Management of a patient with chronic renal failure

Management of a patient with chronic renal failure

I. INTRODUCTION  : Chronic kidney disease (CKD) is a public health problem. It is defined by a glomerular filtration rate (GFR) < 60 ml/min/1.73 m² for more than 3 months. The general clinical manifestations of CKD are multiple and can affect several organs: hematological, bone, gastrointestinal, cardiovascular, neurological, endocrine, and dermatological manifestations.

Oral and dental manifestations are diverse and affect both bone and soft tissue structures: xerostomia, pallor, mucosal lesions, osteodystrophy of the maxillary bone, as well as other manifestations that can accompany the disease. Clinical manifestations are more observed when the stage of the disease is advanced. 

Oral cavity management in patients with chronic renal failure depends on the stage of the disease and the nature of the treatment received by the patients. It must be carried out in consultation with the nephrologist, taking into account the risk of hemorrhage, infection, and drug toxicity .

II. ANATOMICAL AND PHYSIOLOGICAL REMINDER  : 

• Anatomy  : The kidneys are part of the urinary system which also includes the bladder, two long canals that connect the kidneys and the bladder, the ureters, and another canal that connects the bladder to the outside, the urethra. 
• Physiology  : 

• Filtering role: The primary function of the kidneys is to eliminate toxic waste produced by the normal functioning of the body and carried by the blood. These substances are useless to the body and are toxic if they are not eliminated.
• Maintaining the body’s water balance: Absorbed by drinking and eating, water is eliminated mainly through urine but also through stools, sweat and breathing. The kidneys allow the body to maintain the amount of water it needs. Each day, they filter around 190 litres of blood but only reject 1.5 to 2 litres of urine. In total, the daily water intake and output balance out.
• Maintaining the minerals needed by the body: These include sodium and potassium, which come from food. Their lack or excess can cause serious complications… The kidneys therefore ensure that they are maintained at a constant level, with excess being eliminated in the urine.
• Maintaining acid-base balance in the blood: Excess acids from food are eliminated to maintain the ideal blood composition (“neutral” blood pH).
• Production of hormones, enzymes and vitamins: In addition to their role as regulator and filter, the kidneys also produce several hormones, enzymes and vitamins including:

• Renin, essential for regulating blood pressure.
• Erythropoietin (the famous EPO) which acts on the bone marrow to produce red blood cells in sufficient quantity to transport oxygen in the body.
• Calcitriol, the active form of vitamin D, which allows calcium to be absorbed by the intestine and fixed in the bones, in order to guarantee their good condition and robustness.

  III. CLINICAL AND RADIOLOGICAL MANIFESTATIONS : 

A. General clinical manifestations related to CKD:

– Hematological manifestations. These are mainly represented by anemia (secondary to a deficiency in erythropoietins) and thrombopathia (qualitative alteration of platelet function).
– Mineral and bone disorders, associating metabolic anomalies of calcium, phosphorus, and parathyroid hormone (PTH) with renal osteodystrophy lesions.

– Gastrointestinal manifestations, these are nausea and vomiting. 

– Cardiovascular manifestations are the main cause of mortality. They are represented by: high blood pressure (HBP), left ventricular hypertrophy, pericarditis, and uremic cardiomyopathies.

– Neurological manifestations include uremic neuropathies of central or peripheral origin.

– Endocrine manifestations, represented by secondary hyperparathyroidism, and carbohydrate intolerance, as well as lipid disorders.

– Dermatological manifestations. They are very diverse. Pruritus is the most frequent manifestation.

B. Oral and dental clinical manifestations related to CKD: 

1- The metallic taste resulting from the increased concentration of urea in saliva and its transformation into ammonium.

2- Paleness of the mucous membranes due to anemia 

3- Xerostomia: It is present in 28 to 59% of patients with end-stage renal disease (ESRD) due to polyuria caused by the kidneys’ inability to reabsorb sodium. It affects the patient’s quality of life since it can lead to: 

4- Mucosal lesions. The immunosuppression that accompanies CKD can cause:

•  Oral lichenoid lesions,
• Hairy oral leukoplakia,
• Oral candidiasis,
• Neoplastic complications can sometimes be observed. They are represented by lip carcinomas and non-Hodgkin’s lymphomas.

5- Gingival hyperplasia. It is related to the treatment of dialysis and transplant patients. It is aggravated by poor oral hygiene.

