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Dental Management of a Complex Patient > Kidney Disease > Flashcards

Kidney Disease Flashcards

1
Q

The hydrostatic pressure gradient forces

A

glomerular filtration.

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2
Q

–% of renal plasma flow is filtered into Bowman’s capsule; – factors contribute
to the filtration rate

A

20
hemodynamic

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3
Q

Glomerular Filtration Rate (GFR) affected by renal artery pressure
other autoregulation factors of GFR
(3)

A
  1. vasoreactive (myogenic) reflex of afferent arteriole
  2. tubuloglomerular feedback (TGF)
  3. angiotensin II-mediated vasoconstriction of the efferent arteriole
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4
Q
  1. vasoreactive (myogenic) reflex of afferent arteriole
    - causes
A

dilatation or constriction of the afferent arteriole to maintain
stable glomerular pressure in response to variations in systole

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5
Q
  1. tubuloglomerular feedback (TGF)
    - causes
A

dilatation or constriction of the afferent arteriole to maintain
stable glomerular pressure in response to solute concentration changes
detected by the macula densa cells in the distal/ascending Loop of
Henle

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6
Q

Kidney Function
(9)

A
  • Water regulation
  • Electrolyte regulation
  • Extracellular volume/pressure regulation
  • Acid-base homeostasis
  • Endocrine/metabolic
  • Blood plasma filtration
  • Excretion of metabolic waste
  • Urine production
  • Prostaglandin production
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7
Q

Endocrine/metabolic
(5)

A

oKinins
oErythropoietin
oPhosphate
oVitamin D
oRenin

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8
Q

Blood plasma filtration
(2)

A

oGlucose and amino acid reabsorption
oCalcium and phosphate regulation

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9
Q

Excretion of metabolic waste
–, etc.

A

nitrogenous

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10
Q

Acute Renal Failure (ARF)
aka
Acute Kidney Injury (AKI)
A condition in which the…
— results from the cumulative effects of renal failure, retention of excretory products,
and interference with metabolic and endocrine function
Acute renal failure develops… It may be fatal. It’s most
common in those who are…

A

kidneys suddenly can’t filter waste from the blood.
Uremia
rapidly over a few hours or days
critically ill and already hospitalized.

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11
Q

Acute Kidney Injury (AKI)
Acute Renal Failure (ARF)
Symptoms
(6)

A

decreased urinary output
swelling due to fluid retention
nausea
Fatigue
shortness of breath.
Sometimes symptoms may be subtle or may not
appear at all.

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12
Q

ARF
Causes
(3)

A
  1. Pre-renal
  2. Intrinsic Renal
  3. Post-renal
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13
Q

ACE-I: (3)

A

monopril, captopril, enalapril

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14
Q

ARB:

A

angiotensin receptor blocker, (Diovan, Cozaar,
Benicar);

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15
Q

NSAIDs:

A

Indomethacin

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16
Q

PPI: proton pump inhibitors (3)

A

Prilosec, Prevacid &
Nexium (also linked to stomach cancer)

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17
Q

TTP-HUS, thrombotic thrombocytopenic purpura–
— syndrome.

A

hemolytic-uremic

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18
Q

Acute Kidney Injury (AKI)
Acute Renal Failure (ARF)
Treatments
(4)

A

address the underlying cause
fluids
medication
dialysis.

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19
Q

Chronic Kidney Disease
Causes
(6)

A

*Chronic Glomerulonephritis
*Systemic Lupus Erythematosus
*Neoplasms
*Polycystic kidney disease
*AIDS nephropathy
*Diabetic nephropathy
*Etc. (many others)

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20
Q

Chronic Kidney Disease
Risk Factors
(5)

A

Age (≥60 years of age)
Smoking
Obesity
HTN
Diabetes

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21
Q

HTN

A
  • poorly controlled
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22
Q

Diabetes
* —% of patients with type 2 DM will
develop CKD

A

40-50

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23
Q

Chronic Kidney Disease
Risk Factors
(4)

