ckd for dental
TRANSCRIPT
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Management of patient with
kidney diseasesHANAN SHANAB
OMFS Resident
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idneyK
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• Excretion.. Of body waste.
• Homeostasis..regulate
– fluid and electrolytes blance.
– acid-base balance.
Function
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Function
• Body natural Filter.
• Endocrine function.
– calcitrol, erythropoietin and
renin.
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Kidney
Disease
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There are two general types of
serious kidney disease:
Acute renal failureChronic kidney disease (CKD)
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A- Acute Renal failure:
• It is a reversible rapid damage and deterioration of kidney function that
occurs suddenly.
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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.
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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
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20-64 y/o
65 y/o
College of Dental Hygienists of Ontario, CDHO Advisory Kidney Disease and Kidney Failure, 2010-07-15
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Stages of Chronic Kidney Disease(
CKD)
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END STAGE RENAL
DISEASE (ESRD)
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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).
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Peritoneal Dialysis
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Peritoneal Dialysis
• Advantages:
– less costly
– The ability to undertake treatment without visiting a medical facility.
• Complication:
– peritonitis
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Hemodialysis
• Disadvantages:
– Required hospital care.
– Risk for viral transmission (HIV,
Hep B& C)
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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.
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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
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Complications
– long term use of immunosuppressive medication can lead to side effects
like:
• gingival overgrowth,
• opportunistic infections.
• cancer.
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Clin
ica
l M
an
ife
sta
tio
n
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Oral Manifestation
– high urea concentration
in saliva
Altered taste – (metallic)
– ammonia-like smell 1/3 hemodialysis pt.
– Xerostomia
500 ml/day
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– Periodontal problem
– Loose and painful teeth.
– Sensitivity to percussion and mastication,
– tooth mobility and malocclusion.
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– enamel abnormalities, altered eruptions.
– Calculus,
– Pale gingivae (anemia)
– No caries..
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– Uremic frost (crystals deposits more in skin than oral mucosa).
– Stomatitis (in sever RF).
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– Oral mucosa & gingival bleeding. (thrombocytopenia)
– Drug-induced gingival
hyperplasia.(cyclosporine, & Ca channel blocker).
Lee and Gisser 1978; bradford et al 1990
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• 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
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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’
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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
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Osteitis Fibrosa Cystica
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Management During Dental Treatment:
Patient under conservative care
Patient on dialysis
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History and Physical Ex
History of DM, Related bony
disorders,
Medication..?..
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LABS
Complete Blood Count
Liver Function Test Urea & Electrolyte
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Patient under conservative care
1- Consult with the physician
regarding physical status if:
Positive findings in patient history or lab
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Patient under conservative care
3- Screening for bleeding disorders
2- Monitor blood pressure.
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Patient under conservative care
4- Pay meticulous attention to good
surgical technique and accepted oral
hygiene.
To avoid infections, periodontitis and
xerostomia related complication.
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Patient under conservative care
5- Avoid nephrotoxic drugs (
acetamenophen in high doses, acycolovir,
aspirin, NSAID).
6- Adjust the dose of drugs metabolized by
kidney.
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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.
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• 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:
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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.
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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.
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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.
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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.
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HEMODIALYSIS
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If patient on dialysis
• 1. same as conservative care
recommendation.
• 2. consult with the physician
about the risk of bacterial
endocarditis.
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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
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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
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• 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
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• 4. Dosage adjustment in accordance with advice from patient’s physician.
If patient on dialysis
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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%) .
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AVOID
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If patient on dialysis
• 6- Dentist must be aware of pt’s drugs
and dental precaution measures that are
appropriate
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• 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
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• 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
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• 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
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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
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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.
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• 4. request protamine sulfate to be
given when immediate care is
necessary as antidote for the heparin.
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thanx
Thank you
grateful
merci
Thank you
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