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Renal Disease
Case Presentation:
Winfrey Latifa
Case Presentation: Winfrey
Latifa
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35 yr. old AfricanAmerican 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
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Often weak, fatigued,
nauseated
White plaques in mouth
Heavy smoker
Urinates many times a
day
Not allowed to donate
blood or take certain
medications
Kidney Functions
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Fluid volume
pH of plasma
Excrete nitrogen waste
Synthesize erythropoietin & renin
Drug metabolism
Complications From Renal Failure
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Anemia
Abnormal bleeding
Electrolyte and fluid imbalance
Hypertension
Skeletal abnormalities
Drug intolerance
End Stage Renal Disease (ESRD)
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Chronic deterioration of nephrons
Uremia . . . potentially death
Stages
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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
Etiology & Prevalence of ERSD
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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
Case Presentation: Winfrey
Latifa




35 yr. old AfricanAmerican 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
Clinical Features of Chronic Renal
Failure
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Cardiovascular
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Hypertension
Congestive Heart
Failure
Cardiomyopathy
Pericarditis
Atherosclerosis
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Gastrointestinal
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Anorexia
Nausea
Ulcers and GI bleeding
Hepatitis
Peritonitis
Clinical Features of Chronic Renal
Failure
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Neuromuscular
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Weakness
Drowsiness
Headaches
Disturbances of
vision
Peripheral
neuropathy
Seizures
Muscle Cramps
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Dermatological
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Pruritus
Bruising
Uremic frost
Clinical Features of Chronic Renal
Failure
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Hematological
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Bleeding
Anemia
Lymphopenia and
leukopenia
Splenomegaly
Immunological
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Prone to infections
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Metabolic
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Nocturia and
polyuria
Thirst
Glycosuria
Metabolic acidosis
Raised serum urea,
creatinine, lipids and
uric acid
Electrolyte
disturbances
Hyperparathyroidism
Physical Evaluation
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Need to IDENTIFY and ASSESS the
patients underlying conditions:
Physical Evaluation
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“at those times her blood pressure , which is
not usually too high, has been extremely high”
Physical Evaluation
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“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
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Physical Evaluation
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“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
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“BUN and creatinine levels have been high”
Physical Evaluation
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“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
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“BUN and creatinine levels have been high”
Assess loss of glomerular function
 Should obtain total blood analysis to assess any
other hematologic complications (Porath territory)
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Bleeding problems
Anemia
Physical Evaluation
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“often quite weak/fatigued and has nausea a
lot”
Physical Evaluation
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“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
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Physical Evaluation
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“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
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“presents with white plaques which scrape off”
Physical Evaluation
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“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
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“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
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Physical Evaluation
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“has to urinate many times a day”
Physical Evaluation
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“has to urinate many times a day”
Assess patients level of electrolyte disturbance
 Sodium depletion and hyperkalemia (high levels of
potassium
 Potentially fatal
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Questions To Ask:
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Cardiovascular/Hematologic
Questions To Ask:
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Cardiovascular/Hematologic
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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?
Questions To Ask:
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Cardiovascular/Hematologic
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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
Questions To Ask:
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Cardiovascular/Hematologic
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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
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Do you ever have episodes of hyperventilation?
Do you ever have uncaused, intense thrist?
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Immunologic Dysfunction
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Immunologic Dysfunction
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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?
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Immunologic Dysfunction
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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
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Immunologic Dysfunction
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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
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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?
Lab Tests
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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:
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Platelet function analyzer-100 (PFA-100) and platelet
count to screen for potential bleeding problems.
Hematocrit level and hemoglobin count (anemia)
Dental Management
Algorithm
A
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Antibiotics: Consult with physician to
assess need
Anesthetics: No adjustment for Lidocaine
Anxiety: Nitrous oxide and diazepam
require little modification. Avoid CNS
depressants
B
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Bleeding:
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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.
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Bacteremias:
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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 antibiotic
coverage for dental procedures because of the
presence of an arteriovenous shunt for dialysis.
Shunts are particularly vulnerable to infection, which
could be devastating for the patient receiving
hemodialysis.
Patients receiving continuous peritoneal dialysis,
however, do not require antibiotic prophylaxis.
C
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Complications
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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
D
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Drugs
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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
D
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DENTAL MANAGEMENT
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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
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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
E
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Emergency Treatment
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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
ASA PS Level 4
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At least one severe disease that is poorly
controlled.
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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
Thank you!