Kidney Disease Flashcards
what forces glomerular filtration
the hydrostatic pressure
20% of the renal plasma flow is filtered into:
bowmans capsule
what factors contribute to the filtration rate
hemodynamic factors
what is GFR affected by
renal artery pressure and other autoregulation factors of GFR such as:
- vasoreactice (myogenic) reflex of the afferent arteriole
- tubuloglomerular feedback (TGF)
- angiotensin II mediated vasoconstriction of the efferent arteriole
what does the vasoreactice (myogenic) reflex of the afferent arteriole do
causes dilation or constriction of the afferent arteriole to maintain stable glomerular pressure in response to variations in systole
what does tubuloglomerular feedback do
causes dilation or constriction of the afferent arteriole to maintain stable glomerular pressure in response to solute concentration changes detected by macula densa cells in the distal/ascending loop of henle
where in the nephron does angiotensin II constrict
at the glomerulus and proximal convoluted tubule
what are the functions of the kidney
- water regulation
- electrolyte regulation
- extracellular volume/pressure regulation
- acid- base homeostasis
- endocrine/metabolic
- blood plasma filtration
- excretion of metabolic waste
- urine production
- prostaglandin production
what are the endocrine hormones/things secreted by the kidney
- kinins
- erythropoietin
- phosphate
- vitamin D
- renin
what is the function of blood plasma filtration of the kidney
- glucose and amino acid reabsorption
- calcium and phosphate regulation
what metabolic waste is excreted by the kidney
nitrogenous
what do prostaglandins produced by the kidney do
- regulate tubular and hemodynamic transport
- possibly fibroblast production in an immune response
what is another name for acute renal failure
acute renal injury
what is ARF
a condition in which the kidneys suddenly cant filter waste from the blood
what does uremia result from
the cumulative effects of renal failure, retention of excretory products, and interference with metabolic and endocrine function
how long does ARF develop in, is it fatal, and who is it common in
- develops rapidly over a few hours or days
- may be fatal
- most common in those who are critically ill and already hospitalized
what are the symptoms of ARF
- decreased urinary output
- swelling due to fluid retention
- nausea
- fatigue
- SOB
- sometimes symptoms may be subtle or not appear at all
what is the only specific symptom of ARF
decreased urinary output
what are the causes of acute renal failure
-pre renal
- intrinsic renal
- post renal
describe prerenal ARF
- hypovolemia
- decreased CO
- decreased effective circulating volume: CHF, liver failure
- impaired renal autoregulation: NSAIDs, ACE-I/ARB, and cyclosporine
what meds can lead to ARF
- ACE-I: monopril, captopril, enalapril
- ARB: angiotensin receptor blocker, Diovan, Cozaar, Benicar
- NSAIDs: indomethacin
- PPI: proton pump inhibitors Prilosec, Prevacid, and Nexium
- TTP-HUS: thrombotic thrombocytopenic purpura- hemolytic uremic syndrome
nexium is also linked to:
stomach cancer
what are the instrinsic causes of ARF
- glomerular: acute glomerulonephritis
- tubules and interstitium
- vascular: vasculitis, malignant hypertension, TTP-HUS
all of these lead to: - ischemia
- sepsis/infection
- nephrotoxins
what are the nephrotoxins that cause ARF
- exogenous: iodinated contrast, aminoglycosides, cisplatin, amphotericin B, PPIs, NSAIDs
- endogenous: hemolysis, rhabdomyolysis, myeloma, intratubular crystals
what are the postrenal causes of ARF
- bladder outlet obstruction
- bilateral pelvoureteral obstruction (or unilateral obstruction of a solitary functioning kidney)
what are the treatments for ARF
- address the underlying cause
- cardiology and hepatology consultation
- fluids
- medication
what are the causes of chronic kidney disease
- chronic glomerulonephritis
- systemic lupus erythematosus
- neoplasms
- polycystic kidney disease
- AIDS nephropathy
- diabetic nephropathy
what is epistaxis
nose bleeding
what are the risk factors for CKD
- age - over 60 years of age
- smoking
- obesity
- HTN- poorly controlled
- diabetes: 40-50% of patients with type 2 DM will develop CKD
- nephrotoxins/drugs
- infections
- low birthweight
- chronic inflammation
what is the diabetic kidney disease pathogenesis
- nephron hypertrophy and/or nephron loss
- glomerular filtration impairment
- renal fibrosis leading to decreased GFR
what are the CKD diagnostic criteria
- GFR: less than 60 mL/min/1.73 m^2
- urinary albumin/creatinine ratio: greater than or equal to 30 mg/g
- urinary albumin excretion rate: greater than or equal to 30mg/day
what are diagnosis and classification of CKD based on
GFR and albuminuria/proteinuria
what is the GFR in end stage renal disease and what is the treatment
- less than 15ml/min/1.73m^2
- requires kidney replacement therapy - hemodialysis and transplantation
GFR steadily _____ with age
decreases
what are the stages of CKD and the GFR
- stage 1: normal kidney function- 90 or higher
- stage 2: mild loss of kidney function: 89-60
- stage 3a: mild to moderate loss of kidney function: 59-45
