End Stage Renal Disease Enas S. Nimri, D.D.S.

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End Stage Renal DiseaseEnas S. Nimri, D.D.S.
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The Kidney

• The kidneys are responsible for removing
  wastes from the body, regulating electrolyte
  balance and blood pressure, converting Vit D into
  its active form, and stimulating rbc production
  by synthesizing erythropoietin.

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Nephron
The nephron is the functional unit of the kidney
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What is ESRD?

• The deterioration of nephrons resulting in loss
  of ability to excrete wastes, concentrate urine,
  and regulate electrolytes.
• Occurs as chronic or acute renal failure
  progressing to the point where function is less
  than 10 of normal. Function is so low that
  without dialysis or kidney transplantation, death
  will occur from accumulation of fluids and waste
  products in the body.
• ESRD almost always follows chronic kidney
  failure, which may exist for 10 - 20 years or
  more before progression to ESRD.

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Incidence/Prevalence

• - More than 20 million people in the US
  have chronic kidney disease
• - More than 345,000 people suffer from
  ESRD
• - 31 of cases annually occurs in African
  Americans
• - 2 of cases of ESRD each year occurs in
  native Americans
• - 31 of cases of ESRD each year occurs
  in Caucasians in America
• - 60,000 people die annually

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Causes
Hypertension
Chronic Glomerulonephritis
Congestive Heart Failure
Diabetes (most common cause)
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Causes
Systemic Lupus Erythrematosus
Polycystic Kidney Disease
Amyloidosis
Atherosclerosis
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Causes
Aminoglycoside nephrotoxicity (Gentamycin,
Azithromycin)
IV contrast medium
Long term use of NSAIDS
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Causes
Nephrolithiasis
Prostate Cancer
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Symptoms
Unintentional weight loss Nausea or
vomiting Fatigue Headache Generalized itching
Greatly decreased urine output No urine
output Easy bruising or bleeding May have blood
in the vomit or stools Decreased alertness
drowsiness, somnolence, lethargy confusion,
delirium coma Muscle twitching or cramps
Seizures Increased skin pigmentation Skin may
appear yellow or brown Nail abnormalities
Decreased sensation in the hands, feet, or other
areas
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Complications

• Pericarditis, cardiac tamponade, CHF, HTN, edema
• Platelet dysfunction, anemia
• Renal encephalopathy, dementia, seizures,
  peripheral neuropathy
• Hyperparathyroidism, osteoporosis, osteomalacia
• Decreased immune response, increased incidence of
  infection
• Hepatitis C, Hepatitis B, liver failure
• Electrolyte imbalances hyperkalemia,
  hyponatremia, hypocalcemia

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Lab Tests

• Creatinine and BUN levels (chronically high)
• Creatinine clearance (very low).
• Electrolyte measurements (high K, low Na)
• Urinalysis

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Creatinine

• Creatinine is a breakdown product of creatine, an
  important part of muscle.
• Creatinine is excreted entirely by the kidneys.
• With kidney failure, the serum creatinine level
  is high.
• Normal value 0.8 to 1.4 mg/dl.

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BUN (Blood Urea Nitrogen)

• Measures the amount of urea nitrogen (a breakdown
  product of protein metabolism) in the blood.
• Urea is formed in the liver as the end product of
  protein metabolism.
• The urea makes its way into the blood and it is
  ultimately eliminated in the urine by the
  kidneys.
• With kidney failure BUN levels are chronically
  high.
• Normal Value 7 to 20 mg/dl

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Creatinine Clearance

• Creatinine clearance estimates glomerular
  filtration rate (the volume of filtrate made by
  the kidneys per minute). Urine and serum
  creatinine levels are measured along with the
  urine volume in 24 hours. Clearance rate is then
  calculated.
• With kidney failure clearance is chronically low.
• Normal values
• Male 97 to 137 ml/min. Female 88 to
  128 ml/min.

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Treatment

• Diseases that cause or result from chronic renal
  failure must be controlled. Hypertension,
  congestive heart failure, urinary tract
  infections, kidney stones, obstructions of the
  urinary tract, glomerulonephritis, and other
  disorders should be treated appropriately
• Dialysis or kidney transplantation are the only
  treatments for ESRD
• In the U.S., nearly 300,000 people are
  on long-term dialysis and more than 20,000 have a
  functioning transplanted kidney.

