This document discusses the relationship between chronic kidney disease (CKD), kidney transplantation (KT), and periodontal disease. It notes that periodontal disease is a risk factor for CKD, as elevated antibodies against the periodontal pathogen Porphyromonas gingivalis have been linked to CKD progression. Patients with CKD or post-KT have impaired immunity making them susceptible to infection from periodontal bacteria. The document outlines how periodontal bacteria can enter the bloodstream and cause systemic inflammation, increasing risks for vascular damage and conditions like proteinuria. Inflammatory markers associated with periodontal disease may also impact renal allograft survival. Proper management of oral health is important for CKD and KT patients.

1. Sinem Koca
University of Zagreb School of Dental Medicine
January, 2020

2. • chronic infection and inflammation of oral and
periodontal tissues
• characterized by the destruction of connective
tissues of the periodontium and alveolar bone
• may lead to not only local symptoms but also
systemic diseases (cardiovascular diseases,
diabetes, liver disease, chronic obstructive
pulmonary disease, and several types of
cancer)
• important risk factor for CKD

3. • gram-negative bacilli
play a major role
• Porphyromonas
gingivalis is implicated
in periodontal disease.
• Elevated levels of
immunoglobulin G (IgG)
antibodies against P.
gingivalis were shown
to positively correlate
with the onset and
progression of CKD.
Periodontal Disease

4. • either the presence of kidney damage, such as
proteinuria and hematuria or decreased kidney function
• Proteinuria is the presence of excess proteins in
the urine.
• Hematuria is defined by the presence of blood or red
blood cells in the urine.

5. • negative impact on prognosis and quality of life (QoL)
due to the increasing risk of various pathological
conditions

6. • an irreversible reduction of functional nephrons and leads
to an increased risk of various pathological conditions
(cardiovascular disease and neurological disorders,
coronary artery calcification, hypertension, stroke)
• patients have impaired immunity against bacteria and
viruses

7. • KT is performed for patients with end-stage renal disease
as a renal replacement therapy.
• although kidney function is almost normalized by KT,
immunosuppressive therapy is essential to maintain
kidney allograft function and to prevent rejection
• patients are more susceptible to infection

8. • As renal replacement therapy,
peritoneal dialysis,
hemodialysis, and kidney
transplantation (KT) are usually
selected.
• KT should be considered an
immunosuppressive status due to
the immunosuppressive
therapy required in these
patients.
• This immunoreactivity plays an
important role in periodontal
disease.

9. • may worsen oral status
• Calcineurin inhibitors (CNI) such as Cyclosporin
A (CsA) and Tac have played a central role in
immunosuppressive therapy of KT
• CsA is characterized by a major side effect of
gingival overgrowth (GO), which may lead to
occasionally worsening of oral health

10. • patient received KT
• transplanted renal graft achieves normal function
• limitation of amount of drinking water and excessive
dietary restriction are necessary
• oral health is improved by increased drinking of water
and normalization of salivary properties
• prevent the periodontal disease

11. Both CKD and KT present disadvantages in
terms of suppression of immune function!
periodontal bacteria can easily affect them

12. There are several mechanisms through which periodontal
bacteria affect multiple organs:
• systemic bacteremia
• cytokine release and inflammation
• swallowing to the gastrointestinal tract
• direct exposure through alveolar bone destruction
• The first two mechanisms are common pathways for
multiple organ failure.

13. • Bacteremia invades the blood stream through the
periodontitis lesion and influx of inflammation mediators,
such as interleukin (IL)-6 and tumor necrosis factor
(TNF)-α, produced in the lesion can be introduced into
the systemic circulation.
• Bacteremia is an important step in the progression to
systematic inflammation in patients with periodontal
diseases.

14. • gingival ulceration in the periodontal pocket enables
bacteria to enter the systemic circulation
• some periodontal disease bacteria can survive
intracellularly and cause silent systemic inflammation
(such as P. gingivalis and Actinobacillus
actinomycetemcomitans)

15. • various cytokines are involved in the pathogenesis of
periodontal disease
• inflammatory cytokines regulate bone resorption and
inhibit bone formation
• cytokines in periodontal diseases increase vascular
permeability, enhance the expression of adhesion
molecules
• These responses may be associated with proteinuria via
glomerular permeability, renal thrombosis and renal
fibrosis.

16. • inflammatory cytokines originating from bacteremia or
paracrine from distal periodontal lesions will cause
vascular permeability and vascular wall injury
• endothelial dysfunction

18. • Several inflammatory markers such as IL-6 and C-
reactive protein (CRP) may be predictors of renal
allograft survival associated with alloimmune-dependent
acute rejection.
• Specific cells associated with periodontal disease may
produce significantly higher levels of IL-6, and serum
CRP was reported to be elevated in patients with
periodontal inflammation.

19. • Several investigators have reported an increased
frequency of periodontal pathogens in CKD and KT
patients.

20. • CKD and KT patients may exhibit periodontal conditions
worse than that of the healthy general population
• the treatment of periodontal disease attenuates systemic
inflammation and improves surrogate markers of
endothelial function
• it is important to treat oral infectious foci at the pre-
dialysis stage in order to prevent adverse outcomes after
KT

21. • Periodontal disease is an important risk factor for CKD.
• Elevated levels of immunoglobulin G (IgG) antibodies
against P. gingivalis (implicated in periodontal disease)
were shown to positively correlate with the onset and
progression of CKD.
• CKD patients have impaired immunity against bacteria
and viruses, they are more susceptible to infection and
they present disadvantages in terms of suppression of
immune function. Since the gingival ulceration in the
periodontal pocket enables bacteria to enter the systemic
circulation and some periodontal disease bacteria can
survive intracellularly and cause silent systemic
inflammation; it is clear that periodontal bacteria can
easily affect these patients. Bacteremia is an important
step in the progression to systematic inflammation in

22. • Inflammatory cytokines originating from bacteremia or paracrine from
distal periodontal lesions will cause vascular permeability and
vascular wall injury it will lead to endothelial dysfunction. Endothelial
dysfunction is the risk factor of proteinuria and end stage renal
failure.
• Influence of some of the immunosuppressive drugs may worsen oral
health.
• Oral health is improved by increased drinking of water and
normalization of salivary properties and it is necessary for the KT
patient to have limitation of amount of drinking water.
• Frequency of periodontal pathogens in CKD and KT patients,
increases.
• Several inflammatory markers such as IL-6 and C-reactive protein
(CRP) may be predictors of renal allograft and also patient with
periodontal disease may produce significantly higher levels of IL-6,
and serum CRP.