RENAL DISORDERS AND DENTISTRY - Overvierw

• Optimal dental treatment for hemodialysis patients is best administered the day after dialysis due to the reduced heparin effect

Renal Disorders and Dentistry

• Gentamicin is nephrotoxic, avoid use
• Erythromycin is contraindicated in transplant patients taking Ciclosporin
• The following drugs require dose reduction: Aciclovir, Amoxicillin, Ampicillin, Cefalexin, and Erythromycin
• Avoid Tetracyclines other than Doxycycline
• Avoid NSAIDs, unless the patient has mild impairment
• Use caution when administrating dental sedation drugs

Chronic Kidney Injury (CKD/CRF)

• Long-term progressive loss of kidney function as indicated by a low glomerular filtration rate (GFR) over three months or more.
• A sustained reduction in renal function (low GFR) persisting for more than 3 months.
• Caused by diabetes, hypertension, glomerulonephritis, or long-term nephrotoxic medication use can lead to progressive damage.
• Treatment includes controlling underlying causes, dialysis or renal transplantation and addressing complications like anaemia, electrolyte imbalances, and bone disease.
• Early detection and management of risk factors prevent Chronic Kidney Injury (CKD/CRF), such as good blood pressure and diabetes control early.

Nephrotic Syndrome

• Recognizable by heavy proteinuria, low blood albumin (hypoalbuminaemia) and edema, commonly around the eyes (periorbital oedema).
• Glomerular diseases, diabetic nephropathy, or other renal pathologies often cause Nephrotic Syndrome
• Treatment includes steroids alongside addressing underlying causes, monitoring for and managing electrolyte issues, infections, and cardiovascular risks.
• Good diabetic control may reduce risk if secondary to diabetes

Renal Transplant Status

• A patient with a donor kidney replacing failed native kidneys requires lifelong immunosuppression
• Patients require immunosuppression to prevent organ rejection but can still have residual chronic kidney issues.
• Immunosuppression includes steroids combined with drugs like azathioprine or ciclosporin
• Stressful procedures may require Steroid supplementation
• Patients are at risk of infections like oral candidiasis and herpes reactivation, for which prophylactic low-dose aciclovir may be used
• Patients have a long-term risk of malignancy, such as skin cancers, lymphomas
• Providing good care of the transplanted organ through immunosuppressant adherence and infection control prolongs graft survival

Diabetic Nephropathy

• Kidney damage caused by chronic hyperglycaemia with diabetes, the most common cause of end-stage renal failure
• Poorly controlled diabetes results in progressive glomerular damage
• Treatment includes glycaemic control, blood pressure management, dialysis or transplantation
• Prevention includes diet, medication, and regular monitoring

Renal Osteodystrophy

• Bone disease caused by CKD-related disturbances in phosphate, calcium, and vitamin D metabolism.
• Caused by the kidneys inability to excrete phosphate and convert vitamin D to its active form.
• Low calcium triggers secondary hyperparathyroidism, causing bone changes
• Control phosphate through diet and phosphate binders
• Replace active vitamin D and address hyperparathyroidism medically or surgically
• Prevent by early detection and management of CKD, especially monitoring phosphate and PTH levels.

Anaemia of Chronic Kidney Disease

• Normocytic, normochromic anaemia is caused by inadequate erythropoietin production and RBC loss or destruction
• Reduced kidney function causes reduced erythropoietin and fewer RBCs
• Treatment includes Erythropoietin (EPO) injections, Iron supplementation and management of underlying renal disease
• Optimally manage CKD and avoid exacerbating factors to prevent

Sialosis

• Sialosis presents as a non-neoplastic, non-infective swelling of the salivary glands, often the parotid, in dialysis patients
• It is possibly related to metabolic or autonomic changes in advanced renal disease
• Treatment includes managing the underlying condition with dialysis and using ultrasound to rule out malignancy or other causes
• Prevention includes controlling the primary renal disease

Renal Calculi

• Renal Calculi presents as solid masses formed in the collecting ducts and urinary tract, typically made of calcium oxalate, phosphate, or other compounds
• Dehydration, infection, hypercalcaemia, high oxalate diet, and certain genetic predispositions all cause Renal Calculi
• Treatment includes hydration, analgesia for colic, awaiting for spontaneous passage, lithotripsy or surgery
• Prevention includes high fluid intake, addressing underlying metabolic issues, and dietary modifications like a low oxalate, balanced calcium diet