A

Nephrotoxins/Drugs
Infections
Low birthweight
Chronic Inflammation

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24
Q

Test: Glomerular Filtration Rate (GFR)
Chronic Kidney Disease

A

<60 ml/min/1. 73 m

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25
Q

Test:
Chronic Kidney Disease
Urinary albumin/creatinine ratio

A

≥ 30 mg/g

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26
Q

Test: Urinary albumin excretion rate
Chronic Kidney Disease

A

≥ 30 mg/day

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27
Q

Diagnosis and Classification of CKD are based on

A

GFR and albuminuria/proteinuria

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28
Q

End-Stage Renal Disease (ESRD)
(2)

A
  • GFR <15 ml/min/1.73 m2
  • Requires kidney replacement therapy (hemodialysis, transplantation)
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29
Q
  • GFR steadily decreases with
A

age

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30
Q

CKD
Complications
I. Fluid and electrolyte imbalance
(3)

A
  • Dysregulation of Na+, K+ and H2O reabsorption
  • Hyperkalemia
  • Edema
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31
Q

CKD
Complications
II. Hypertension
(3)

A
  • RAS activation
  • Aldosterone and catecholamine activation
  • Hypervolemia
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32
Q

CKD
Complications
V. Anemia [Hb <12 g/dl (F); <13.5 g/dl (M)]
(3)

A
  • Decreased Epo and RBC survival
  • Impaired iron absorption (insufficient hepcidin),
    blood loss (dialysis)
  • Normocytic, normochromic anemia
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33
Q

CKD
Complications
VII. Dyslipidemia
(2)

A
  • Dysregulated metabolism of lipid and uremic toxin-mediated
    lipid alterations
  • Atherosclerosis
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34
Q

CKD
Complications
VIII. Metabolic acidosis
(2)

A
  • Decreased excretion of NH4+
  • Decreased absorption of H+ and HCO3-
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35
Q

CKD
Complications
IX. Mineral bone disorder (MBD)
* Decreased — levels
* Dysregulation of (2)
* Increased (2) levels
* Diseases (2)
* Calciphylaxis –

A

vitamin D
Ca2+ and PO4-3
PTH and FGF23
Renal Osteodystrophy, secondary hyperparathyroidism
extraosseous calcifications
➢Blood vessels of dermis & subcutaneous fat

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36
Q

CKD
Complications
others (3)

A

III. Cardiovascular Disease
IV. Endocrine dysfunction
VI. Hyperuricemia (uric acid) and Uremia (urea)

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37
Q

CKD
Diabetic Management
Control DM –HbA1
Control HTN –BP – mm Hg
Control HLD –LDL <—mg/dl
Diet/lifestyle modification –BMI

A

<8%
<140/90
100
18.5 -24.9 kg/m2

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38
Q

Control HTN –BP <140/90 mm Hg
(5)

A
  • Cardioselective beta-blocker
  • Diuretics
  • ACE inhibitor
  • ARB
  • Calcium channel blocker
39
Q

Diabetic management
Management of other comorbidities
and complications
(5)

A
  • Neuropathies
  • Anemia
  • Mineral bone disease
  • Metabolic acidosis
  • Hyperkalemia
40
Q

CKD
Oral Manifestations
(7)

A

Xerostomia/dry mouth
Halitosis
Dysgeusia
Infections
Enamel defects
Uremic stomatitis (rare)
Petechiae and ecchymosis

41
Q

Dysgeusia

A
  • Metallic taste
42
Q

Infections
(4)

A
  • Opportunistic
  • Periodontal
  • Odontogenic
  • Salivary
43
Q

Enamel defects
(1)

A
  • Children
44
Q

Uremic stomatitis (rare)
(1)

A
  • BUN >55 mg/dl
45
Q

Osteodystrophy
* Lack of
* Causes lack of
* Stimulates (2)
* Inhibits

A

hydroxylation of 25(OH)D to 1,25(OH)2D which takes place in the kidneys
Ca+ absorption from intestines
parathormone secretion and Ca+ loss from bone
bone mineralization

46
Q

Osteodystrophy Causes
(6)

A
  • Loss of lamina dura
  • Demineralization (“ground-glass”)
  • Expansile radiolucencies (CGCG, brown tumor)
  • Wide trabeculae
  • Loss of cortication
  • Sclerosis
47
Q

