This document summarizes the management of patients with kidney disease. It discusses: 1) There are two types of serious kidney disease - acute renal failure which is reversible damage, and chronic kidney disease which is generally caused by long-term diseases and results in reduced kidney function over time. 2) For patients with end-stage renal disease, kidney replacement options include hemodialysis, peritoneal dialysis, or kidney transplantation, each with their own risks and complications. 3) Oral manifestations of kidney disease can include high urea in saliva, xerostomia, periodontal disease, tooth sensitivity and mobility. Management of dental treatment depends on the patient's kidney function and treatment type.

1. Management of patient with
kidney diseasesHANAN SHANAB
OMFS Resident

2. idneyK

3. • Excretion.. Of body waste.
• Homeostasis..regulate
– fluid and electrolytes blance.
– acid-base balance.
Function

4. Function
• Body natural Filter.
• Endocrine function.
– calcitrol, erythropoietin and
renin.

5. Kidney
Disease

6. There are two general types of
serious kidney disease:
Acute renal failure
Chronic kidney
disease (CKD)

7. A- Acute Renal failure:
• It is a reversible rapid damage and deterioration of kidney function that
occurs suddenly.

10. B- Chronic Kidney Disease
– glomerular filtration rate (GFR) < 60 ml/min/1.73 m2.
– evidence of renal damage (micro- or macroalbuminuria, persistent
hematuria, radiological anomalies)
during a period of more than 3 months
Mahmud Juma Abdalla Abdel HAMID, Claus Dieter DUMMER, Lourenço Schmidt PINTO: Systemic Conditions, Oral Findings and Dental Management of Chronic
Renal Failure Patients: General Considerations and Case Report; Brazz Dent J (2006) 17(2): 166-170
increase of serum creatinine and blood ureic nitrogen levels.

11. Chronic kidney disease (CKD) is generally caused
by long-term diseases, such as
Mahmud Juma Abdalla Abdel HAMID, Claus Dieter DUMMER, Lourenço Schmidt PINTO: Systemic Conditions, Oral Findings and Dental Management of Chronic
Renal Failure Patients: General Considerations and Case Report; Brazz Dent J (2006) 17(2): 166-170

12. 20-64 y/o
65 y/o
College of Dental Hygienists of Ontario, CDHO Advisory Kidney Disease and Kidney Failure, 2010-07-15

13. Stages of Chronic Kidney Disease(
CKD)

14. END STAGE RENAL
DISEASE (ESRD)

15. Patients with ESRD can rely on kidney
replacement therapeutic modalities such as:
• Hemodialysis (HD),
• Peritoneal dialysis (PD). or
• Renal transplantation.
National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC)A service of the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDk), National Institutes of Health (NIH).

16. Peritoneal Dialysis

17. Peritoneal Dialysis
• Advantages:
– less costly
– The ability to undertake
treatment without visiting a
medical facility.
• Complication:
– peritonitis

18. Hemodialysis
• Disadvantages:
– Required hospital care.
– Risk for viral transmission (HIV,
Hep B& C)

19. Hemodialysis
• Complications:
– If patients do not adhere to the restriction in fluid intake,
– (chronic) fluid overload may occur, resulting in:
• hypertension,
• acute pulmonary edema,
• congestive heart failure and
• consequently death.

20. Renal Transplant
• Acute and chronic rejection
remains a major clinical
hurdle despite recent
advances in
immunosuppressive
strategies especially 3-6
months post- transplant.
Bv Ciancio G, Burke GW, Jorge D, Rosen A, Miller J. Immunosuppresive treatment options in renal transplantation. Minerva Urol Nefrol 2005;
57: 141-149

21. Complications
– long term use of immunosuppressive medication can lead to side effects
like:
• gingival overgrowth,
• opportunistic infections.
• cancer.

22. ClinicalManifestatio

23. Oral Manifestation
– high urea concentration
in saliva
Altered taste – (metallic)
– ammonia-like smell 1/3
hemodialysis pt.
– Xerostomia
500 ml/day

24. – Periodontal problem
– Loose and painful teeth.
– Sensitivity to percussion and mastication,
– tooth mobility and malocclusion.

25. – enamel abnormalities, altered
eruptions.
– Calculus,
– Pale gingivae (anemia)
– No caries..

26. – Uremic frost (crystals deposits
more in skin than oral mucosa).
– Stomatitis (in sever RF).

27. – Oral mucosa & gingival
bleeding. (thrombocytopenia)
– Drug-induced gingival
hyperplasia.(cyclosporine, & Ca
channel blocker).
Lee and Gisser 1978; bradford et al 1990

28. • Infections:
Candida, CMV & HSV
R Proctor; N Kumar; A Stein; D Moles; S Porter “Oral and Dental Aspects of Chronic Renal Failure’’ Journal of Dental Research; Mar 2005; 84, 3;
Health & Medical Complete pg. 199

29. In CRF Classical triad:
– 1.loss of lamina dura,
– 2.Demineralized bone ( ground glass appearance)
– 3.Localized maxillary and mandibular radiolucent lesions, central giant cell
granuloma ‘brown tumor’

30. Renal Osteodystrophy
Chronic renal
failure
Decrease
glomerular
function
Decrease
1,25(OH)2D3
Increase
serum
phosphate
Decrease
serum
Calcium
Increase the PTH secretion
Renal Osteodystrophy
Osteomalacia, Osteitis Fibrosa Cystica, Osteosclerosis

31. Osteitis Fibrosa Cystica

34. Management During Dental Treatment:
Patient under conservative
care
Patient on dialysis

35. History and Physical Ex
 History of DM, Related bony
disorders,
 Medication..?..

36. LABS
Complete Blood Count
Liver Function Test Urea & Electrolyte

37. Patient under conservative care
1- Consult with the physician
regarding physical status if:
Positive findings in patient history or lab

38. Patient under conservative care
3- Screening for bleeding disorders
2- Monitor blood pressure.

40. Patient under conservative care
4- Pay meticulous attention to good
surgical technique and accepted oral
hygiene.
To avoid infections, periodontitis and
xerostomia related complication.