- stage 3b: moderate to severe loss of kidney function: 44-30
- stage 4: severe loss of kidney function: 29-15
- stage 5: kidney failure: less than 15
what stages of CKD start on dialysis
stage 4 and stage 5
what are the CKD complications
- fluid and electrolyte imbalance
- hypertension
- cardiovascular disease
- endocrine dysfunction
- anemia
- hyperuricemia
- dyslipidemia
- metabolic acidosis
- mineral bone disorder
what are the fluid and electrolyte imbalance complications in CKD
- dysregulation of Na+, K+, and H2O reabsorption
- hyperkalemia
- edema
what are the hypertension complications in CKD
- RAS activation
- aldosterone and catecholamine activation
- hypervolemia
what are the anemia complications with CKD
- Hb less than 12 g/dl for women and less than 13.5g/dl for males
- decreased Epo and RBC survival
- impaired iron absorption (insufficient hepcidin), blood loss (dialysis)
- normocytic, normochormic anemia
what are the hyperuricemia complications in CKD
uric acid and uremia (urea)
what are the dyslipidemia complications of CKD
- dysregulated metabolism of lipid and uremic toxic-mediated lipid alterations
- atherosclerosis
what are the metabolic acidosis complications of CKD
- decreased excretion of NH4+
- decreased absorption of H+ and HCO3-
what are the mineral bone disorder complications associated with CKD
- decreased vitamin D levels
- dysregulation of Ca2+ and (PO4)3-
- increased PTH and FGF23 levels
- renal osteodystophy /secondary hyperparathyroidism
- calciphylaxis- extraosseous calcifications: blood vessels of dermis and subcutaneous fat
what are the manifestations of CKD in the jaw
brown tumors
where are brown tumors found
in the maxilla and mandible but more common than the mandible
what must be controlled in diabetic management in CKD
- control DM: HbA1 less than 8%
- control HTN: BP less than 140/90mmHg
- control HLD: LDL less than 100 mg/dl
- diet/lifestyle modification: BMI 18.5-24.9 kg/m^2
- neuropathies
- anemia
- mineral bone disease
- metabolic acidosis
- hyperkalemia
what drugs can be used to manage diabetic HTN
- cardioselective beta blocker
- diuretics
- ACE inhibitor
- ARB
- calcium channel blocker
what are the oral manifestations of CKD
- xerostomia/dry mouth
- halitosis
- hysgeusia: metallic taste
- infections
- enamel defects in children
- uremic stomatitis
- petechiae and ecchymosis
- osteodystrophy
what oral infections are seen in CKD
- opportunistic
- periodontal
- odontogenic
- salivary
describe uremic stomatitis in CKD
- rare
- BUN greater than 55 mg/dl
what is osteodystrophy in CKD and what does it do
- lack of hydroxylation of 25(OH)D to 1,25(OH)2D which takes place in the kidneys
- causes lack of calcium absorption from intestines
- stimulates parathormone secretion and calcium loss from bone
- inhibits bone mineralization
what are the causes of osteodystrophy
- loss of lamina dura
- demineralization (ground glass appearance)
- expansile radiolucencies (CGCG, brown tumor)
- wide trabeculae
- loss of cortication
- sclerosis
osteodystrophy has similar bone changes to:
- osteitis deformans (Paget’s disease)
- fibrous dysplasia
what does alternative filtering of the blood do and what is it initiated in
- removes uremic toxins
- initiated in ESRD
what are the two modalities of alternative filtering of the blood
- hemodialysis (venous access)
- peritoneal dialysis
describe hemodialysis and how often it is done and what are the downsides
- arteriovenous fistula
- arteriovenous graft
- central venous catheter (special, short term)
- machine filters blood
- heparin is typically used
- every 2-3 days (three/week) ; 3-4 hours/session
- risk of infectious disease - Hep B and C
- induces fatigue and dizziness
describe peritoneal dialysis and how often is it done
- hypertonic solution in peritoneal cavity
- peritoneal membrane used for exchange
- 3-5x/day or overnight
when is dental treatment done in relation to hemodialysis
the day after
what must match in kidney transplant, what is the life expectancy
- ABO matching
- HLA matching
- can be from live (better) or decreased donor
- related mismatched donor (3/6 match) is better than deceased donor
- greater than 5 year life expectancy
what are the absolute contraindications for a kidney transplant
- AIDS
- active hepatits
what causes rejection in kidney transplants and are they direct or indirect causes
- activated cytotoxic T cells (direct)
- alloantibodies (direct)
- delayed type hypersensitivity- arteriosclerosis of transplant (indirect)
kidney organ transplants require:
immunosuppression
what are the induction medications for kidney transplants and why are they used
- to prevent acute rejection
- antithymocuyte globulin
- alemtuzumab (anti-CD52)
what are the maintenance drugs for kidney transplants
- azathioprine
- mycophenolate mofetil
- steroids
- calcineurin inhibitors
- mTOR inhibitors
- belatacept
what is azathioprine and what does it do
- antimetabolite
- inhibits DNA and/or RNA synthesis
what is mycophenolate mofetil similar to and what does it do
- similar to azathioprine
- less bone marrow suppresion
how are steroids used in maintenance of kidney transplant
low doses, adjunct