Oral manifestations
Alternative filtering of the blood

A

removes uremic toxins; initiated in ESRD

48
Q

Two modalities

A

Hemodialysis (venous access)
Peritoneal dialysis

49
Q

Hemodialysis (venous access)
* Arteriovenous fistula
* Ateriovenous graft
* Central venous catheter (special, short-term)
* — filters blood
* — is typically used
* Every —
* Risk of infectious disease – (2)

A

Machine
Heparin
2-3 days; 3-4 hours/session
Hep B; Hep C

50
Q

Peritoneal dialysis
* — solution in peritoneal cavity
* — used for exchange
* —x/day or —

A

Hypertonic
Peritoneal membrane
3-5, overnight

51
Q

Dental treatment planned for the
day – hemodialysis

A

AFTER

52
Q

Kidney Replacement Therapy
Organ Transplant
Requires Matching
(4)

A
  • ABO matching
  • HLA matching
  • > 5- year life expectancy
  • Can be from live (better) or deceased donor
53
Q
  • Can be from live (better) or deceased donor
A

oRelated mismatched donor (3/6 match) is better
than deceased donor

54
Q

Organ Transplant
Absolute contraindications
(2)

A
  • AIDS
  • Active hepatitis
55
Q

Organ Transplant
Rejection may be a problem
(3)

A
  • Activated cytotoxic T cells (direct)
  • Alloantibodies (direct)
  • Delayed type hypersensitivity –arteriosclerosis of
    transplant (indirect)
56
Q

Kidney Replacement Therapy
Organ Transplant
Requires

A

immunosuppression

57
Q

Kidney Replacement Therapy
Organ Transplant
Induction (prevent acute rejection)
(2)

A
  • Antithymocuyte globulin
  • Alemtuzumab (anti-CD52)
58
Q

Kidney Replacement Therapy
Organ Transplant
Maintenance (unless identical twin)
(3)

A
  • Azathioprine
  • Mycophenolate mofetil
  • Steroids
59
Q
  • Azathioprine
    (2)
A

oAntimetabolite
oInhibits DNA and/or RNA synthesis

60
Q
  • Mycophenolate mofetil
    (2)
A

oSimilar to azathioprine
oLess bone marrow suppression

61
Q
  • Steroids
    (1)
A

oLow doses, adjunct

62
Q

Kidney Replacement Therapy
Organ Transplant
Important adverse effects
(2)

A
  • Cytopenias (bone marrow suppression)
  • Increased risk of developing skin and
    hematologic cancers
63
Q

Cytopenias (bone marrow suppression)
➢ Bleeding
(1)

A

▪ Severe thrombocytopenia <50K

64
Q
  • Cytopenias (bone marrow suppression)
    ➢ Susceptibility to infection
A

▪ Severe leukopenia/neutropenia
oWBC <2000
oANC <500

65
Q

Kidney Replacement Therapy
Organ Transplant
Maintenance (unless identical twin)
* Calcineurin inhibitors
(4)

A

oCyclosporine
oTacrolimus
oBoth decrease production of IL-2
mRNA and proinflammatory
cytokines
oDiabetes and nephrotoxicity
complications

66
Q

Kidney Replacement Therapy
Organ Transplant
Maintenance (unless identical twin)
* mTOR inhibitors (mTORi)
(3)

A

oSirolimus
oEverolimus
oInhibits T cell proliferation signaling

67
Q

Kidney Replacement Therapy
Organ Transplant
Maintenance (unless identical twin)
* Belatacept
(2)

A
  • Binds costimulatory molecules
  • T cell anergy and apoptosis
68
Q

Kidney Replacement Therapy
Organ Transplant
Oral adverse effects
(2)

A
  • Gingival hyperplasia (cyclosporine)
  • Aphthous-like ulcers (mTORi)
69
Q

Determine level of renal impairment and disease control

A
  • BP –Avoid arm with AV shunt when measuring BP
  • GFR
  • BUN
  • Creatinine clearance
  • Serum creatinine
  • Electrolytes
70
Q

Level of Renal Impairment may affect bleeding –assess risk
* Patients can be at risk for both (2)
* Quantitative and qualitative
* — measures as necessary
* Be aware of signs and symptoms of —
* Referral to a specialized center as necessary

