Chronic renal failure and its management in odontostomatology
Introduction
- Part 1: General information on the kidney and renal failure
l. Anatomical-physiological reminders of the kidney:
- Anatomy
- Renal physiology
- Biological or functional explorations of the kidney
- Chronic kidney disease: 3.1. Definition of CKD 3.2. Classification of CKD
3.3. Population at risk 3.4. Complications of CKD
3.5. Treatment:
3.5. l. Conservative treatment
3.5.2. Replacement treatment: hemodialysis, peritoneal dialysis, kidney transplantation.
Part 2: Chronic renal failure and its impact on the oral cavity
l. Oral manifestations associated with chronic renal failure: II. In children
12. In adults
Part 3 : management of a patient with renal pathology in
Odontostomatology
- Potential problems encountered during the dental and stomatological management of an IRC
- What to do if you have kidney failure:
- How to behave when faced with a patient undergoing conservative treatment
- What to do when dealing with a patient on hemodialysis
- What to do when dealing with a patient who is a candidate for a kidney transplant
- How to handle a transplant patient Conclusion
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Introduction :
In their daily practice, dentists are often confronted with therapeutic problems, especially when dealing with patients with defects.
Among these defects, chronic renal failure (CRF) which requires treatment
Specific odontological compared to other healthy patients.
In Algeria, approximately 4,000 new cases of chronic kidney failure are recorded each year.
It is estimated that almost 6 million Algerians are at risk of kidney damage and 1.5 million have chronic kidney disease, specifying that this condition affects 20% of hypertensive patients, 30% of dyslipidemic patients, 40% of diabetic patients, 25% of subjects aged over 60 and 60% of patients treated for cancer.
Close collaboration between the dentist and the treating nephrologist is necessary for these patients. This allows for a better therapeutic approach and avoids potential complications secondary to oral and dental procedures 
Part 1/ General information on the kidney and renal failure
chronic
- Anatomo-physiological reminders of the kidney
- Anatomy:
The kidneys are vital organs that help ” purify ” the blood by filtering waste (urea, uric acid), toxins, and eliminating excess water and salts. They are paired and shaped like a bean.
They are located on either side of the spinal column. The functional unit of the kidney is the nephron, each kidney contains nearly a million of them. Each nephron has two parts: the
dry rot (plasma filtration) and the tubule (urine formation).
- Renal physiology:
The kidney performs several functions:
- Eliminate waste and water!: The kidney eliminates waste and excess fluid carried by the blood in the form of urine (1.5 to 2L) through the glomeruli, and therefore the kidneys participate in the body’s water regulation.
- Regulate blood pressure: The kidneys synthesize angiotensin and renin , which regulate the amount of sodium and fluid in the body, as well as the phenomena of vasodilation and vasoconstriction. Through these mechanisms, they participate in the regulation of blood pressure.
- Participate in the formation of red blood cells: erythropoietin is synthesized in the kidney, once carried by the blood to the bone marrow, this hormone will stimulate the production of red blood cells.
- Maintain healthy and strong bones: Calcitrol, a kidney hormone, helps to
maintain adequate levels of calcium and phosphate in the blood and bones. The kidney also helps activate vitamin D.
- Biological or functional explorations of the kidney:
A biological assessment of renal function allows us to assess the proper functioning of the kidney, among these tests we have
- Urea: Urea is formed in the liver from the breakdown of dietary proteins. It is a waste product. Its blood levels (uremia) increase in cases of kidney failure. In clinical practice, urea measurement is only useful in conjunction with creatinine measurement in cases of kidney failure.
- Creatinine: their elevation in the blood indicates renal failure.
- Creatinine clearance or Glomerular filtration rate (GFR)_;_
Its value varies depending on the patient’s gender, age, weight, and blood creatinine level. A value above 60 ml/min indicates adequate kidney function.
- Blood enzyme count: variations in the blood levels of different hormones provide information on the proper functioning of the kidney.
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- Urinary proteins: the presence of proteins in the urine often indicates damage to the glomeruli.
- Chronic renal failure:
- Definition of IRC:
Chronic kidney failure is defined by the progressive and irreversible deterioration of kidney function, which causes the kidneys to no longer filter blood properly and perform their endocrine functions. The two main causes are high blood pressure and diabetes.
