do to white blood cell dysfunction • Infection needs to be aggressively treated because of patients immune suppressed state

20. Physical Evaluation • “has to urinate many times a day”

21. Physical Evaluation • “has to urinate many times a day” • Assess patients level of electrolyte disturbance • Sodium depletion and hyperkalemia (high levels of potassium • Potentially fatal

22. Questions To Ask: • Cardiovascular/Hematologic

23. Questions To Ask: • Cardiovascular/Hematologic • Have you noticed any swelling of you legs or ankles? • Do you ever have chest pain or trouble breathing? • Do you bruise easily? Do you have bruises anywhere whose cause you're unsure of? • Do you ever have episodes of nose bleeds or bleeding from anywhere else that's without a reason?

24. Questions To Ask: • Cardiovascular/Hematologic • Have you noticed any swelling of you legs or ankles? • Do you ever have chest pain or trouble breathing? • Do you bruise easily? Do you have bruises anywhere whose cause you're unsure of? • Do you ever have episodes of nose bleeds or bleeding from anywhere else that's without a reason? • Metabolic Problems

25. Questions To Ask: • Cardiovascular/Hematologic • Have you noticed any swelling of you legs or ankles? • Do you ever have chest pain or trouble breathing? • Do you bruise easily? Do you have bruises anywhere whose cause you're unsure of? • Do you ever have episodes of nose bleeds or bleeding from anywhere else that's without a reason? • Metabolic Problems • Do you ever have episodes of hyperventilation? • Do you ever have uncaused, intense thrist?

26. Immunologic Dysfunction

27. Immunologic Dysfunction • How long have you had the white spots inside your mouth and on your tongue? • Have you had them before? • How long have these been recurring? • Have you had any other infections recently?

28. Immunologic Dysfunction • How long have you had the white spots inside your mouth and on your tongue? • Have you had them before? • How long have these been recurring? • Do they go away eventually? • Have you had any other infections recently? • General

29. Immunologic Dysfunction • How long have you had the white spots inside your mouth and on your tongue? • Have you had them before? • How long have these been recurring? • Do they go away eventually? • Have you had any other infections recently? • General • What meds have you been told you can no longer take? • Do you have any other systemic diseases? • How much do you smoke? • How long have you been smoking? • How difficult would it be for you to quit?

30. Lab Tests • Creatinine clearance, blood urea nitrogen (BUN), and glomerular filtration rate (GFR) can help diagnose renal failure and show its severity. • Screen for the two most common causes of kidney failure: diabetes mellitus & HTN • Bleeding and clotting abnormalities are common in RF: • Platelet function analyzer-100 (PFA-100) and platelet count to screen for potential bleeding problems. • Hematocrit level and hemoglobin count (anemia)

31. Dental Management Algorithm A • Antibiotics: Consult with physician to assess need • Anesthetics: No adjustment for Lidocaine • Anxiety: Nitrous oxide and diazepam require little modification. Avoid CNS depressants

32. B • Bleeding: • Abnormal bleeding and bruising can be common in patients with renal failure. This is attributed to abnormal platelet aggregation and adhesiveness, decreased platelet factor 3, and impaired prothrombin consumption. • In addition there may be decreased production of platelets. Platelet function analyzer-100 (PFA-100), activated partial prothrombin time (aPTT), and platelet count can help screen for potential bleeding problems.

33. Bacteremias: • Infective endocarditis (usually staphylococcal) occurs in 2% to 9% of patients receiving hemodialysis even in individuals with no preexisting cardiac defects. These patients warrant some form of antibioticcoverage for dental procedures because of the presence of anarteriovenous shunt for dialysis. • Shunts are particularlyvulnerable to infection, which could be devastating for thepatient receiving hemodialysis. • Patients receiving continuousperitoneal dialysis, however, do not require antibiotic prophylaxis.

34. C • Complications • ESRD can lead to: - Hypertension due to increased sodium retention - Congestive Heart Failure - Seizures • Places pt. at risk for infections, e.g. infective endocarditis • Accelerated atherosclerosis seen with progression of renal disease • Abnormal bleeding/delayed clot formation *important for dental surgeries

35. D • Drugs • Reduce drug dosage and prolong administration to compensate for reduced GFR (prevent toxicity) • Adjust dosages of nephrotoxic drugs: acyclovir, aminoglycosides, aspirin, tetracycline, NSAIDs • Acetaminophen preferred over asprin • Anti-anxiety drugs such as nitrous oxide and diazepam require little modification • Avoid CNS depressants such as barbiturates and narcotics due to risk of over-sedation • General anesthesia not recommended when hemoglobin concentration is below 10g/100mL • Frequency and dosage of drugs must be modified during uremia

36. D • DENTAL MANAGEMENT • Consult with physician regarding physical status and level of control • Avoid dental treatments and procedures if the disease is advanced or poorly controlled (Because Ms. Latifa’s condition is both advanced and poorly controlled, deferment of treatment may be necessary until a physician is seen) • If another systemic disease common to renal failure is present (diabetes, lupus), dental tx is best after consultation with a physician and in a hospital setting • Screen for bleeding disorders

37. Monitor blood pressure closely (before and during procedure) • If bleeding is anticipated, hematocrit levels can be raised with erythropoietin • Good surgical techniques are crucial in decreasing risk of excessive bleeding and infection • Avoid nephrotoxic drugs • Adjust dosages for drugs metabolized by kidneys • If orofacial infection occurs, treat aggressively using culture and sensitivity tests with appropriate antibiotics • Patient should be hospitalized when severe infection occurs or major dental procedure is necessary • More frequent recall appointments

38. E • Emergency Treatment • Refer to physician to stabilize • Screen for bleeding disorders • Must have local or systemic hemostatic agents available • Closely monitor BP • Avoid Nephrotoxic drugs, if necessary low dose acetominophin • No substitute for good surgical technique

39. ASA PS Level 4 • At least one severe disease that is poorly controlled. • Despite “episodes” pt. not under regular care of physician • BUN and creatine levels have been elevated • Polyurea • Fatigue and nausea indicate later stage • Stomatitis • Delay treatment until pt. under care of physician and current physical status is available

40. Thank you!