CAT in front of a renal failure

  CAT in front of a renal failure:

1- Introduction  :

      In his daily practice, the dentist is often confronted with therapeutic problems, especially when dealing with patients with general diseases.

     Some of these diseases require special care, due to their odonto-stomatological expression, the medications taken and the complications they cause, such as nephropathies. 

2- Anatomical reminder of the kidney:

• Most people have two kidneys, but you can live a normal life with just one.
• The kidneys are two organs located on either side of the spinal column, in the retroperitoneal compartment, between the tenth and eleventh ribs.
• They are shaped like a bean, with a firm consistency. The kidney has an arterial blood inlet: the renal artery and a venous blood outlet: the renal vein.

CAT in front of a renal failure

CAT in front of a renal failure

2-1 Macroscopic aspect:

• On a cross-section: 

The kidney is made up of two distinct areas:

• The medulla: deep and central
• The peripheral cortex. We need to know how we k

2-2 Microscopic appearance:

• Each kidney has about 800-1.5 functional units called nephrons.
• Visible only under microscopy. The majority of the nephron is located in the renal cortex.

• Each nephron consists of a glomerulus and a tubule.

a. The glomerulus:

• The glomerulus has the shape of a sphere limited by an envelope called Bowman’s capsule.
• It has two poles:

• A urinary pole: where the proximal convoluted tubule is inserted, which connects the tubule with the glomerulus.
• A vascular pole: where the afferent arteriole enters and the efferent arteriole leaves.

Role: production of primary urine by filtration of the blood.

b. The tubule: 

CAT in front of a renal failure

• It is subdivided into four segments:

• Proximal convoluted tubule: which follows the glomerulus.
• Loop of Henle: the descending branch is slender and the ascending branch is wide.
• Distal convoluted tube
• The collecting tube or canal that opens at the bottom of the minor calyces which drain into the major calyces, which empty urine into the renal pelvis.
• Each of its segments has a precise physiological function, which involves both reabsorption phenomena: recovery of part of the water, sodium, etc. and secretion , to transform the primitive urine, formed in the glomerulus, into definitive urine, the quantity and composition of which vary so that the internal environment of the body remains balanced.

Role of the nephron:

• Impermeability to macromolecules larger than 60kD (dalton). That is to say, the nephron and more precisely the glomerulus functions as a filter, allowing only molecules smaller than 60kD to pass through.
• With a high filtration rate of 120ml/min, they filter approximately 180L/day of fluids carried by the bloodstream but only reject 1.5 to 2 liters of urine per 24 hours. This implies that almost all of the filtered fluids are reabsorbed by the nephron tubules in order to maintain the balance of the internal environment.

2.3- Physiology of the kidney:

The kidneys perform three functions:

• Blood purification: The kidney is the body ‘s purifying organ for eliminating waste and toxic substances (medicines, urea, ammonia, etc.)
• Maintaining hemostasis of the internal environment:

• Maintaining hydro-electrolyte balance: hydro-electrolyte imbalance causes serious complications: heart failure, acute pulmonary edema .
• Maintaining acid-base balance: which reflects the stability of the body’s pH. An imbalance can cause acidosis.
• Maintaining the phospho-calcium balance: which plays an important role in the architecture of bone tissue.
• The secretion of several hormones (endocrine function):

• Renin: responsible for the production of angiotensin II and aldosteron which are involved in the regulation of blood pressure.
• Erythropoietin: which acts on the bone marrow to produce red blood cells
• Calcitriol: active form of vitamin D, responsible for the formation and turnover of bone tissue.

Chronic renal failure

Increased renin

Decreased erythropoietin

Decreased calcitriol

• Which explains: 

• Habitual hypertension in chronic renal failure.
• Anemia due to a decrease in red blood cells.
• Osteoporosis, disappearance of the lamina dura and loose trabeculation of the jaws.

3- Classifications of nephropathies:

• Kidney disease due to a functional disorder or organic lesions of the kidney. Nephropathies are classified according to their initial anatomical location.

The different types of nephropathies:

1. Glomerular nephropathy:

• Their causes are varied but we can, however, distinguish between secondary glomerulopathies (due to an identified disease) and primary glomerulopathies (when the renal damage is isolated, without a known cause). 

2. Tubulopathies or tubular nephropathies:

• This type of nephropathy is often secondary to drug poisoning (notably many antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, etc.) or non-drug poisoning (mercury, arsenic, lead, etc.), or to general or renal infections, etc.

3. Interstitial nephropathies:

• Depending on their mechanism, two main types of interstitial nephritis are distinguished:
• By urinary route: 

Also called ascending interstitial nephritis, or pyelonephritis, they are due to an infection or a malformation of the excretory tract (calyces, renal pelvis, ureters, bladder, urethra).

• By blood:

They occur when the blood carries an infectious (septicemia), toxic (for example, a drug molecule) or antigenic agent to the kidneys.

