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Renal Failure and Dialysis Dentist Role

Renal Failure and Dialysis Dentist Role. What Are The Kidneys?. Nephrons are the functional units of the kidneys Within each kidney there are about 1 million nephrons Responsible for filtration & making urine Responsible for regulating electrolytes & acid/base balance

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Renal Failure and Dialysis Dentist Role

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  1. Renal Failure and DialysisDentist Role

  2. What Are The Kidneys? • Nephrons are the functional units of the kidneys • Within each kidney there are about 1 million nephrons • Responsible for filtration & making urine • Responsible for regulating electrolytes & acid/base balance • Responsible for converting Vit D to its active form Calcitriol • Responsible for removing wastes from the body • Erythropoietin Production : Formation of RBC • Normal renal function is monitored by GFR  Normal GFR  @125 ml/min • When GFR drops below 60ml/min, the patient will be symptomatic

  3. Renal Laboratory Tests • Creatinine • With renal disease the kidney is not working properly, thus the serum creatinine will be high (it is not getting excreted)  normal values 0.8 to 1.4 mg/dl • BUN: Blood Urea Nitrogen • With renal disease the kidney is not working properly, thus the BUN is higher than normal because the urea is not being excreted  normal values 7 to 20 mg/dl • Creatinine Clearance: • Estimate of Glomerular Filtration Rate (GFR)  Volume of Filtrate made by kidney/min • With renal disease the Creatinine Clearance will be low (kidney is not working well) • Normal Values: • Men  97-137 ml/min • Women  88-128 ml/min

  4. What Happens When the Kidneys Aren’t Working Properly? • Build up of toxins within the body • Acid/Base imbalance • Vitamin D deficiency • Anaemia • Acute Renal Failure   ESRD • Chronic Renal Failure  ESRD

  5. Acute Renal Failure • Definition: sudden loss of kidney function occurring over hoursdays • If untreated goes to Chronic Renal Failure or End Stage Renal Disease • Reversible if Aggressively treated • Etiology: • Prerenal • Intrarenal • Postrenal

  6. Prerenal • The kidneys are not being perfused because: • Hypovolemic Shock (hemorrhage-internal or external) • Decreased cardiac output  MI, CHF, Hypertension • Some interruption of blood flow to the kidneys

  7. Intrarenal • The kidneys are damaged because: • Toxins • Glomerulonephritis • Stones • Infection-direct • Sepsis • Trauma • Clot • Obstruction

  8. Postrenal • The outflow from the kidneys is blocked due to: • Urethral/Ureteral block • Infection • Urethral/Ureteral constricture

  9. ARF: Treatment • Fix the Cause • Emergent Dialysis • Sodium Bicarb for Acid/Base imbalance • Lab Monitoring • Control of Potassium build-up • Maintenance of fluid balance: • Daily weights • Urine output measurements • Blood Pressure • Proper nutrition  limit Na, K and Phosphorus

  10. Chronic Renal Failure • Fairly uncommon • Insidious and progressive loss of kidney function  is Irreversible • 2/3 – ¾ loss of function • Ends with End Stage Renal Disease

  11. CRF: Causes • Diabetes Mellitus • Uncontrolled Hypertension • Glomerulonephritis • Neoplasia • Obstruction • Drugs  Cocaine and Heroin • Amyloidosis • SLE • Polycystic Kidney Disease (Hereditary) • Age after the age of 40 you lose 1ml/min kidney kidney function/yr

  12. CRF: Stages • Stage 1 • Persistent albuminuria (protein in urine suggesting improper renal filtration • Stage 2 • GFR 60-89 • Stage 3 • GFR 30-59 • Stage 4 • GFR 15-29 • Stage 5 • GFR <15  Also Known as End Stage Renal Disease

