Kidney

Question 1

1 DM, #2 HTN, chronic glomerulonephritis, polycystic kidney disease

Chronic Kidney Disease

a progressive loss of renal function that persists for 3+ months

Causes

Pathophysiology

• Destruction of nephrons (compensated until 50+% lost)

Answer 1

Complications

Azotemia (nonprotein N2 compounds in blood) – measured by BUN (blood urea nitrogen), precursor of Uremia (urea in blood) >> metabolic acidosis due to ammonia retention

Secondary hyperparathyroidism & Renal osteodystrophy:

Anemia: reduced kidney erythropoietin production

Bleeding: platelet dysfunction due to toxins in blood

Cardiovascular (atherosclerosis, CHF left ventricle hypertrophy): due to reduced urine output/Na retention

Dermatologic: Pruritus & hyperpigmentation (carotene-like pigments). Uremic frost (urea crystal after sweat evap)

Immunocompromise

Question 2

Renal Osteodystrophy and Secondary Hyperparathyroidism

Renal osteodystrophy is result of hyperparathyroidism in ESKD

1. Healthy kidneys produce calcitriol, a form of vitamin D, to help the body absorb dietary calcium into the blood and the bones.
2. In a patient with kidney failure, the kidneys stop making calcitriol.
3. The body then can’t absorb calcium from food and starts removing it from the bones.

Answer 2

92% pts on hemodialysis has hyperparathyroidism

Signs/Symptoms: Bone/joint pain, bone fracture/deformation

PTH increases serum Ca (increases osteoclast activity)

Calcitonin decreases serum Ca (by reducing osteoclast activity and inhibit renal Ca reabsorp/promotes excretion) ​

Hyperparathyroidism: painful bones, renal stones, abdominal groans, and psychic moans,

Question 3

Staging

Answer 3

Urinalysis

GFR measures overall renal func.

[Creatinine] proportional to GFR.

Measurable in urine (Creatinine clearance) and blood (serum creatinine level).

BUN common indicator but less specific than creatinine

Kidney damage marker = protein in urine

Question 4

Medical Management

Answer 4

Early stages treat comorbidity factors

Stage 5 dialysis is necessary: •Peritoneal (20%) vs Hemodialysis (80%)

Hemodialysis

Done every 2-3 days taking 3-4 hours per session

Usually done through a permanent AV shunt in the forearm

Patients are usually on heparin

Hepb/c/HIV transmission.

Question 5

Oral Manifestations

• Pallor of oral mucosa (anemia)
• Palatal petechiae (bleeding)
• Red discoloration of cheeks (carotene pigment)
• Xerostomia and altered taste

Answer 5

Radiographic Osseous Changes

• Loss of lamina dura
• Demineralized bone (ground glass appearance)
• Brown tumors (central giant cell granulomas)

Question 6

Dental management

Med consult: stage 4+, esp if comorbid conditions present (DM, HTN, SLE etc). Tx in hospital setting

Dental treatment timing: day after hemodialysis (pt fatigue/bleeding. Heparin last only 3-6 hr).

Monitor BP (AV-fistula - caution with BP cuff, IV meds)

Dental infection: Aggressive tx (immunocomp). Abx selection based on culture/sensitivity testing. Hospitalization PRN

Risk of infective endocarditis (AV-fistula or oral route). AHA recommend: Abx not needed unless abscess (I&D).

Adrenal insufficiency: corticosteroid supplementation if indicated

Bleeding: local (collagen, suture) and systemic (desmopressin – promotes clots) measures. Order aPTT, platelet count

Chair position: Orthostatic hypotention from antihypertensives

Answer 6

Medication: dosage adjustment when GFR<60 (stage 3). Duration of meds may be shortened by drug removal during dialysis

Avoid long-term NSAIDs – Ibuprofen no adjustment needed.

Avoid APAP in high doses – APAP adjust if GFR<10

Abx Penicillin/Amoxicillin – adjust if GFR<10

Anesthetics: generally NOT require dosage adjustment

Antianxiety: single-dose BNZ does not require dose adjustment

Contraindicated: narcotics (prolonged sedation/resp depr), aminoglycosides, acyclovir, aspirin, NSAIDs