Management of patients at risk of CHRONIC RENAL FAILURE
The kidney is the organ of filtration of the human body, it allows to filter the blood and rid the body of its toxic substances and metabolites, any pathology affecting this organ must be the object of particular attention of the practitioner during the care.
The management of patients with chronic renal failure must be rigorous and requires collaboration between the practitioner and the treating physician.
- PHYSIOLOGICAL PARREL:
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 maintain proper calcium and phosphate levels in the blood and bones. The kidney also helps activate vitamin D.
- EXPLORATION OF RENAL FUNCTION:
- DEFINITION :
Chronic renal failure is defined by the progressive and irreversible deterioration of the functioning of the kidneys, which no longer filter the blood correctly and no longer perform their endocrine functions.
The agreed threshold for defining a decrease in glomerular filtration rate is <60
ml/min/1.73 m². GFR is only altered when nearly 75% of the nephrons are affected.
The risk factors selected for screening are:
- Diabetes; main cause (25% of CKD are caused by diabetes);
- Treated or untreated high blood pressure;
- Atheromatous cardiovascular disease;
- Heart failure;
- Obesity (BMI > 30 or 35 kg/m²);
- Systemic or autoimmune diseases (lupus, vasculitis, rheumatoid arthritis, etc.);
- Urological conditions (urinary malformation, recurrent urinary infections, etc.);
To these main etiologies, we must add: chronic interstitial nephritis, vascular nephropathies, chronic nephropathies of undetermined etiology, hereditary and familial nephropathies and other renal diseases.
- CLASSIFICATION:
- COMPLICATIONS OF IRC:
Cardiovascular manifestations:
-HTA
-myocardial alterations
– rhythm disorders
Neurological manifestations:
-decreased ability to concentrate
-memory disorders, depression.
-feeling of discomfort, drowsiness
Hematological manifestations:
-anemia
– hemostasis disorder (due to platelet damage or reduced capillary resistance).
Infectious complications
Immune system dysfunction
Bone manifestations:
Bone demineralization
Skin manifestations:
Pallor, itching
Digestive symptoms:
anorexia, vomiting, nausea
MOUTH EVENTS:
In children , kidney failure can cause delayed development and dental eruption.
In adults , the manifestations are:
-Uraemic breath due to a high salivary concentration of urea
-Parotitis.
-Gum bleeding.
-cyclosporine-induced gingival hyperplasia
In patients on immunosuppressants:
- Candidiasis.
- Herpes, CMV infections.
- Gingival hyperplasia observed in patients taking ciclosporin, calcium channel blockers, etc.
- Lymphomas, skin cancers, oral hairy leukoplakia and Kaposi’s sarcoma may occur.
- TREATMENT:
- Conservative treatment:
Treatment of CKD before the terminal stage includes dietary measures (diet adapted to renal excretion to avoid retention of substances usually eliminated by the kidney) and medication (treatment of hypertension, treatment of hyperphosphatemia,
hypocalcemia..)
- Replacement treatment:
When renal failure cannot be corrected by dietary measures or medication, replacement methods must be used.
- Hemodialysis:
Hemodialysis is the most widely used method. It is an extra-renal purification process:
- From a vascular access “arteriovenous fistula”, the patient’s blood is brought to the filter (semi-permeable membrane: “ artificial kidney”),
- The elimination of excess water and waste will take place through exchanges between the patient’s blood and a sterile liquid (the dialysate). The exchanges take place according to a diffusion process
: substances move from the most concentrated medium to the least concentrated. Thus, urea or creatinine in too high a concentration in the blood are eliminated in the dialysate.
- After purification through this filter, the blood is returned to the patient through the venous blood line .
The patient is placed on anticoagulant treatment during the hemodialysis session. A session lasts from 3 to 5 hours and takes place on average 3 times per week.
- Peritoneal dialysis:
This method has the same principle as hemodialysis
It involves the removal 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 able to be carried out at home.
The main complications of this method are essentially
- infection of peritoneal dialysis fluid;
- infection in the subcutaneous tract or catheter orifice
- Kidney transplant:
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) to prevent rejection. As a result, the risk of infection increases.
- POTENTIAL PROBLEMS ENCOUNTERED DURING THE ODONTOSTOMATOLOGICAL MANAGEMENT OF CKD:
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:
Due to platelet adhesion disorder Heparin therapy in hemodialysis patients
Approximately 10% of patients with severe uremia have thrombocytopenia due to impaired 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 pencillins, tetracyclines, etc.;
Drug combinations are not recommended
The prescription of acetylsalicylic acid and its derivatives and nonsteroidal anti-inflammatory drugs is prohibited in hemodialysis patients because they potentiate bleeding.
The prescription of paracetamol, on the other hand, is not contraindicated.
Rules for prescribing antibiotics
- ACTION TO BE TAKEN
Behavior to adopt when dealing with a patient under conservative treatment: Contact with the attending physician: stage of the disease and its complications. Exploration of hemostasis with an FNS assessment,
Avoid overdose of local anesthesia with renal elimination.
Adrenaline is not contraindicated except in cases of associated hypertension. Control the hemorrhage after extraction by several local hemostasis procedures (risk of hemorrhage)
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 test
-Exploration of hemostasis with an FNS assessment,
– Measure blood pressure (avoid the arm with the AF V (arteriovenous fistula)
– Schedule the tooth extraction outside of dialysis sessions, the day following hemodialysis.
-In case of emergency, tooth extraction must be done after 8 hours: heparin elimination time.
– Infectious risk (due to leukocyte disorders): Prescription of non-nephrotoxic antibiotic propbylaxis before dental extraction, respecting the prescription conditions (dosage, duration)
-Local hemostasis (digital compression, topical application of local hemostatic agents, sutures)
-Nonsteroidal anti-inflammatory drugs, and salicylates (acetyl acid: aspirin) and its derivatives are prohibited, 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.
How to handle a kidney transplant patient
The precautions to be taken are intended to limit infections, the prevalence of which is greatly increased by the use of immunosuppressive drugs and corticosteroids.
- Contact your doctor to find out what medication you are currently taking.
- Measure blood pressure.
Management of patients at risk of CHRONIC RENAL FAILURE
Deep cavities may require root canal treatment to save the tooth.
Dental veneers can correct stained or malformed teeth.
Misaligned teeth can cause speech problems.
Dental implants prevent bone loss in the jaw.
Antiseptic mouthwashes reduce bacteria that cause infections.
Decayed baby teeth must be treated to avoid complications.
An electric toothbrush cleans more effectively than a manual one.