what are the calcineurin inhibitors, what do they do and what diseases are complications seen in
- cyclosporin
- tacrolimus
- both decrease production of IL-2 mRNA and proinflammatory cytokines
- diabetes and nephrotoxicity complications
what are the mTOR inhibitors and what do they do
-sirolimus
- everolimus
- inhibits T cell proliferation signaling
what does belatacept do
- binds costimulatory molecules
- t- cell anergy and apoptosis
what are the adverse effects of kidney transplant
- cytopenias (bone marrow suppression)
- bleesing: severe thrombocytopenia less than 50K
- susceptibility to infection: severe leukopenia/neutropenia. WBC less than 200 and ANC less than 500
- increased risk of developing skin and hematologic cancers
what are the oral adverse effects of kidney transplants
gingival hyperplasia (cyclosporine)
- aphthous like ulcers (mTORi)
what are the dental treatment considerations with renal disease
- determine level of renal impairment and disease control
- level of renal impairment may affect bleeding-assess risk
- asses indication for antibiotics
- drug interactions/side effects
what is the level of renal impairment and disease control determined by in dental treatment considerations
- BP
- GFR
- BUN
- creatinine clearance
- serum creatinine
- electrolytes
describe the level of renal impairments that may affect bleeding in dental treatment
- patients can be at risk for both bleeding and thrombosis
- quantitative and qualitative platelet impairment: platelet count, PT-INR, PTT
- hemostatic measures as necessary
- be aware of signs and symptoms of thrombosis
- referral to a specialized center as necessary
advanced uremia ->
decreased immune function
how should infections in dental treatment in renal disease be treated
aggressively
if invasive procedures in patients with stage 4 severe or end stage renal disease what should you do
consult physician about need for antibiotics
is antibiotic prophylaxis routinely necessary for peritoneal dialysis
no
is antibiotic prophylaxis necessary for patients with a synthetic AV graft
may be
is antibiotic prophylaxis necesssary in hemodialysis patients if performing incision and drainage
yes
what are the considerations with drug interactions and side effects
- check drug excretion mechanism
- carefully review possible drug interactions with current medication list when prescribing new medications
- consult with patients physician
what drugs should you be cautious about with renal disease
nephrotoxic drugs such as acyclovir, NSAIDs, aspirin, aminoglycosides and tetracycline
how should acetominophen be used in renal disease
- nephrotoxic at high doses
- increase dosing interval
- every 6 hours if GFR is greater than 10 but less than 50 ml/min
- every 8 hours if GFR is less than 10ml/min
how should NSAIDs be used in renal disease
- avoid
- except for aspirin for CVD
- especially long term use
- interaction with antihypertensives
- impairment of prostaglandin production: vasoconstriction, reduced renal perfusion
how should opioids be used in renal disease
- avoid completely
- risk for accumulation of toxic metabolites
- ?tramadol with dose adjustment and/or increased dosing internal
- consult with physician
how should benzodiazepines be used in renal disease
- caution
- consider half life, active metabolite
- single dosing, consult with physician
how should acylovir be used in renal disease
- increase dosing interval q8h or q12h
how should antibiotics be used in renal disease
- no adjustment required for: clindamycin, doxyclycline, erythromycin, metrondiazole
- adjustment required:
- amoxicillin - q12h or q24h
- cephalexin: q6-18h or q12-24h
- azithromycin- avoid if GFR less than 10
how should fluconazole be used with renal disease
reduce to 50% or 25% of original dose
how should nystatin be used in renal disease
no adjustment
what are the goals of pre-transplant dental clearance
- remove active foci of infection and limit potential foci of infection - think 6 months
- defer elective treatment within first 6 months post transplant
how should you remove active foci of infection and limit potential foci of infection
- treat active foci of infection: SRP, endo tx, restorations
- extract teeth with questionable/poor prognosis
- assess caries risk and need for adjunts (fluoride)
- educate patient on importance of maintaining good homecare, diet and professional maintenance
how should renal disease patients be monitored
- opportunistic infections
- toxicities/side effects of systemic treatment
- cancer
what opportunistic infections must be monitored in renal disease
- odontogenic
- candidiasis
- aspergillosis
- HSV
- OHL
- CMV
what are the toxicities and side effects of systemic treatment that need to be maintained in renal patients
- adrenal insufficiency - long term high dose corticosteroids
- gingival hyperplasia- cyclosporine
- pyogenic granuloma and OFG like lesions- tacrolimus
- oral ulcerations- sirolimus
what cancers do we need to monitor in renal patients
- non melanoma skin cancer- basal cell and SCC
- post transplantation lymphoproliferative disorder- usually EBV associated, B cell
- other solid cancers including oral SCC