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Dialysis Method of removing toxic substances
from the blood.Blood is diverted from the access
through a filter. The blood flows counter-current
to a special solution called the dialysate. The
electrolyte imbalances and toxins in the blood
are corrected and the is returned to the body.
Peritoneal
Hemodialysis
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Peritoneal

• Works by using the body's peritoneal membrane,
  inside the abdomen, as a semi-permeable membrane.
  Solutions that help remove toxins are infused in,
  remain in the abdomen for a certain time period,
  and are eventually drained out. This can be done
  at home on a continuous basis.
• Indicated in patients with acute renal failure,
  require occasional dialysis, or those who are
  young and have the capability of doing this at
  home.

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Hemodialysis

• Works by circulating the blood, from an access in
  the body, through a semi-permeable filter in the
  dialysis machine that helps remove toxins. The
  cleansed blood is then returned to the body.
• Typically, most patients undergo hemodialysis for
  three sessions every week. Each session lasts 3-4
  hours
• Patients on hemodialysis are always heparinized
  to prevent clotting of the AV access.
• Indicated in chronic tx and obese patients

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Catheters
Subclavian

• Catheters are a form of temporary access.
  Large-bore catheters placed in large veins that
  can support acceptable blood flows. Most
  catheters are used in emergency situations, for
  short periods of time. However, catheters called
  tunneled catheters can be used for prolonged
  periods of time, often weeks to months.

Femoral
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Arterio-Venous Connections

• Permanent access is created by surgically joining
  an artery to a vein. This allows the vein to
  receive blood at high pressure, leading to
  thickening of the vein's wall. The "arterialized
  vein" can sustain repeated puncture and provides
  excellent blood flow rates. The connection
  between an artery and a vein can be made using
  blood vessels (an arteriovenous fistula, or AVF)
  or a synthetic bridge (arteriovenous graft, or
  AVG).

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Arterio-Venous Fistula (AVF)

• The AVF is desirable, because rates of infection
  are very low and it is durable. It may take many
  months for the AVF to mature, so careful planning
  is required.

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Arterio-Venous Graft

• The AVG can be accessed a few weeks after
  grafting. It provides good flows but has a high
  complication rate. It should be attempted only if
  the AVF is not feasible.

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Oral Complications

• Pallor of oral mucosa secondary to anemia.
• Xerostomia due to medications
• Metallic taste and saliva may have characteristic
  ammonia-like odor due to high urea content.
• In severe renal failure, stomatitis may be
  present.
• Excessive postoperative bleeding
• Radiographic changes due to secondary
  hyperparathyroidism
• loss of lamina dura
  demineralized bone
• ground glass appearance

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Dental Considerations for all ESRD patients

• Physician should be consulted. Decide on
  treatment setting (inpatient vs. outpatient).
  If ESRD is well-controlled, generally no problem
  in providing outpatient care.
• Monitor blood pressure in arm without shunt
• Use good surgical technique to minimize bleeding
• Antibiotic prophylaxis if needed
• Modify drug selection and drug dosage
• Universal infection control
• Obtain pretreatment lab values for bleeding time
  (BT), platelet count, hematocrit, hemoglobin, CBC
  with differential, INR,PT,PTT

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Normal Lab Values
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Dental Considerations for Patients on Dialysis

• AVF is susceptible to infection (endarteritis)
  due to dental bacteremia and can cause
  endocarditis. Physician and dentist must
  determine whether or not to administer
  prophylactic antibiotics.
• Avoid dental treatment on day of dialysis due to
  possibility of excessive bleeding. Best time for
  dental treatment is the DAY AFTER hemodialysis.

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Dental Considerations for Transplant Patients

• Pretransplant eliminate all source of infection
• eliminate active dental
  disease
• aggressive OH regimen
• Postransplant Emergency tx only for 1st
• 6 months
• Immunosuppressed pt
  requires supplemental
  corticosteroids

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Drug Interactions

• Drugs primarily excreted by the kidney or that
  are nephrotoxic Tetracycline, Acyclovir,
  Acetaminophen, ASA, NSAlDS, Vancomycin, and
  Gentamycin.
• Certain drugs are removed during hemodialysis and
  require additional dose to be given after
  hemodialysis.

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References

• Medline
• Little JW, Falace DA. Dental Management of the
  Medically Compromised Patient. 4th ed. St Louis,
  MO Mosby Year Book, Inc 1993 248-257.
• Naylor GD, Fredericks MR. Pharmacologic
  considerations in the dental management of the
  patient with disorders of the renal system.Dent
  Clin North Am. 1996 Jul40(3)665-83.
• El Mouedden et al., Tox. Sci. (2000) 56229-239.
• www.lxi.leeds.ac.uk/.../rsna00/subtraction.htm