medical complications in dental practice - renal

1. Renal Disorders
Dr SuryatiYakob
MRCP (UK) FRCP ( Edin)
Hospital Selayang, Hospital SG Buloh

2. Outline

3. Outline
• CKD and complications
• Dental complications in CKD
• Perioperative risks in CKD
• Reducing perioperative risks
• Summary

4. Functions of
Kidney
Blood
pressure
Filtering
Toxin
Production of
RBC
Calcium Balance
Bone formation
Fluid
Balance
Acid - Base
Balance

5. Kidney Disease in General
Acute Kidney Injury Causes of AKI
KDIGO 2012

6. CKD – Definition (KDIGO 2012)
1. Markers of Kidney Damage ≫ 1 > 3 months
AER ≫ 30 mg/d or ACR 30 mg/g
Urine sediment abnormalities
Electrolytes and other abnormality
due to tubular disorder
History of
kidney transplant
Histopathology Abnormalities
Structural abnormalities
2. Decreased GFR > 3 months
GFR < 60 mls/min/1.73m2

7. Causes of
CKD

8. Symptoms
of CKD
Late
Stage

9. Global Prevalence of Chronic Kidney
Disease
Nathan R Hill et al.PONE| DOI:10.1371/journal.pone.0158765 July 6, 2016

10. 876 individuals, 15,147 respondents from the National Health and Morbidity Survey 2011

11. 851 cases
Mean age : 61 years old
DN 44.9%
HPT 24.2%
Obstructive uropathy 9.2%

12. New Dialysis andTransplant Patient
2005-2014
unctioning transplant at 31st
December 1716 1771 1788 1808 1852 1881 1907 1891 1870 1844
Figure 1.1: Stock and flow of RRT, Malaysia 2005 2014
(a) New dialysis and transplant patients
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
5,000
5,500
6,000
6,500
7,000
No.
of
patients
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Stock and Flow-New Dialysis patients 2005-2014
New Dialysis
0
20
40
60
80
100
120
140
160
180
200
No.
of
patients
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Stock and Flow-New Transplant patients 2005-2014
New Transplant
MDTR 2014
6107
948 PD

13. Classification
and Risk
Stratification
KDIGO ( 2012)

14. Modalities of Renal ReplacementTherapy
Interchangeable, depends on residual renal function
Ramesh Khanna & Karl D. Nolph
PD
preferred
NATIONAL
POLICY
PALLIATIVE

15. Outline
• Kidney disease in general – AKI and CKD
• CKD Complications
• Dental complications in CKD
• Perioperative risks in CKD
• Reducing perioperative risks
• Summary

16. CKD
Complications
Nutrition
Uremia and
Acidosis
Fluid and
Electrolytes
Imbalance
CAD
CKD-MBD
Anemia
Pharmaco-
kinetics
Bleeding
Arrhythmia
Risk of Infection

17. CKD and Pharmacokinetics
• Pharmacokinetics is the study of the course of a drug in the body and is
used to predict serum concentrations and drug activity
• Pharmacokinetic studies are frequently not performed in patients with renal
failure but physicians should be aware of data when available
Pharmacokinetic factors to consider in drug distribution:
Drug absorbed
(oral, IV, rectal,
lung)
Drug in blood
Drug Metabolism
(liver, kidney, GI
tract)
Elimination
Urine, Biliary,
Dialysis, Lung
Skin
Drug in other
fluids
Drug in tissue
4
GI, gastrointestinal. IV, intravenous.
Volume
distribution
Protein
Binding
Decreased GI
Absorption
Altered First Pass
Metabolism
1. Impaired
- glomerular filtration
- renal epithelial cell metabolism
2. Decreased renal tubular secretion
Mode of Dialysis
- HD, HDF
- CRRT
- PD

18. Drug Dose Adjustment in CKD
Adapted from Jover-Cerveró A et al. Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.

19. Drug Dose Adjustment in CKD
Adapted from Jover-Cerveró A et al. Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.

20. General Management of CKD
KDIGO 2012

21. Outline
• Kidney disease in general – AKI and CKD
• CKD Complications
• Dental complications in CKD
• Perioperative risks in CKD
• Reducing perioperative risks
• Summary

22. 90%
Bleeding
tendency
Uremic Related
Xerostomia
Infection
Calculus
Transplant/Drug
Related
Tooth Structure
Abnormality
Dental Caries
Teeth
discolouration
CKD-MBD
SOFT
TISSUE
HARD
TISSUE
Periodontal Disease -Chronic inflammatory condition and
associated with atherosclerosis and malnutrition

23. Periodontal Disease in CDK and ESRD -
Pathogenesis
• Decreased, fluid restriction à Xerostomia à caries, mucositis and
oral infection
• Dialysis vintage - gingivitis, probing depth, attachment loss, and
enamel hypoplasia
Salivary Production
• Different levels of protein, potassium, magnesium and
phosphorus concentrations
• Predispose to calculus formation
Salivary Chemistry
• Normal commensal – gram positive organism
• CKD – gram negative organism à endotoxin
Microbiology of
Periodontal Infection
• No clear correlation
Hyperparathyroidism
Venkatesh KA et al.Cardiorenal Med 2013;3:71–78

