Renal Diseases, Dialysis & Transplantation

• Kidney Function:

  Excrete waste including dental drugs

  Regulate fluid volume and acid / base

  Maintenance of blood pressure

  Synthesise three hormones:

  erythropoietin: RBC production

  renin: BP control

  1,25-dihydroxycholecalciferol: Vitamin D metabolism and calcium control
• kidney is a target organ for...

  parathormone - regulates calcium levels in the body

  aldosterone - regulates blood pressure by managing sodium and potassium levels in the body

  anti-diuretic hormone (ADH) - regulates volume of water in the body
• Normal parameters:

  Filter (GFR) 100ml / min (150L / day)

  99% of the 100ml / min is reabsorbed

  Urine production 0.5 - 1.5 ml / kg / hr (1- 2.5 L per day (70Kg)

  Glomerular filtration rate (GFR) is estimated from blood creatinine level, age, race & gender
• Kidney disease:

  Asymptomatic until advanced stage

  Affects 15% of UK population over age 35

  Up to 40% of those affected are unaware

  Hypertension and Diabetes are main risk factors

  Asian and Black Caribbean at most risk
• risk factors for kidney disease

  diabetes: 38%

  hypertension: 26%

  glomerulonephritis: 16%

  other diseases: remaining 20%

  Modifiable risk factor:

  diabetes

  hypertension

  cardiovascular problem: MI etc

  obesity

  tabacco usage
• kidney disease stages

  Healthy, normal GFR is 100. This gives approximate % of kidney

  Stage 4 and 5, transplant or dialysis patients are at high risk for dental treatment

  Stage 1: >90

  Stage 2: <90, >60

  Stage 3: <60, >30

  Stage 4:<30, >15

  Stage 5:<15

  
• Consequence for kidney diseases:

  - Increased cardiovascular risk

  - Anaemia & reduced immunity (low erythropoetin production → anaemia; high urea retention → immunosuppression)

  - Increased Risk of bleeding (platelet affected)

  - Fluid Imbalance

  - Decreased bone health (disruption in 1,25-dihydroxycholecalciferol production → decreased calcium reabsorption)

  - Build up of toxins within blood (cerebral function)

  - Reduced drug excretion (higher drug retention)
• Dental implications:

  Take care with stage 4 and 5 renal failure patient

  Increased periodontal disease

  Oral signs of anaemia (angular chelitis, oropharyngeal web)

  Bone abnormalities

  Potential increased bleeding tendency

  Care with Ibuprofen (NSAIDs )

  Good oral health supports nutrition / preparation for transplant
• Renal diseases with low calcium level in the mouth:

  failure to excrete PO4 + Low Vitamin D → low calcium ion → increased production of parathormone in thyroid gland → increased osteoclast production and activity →central giant cell granuloma

  
• Common dental drug and CKD:

  Lignocaine: no alteration

  Articaine: no alteration

  Amoxycillin: Reduce dose if end stage (GFR <10)

  NSAID’s: Avoid if end stage (GFR <10) or diabetes

  Erythromycin: Avoid due to drug interactions

  Midazolam: Use with caution if stage 4+ (GFR < 30)
• Haemodialysis:

  3 times per week, time consuming and labour intensive

  Requires AV fistular for vascular access

  Requires dialysis machine

  Can be done at home

  Requires anticoagulation with heparin

  
• AV fistulae

  Do not put a needle or measure BP in this arm
• Peritoneal dialysis


  dialysis in which the lining of the peritoneal cavity acts as the filter to remove waste from the blood - not suitable for more advanced cases
• dialysis

  Necessary once function is no longer able to meet demand: GFR <10 (<10% function) e.g. End Stage Kidney Disease
• Oral surgery and haemodialysis:

  Treat on morning of non dialysis days: maximum day until next dialysis

  Place Surgicel® (haemostatic agent - promotes clotting) in the socket and sutured to promote blood resorption

  Local haemostatic measures if surgery

  Antibiotic prophylaxis due to immune defect

  Liase with renal team

  Avoid injections / BP measurement in AVF arm
• Kidney transplantation:

  5000 kidney transplant per year

  Very successful 86% - 91% @ 5 Years

  Cost effective

  Physiological benefit

  Live donor / cadaveric donor

  Requires immune suppression for life
• Transplant waiting list:

  Currently 6138 on transplant WL (Feb 2020)

  1118 either died or became too ill for Rx

  30% increase in transplants (4762 in 2019)

  56,300 total number of functioning transplants in UK
• Oral side effect from immunosuppression that comes from kidney transplantation: generalised

  Delayed Healing

  Infection

  Candida (widespread)

  Herpes Simplex

  Accelerated Periodontal Disease

  Leukoplakia (EBV)
• Oral side effect from immunosuppression that comes from kidney transplantation: malignancy


  Occurs in 3 - 31 % of transplant patients:

  Lip Squamous Cell Carcinoma (SCC) most common

  Oral Squamous Cell Carcinoma (SCC)

  Basal Cell Carcinoma (BCC)

  Kaposis Sarcoma
• Summary:

  CKD more of a concern at stage 4 & 5 (GFR<30)

  Routine dentistry can be performed with minimal risk. More caution with surgical procedures

  Most dental drugs can be used without modification

  If invasive procedure treat haemodialysis patients on non dialysis day with local haemostatic measures