Top Tips in Managing Patients with Chronic Kidney Disease

Recently, I have been seeing lots of patients with chronic kidney disease. How does this impact the dental care I plan for these patients...?

Causes of Kidney Disease

Kidney disease can be mild, moderate or severe with the main 2 causes being:

1. Uncontrolled hypertension
2. Uncontrolled diabetes leading to diabetic nephropathy

This can manifest as chronic renal failure, or renal osteodystrophy where increase plasma phosphate leads to secondary hyperparathyroidism. 

Systemic Signs of Kidney Disease

Cardiovascular: Hypertension, congestive cardiac failure, atheroma, cardiac arrhythmia

Gastro-Intestinal: Anorexia, vomiting, nausea, peptic ulcers

Neurological: Headaches, tremor, sensory disturbances

Dermatological: Itching, hypepigmentation

Haematological: Anaemia, increased bleeding 

Metabolic: Thirst, nocturia/polyuria, electrolyte disturbances, secondary hyperparathyroidism

Treatment of Kidney Disease

Management of mild/moderate kidney disease can be to control causative factors such as anti-hypertensive drugs or more effective diabetic control. Otherwise in severe cases, treatment can be:

• Peritoneal haemodialysis  (inside the body using the periotonium)
• Extra-corporal haemodialysis (outside of the body exchange)
• Transplant

Oral and Dental Manifestations of Kidney Disease

When examining patients with kidney disease, you may come across the following signs:

• Oedema around the face (peri-orbital is common) or ankles
• Oral ulceration
• Pale oral mucosa 
• Opportunistic dental infections e.g. candidiasis, herpes zoster due to immunosuppression
• Gingival hyperplasia (induced if patient is taking ciclosporin)
• Swelling of the salivary glands - parotid is most common

Tops Tips

• Patients should be treated under local anaesthetic if possible, as sedation or general anaesthetic drugs will have a impaired excretion. Liaison with a patient's physician and anaesthetic team is recommended
• Avoid NSAIDs and some antimicrobials e.g. tetracycline, erythromycin
• Consider prescribing reduced doses of other antimicrobials e.g. acyclovir, amoxicillin, and recommend paracetamol for post op pain
• Patients are at an increased bleeding risk mostly down to platelet dysfunction rather than the effect of the heparin used during dialysis (which has a very short half life). Investigatory bloods may be indicated and use of local haemostatic measures
• Treat patients the day after dialysis to allow the effect of heparin to be eliminated and when patient is feeling most well
• Patients undergoing haemodialysis may have an arterio-venous fistula access in an arm - DO NOT use this arm for venous access
• If patient has had a kidney transplant, they may be immunosuppressed. If they are taking steroids, steroid cover for surgery may be indicated. Ciclosporin as mentioned above also can cause gingival overgrowth. Antibiotic cover may be necessary and consideration of bleeding risk if they are also anticoagulated. 

Overall, mild or moderate kidney disease should be suitable to be seen in primary care. For patients undergoing dialysis or who have had a kidney transplant it may be more practical for them to be seen in secondary care especially if co-coordinating care with their renal team. To read more about the management of these patients, see this BDJ article. 

Have you managed patients with chronic kidney disease? What adjustments did you make if any? Let me know in the comments below!

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5 Top Tips for Speciality Training Interviews

It's been over a year since my Speciality Training Interviews but with everyone's coming up in the next couple of weeks here are my top 5 tips...

1. Read the Personal Specification

As you will know, most of the information you need for StR and DCT posts is on the COPDEND website; but most importantly you must read the personal specification for your chosen speciality.

This will really help guide you to how many boxes you tick and how to answer questions in the interviews. If you're looking to apply to training in the future this is a good guide to identify areas to strengthen your application.

2. Prepare your Portfolio

For most interviews you will need a portfolio. Some will give you a template to work to, some there is very little guidance - you may have a dedicated station for this or just asked to bring it along to view at some point in the interview. 

If you don't have a template to work to check out my previous post which gives you a guide. Working on your portfolio is time consuming but really important so give yourself plenty of time. You may not think you have a lot to include but think laterally e.g. lunch & learn presentations, if you've written any patient information leaflets. Make sure you are succinct and organise the portfolio clearly. 

3. Know your Stations

Most of speciality training is via national recruitment where at the interviews are broken up into stations very similar to DCT interviews. Depending on your speciality these may include:

• Clinical station - testing your clinical knowledge of the speciality
• Academic station - testing your knowledge of research, academia and evidence based dentistry 
• Practical station - depending on your speciality depends on whether you have this station and what practical skills are tested
• Communication station - with a actor to test your communication skills
• Portfolio station - testing your commitment to the speciality and achievements to date
• Situational Judgement Test - not in every speciality yet but may be further in the future

Check on Oriel what stations you have, their length and structure or ask previous candidates for a guide. 

4. Practice, practice, practice

With all interviews I would recommend practising scenarios and interview techniques with peers and mentors to build up your confidence beforehand. By now you have done quite a few different interviews and had practice of these but from your reading of the personal specification and information on oriel you will know how this interview is structured so you can practice accordingly.

5. Be prepared

Set aside enough time to prepare for this interview it's a toughy! Don't worry if you don't get a post first time round, plenty of good candidates have to apply several times before they get a post. Depending on your speciality the material you chose to read before the interview will vary but generally I would recommend:

• Read this Medical Interviews Book... it has excellent guidance on all types of medical interview. It is medical focused but you can apply most of it to the dental interviews. 
• Read guidance that applies to your speciality e.g. NICE, SDCEP, BSDH, FGDP etc. 
• Read recent published articles applicable to your speciality and pick a couple you really like and critically appraise them 
• Read of any recent changes in your speciality and be aware of brief outline of the StR curriculum that applies to you
• Be aware of national issues in dentistry e.g. Never Events, recruitment, WHO checklists

And finally good luck! Don't get too stressed and support each other. National recruitment is stressful but there is always another year to apply!

Do you have any tips for StR interviews? Let me know in the comments below!

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