.. IRC Classification:
There are different stages of CKD, determined by estimating the glomerular filtration rate (GFR: assessed by creatinine clearance). The lower the GFR, the more severe the CKD:
*Presence of markers of renal damage:
8 Morphological abnormalities (on ultrasound or other examinations, etc.),
8 Histological abnormalities (a renal biopsy)
8 Biological abnormalities: proteinuria, albuminuria, hematuria, leukocyturia.
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- Population at risk of chronic kidney disease:
- Complications of CKD:
Chronic kidney disease is asymptomatic until it is very advanced. Complications are multiple and can affect multiple systems.
- Cardiovascular manifestations:
High blood pressure Uremic heart disease, Uremic pericarditis
- Hematological manifestations: Anemia
Leukocyte abnormalities,
Hemostasis disorders (due to platelet damage or reduced capillary resistance)
- Neurological manifestations: Uremic polyneuritis,
- Digestive and nutritional manifestations:
Anorexia, nausea, morning vomiting, uremic parotitis
- Bone manifestations: Diffuse decalcification
Dwarfism or renal rickets in children in cases of prolonged renal failure
- Skin manifestations: Pruritus
- treatment :
- Conservative treatment:
Dietary and medicinal measures
- Replacement treatment:
When renal failure cannot be corrected by dietary measures or
to the methods of substitution
- Hemodialysis:
Is a method of purifying the blood by creating an extracorporeal circulation circuit
and its passage through a dialyzer . Hemodialysis is a method of purifying blood by creating an extracorporeal circulation circuit and its passage through a dialyzer .
When there is severe kidney failure , the body gradually takes on substances that need to be eliminated by dialysis.
Dialysis involves bringing blood into contact with a sterile liquid (the dialysate ) whose composition is close to that of plasma (the liquid that makes up approximately 60% of blood) through a membrane that acts as a filter. In hemodialysis, this process takes place outside the body and the membrane is artificial.
-A session varies from 3 to 5 hours
-on average 3 times a week
The patient is placed on anticoagulant treatment during the hemodialysis session.
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This method has the same principle as hemodialysis
It consists of the elimination of waste through the peritoneal membrane (the membrane that surrounds the organs located in the abdomen) between the patient’s blood and the dialysate introduced into the peritoneal cavity using a catheter.
It has the advantage of not requiring the use of anticoagulants and of being possible to perform at home.
The main complications of this method are essentially
- infection of peritoneal dialysis fluid;
- infection in the subcutaneous tract or catheter orifice
At the terminal stage, transplantation is the only treatment that allows patients to return to a near-normal life.
It involves inserting a kidney into a recipient with renal failure, most often from a brain-dead donor or a living donor who is a relative of the recipient.
Kidney transplant recipients are subjected to long-term immunosuppressive medical therapy (Cyclosporine, Tacrolimus, Azathioprine, mycophenolate, corticosteroids) intended to prevent rejection. As a result, the risk of infection increases, as does the (reduced) risk of developing skin cancer or hematological malignancies.
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- Part 2 : Chronic renal failure and its impact on the cavity 1- Oral manifestations associated with chronic renal failure:
- In children:
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Enamel hypoplasia Delayed eruption.
t.2. In adults:
-Palor of the mucous membranes
-Xerostomia, candidiasis, parotid infections following a decrease in salivary secretion in late dialysis patients.
-Dysgeusia
-Halitosis (breath with ammonia odor)
-Uraemic stomatitis: ulcers mainly located on the ventral surface of the tongue and the floor of the mouth
-Petechiae and ecchymoses. Gum hemorrhages. Ulcerative-necrotic gingivitis. Periodontal diseases.
-Bone lesions; manifested by classic radiographic signs: loss of the lamina dura, demineralization, widening of the trabecular spaces, radiolucent lesions of the jaws, and metastatic calcifications.
-To these manifestations, we must add those which are of therapeutic origin (in particular immunosuppressive):
-Candidiasis, Herpes
-Gingival hyperplasia.
Lymphomas, skin cancers, hairy leukoplakia and Kaposi’s syndrome may occur.
Part 3: Management of a patient with a pathology
renal in odonto- stomatology
essential problems encountered during dental care:
- . Anemia
- HBP and other associated underlying pathologies (cardiovascular disorders, diabetes)
- Infectious risk:
-oral and dental infectious foci can generate distant infections in an affected, weakened kidney: focal infection
-‘Infectious risk related to leukocyte disorders
-Infectious risk related to medication: corticosteroid therapy and immunosuppressants (in the case of kidney transplant).