A

bleeding and thrombosis
platelet impairment
Hemostatic
thrombosis

71
Q
  • Quantitative and qualitative platelet impairment
    (3)
A

➢ Platelet count
➢ PT-INR
➢ PTT

72
Q

Advanced uremia →

A

decreased immune function

73
Q

Assess Indication for Antibiotics
Treat infections —

A

aggressively

74
Q

If invasive procedures in patients with stage 4 (severe) or end-stage renal disease →

A

consult physician about need for antibiotics

75
Q

Antibiotic prophylaxis IS NOT routinely necessary for

A

peritoneal dialysis

76
Q

Antibiotic prophylaxis may be necessary for patients with a

A

synthetic AV graft

77
Q

Antibiotic prophylaxis is necessary in hemodialysis patients if performing

A

incision and
drainage

78
Q

Drug interactions/side effects –dose adjustment may be necessary
(4)

A
  • Check drug excretion mechanism
  • Caution with nephrotoxic drugs (acyclovir, NSAIDs, aspirin, aminoglycosides,
    tetracycline)
  • Carefully review possible drug interactions with current medication list when
    prescribing new medications
  • Consult with patient’s physician
79
Q

Acetaminophen
(4)

A
  • Nephrotoxic at high doses
  • Increase dosing interval
    oq6h (GFR >10 but <50ml/min)
    oq8hs (GFR <10ml/mim)
80
Q

NSAIDs - AVOID
* Except for — for —
* Especially —
* Interaction with —
* Impairment of — production
➢ —, reduced renal —

A

aspirin, CVD
long-term use
antihypertensives
prostaglandin
Vasoconstriction, perfusion

81
Q

Opioids - AVOID
* Risk for accumulation of —
* ? with dose adjustment and/or increased dosing interval
* Consult with physician

A

toxic metabolites
Tramadol

82
Q

Benzodiazepines - CAUTION
* Consider
* — dosing, consult with physician

A

half-life, active metabolite
Single

83
Q

Acyclovir

A
  • Increase dosing interval q8h or q12h
84
Q

Antibiotics
* No adjustment required
(4)

A

oClindamycin
oDoxycycline
oErythromycin
oMetronidazole

85
Q

Antibiotics
* Adjustment required
(3)

A

oAmoxicillin –q12h or q24h
oCephalexin –q6-18h or q12-24 h
oAzithromycin –avoid if GFR <10

86
Q

Fluconazole

A
  • Reduce to 50% or 25% of
    original dose
87
Q

Nystatin –

A

No adjustment

88
Q

Goals of pre-transplant dental clearance
Remove active foci of infection and limit potential foci of infection (think 6 months)
*Treat active foci of infection
(3)

A

oSRP
oEndodontic treatment
oRestorations

89
Q

Goals of pre-transplant dental clearance
Remove active foci of infection and limit potential foci of infection (think 6 months)
(4)

A

*Treat active foci of infection
*Extract teeth with questionable (even if in your opinion minimally)/poor prognosis
*Assess caries risk and need for adjuncts (fluoride)
*Educate patient on importance of maintaining good homecare, diet and professional
maintenance

90
Q

Take into account patient compliance and, unfortunately, patient — when
planning treatment

A

economics

91
Q

Defer elective treatment within first 6 months post-transplant

A
  • Emergency care only –consider specialized center
92
Q

If planned correctly pre-transplant and patient is compliant
Dental Maintenance
Surveillance
(3)

A
  • Opportunistic infections (odontogenic, candidiasis, aspergillosis, HSV, OHL, CMV)
  • Toxicities/side effects of systemic treatment
  • Cancer
93
Q

Toxicities/side effects of systemic treatment
oAdrenal insufficiency –
oGingival hyperplasia -
oPyogenic granuloma and OFG-like lesions -
oOral ulcerations –

A

long-term high-dose corticosteroids
cyclosporine
tacrolimus
sirolimus

94
Q

Cancer
(3)

A

oNon-melanoma skin cancer (basal cell and squamous cell carcinoma [SCCa])
oPost-transplantation lymphoproliferative disorder (frequently EBV associated, B cell)
oOther solid cancers including oral SCCa

Dental Management of a Complex Patient (13 decks)

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