Liver and renal Flashcards
Diagnosis and Tx plan for:
A 50-year-old male attends your general dental practice. You take the following history:
C/O: Painful and broken tooth in upper left of his mouth
H/P/C: The tooth broke 3 days ago
Painful with cold and hot drinks
The pain lasts for about 5 minutes
It is very sensitive to touch - TTP
M/H: He reports being perfectly fit and healthy
Medications: Paracetamol for pain relief
S/H: Enjoys drinking alcohol socially
Non smoker
irreversible pulpitis
after discussing all the available options you elect to remove tooth 26.
The gentleman also has a retained root 25 which you have discussed removing.
he has only provided his consent to the removal of tooth 26 as the root is not sore.
- He wishes to keep the root as he has read it is important if you want implants.
potential medical reasons for not being able to achieve haemostasis
several
inc
- inherited/congital bleeding disorders
- medication induced
- haematological disease
- liver disease
haemstasis processs
complex, multi-stage process and impairment at any stage could result in inability to stop bleeding
inherited/congential bleeding disorders examples
haemophilia A and B
von Williebrand’s disease
medications that can inhibit haemostasis
- Antiplatelet:
- Aspirin, Clopidogrel, Prasugrel or Ticagrelor
- Anticoagulants:
- Heparin, warfarin, apixaban
- Low Molecular Weight Heparin
- New or Novel Oral Anticoagulant or Target-specific anticoagulants
- Coumarin Anticoagulants
Other drugs:
- Side effect of chemotherapy agents in the management of malignancy. effect bone marrow; lower platelet count
- HIV or other diseases where the bone marrow is suppressed by the agents used
- Antimicrobials: Rifampin
- Anti - seizure medications: Phenytoin, Valproic acid
- Haloperidol
- Quinine (malaria)
5 commonly known haemostatic inhibiting medication
Antiplatelet:
- Aspirin, Clopidogrel, Prasugrel or Ticagrelor
Anticoagulants:
- Heparin, warfarin, apixaban
Low Molecular Weight Heparin
New or Novel Oral Anticoagulant or Target-specific anticoagulants
Coumarin Anticoagulants
haematological diseases that can affect haemostasis
leukaemia
immune throbocytopenia purpura (ITP)
myeloma
infections that can affect haemostasis
viral infections e.g. HIV, Hep C
which hepatits infections cause the most concern with haemostasis
B and C - worried
A not as worried
5 types of liver diseases that can inhibit haemostasis
alcoholic liver disease
liver cirrhosis
hepatitis B or C infection
primary biliary cirrhosis
hepatocellular carcinoma
acute liver disease is
autoimmune primary biliary cirrhosis
chronic liver diseases occurs in
stages
what occurs as result of liver disease
Changes in both the qualitative and quantitative coagulation factors
- Impaired liver function has an impact upon the hepatic synthesis of clotting factors and proteins involved in the fibrinolytic system
- including the vitamin K dependent coagulation proteins (II, VII, IX, X).
vit K dependent clotting factors
II
VII
IX
X
what clotting factor is the most concern for liver disease
VII
prolongs PT
shortest half life - quickest to go
what can occur to blood cells as a result of liver disease
thrombocytopenia and thromobocythaemia
various mechanisms
- Splenic sequestration (old platelets -> macrophages in spleen)
- Impaired hepatic synthesis and / or increased degradation of thrombopoietin by platelets sequestered in the congested spleen (change in portal circulation so take out premature platelets -> organ damage)
alchohol impact on haemostasis
can have a direct effect - suppress bone marrow and thus impair production of cells
need to disclose truthfully
renal disease impact on haemostasis
abnormalities in platelet function in renal disease and these are independent of thrombocytopenia.
This is poorly understood on the whole but there may well be defects in platelet adhesion, secretion and storage as a result uraemia
7 stages of managing haemorrhage in GDP
- Apply pressure to the socket +/- LA soaked guaze.
- Pack the socket with a suitable adjuvant material such as oxidised cellulose or a collagen sponge
- Suture the surgical site
- Re-evaluate the medical history
- If available, you could consider a tranexamic mouthwash
- Cautery – Bipolar/ Silver nitrate sticks.