Renal Cancer

• Renal Cancer presents as a malignant growth in the kidney, including Wilms’ Tumour (Nephroblastoma)
• Wilms’ Tumour (Nephroblastoma) is a childhood renal cancer with a good prognosis if treated early
• Renal cancers can involve genetic factors, smoking, and other risks
• Treatment includes nephrectomy and possibly radiotherapy and chemotherapy
• Prevention involves early detection when investigating haematuria

Acute Kidney Injury (Acute Renal Failure)

• Acute Kidney Injury presents as a rapid loss of kidney function that can be signaled by reduced urine output, and potential life-threatening electrolyte imbalances
• Hypovolaemia, severe infections, toxic injuries to kidneys, etc. can cause Acute Kidney Injury
• Treatment includes restoring fluid volume, treating infection and managing hyperkalaemia using IV insulin, glucose, and calcium resonium and potentially dialysis
• Maintaining adequate hydration, blood pressure, avoiding nephrotoxic drugs, and promptly treating infections can prevent Acute Kidney Injury

Drugs, Treatments, and Tests

• Steroid Therapy (e.g., Prednisolone):

  • Use: Immunosuppression during renal transplants and nephrotic syndrome
  • Reduces inflammation and immune response

• Azathioprine / Ciclosporin:

  • Use: Long-term immunosuppression post-transplant
  • Inhibits immune cell proliferation or function; ciclosporin is known for gingival hyperplasia

• Heparin:

  • Use: Anticoagulation for dialysis
  • Enhances antithrombin III, reducing thrombin and factor Xa to prevent clot formation

• Low-Dose Aciclovir:

  • Use: Prophylaxis against viral infections in immunosuppressed patients
  • Inhibits viral DNA polymerase

• Antibiotic Prophylaxis:

  • Use: for renal transplant, which is now not generally required unless within 6 months of transplant or under specialist advice
  • Prevents bacterial infection in immunocompromised patients

• Gentamicin:

  • Use: Broad-spectrum antibiotic, but is nephrotoxic
  • Avoid or use with caution in patients with CKD due to kidney toxicity

• Erythromycin:

  • Use: Antibiotic for bacterial infections
  • Requires dose reduction or avoidance in patients on ciclosporin due to drug interaction

• Aciclovir / Amoxicillin / Ampicillin / Cefalexin:

  • Use: Common antibiotics and antivirals
  • Requires dose adjustments in CKD

• Tetracyclines (except doxycycline):

  • Use: Broad-spectrum antibiotics
  • Avoid in renal impairment due to potential toxicity

• NSAIDs (e.g., Diclofenac):

  • Use: Pain relief, anti-inflammatory purposes, also for renal colic
  • Avoid in significant renal impairment due to risk of worsening kidney function

• Drugs Used in Dental Sedation

  • Use: Sedatives for dental procedures
  • Use with care in CKD due to altered drug metabolism/excretion

• Lithotripsy

  • Use: Non-surgical treatment for kidney stones
  • Delivers shock waves to break stones into passable fragments

• IV Glucose and Insulin Infusions

  • Use: Acute management of hyperkalaemia in renal failure
  • Drives potassium into cells, which lowers blood potassium levels

• Calcium Resonium

  • Use: Agent to reduce hyperkalaemia
  • Binds potassium in the gut for excretion

• KUB (Kidney-Ureter-Bladder) X-Ray and Renal Ultrasound

  • Use: Imaging to detect kidney stones/structural abnormalities
  • Visualizes stones or assesses kidney size/shape

• U & E (Urea & Electrolytes) Test

  • Use: Blood test checking kidney function (urea, creatinine, electrolytes)
  • Provides information on renal function and electrolyte balance

• Nephrectomy, Radiotherapy (DXT), Chemotherapy

  • Use: Possible treatments for renal cancer e.g. Wilms’ tumour
  • Surgical removal of the affected kidney, using radiation/anticancer drugs to control malignant cells

• Be aware of immunosuppression, infection risk, and potential steroid supplementation for invasive procedures in patients with renal disorders

• Adjust doses of renally excreted drugs while avoiding nephrotoxic agents where possible

• Monitor cardiovascular status in patients with CKD and manage bleeding risk, especially if on heparin or with platelet dysfunction

Optimal dental treatment for hemodialysis patients is best administered the day after dialysis. Several drugs require dose reduction, and some antibiotics should be avoided.