Renal Failure patient and dental treatment protocol

The kidneys play a vital role in the excretion of waste products and toxins such as urea, creatinine and uric acid, regulation of extracellular fluid volume, serum osmolality and electrolyte concentrations, as well as the production of hormones like erythropoietin and 1,25 dihydroxy vitamin D and renin

Proplems in these functions is called renal failure

Classification of Renal Failure

• Acute renal failure (ARF) is characterized by a sudden, significant reduction in glomerular filtration rate(GFR).

Patients with ARF are typically not suitable for elective dental care.

• Chronic renal failure(CRF) isc aprogressiveloss of functional nephronsand

reductioninGFR.Thenaturalend-pointofCRFisend-stagerenalfailure(ESRF),whichcanonly

be managed with dialysis and/or kidney transplantation.

Renal disease mainly comprises the so-called nephritic syndromes which may progress to chronic renal failure (CRF).

• Progression to CRF leads to the need for dialysis and possibly transplantation.

• CRF patients may be taking corticosteroid and other immunosuppression drugs.

• This can make medical management difficult for these patients.

Diagnosis of renal failure

• Renal function is inferred by assessing changes in GFR using the following methods:

o insulin clearance (not widely used in practice)

o creatinine clearance (common method but overestimates GFR)

o precise 24-hour urine samples(laborious)

o formula using serum creatinine levels (factoring in age, sex, race)

Clinical Manifestations of renal failure

clinical features dependent on underlying systemic or renal issue and rate of renal function impairment

Arterial hypertension common complication, resulting from retention of sodium and water,and activation of RAAS (renin-angiotensin-aldosterone system)

Uremia presents as generalized paleness (secondary to anemia), brown hyper-pigmented nails and skin (secondary to retention of dietary pigments) and intense itching (secondary to build-up of calcium and phosphate microcrystals)

Anemia secondary to impaired erythropoiesis

Hemostatic impairment altered due to platelet dysfunction and anti-coagulant use in dialysis

Platelet dysfunction increased risk of bleeding due to :

 diminished platelet count due to mechanical trauma from dialysis .

 reduced platelet adhesion due to increased prostacyclin activity

 decreased platelet factor and decreased capillary strength.

Immunosuppression uremia results in decreased cellular immune function and impaired chemotaxis

Renal osteodystrophy impaired mineral metabolism,increasing risk of fractures, bone defects, pain and calcifications

Treatment & Prognosis

 Conservative management aims to: prevent or correct metabolic changes and preserve remaining renal function.

 Surgical management is only considered once conservative management fails. Management includes renal transplant or dialysis.

 Dialysis is the mechanical removal of excess water and metabolites from the blood in the context of kidney failure.

Peritoneal dialysis involves placement of a catheter into peritoneum of abdomen. Filtration takes placevia osmotic flow.

Hemodialysis (HD) involves a dialyzer, which carries blood through a semipermeable membrane and filters out toxins and metabolites. Usually performed three days a week, which requires a permanent vascular access in the form of a catheter or arteriovenous fistula. HD patients receive anticoagulants such as heparin to ensure a permeable vascular access and constant blood flow through the dialyzer.

 Renal transplantation is indicated in patients with irreversible renal failure. Patients receive immunosuppressive therapy before and after surgery to prevent rejection. This persists for life unless the organ was donated by an identical twin.

Dental Management of Renal Failure Patients

General modifications :

o Multidisciplinary approach to health care involving creation of dental plan in context of patients overall medical status

o Consultation with patient’s nephrologist to determine the state of the disease, treatment being received, ideal timing for dental treatment, and possible medical complications that may arise. Proposed changes to patients’ medications or treatment timingmust discussed with the nephrologist.

o Prior to invasive dental treatment must obtained complete blood count and/or coagulation tests to identify any alterations

o Prompt elimination of sources of infection or oral trauma

o Consideration for antibiotic prophylaxis when treatment involves bleeding or risk of septicemia (extractions, periodontal therapy, endodontics, periapical surgery, orthodontic braces, implant surgery, reimplantation).

o Continuous cardiac monitoring in combination to stress reduction methods (sedation)

o Dose adjustment of drugs whose pharmacokinetics are altered in context of renal failure

• Potential problems include:

 Impaired drug excretion.

Anemia.

Bleeding tendencies.

Associated anticoagulant therapy.

Hypertension.

 Infections e.g. hepatitis B

Renal osteodystrophy

The main concern : bleeding tendency.

• Ensure careful hemostasis if surgery is necessary.

• Local anesthesia is safe unless there is severe bleeding tendency.

• Prophylactic antibiotics are to be prescribed due to immunosuppression.

Dental treatment is best carried Out on the day after dialysis.

• Tetracycline should be avoided in chronic renal failure.

• Patients with renal failure are on immunosuppressive drugs.

• Drugs provided during dental treatment must be given with caution as some drugs may affect Glomerular filtration rate.

Aspirin and NSAIDs should be avoided as they affect renal function.

• Codeine and dihydrocodeine are favored as analgesics and diazepam may be used.

• Retarded teeth eruption can be demonstrated in children with renal failure.

• Dry mouth and decreased salivary flow result in calculus accumulation.

• Alter the dosage of drugs eliminated by kidney i.e.penicillin.

Benzodiazepines do not require dose adjustments, however excessive sedation may occur

Hemodialysis patients should receive dental care on non-dialysis days in order to prevent excess bleeding. Heparin which has a half-life of four hours, must be eliminated from circulation prior to treatment.

Invasive treatment should be preceded by complete blood count and coagulation tests. Local hemostatic measures must be available, including mechanical compression, sutures, topical thrombin, microfibrillar collagen and oxidized cellulose.

Additional

Hemostatic measures may include desmopressin fo severe bleeding renal failure patients, conjugated estrogens, and tranexamic acid rinse or oral tablet (10-15 mg/kg/day).

o Antibiotic prophylaxis remains controversial for these patients. In general, patients with central lines may receive antibiotics one hour prior to dental treatment to prevent bacterial endocarditis.

Transplant patients

o Elective dental care should be avoided within the first 6 months after transplantation

o All sources of infection and hopeless teeth must be extraction prior to transplantation

o Risk of oral infection after transplantation is very high due to concurrent immunosuppressive therapy. Antibiotic prophylaxis is a necessity before invasive dental care.

o Stress dosing may be required for patients receiving prolonged corticosteroids

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