6- Petechiae, ecchymoses and gingival bleeding. These mucosal lesions result from platelet dysfunction and the effects of anticoagulants. 

7- Increased tartar formation. Increased tartar accumulation is noted. It is induced by increased urea in saliva and impaired calcium and phosphorus metabolism.

8- Erosions on the lingual surfaces of the teeth. These losses of enamel substances are noted due to frequent regurgitation and vomiting induced by uremia. The use of drugs associated with dialysis also promotes dental erosions.

9- Osteodystrophy of the maxillary bone. It results in bone demineralization with loss of trabeculations and thinning of the cortex. It is the alteration of mineral metabolism in patients with CKD that is the cause. 

C. Radiological signs:   These are radiolucent bone lesions. Consequences of this condition include TMJ abnormalities, dental malocclusions, pulp chamber calcifications, delayed eruption, and potential bone fractures following dental extractions.

IV. CARE IN ORAL SURGERY: 

The conditions inherent to renal failure and its multiple oral manifestations deserve special attention by the dentist. The side effects and characteristics of the treatments received by patients must be sufficiently known to be better managed. Therefore, patients with renal failure require special considerations in dental treatments: 

• General protocol:

1. Collaboration with the nephrologist is an essential requirement in the management.
   
   2. The dentist must base himself on a biological assessment (NFS, TS). This assessment makes it possible to assess the risk of hemorrhage, infection and syncope. Consequently, it makes it possible to establish the necessary anti-infectious and anti-hemorrhagic premedications.

2.  The principle of IRC management is based on a search for infectious foci of dental origin and then on oral management.
3. Blood pressure should be monitored before and during treatment, with sedation administered to reduce anxiety if necessary.
4. Para apical anesthesia is the recommended one. Intra-ligamentary anesthesia should be avoided due to the increased risk of infection. Locoregional anesthesia is not recommended due to the risk of hematoma formation.
5. Regarding drug prescription, the metabolism and elimination of certain drugs are modified in situations of renal failure. In such cases, a modification of the dosage is necessary. Indeed, the evolution of renal failure is done according to 5 stages according to the GFR (Table 1).

Stadium	Definition	GFR (ml/min)
1	Renal damage without CKD	> 90
2	Mild renal failure	60-89
3a	Mild to moderate IR	44-59
3b	Moderate to severe IR	30-43
4	Severe renal failure	15-29
5	End-stage renal failure	<15

Table 1: Stages of kidney failure
KIDNEY DISEASE IMPROVING GLOBAL OUTCOMES (KDIGO).2012

 Regarding the prescription of ATB, only Spiramycin, Metronidazole, and Clindamycin can be prescribed without dosage modification (Table 2). Corticosteroids can be prescribed without dose adjustment. NSAIDs are contraindicated in cases of moderate to terminal IR (stage 3-5). Paracetamol is the analgesic of choice, the intake interval should be spaced 8 hours apart in cases of IRT (stage 5) (Table 3).

Renal failure	Stage 1 to 3	Stage 4	Stage 5
Amoxicillin	No adjustment	D0 then D0/2 every 12 hours	D0 then D0/2 every 24 hours
Azithromycin	No adjustment	Contraindication	Contraindication
Clarithromycin	No adjustment	Poso/2	Poso/2
Spiramycin	No adjustment
Metronidazole
Clindamycin
Amoxicillin/Clavulanic acid	No adjustment	Taken every 12 to 24 hours	Contraindication

Table 2: Rules for prescribing antibiotics.

Renal failure	Stage 1 and 2	Stage 3	Stage 4	Stage 5
Paracetamol	Yes	Yes	Yes	Inter /2 sockets: 8h
NSAIDs	30% to 50%	No	No	No
Nefopam	Yes	Yes	Yes	No
Codeine	Yes	Yes	Yes	Inter / socket: 8h
Tramadol	Yes	Yes	Inter/take: 12h	No

Table 3: Prescription rules for anti-inflammatories and analgesics.

 • Particularities of care for dialysis patients:

The evolution of any CKD generally leads to end-stage renal failure requiring renal replacement therapy: hemodialysis, peritoneal dialysis, or renal transplantation).
Patients on peritoneal dialysis do not require any special measures in terms of dental treatment, beyond those already formulated above. We will therefore focus our attention on hemodialysis.
Two risks must be avoided: the risk of hemorrhage and infection.