24. Outline
• Kidney disease in general – AKI and CKD
• CKD complications
• Dental complications in CKD
• Perioperative risks in CKD
• Reducing perioperative risks
• Summary

25. Surgery in the Eyes of Nephrologist

26. CKD
Complications
Nutrition
Uremia and
Acidosis
Fluid and
Electrolytes
Imbalance
CAD
CKD-MBD
Anemia
Pharmaco-
kinetics
Bleeding
Arrhythmia
Risk of Infection

27. R
E
V
I
E
W
Procoagulant
State
Bleeding State
F I G U R E 2 : Factors involved in the increased risk of thrombosis in patients with renal failure (for details see the text).
F
U
L
L
R
E
V
Hemostasis in CKD

28. Risk of Bleeding
1. NDT. 2003; 18: 1834–1841
2. Blood Rev 2011; 25: 271–278

29. Risk of Bleeding in CKD
Platelet and PWI
Dysfunction Platelet ∝
granule
Arachidonic
acid and
Prostaglandin
metabolism
Uremia
Haemodialysis Calcium
Anemia
Oxidative
Stress
Drugs

30. 9376 citations from multiple databases for cohort studies published between 1990 and
2011.
Included patients undergoing any major surgery, with a sample size of at least 100
patients with CKD( Elevated serum creatinine value or a low EGFR)
Outcomes compared with a reference group of at least 100 patients without chronic
kidney disease.
Primary outcomes were
1. Receipt of perioperative blood transfusions and
2. Need for reoperation for reasons of bleeding.

31. 23 studies met criteria for review - 20 cardiac surgery and 3
non–cardiac surgery
CKD associated with
1. A greater risk of requiring blood transfusion – OR 2.7
2. More reoperation for reasons of bleeding – OR 1.6

32. Hemostasis in CKD
Bleeding
Procoagulant

33. Risk ofThrombosis
Blood Rev 2011; 25: 271–278
Am J Kidney Dis 2011; 58: 746–755
Semin Dial 2003; 16: 245–256

34. ArterialThrombosis
• ACS
• Cerebrovascular
event
• Peripheral arterial
thrombosis
Venous thrombosis
• DVT,PE
• HD vascular access
thrombosis – AVF,
AVG and HD catheter
• Central vein
thrombosis

35. Risk of Thrombosis
Coronary Artery Disease in Chronic Kidney Disease Current Cardiology Reviews, 2013, Vol. 9, No
Fig. (2). Pathophysiology of progressive atherosclerosis in chronic kidney disease.
Smoking
Traditional risk factors
Smoking
Diabetes
Dyslipidemia
Hypertension
CKD-related risk factors
Inflammation, Oxidative stress, and
Endothelial dysfunction
Pro-inflammatory cytokines
↓NO Carbamylated LDL
↓NO, Carbamylated LDL
ADMA, P-cresylsulfate
Vascular calcification
Calcium-phosphate product, PTH
CKD
CKD Atherosclerosis
Atherosclerosis
BSALP, TRACP-5b, fetuin-A, BMP-4
Hyperhomocysteinemia
Immunosuppressants
Corticosteroids
Corticosteroids
Calcineurin inhibitors
Cyclosporine
ATHEROSCLEROSIS

36. CKD and CAD
GFR Mortality
>90 cc/min 2%
60-90 cc/min 3.4%
30-60 cc/min 8.8%
< 30 cc/min 15.5%
United States Renal Data System. 2016;
USRDS annual data report: Epidemiology of kidney disease
in the United States. National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2016

37. Cause of Death 2010-2014
22nd Report of the Malaysian Dialysis andTransplant Registry

38. CKD and Perioperative Risk
acute renal failure cardiovascular complications
increased morbidity and mortality
Howell SJ et al. BJA 1998; 80: 14– 9 59
Howell SJ et al. BJA 1999; 82: 679 – 84
O’Hare AM et al. JASN . 2003;14:1287–95.
Lok E et al. Am Heart J 2004; 148:430–8.

39. CVS
Hemostasis
Fluid and
Electrolytes
Metabolic
Acidosis
Autonomic
neuropathy Peri
Operative
Risk
Pharmacokinetics
Pharmacodynamics

40. Outline
• Kidney disease in general – AKI and CKD
• CKD complications
• Dental complications in CKD
• Perioperative risks in CKD
• Reducing perioperative risks
• Summary

41. Reducing Perioperative Risks

42. Nephrology Intervention
• Haemodialysis

43. Hemostasis Control
(E. A. Georgakopoulou et al. 2011)

44. BloodTransfusion
KDIGO 2012

45. If possible , AVOID blood transfusion except in
1. Urgent treatment of anemia – acute bleeding,
unstable CAD, rapid preoperative Hb correction
2. ESA therapy ineffective
3. ESA therapy has potential harm – previous
current malignancy, previous stroke

46. Nephrology Intervention
• Peritoneal Dialysis
• Transplant

47. Dental Problems in RenalTransplant
Patients
PreTransplant PostTransplant
• Malignancy
• Infections

48. Take Home Message

49. suryatiyakobhs@gmail.com
www.dermaorgan.gov.my