4. Vascular nephropathies:

• Such as nephroangiosclerosis, which is the sclerosis of the arterioles of the kidney, sometimes secondary to an increase in blood pressure that is poorly or not treated. Vascular nephropathy also characterizes an attack on the vessels of the kidney in general.

5. Other conditions: 

• Renal developmental abnormalities: polycystic kidney, horseshoe kidney.
• Kidney stones.    

• Diabetic nephropathy: damage to the small vessels of the kidneys occurring during diabetes mellitus.
• Analgesic nephropathy: Chronic kidney disease caused by the overuse of certain analgesics.
• Pregnancy nephropathy.

• Diseases of the large vessels of the kidney: thrombosis of the renal veins responsible for anuria or nephrotic syndrome.
• Nephritic syndrome: characterized by: oliguria, proteinuria, edema, high blood pressure and acute renal failure.  

4- CAT itself:

The protocol common to all nephropaths:

• Work in contact with the attending physician (current treatment, the various risks).
• Avoid treatment if the disease is unstable;
• Make the patient comfortable and reduce stress (quick care in the morning) 
• Monitor blood pressure;
• Take different precautions in relation to different risks.
• Administer anesthesia with or without VC at reduced doses. 
• At the time of prescription: 
• Painkillers: 

– Paracetamol

• The ATBs:

– Azithromycin, Clindamycin, Doxycycline, Penicillin V, Rovamycin.

• Local anesthesia: Lidocaine
• Sedative/hypnotic: Benzodiazepine 
• Dosage reduction of renally excreted drugs by applying the following possibilities:
  • prescribe lower unit dosages while maintaining the usual interval.
  • Prescribe usual dosages with increased intervals between doses.  
• Hospitalization of the patient for urgent procedures (cellulitis; fractures, etc.).

1. Acute renal failure:

• Definition : sudden, generally reversible, loss of renal function, it occurs rapidly following a sudden drop in BP (due to surgery, illness or severe infection or shock). 
• IRA can be classified according to:

1. From the location of the injury:

• Pre-renal, post-renal or renal involvement.

2. The type of the attendee:

Functional IRA:

due either:

• Heart failure.
• Severe dehydration.
•  A significant hemorrhage.
•  Use of diuretics 

Organic IRA:

Secondary to the destruction of one of the constituents of the kidney ensuring blood filtration due to: 

• Medicines.
• Toxic metals.
• A serious kidney infection 
• An autoimmune disease 

• IRA of mechanical origin:
• Due to an obstacle preventing the normal elimination of urine:
•  Urinary lithiasis (stone) 
• Tumors: 

          *prostate adenoma 

 *prostate cancer 

          *bladder cancer 

          *certain pelvic cancers

Signs and symptoms:

• Digestive bleeding.
• Convulsion. 
• Decrease in PA.
•  Increased pulse.
•  Skin folds.
•  Dryness of the mucous membranes and oligouria.
• Oral manifestations:

– Erythematopultaceous and ulcerative stomatitis: candidiasis 

– Ulcers on the ventral surface of the tongue, on the floor of the mouth and cheeks.

– Gingivitis.

• Action to take:

TRT of oral lesions:

• Good oral hygiene 
• BB with hydrogen peroxide or chlorhexidine.

 Precautions during dental care :

• Any procedure is only performed in an emergency setting, in a hospital environment and must be preceded by antibiotic prophylaxis to combat the risk of infection.
• Take precautions specific to the pathology in question or concomitant.
• Bleeding control through good hemostasis.

2. Chronic renal failure:

• Definition : a prolonged, often permanent, decrease in exocrine and endocrine renal functions.
• It is expressed mainly by a decrease in the glomerular filtration rate (GFR) with an increase in creatinine and uremia:

              – Creatinemia: 7 to 12 mg/l

              – Blood urea: 0.1 to 0.5g/l

              – Creatinine clearance (normal 120ml)

• Glomerular filtration rate: Kock Roft and Golt:

            140 – age × weight K= 7.2

             Creatinine × K K=7.5

• The measurement of glomerular filtration rate remains a commonly performed test to determine the degree of chronic renal failure, expressed in ml/min/1.72m².

Depending on the glomerular filtration rate and serum creatinine, renal failure can be mild, moderate, severe or terminal:

Stage I: >90 means normal or high GFR.

Stage II: 60-89 means minimal failure: mild CRI.

Stage III: 30-59 means moderate failure: moderate CKD.

Stage IV: 15-29 means significant failure: severe CKD.

Stage V: < 15 means total failure: terminal CKD.

        Renal failure is generally defined as a GFR of less than 60 ml/min for 3 months. Dialysis or, if possible, a kidney transplant will be performed if the GFR is less than 10 or 15 ml/min.

• Clinical manifestations:

– Anorexia, nausea, vomiting, diarrhea.