* Concerning the risk of hemorrhage:

– Dental care should be performed outside of dialysis days, to ensure that there is no risk of hemorrhage following the use of heparin during dialysis (half-life of approximately four hours).
– It is necessary to ensure the availability of local hemostatic means . We recall that these are: mechanical compression, sutures, oxidized regenerated cellulose, etc. (4,5)

* Concerning the risk of infection:

– Bacterial endocarditis is a potential complication in dialysis patients. Antibiotic prophylaxis is recommended 1 hour before dental procedures: 2g to 3g of amoxicillin orally and in case of penicillin allergy, clindamycin is the drug of choice (600 mg orally.

* Periodic monitoring is necessary, with the adoption of measures aimed at avoiding both contagion of medical staff and cross-contamination in the dental clinic (ask for serological status: HBsAg, anti-HCV AC, and HIV 1 and 2, use personal protective equipment, ensure good medical record keeping, respect hygiene and asepsis measures, etc.).

• Specific features of care for kidney transplant patients:

– An oral hygiene program should be established.

– It is essential to eliminate existing dental infectious foci: teeth with a poor prognosis must be extracted (non-restorable teeth and those with advanced periodontitis).

– In the case of dental care, a medical consultation is necessary to know: the patient’s state of health, the need for antibiotic prophylaxis, the possible modification of the dosages of certain medications, the biological assessment, etc.)

– The potential for oral infections after transplantation is very high (patients on immunosuppressive therapy), therefore antibiotic prophylaxis is indicated in case of invasive dental procedures.
– During the first six months after transplantation, patients should avoid any non-urgent dental treatment.

DECISION TREES

Management of a patient with chronic renal failure

CONCLUSION

Renal failure patients present a risk of infection (immunodepression), hemorrhage (primary hemostasis disorder), and drug toxicity (contraindicated drugs: NSAIDs in case of moderate to terminal RI, etc.). These patients require comprehensive care, in collaboration with the nephrologist. Certain points must be optimized in order to improve the care of IRC patients:

– Integrate oral health assessment and management into the overall treatment plan for CKD at an early stage.

– Schedule urgent consultations for IRC patients.
– On the day of the procedure: save time by preparing the equipment and hemostasis methods in advance, have an effective operating assistant, group the procedures.
– Establish a follow-up protocol: sanitation and search for infectious foci.

Management of a patient with chronic renal failure

BIBLIOGRAPHY

1. Gharbi MB, et al. Chronic kidney disease, hypertension, diabetes, and obesity in the adult population of Morocco: how to avoid “over”- and “under”-diagnosis of CKD. Kidney Int. 2016 Jun;89(6):1363-71.
2. Asserraji M, etcoll.Epidemiological profile of end stage renal disease at the Military Hospital in Rabat, Morocco.Pan Afr Med J. 2015 Apr 30;20:439.

3- Elmoutaki S, Benjelloun S. Profile of at-risk patients monitored and consulted at the preventive pedodontics department of the CCTD of Casablanca. Thesis Méd Dent 2017.

3. Dioguardi.M, et al. Oral manifestations in chronic uremia patients. Ren Fail. 2016;38(1):1-6.
   5- Cerveró AJ. Dental management in renal failure: Patients on dialysis. Med Oral Patol Oral Cir Bucal. 2008 Jul 1;13(7):E419-26.
4. Honarmand M, et al. Oral manifestation and salivary changes in renal patients undergoing hemodialysis. J ClinExp Dent. 2017 Feb 1;9(2):e207-e210.
5. LaurentF. Medical risks. Guide to management by the dental surgeon (63-66) ADF Paris 2013.
6. Prescription in patients with hepatic or renal insufficiency. Ed. Clinical and therapeutic pharmacology. December 2015.
7. Roche Y. Medical risks in the dental office in daily practice: Chronic renal failure and dialysis. 2010, Pages 479–493.
8. Lacour.B, et al. Diagnosis, biological monitoring of chronic renal failure and management of terminal chronic renal failure. Rev Franc Lab, 2013 Apr 451: 59-73.
9. Mazouz K. Chronic renal failure: knowledge and perception by general practitioners of the Marrakech delegation. Med et pharm thesis, Marrakech, 2015, n° 110/15.

Management of a patient with chronic renal failure

  Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.
 

Management of a patient with chronic renal failure