  13. Weight loss (anorexia) Lethargy (anemia), Pitting Edema Chronic azotemia Nail abnormalities High Creatinine and BUN Seizures/ Tremors Coma Increased susceptibility to infection Dyspnea Confusion Weakness Altered Mental Status Decreased/No Urine Output Low EPO; shortened RBC life span Infertility Thrombocytopenia Bone Pain/ Fracture Among Many Others… CRF: Symptoms

  14. CRF: Treatment • Treatment: • Treat Underlying chronic condition (DM, HTN, Infection, Neoplasm (benign or malignant)) • Antibiotics • Palliative and Supportive Therapy  fluids and electrolytes • Vitamin B complex and anabolic steroids • Avoid nephrotoxic drugs • Hemo or peritoneal dialysis • Diet • Low protein  cannot rid body of toxic metabolic products • Prognosis: poor long term

  15. Sudden onset Reversible(usually) Temporary Oliguric or non-oliguric Oliguric - <400 cc/24 hr Non-oliguric - > 800cc/24 hr Insidious onset Progressive in its destruction of nephrons and renal structure Irreversible Acute vs. Chronic Renal Failure

  16. End Stage Renal Disease • The endpoint of the progression of Acute or Chronic Renal Failure (if Acute did not resolve) • Can take 10-20 years to go from CRF to ESRD • Function of the kidney is <15% and usually <10%

  17. ESRD: Causes • Same causes as Acute and Chronic Renal Failure: • Hypertension • Diabetes Mellitus • Long Term NSAID toxicity • Polycystic Kidney Disease • SLE • Glomerulonephritis • Congestive Heart Failure • …

  18. ESRD: Death • Occurs from the build-up of toxic products within the body effecting each organ system

  19. ESRD Treatment • Dialysis ( Haemo & Peritoneal ) • Dialysis basically acts as an external kidney • Usually  3 sessions/wk  each session is 3-4 hours long • Patients always given heparin to prevent clotting of the AV access • Peritoneal Dialysis Is less efficient than hemodialysis • Kidney Transplant

  20. Renal Transplant • Replacement of nonworking kidneys with donor kidney: one can survive with one functional kidney • Donor kidney is attached to renal artery and vein and ureter. Unless nonworking kidneys are infected, they are left in place

  21. What About Dentistry?

  22. Oral Complications of Renal Disease • Anemia causes the oral mucosa to become more pale • Medications for renal disease cause xerostomia • Urea content causing metallic taste • Patients may have excessive bleeding • Hyperparathyroidism due to build up of phosphate and also due to Vitamin D not being activated allowing for Ca to be absorbed by the gut • Loss of Lamina Dura • Brown’s Tumor • Demineralization of Alveolar Bone

  23. ESRD: Dental Considerations • Consult with Physician: • Make sure pt can be treated in outpatient setting • Pretreatment PT, PTT, Bleeding Time, INR, RFT, Hb • Monitor blood pressure in arm without shunt • Antibiotic prophylaxis • Drug selection  may want to avoid NSAIDS

  24. Dialysis: Dental Considerations • Indwelling Catheter is susceptible to infection  Ab Prophylaxis • Try to avoid treatment dialysis days or at least 4 hours after dialysis due to possibility of bleeding • Best time to do dentistry on a patient undergoing dialysis: DAY AFTER

  25. Transplant Patients: Dental Considerations • Pretransplant: • Get rid of all infection: • Extraction of: • Caries close to pulp • Periodontal Disease  pockets > of = to 5mm • Unrestorable teeth • Aggressive Oral Hygiene • Postransplant: • 6 months post  only emergent care • Remember pts will be pumped up with steroids to prevent graft rejection  may want supplemental corticosteroids for stress

  26. Antibiotic Prophylaxis or Dental Patients at Risk for Infection • “Vascular catheters, such as those required by patients undergoing dialysis, chemotherapy, or frequent administration of blood products, are susceptible to bacterial infections.” • Prophylax dialysis patients: • 2g Amoxicillin 1 hr prior to procedure • 600mg Clindomycin 1 hr prior toprocedure (if Pen allergy)

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