-Risk of viral transmission (hepatitis B and C): in hemodialysis patients
- Bleeding risk:
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- platelet adhesion disorder
-heparin therapy in hemodialysis patients
-thrombocytopenia due to a deficiency in platelet production
- Intolerance to nephrotoxic substances metabolized by the kidney:
- Avoid nephrotoxic drugs
- Favor antibiotics with elimination other than renal: e.g.: spiramycin, erythromycin, etc.
-In case of absolute necessity; the prescription of penicillin, or tetracyclines…; the doses and dose intervals must be adapted to renal function.
- Drug combinations are not recommended
- The prescription of acetylsalicylic acid and its derivatives and anti-inflammatory drugs
Non-steroidal drugs are prohibited in hemodialysis patients because they potentiate bleeding.
-The prescription of paracetamol, on the other hand, is not contraindicated.
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Table: Medications to be prescribed, modified or changed during dental care for patients with renal failure:
Drugs
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Dose adjustment according to creatinine clearance
(CC)
Normal value CC= 10-SOml /min CSlOml /min
ANTIBIOTICS
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Amoxicillin
500 to 1000mg/8h
500 to 1000mg/8h-
–
500 to 1000mg/8h-
Amoxicillin /
—- –
500 to 875mg/8h
12 p.m.
No adjustment in t
24h
No adjustment
clavulanic
clin damycin
300mg/8h
—-+—— —
Doxycicline Erytbromycin. Metronidazol Azithmomycin
100mg/241′, 200 to 500rog/6b
250 to 50 mg/6 hours 500 mg / 24 hours , 3 days
No adjustment in t No adjustment in t No adjustment in t
250 to 500mg/8 to 12h
No ANTIFUNGAL adjustment
No adjustment No adjustment No adjustment
250 to 500mg/8 to 14 hours
No adjustment
Amphothericin Fluconazole
0.3 to 1 mg/24 hours
200mg/24h
No adjustment +- 50 to 200mg/24h
Not
– –
adjustment 100 to 100mg/24h
ANT ALGIQUES -::. –
Par.acetam ol
500 to 1,000mg / 4-6h No adjustment in t,
only in short courses
No adjustment, only for short courses
Aspirin
Contraindicated
(water retention, deterioration of renal function, risk
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- What to do when faced with chronic renal failure:
- Behavior to adopt when dealing with a patient undergoing conservative treatment:
Contact with the attending physician: stage of the disease and its complications. Exploration of
!Hemostasis with an FNS assessment,
Avoid overdosing on local anesthesia with renal elimination. Adrenaline is not contraindicated except in cases of associated hypertension .
Control bleeding after extraction by several local hemostasis procedures (Risk of bleeding)
Post-extraction antibiotic therapy is not systematic. Appropriate drug prescription
- What to do when dealing with a patient on hemodialysis:
Contact with the attending physician
Risk of viral transmission: request a serological assessment (HIV-HBS-HCV) Exploration of hemostasis with an FNS assessment,
Measure blood pressure (avoid the arm with the AVF (arteriovenous fistula)) Schedule tooth extraction outside of dialysis sessions, the day following hemodialysis.
In case of emergency, tooth extraction must be done after 8 hours: elimination time
heparin.
Infectious risk (due to leukocyte disorders): Prescription of non-nephrotoxic antibiotic prophylaxis before dental extraction, respecting the prescription conditions (dosage, duration)
Local hemostasis (digital compression, topical application of local hemostatic agents, suturing)
Nonsteroidal anti-inflammatory drugs and salicylates (acetyl acid: aspirin) and its derivatives are prohibited, as they potentiate bleeding.
- What to do when dealing with a patient who is a candidate for a kidney transplant :
A careful clinical and radiological examination of the oral cavity must be carried out by the practitioner in order to detect all infectious foci which will be eradicated, because any infection carries the risk of rejection of the kidney graft.
Avulsions should be performed following the same protocol as for dialysis patients.
Chronic renal failure and its management in odontostomatology
Untreated cavities can cause painful abscesses.
Untreated cavities can cause painful abscesses.
Dental veneers camouflage imperfections such as stains or spaces.
Misaligned teeth can cause digestive problems.
Dental implants restore chewing function and smile aesthetics.
Fluoride mouthwashes strengthen enamel and prevent cavities.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.