41. Patient under conservative care
5- Avoid nephrotoxic drugs (
acetamenophen in high doses, acycolovir,
aspirin, NSAID).
6- Adjust the dose of drugs metabolized by
kidney.

42. Drug administration require adjustment during uremia for
reasons beside nephrotoxicity and renal metabolism:
• 1. low serum albumin value reduces the number of binding sites, increasing
toxicity.
• 2.uremia can modify hepatic metabolism of drugs ( increase or decrease)
the clearance.

43. • 3. Antacid may complicate uremic effect.
• 4. ASA & NSAID potentiate uremic platelet defects so these antiplatelets
must be avoided.
Drug administration require adjustment during uremia for
reasons beside nephrotoxicity and renal metabolism:

44. Alba Jover Cerveró, José V. Bagán, Yolanda Jiménez Soriano, Rafael Poveda Roda ‘’Dental management in renal failure: Patients on dialysis’’
Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.

45. Alba Jover Cerveró, José V. Bagán, Yolanda Jiménez Soriano, Rafael Poveda Roda ‘’Dental management in renal failure: Patients on dialysis’’
Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.

46. Alba Jover Cerveró, José V. Bagán, Yolanda Jiménez Soriano, Rafael Poveda Roda ‘’Dental management in renal failure: Patients on dialysis’’
Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.

47. Patient under conservative care
7- Aggressive managing orofacial
infections with culture and sensitivity
tests and appropriate Antibiotic (avoid
nephrotoxic).
8- consider hospitalization for sever
infection or major procedure.

48. HEMODIALYSIS

49. If patient on dialysis
• 1. same as conservative care
recommendation.
• 2. consult with the physician
about the risk of bacterial
endocarditis.

50. Can take Oral
Non-Allergic to penicillin
– Amoxicillin
• Adult dose: 2 g PO
• Pediatric dose: 50 mg/kg
PO
Allergic to penicillin
– Clindamycin
• Adult dose: 600 mg PO
• Pediatric dose: 20 mg/kg PO
– Cephalexin or other first- or
second-generation oral
cephalosporin in equivalent dose
anaphylaxis)
• Adult dose: 2 g PO
• Pediatric dose: 50 mg/kg PO
– Azithromycin or clarithromycin
• Adult dose: 500 mg PO
• Pediatric dose: 15 mg/kg PO

51. Can’t take Oral
Non- Allergic to penicillin
– Ampicillin
• Adult dose: 2 g IV/IM
• Pediatric dose: 50 mg/kg
IV/IM
Allergic to penicillin
– Clindamycin
• Adult dose: 600 mg IV
• Pediatric dose: 20 mg/kg
IV
– Cefazolin or ceftriaxone
anaphylaxis)
• Adult dose: 1 g IV/IM
• Pediatric dose: 50 mg/kg
IV/IM

52. • 3. consider corticosteroid
supplementation as indication.
Avoid adrenal crisis
•They are taking large doses
of corticosteroids (10 mg
daily of prednisone or
equivalent).
If patient on dialysis

53. • 4. Dosage adjustment in accordance with advice from patient’s physician.
If patient on dialysis

54. If patient on dialysis
• 5. beware of ArterioVenous (AV)
fistula or shunt.
– Susceptible to infection
(endarteritis), become a source
of bacteremia, resulting in
infective endocarditis (2-9%) .

55. AVOID

56. If patient on dialysis
• 6- Dentist must be aware of pt’s drugs
and dental precaution measures that are
appropriate

57. • Because approximately 40% of pt. on
dialysis patients have CHF & 9% may
die from cardiac complication each
year.
– So pt. is taking antihypertension,
Anticoagulant& Drugs for CHF

58. • 7. Assess liver function and screen it for opportunistic infection.
– Increase risk for carrier state of Hep B and C ,and HIV
If patient on dialysis

59. • 8. determine the hemostasis status is
important
They have tendencies to bleed from the
physical destruction of platelets &
using of heparin.
If patient on dialysis

60. Bleeding Precaution
• 1. timing of dental treatment
– Avoid the day of the dialysis ( fatigue ,
bleeding tendencies (heparin 3-6 hrs
activity), fluid overload
– Choose the day after the dialysis to
provide a time for clot retention.
• 2. primary closure and hemostatic agents

61. Bleeding Precaution
• 3. contacting the nephrologist
when necessary &requesting
the heparin dose to be reduced
or eliminated during the 1st
hemodialysis session after the
surgical procedures.

62. • 4. request protamine sulfate to be
given when immediate care is
necessary as antidote for the heparin.

64. thanx
Thank you
grateful
merci
Thank
you

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