Kidney dysfunction

Question 1

For kidney dysfunction, mention:

- The role of the kidney in health (6)

Answer 1

· Filter fluids
· Excrete waste
· Produces urine
· Control electrolyte balance in the body as well as sodium, bicarbonate, potassium and calcium
· Produce erythropoietin- stimulates bone marrow = red blood cells
· Regulate serum pH

Question 2

For kidney dysfunction, mention:

- The 7 effects of kidney dysfunction

Answer 2

Effects 
• Anemia
• Hypertension
• Bone density
• Increased bleeding, bruising, petechiae
• Vascular disease
• Peripheral edema, inflammation
• Hyperpigmentation

Question 3

For kidney dysfunction, mention:

- The 8 oral findings associated with renal disease

Answer 3

Oral findings
· Petechiae
· Xerostomia
· Halitosis
· Stomatitis
· Erythema
· Oedema
· Candidiasis
· Tongue and mucosal pain

Question 4

Discuss the dental management considerations for patients undergoing dialysis or kidney transplant

Answer 4

· Heparin is given when dialysis occurs. It prevents clotting during procedure
· Effects several hours after dialysis procedure
· Schedule dental appointments at least 1 day after dialysis- when effects of heparin are no longer present and when blood waste products are removed
· Patients on chronic dialysis – prone to infection­ FREQUENT maintenance program to maintain oral health
· Invasive dental procedures­ determine risk of bleeding­ INR

Question 5

Describe the INR ranges

Answer 5

· Measures clotting tendency of blood
· Normal INR (not on warfarin): <1.0
· Therapeutic range (on warfarin or heparin): 1.0 ­- 2.5
· Acceptable upper limit for dental Tx (on warfarin or heparin): <3.5 (specialist tx)

Question 6

List the alternatives to Warfarin and Heparin and discuss why alternatives are not really used

Answer 6

· Fewer blood thinning medications include: Apixaban (Eliquis), Dabigatran (Pradaxa), Edoxaban (Savaysa) and Rivaroxaban (Xarelto)
· Direct thrombin inhibitor (blocks it)
· Prevents pooled blood in heart from clotting
· Lack widely available monitoring tests for anticoagulation
· Safer and easier for patients to use
· However, accumulate in patients with renal impairment – therefore, not appropriate for patients with kidney disease for patients with renal impairment

Question 7

Describe the issue of shunt diseases and renal disease

Answer 7

· Shunt devices, if infected are at risk of bacteraemia- predisposing patient to infective endocarditis- whether with or without valvular disease
· Consultation with specialist/GP to determine the need for antibiotic prophylaxis
· May have high levels of resistance to organisms due to frequent use of antibiotics

Question 8

List questions you would ask a patient with renal disease and a consideration when performing blood pressure reading

Answer 8

· What type of kidney problem do you have?
· Has your GP or specialist recommended that you take antibiotics before dental treatment?
· Are you on hemodialysis?
· Kidney transplant patient- What drugs are you taking to prevent rejection of your kidney?

Pressure from the blood pressure cuff can cause arterio-venous shunt to collapse so blood pressure should be taken on the opposite arm

Question 9

Describe the prescription of medications for patients with a kidney disease

Answer 9

· Medications and metabolites are cleared through the urine via kidneys–Kidney dysfunction- toxic levels increase
· Medications that use the kidneys as major pathway for elimination are contraindicated or used with caution: Aspirin, NSAIDs/ibuprofen, Penicillin

Question 10

Describe the dental management of the patient with renal transplants

Answer 10

· Immunosuppressive therapy is given after transplantation. Cyclosporin, prednisone may be used­
· Monitor for gingival hyperplasia­
· Discuss the importance of plaque removal to reduce gingival enlargement