- Bone wax
consider phoning your local oral surgery or Oral and Maxillofacial Department.
- rural -> contact your local A and E department if there is no OMFS or oral surgery unit.
Re-eval MHx – not disclosed or not diagnosed?
He tells you that his platelets were measured as 50 x 109/L. The doctors think this is the reason why you could not achieve haemostasis following the tooth extraction.
The patient also tells you that he has now been referred to a Gastroenterology clinic.
He asks you, “Why are my platelets reduced and why have I been referred to the gastroenterology clinic?”
not in our scope of practice to discuss this - he should discuss with his GDP
can tell pt
- platelets are reduced - likely had impact on his ability to stop bleeding
- however, in isolation platelets levels greater than 50 x 109/L should still be a safe level to achieve haemostasis following a single uncomplicated tooth extraction
- probable that there may other features affecting coagulation
encourage to attend medical appointment
keep us informed of updates of medical situation to ensure dental care can be planned appropriately
- unable to provide any operative care until he has been fully assessed
platelet count ranges
A normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood. Having more than 450,000 platelets is a condition called thrombocytosis; having less than 150,000 is known as thrombocytopenia.
- 50 x 109/L – low platelet count; cut of for secondary care Tx
Above 50 – achieve haemostasias for single uncomplicated extraction
- But if multiple extractions à problems likely
thromobocytopenia
a condition characterized by abnormally low levels of platelets, also known as thrombocytes, in the blood (normal range 150,000 - 450,000)
features of thrombocytopenia (3)
- Easy or excessive bruising (purpura)
- Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs.
- Prolonged bleeding from cuts
major mechanisms for thrombocytopenia in liver cirrhosis (2)
(1) platelet sequestration in the spleen;
(2) decreased production of TPO in the liver.
* Historically, thrombocytopenia has been thought to arise from the increased pooling of platelets in an enlarged spleen (splenomegaly)*
thrombocytopenia impact on liver and liver disease
further aggravates hepatic destruction and contributes the pathogenesis of CLD and cirrhosis
suggesting that measures to prevent platelet loss may be useful as a therapeutic approach to treat CLD
year later, man comes back - gastro clinic needs him dentally fit
bruise on hand when shaking
UKELD 49
what other features may he present with?
Liver diease
- Jaundice - skin and sclera of eyes
- leukonychia (white spots on nails),
- clubbing,
- palmar erythema,
- Dupuytren’s contracture - knots of tissue create cord pulling fingers into bent position
- spider naevi bleeding
- swelling in legs and ankles
- itchy skin
- ascites,
- peritonitis,
- nausea, vomitting
Alcohol related: tremors, cognitive impairment
not seen
- oesophageal varices (ballooning of vessels – easily damaged),
- encephalopathy or hepatorenal syndrome.
stool and urine colour liver disease
dark urine colour
pale stool colour
infective causes of liver disease
hepatitis virus - B, C, D (A rarely has significant consequences)
non-infective causes of liver disease (6)
- autoimmune - primary billary cirrhosis
- alcohol related
- non-alcoholic fatty liver disease (NAFLD)
- haemochromaatosis
- drug induced - paracetamol,
- hepatocellular carcinoma (malignancy)
paracetamol affect on liver
toxic to liver, unrepairable damage if OD
haemochromatosis
inherited; comes with age;
excess Fe absorption from gut;
macrophage in liver storage – multi organ damage;
take a pint of blood to drop
basic stages of liver disease (3 stages)
Hepatitis: Inflammation of the liver which may or may not be reversible depending on the disease
Liver cirrhosis
- Irreversible liver necrosis and fibrosis
Liver failure
- Failure of normal liver function
UKELD score significance
United Kingdom Model for End Stage Liver Disease
- system which predicts a person’s prognosis in chronic liver disease
- used as to guide determine the need for liver transplant.
UKELD scotland guidelines
UKELD score of 49 is the minimum level at which a patient should be assessed for a liver transplant.
- equates to > 9% mortality rate within 12 months
- higher score = higher % mortality
- e.g. 60 has 50% 1 year motality
dental impact when UKELD reaches 49
significant level of liver disease that may implicate with rest of body
- need to plan; no Tx that day
how to manage a liver disease pt effectively
- liaise with the hepatology unit to establish the medical condition of this gentleman and to be able to work together to ensure this gentleman receives appropriate medical care to facilitate safe dental treatment in the correct environment.
