L14: renal failure and dental implications Flashcards
Congenital issues that can arise with kidney structure
- horseshoe kidney (1:600 and mainly affects men)
- ectopic kidney - kidney is not in the normal position
- renal agenesis: unilateral = 1:1000 only one kidney, bilateral = 1:10,000 - not compatible with life.
- dysplastic kidney diseases - many when the kidneys are both present but the structure of them are abnormal
- ureteric abnormalities causing drainage issues
Linking a kidney function with a disease
Excretion of:
- water - fluid overload
- metabolic waste products - toxin build up (e.g. uraemia)
- electrolytes - electrolyte disturbances
- drugs x differential drug handling
Metabolic functions:
- acid base balance - metabolic acidosis
- vitamin D - renal bone disease/vascular calcification
- erythropoietin - renal anaemia
- gluconeogenesis - hypoglycaemia
Blood pressure control (RAAS) - hypertension
Chronic kidney disease (CKD) epidemiology
- 9% global prevalence
- more common in males and makes them more likely to require dialysis
- more prevalent in poorer countries
Risk factors for CKD
Hypertension, diabetes mellitus, glomerular diseases, history of previous AKI, drugs affecting kidney function, obstructive uropathy/disorders, multisystem diseases with renal involvement, family history of CKD - including inherited nephropathies/ciliopathies, cardiovascular disease
Progressive CKD and the need for renal replacement therapy.
- renal transplantation - use someone else’s kidney to augment pre-existing natural kidney function - either donated from someone who is alive (live related, live unrelated or altruistic, or from someone who has died (cadaveric)
- dialysis - haemodialysis (in hospital) or peritoneal dialysis (at home)
- conservative management - for those patients where transplantation or dialysis is not expected to make a long-term mortality/morbidity benefit
Renal transplantation
Min 36
Dialysis
Min 38
Dental issues in CKD
- estimated 90% prevalence of oral symptoms in patients with CKD
- issues with salivary glands, the periodontium, the teeth, the alveolar bone, the gums, and oral mucosa
- interventions that nephrologists make can complicate dental treatments offered by dentists.
Where is vitamin D3 found?
Vitamin D3 (cholecalciferol) is made in the skin. Found in oily fish, egg yolks, and fortified food,
Where is vitamin D2 found?
Vitamin D2 (ergocalciferol) is found in fortified foods, salmon, mushrooms and egg yolks.
Vitamin D metabolism
Vitamin D3 and vitamins D2 are taken to the liver and are hydroxylated into 25-hydroxyvitamin D/calcidiol/25(OH)D. The kidney converts this in 1,25dihydroxyvitamin D/1,25(OH)2D/calcitriol = metabolic active component involved in bone metabolism.
What happens to vitamin D metabolism in kidney disease?
Not enough vitamin D activation into calcitriol, so vitamin D levels are low, reducing calcium levels and increasing phosphate levels (because phosphate clearance is directly related to kidney function). Stimulate PTH production - which causes bone breakdown through osteoclastic activity, and leads to calcification in blood vessels and thus hypertension.
What happens to wound healing in people with kidney disease?
CKD has a unique metabolic milieu, acidosis, inflammation and toxin build-up. These all lead to relative immunoparesis and thus a dampened immune response. Uraemia toxin accumulation can also cause bleeding diasthesis, so can impact on healing in the mouth during extractions etc.
How does anaemia affect wound healing?
CKD patients are usually anaemic which will impact tissue oxygenation and mean any bleeding from treatments may have more impact in these patients.
How can drugs used to treat renal disease cause poor wound healing?
Certain drugs used to treat renal diseases associated with poor wound healing. Particularly sirolimus (in renal transplants) and bleeding, especially if the patients are anti coagulated all the time.
