renal disease case presentation: winfrey latifa. case presentation: winfrey latifa 35 yr. old...
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Renal DiseaseRenal Disease
Case Presentation: Winfrey Latifa
Case Presentation: Winfrey Latifa
Case Presentation: Winfrey Latifa
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
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
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 FunctionsKidney Functions
Fluid volume pH of plasma Excrete nitrogen waste Synthesize erythropoietin & renin Drug metabolism
Fluid volume pH of plasma Excrete nitrogen waste Synthesize erythropoietin & renin Drug metabolism
Complications From Renal FailureComplications From Renal Failure
Anemia Abnormal bleeding Electrolyte and fluid imbalance Hypertension Skeletal abnormalities Drug intolerance
Anemia Abnormal bleeding Electrolyte and fluid imbalance Hypertension Skeletal abnormalities Drug intolerance
End Stage Renal Disease (ESRD)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
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
Etiology & Prevalence of ERSDEtiology & 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
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
Case Presentation: Winfrey Latifa
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
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
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
Clinical Features of Chronic Renal Failure
Cardiovascular Hypertension Congestive Heart
Failure Cardiomyopathy Pericarditis Atherosclerosis
Cardiovascular Hypertension Congestive Heart
Failure Cardiomyopathy Pericarditis Atherosclerosis
Gastrointestinal Anorexia Nausea Ulcers and GI bleeding Hepatitis Peritonitis
Gastrointestinal Anorexia Nausea Ulcers and GI bleeding Hepatitis Peritonitis
Clinical Features of Chronic Renal Failure
Neuromuscular Weakness Drowsiness Headaches Disturbances of
vision Peripheral
neuropathy Seizures Muscle Cramps
Dermatological Pruritus Bruising Uremic frost
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
Physical Evaluation
Need to IDENTIFY and ASSESS the patients underlying conditions:
Physical EvaluationPhysical Evaluation “at those times her blood pressure , which is
not usually too high, has been extremely high” “at those times her blood pressure , which is
not usually too high, has been extremely high”
Physical EvaluationPhysical 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
“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
Physical EvaluationPhysical 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 and creatinine levels have been high”
“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 and creatinine levels have been high”
Physical EvaluationPhysical 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 and creatinine levels have been high” Assess loss of glomerular function Should obtain total blood analysis to assess any other
hematologic complications (Porath territory) Bleeding problems Anemia
“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 and creatinine levels have been high” Assess loss of glomerular function Should obtain total blood analysis to assess any other
hematologic complications (Porath territory) Bleeding problems Anemia
Physical Evaluation
“often quite weak/fatigued and has nausea a lot”
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
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”
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
Physical EvaluationPhysical Evaluation
“has to urinate many times a day” “has to urinate many times a day”
Physical EvaluationPhysical Evaluation
“has to urinate many times a day” Assess patients level of electrolyte disturbance Sodium depletion and hyperkalemia (high levels of
potassium Potentially fatal
“has to urinate many times a day” Assess patients level of electrolyte disturbance Sodium depletion and hyperkalemia (high levels of
potassium Potentially fatal
Questions To Ask:Questions To Ask: Cardiovascular/Hematologic Cardiovascular/Hematologic
Questions To Ask: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?
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?
Questions To Ask: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
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
Questions To Ask: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?
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?
Immunologic Dysfunction Immunologic Dysfunction
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?
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?
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
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
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?
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?
Lab TestsLab 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)
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)
Dental Management Algorithm
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
A Antibiotics: Consult with physician to
assess need Anesthetics: No adjustment for Lidocaine Anxiety: Nitrous oxide and diazepam
require little modification. Avoid CNS depressants
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.
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.
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 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.
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 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
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
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
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
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
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
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
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
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
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
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
ASA PS Level 4ASA 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
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
Thank you!Thank you!