- Blood tests: FBC, Coagulation/clotting screen (PT + ration, APTT + ratio, thrombin time,TCT ratio) +/- INR , LFTS , Us and Es
- Appropriate radiographs: OPT +/- intraoral views as required (periapicals – anterior teeth esp – blurred in OPT), full mouth pocket chart if required after bloods
liver pt requires
mutlidisciplinary care
liaise with hepatology unit to see if fit for tx as coagulation will be prolinged
may need platelet top up, tranexamic acid
if bilirubin not conjugated or excreted ->
will accumulate in body and colour skin and mucous membranes (jaundice) and whites of eyes (icterus)
- Detectable at levels greater than 40micromol/L
- Urine darkens
causes for bilirubin not being conjugated
- enzyme defect
- parenchymal liver disease
causes for why billrubin may not be excreted
biliary obstruction - pancreas inflammed
PT ratio aim
1
low HB
anaemia possible
low platelet
bleeding tendency
increased billirubin
If bilirubin not conjugated (enzyme defect or parenchymal liver disease) or excreted (biliary obstruction – pancreas inflamed) – will accumulate in body and colour skin and mucous membranes (jaundice) and whites of eyes (icterus)
- Detectable at levels greater than 40micromol/L
- Urine darkens
increased prothrombin time
more bleeding
less likely to want to do extraction
possibly due to depressed synthesis of blood clotting factors and excess fibrinolysis
drugs to be careful of when liver function impaired
metabolised in liver e.g. - local anaesthetics (amides)
NSAIDs - increase bleeding risk
antibiotics - dose
sedation risk
LA in liver disease pts
Lignocaine is fully metabolised in the liver.
only 5-10% of Articaine is processed in the liver,
- the majority of the drug being metabolised in the plasma.
- advantageous - decreases the metabolic demand on the liver.
Clinical opinion is very varied
-
Articaine infiltrations is advantageous in the management of patients with advanced liver disease.
- possible to use Articiane infiltrations to avoid IAN blocks.
- reduces the risk of haematoma formation and its significant consequences.
analgesia in liver pts
NSAID
- increase bleeding risk which will result in mucosal bleeding
- concern in those with oesophageal varices
- hepatorenal syndrome.
- inhibition of prostaglandins leads to decrease in renal perfusion, reduction in GFR and sodium retention. (bleeding risk and kidney damage)
avoided in all but the most mild cases of liver disease (even in these situations due consideration should be given to its use)
paracetamol - hepatotoxic but risks less than NSAIDs
consult with hepatology team if in doubt
antibiotics in liver disease
only in large infection
dose may have to be altered
type
- Amoxicillin should be safe to prescribe
- dose of metronidazole maybe altered in moderate and severe liver disease.
- Erythromycin is not a first line drug but does have effects on the liver and should not be routinely prescribed in this group of patients
sedation in liver disease pt with anxiety
Dentist led IV sedation with midazolam is not appropriate
anxiety is such that it requires sedation inhalation sedation - anaesthetist led Propofol sedation or even general anaesthesia should be considered.
However, the safest way to provide care for this gentleman is with local anaesthetic only.
what to do if liver disease pt has high risk bleeding post dental extraction
where and how tx
assessed and treated in a hospital in association with a hepatology unit and appropriate medical back up
- may require a bed such that he can be assessed and monitored pre- and post-operatively by medical colleagues.
- Treat earlier in the day so time to deal with issues that may arise
- Arrange to speak and see how they are later (possible phone call too)
- Rebound bleed – usually 4-6 hours after Tx
methods used to help facilitate tx that may cause bleeding in liver disease pt
- vitamin K replacement
- FFP transfusion
- +/- platelet transfusion
Repeat blood just before – platelets 50+ (if not get platelet transfusion – FFP fresh frozen plasma, vit K)
tx planning if pt needs medical transfusion for tx
do as much treatment as possible when a person is given product as transfusion come with associated risks
what to do before tx in regards haemostatic aids
check in date
