Tuesday, 21 May 2019

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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