– Dyspnea, pulmonary edema.

– HTA.

– Muscle pain and cramps.

– Alteration of the myocardium.

– Anemia, thrombopathia, hypocalcemia, hyperphosphatemia.

– Rickets in children with early CKD.

– Renal osteodystrophy causing bone demineralization with pain.

• Oral manifestations: 

They are generally based on the severity of the renal failure:

• In children, kidney failure can cause delayed development and dental eruption;
• Amelogenesis imperfecta.

   In adults, the manifestations are: 

– Uremic breath,

– Parotitis observed in patients who are on late dialysis or insufficiently on dialysis.

– Ulcerative-necrotic gingivitis, uremic stomatitis.

– Fungal (candidiasis) and viral (herpes) infections are also common in patients taking immunosuppressants.

– Renal osteodystrophies can manifest themselves radiologically at the level of the jaws by:

– Demineralized cortex, loss of lamina dura, widening of trabecular spaces.

The treatment:

• The aim of CKD treatment is to correct the disorders caused by kidney damage and to ensure the various functions of a normal kidney, especially those of excretion of waste products from nitrogen metabolism and regulation of the hydro-electrolytic balance and also of blood pressure.
• There are two types of treatment:

1. Conservative :

Goals:

 • slow down the progression of nephropathy.

       • prevent complications.

It involves the control of food intake and the correction of extra-renal visceral manifestations, two of which are important: hypertension and phospho-calcium metabolism disorders.

2.  Substitution:

• Hemodialysis  : This is an extra-renal purification procedure requiring access to the vessels, most often via an arteriovenous fistula consisting of putting the patient’s blood in contact with a dialysate three times a week via a semi-permeable membrane. The patient is placed on anticoagulant treatment during the hemodialysis session, 
• Dialysis actually only compensates for about 15% of kidney function.

• Peritoneal Dialysis: This involves using the peritoneum as a filter membrane and sterile dialysate through a catheter placed permanently in the abdomen.
• Kidney Transplant: A properly transplanted kidney provides ten times the function of dialysis.

A kidney transplant is not forever; young patients may require two or more transplants during their lifetime.

Transplant patients are put on immunosuppressive therapy to prevent rejection of the transplanted kidney.

 If a transplant fails, patients can return to dialysis and wait for another transplant.

A-CAT in the presence of chronic renal failure not on dialysis: (stages 1, 2 and 3)

 Risk of infection and poisoning: 

• for the risk of infection: antibiotic prophylaxis: antibiotics with elimination other than renal elimination must be used: rovamycin

  Dosage: rovamycin 3M IU ½ h before the procedure, repeated 6 hours after, then for one week 2x / day.

• Combat the risk of poisoning by reducing the quantity of anesthetic product, avoiding drugs that are eliminated by the kidneys, and if necessary, reducing the dose or spacing out the doses.
• Emphasize local hemostasis.

2. CAT in front of a chronic renal failure patient on dialysis:

Stage 4 and 5:

a- Hemodialysis patients: risk of infection, intoxication, contamination and hemorrhage:

• Request serology, FNS to check hemoglobin level and hemostasis assessment; 
• Take the patient 24 hours before or after the dialysis session (the effect of heparin can persist for 8 hours after).
• ATBprophylaxis: Rovamycin 3 M IU half an hour before the procedure, repeat 6 hours later, then for 2 weeks twice a day.
• Anesthesia without vasoconstrictor with respect to the method of administration.

   Truncal anesthesia is prohibited (Risk of hematomas).

• Avoid drugs that are eliminated by the kidneys; if necessary, reduce the doses. 

b- Peritoneal dialysis: same CAT as for non-dialysis CKD.

C-CAT in front of a kidney transplant patient: stage 5: 

1- Patient candidate for transplantation: 

  Carry out a CB repair

• You have to be radical 🡪 Any infection carries the risk of graft rejection.
• It should be followed every two months.

2- Transplanted patient:

• High risk of infection (under immunosuppressants): Coverage antibiotic therapy two days before the procedure, and continued until healing.
• In case of infection 🡪 curative antibiotic therapy, the choice of which should be discussed with the attending physician.

D-CAT before IRC with concomitant pathology:

The specific CAT must be applied with the IRC CAT.

CAT in front of a renal failure

4- Conclusion:

Nephropaths, being very vulnerable subjects, require rapid care with careful questioning, a complete examination, a lot of attention in work and post-operative monitoring.

CAT in front of a renal failure

  Baby teeth must be cared for to prevent future problems.
Periodontal disease can cause loosening.
Removable dentures restore chewing function.
In-office fluoride strengthens tooth enamel.
Yellowed teeth can be treated with professional whitening.
Dental abscesses often require antibiotic treatment.
An electric toothbrush cleans more effectively than a manual one.
 

CAT in front of a renal failure