Page 16 - GP spring 2023

Dental Management of Patients with Chronic Kidney Disease

Authors: Juhee Kim, Angela M. De Bartolo, DDS and Analia Veitz-Keenan, DDS

Introduction Leading causes of CKD frequently encountered in dental
Chronic Kidney Disease (CKD) is an increasing burden in public practice
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health, affecting more than 10% of the population worldwide. Ac-
cording to the Centers for Disease Control and Prevention (CDC), Hypertension
about 15% of adults in the United States, about 37 million people, Hypertension is considered both the cause and complication
are estimated to have CKD. In addition, most of the patients with of CKD. In other words, CKD and hypertension serve as
CKD are undiagnosed: about 9 in 10 adults in the United States risk factors for one another. Hypertension would accelerate
with CKD are unaware of the fact that they have CKD. the rate of progression of CKD to advanced stages, and the
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One of the reasons why most CKD patients are undiagnosed is that presence of CKD would increase the risk of hypertension and,
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patients with early stages of CKD are often asymptomatic. The ultimately, cardiovascular complications. Thus, hypertension
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CKD diagnosis is established by any abnormal structure or func- must be well-controlled with regular monitoring, and appro-
tion in the kidney for more than three months. There are five stages priate management strategies to avoid progression of CKD to
of CKD, and each stage is determined by the estimated glomerular advanced stages and prevent cardiovascular complications re-
filtration rate (eGFR) (Table 1). The leading causes of CKD glob- sulting from CKD.
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ally are type 2 diabetes mellitus (T2DM), which accounts for about
30% of CKD, and hypertension, which accounts for about 27.2% of Type 2 Diabetes Mellitus (T2DM)
CKD. In addition, since the risk of CKD increases with age, it is im- T2DM is considered the leading cause of CKD. About 40%
perative that patients who have hypertension, diabetes mellitus type of patients with T2DM will eventually develop CKD. Poor
II, and are older than 65 should be regularly screened for CKD. 5 glycemic control and hyperglycemia can lead to overactiva-
tion of the renin-angiotensin-aldosterone system, damage to
Although the early stages of CKD are often asymptomatic, CKD is the filtration barrier, increase inflammation, mesangial expan-
a progressive disease that could lead to several systemic complica- sion, and ultimately progressive neuropathy. Thus, the level
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tions, such as anemia, renal osteodystrophy, and renal hyperpara-
thyroidism. Uncontrolled CKD can ultimately lead to end-stage of glycemic control and duration of T2DM significantly influ-
renal disease (ESRD), the most advanced stage of CKD. Such ence the development and progression of CKD.
complications lead to high morbidity, poor life quality, and even-
tually high mortality. Thus, early detection of patients with early Common systemic complications of CKD frequently encoun-
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stages of CKD is of paramount importance. tered in dental practice
The high prevalence of undiagnosed CKD patients necessitates the Anemia
need to increase awareness of CKD. Dental professionals who reg- Being one of the most common complications of CKD, anemia
ularly see patients could potentially serve as one of the frontlines accounts for the poor quality of life, increased morbidity, and
to increase awareness through monitoring and assessing patients’ mortality in CKD patients. Decreases in endogenous erythro-
needs, identifying common comorbidities associated with CKD, poietin (EPO) levels, iron deficiency resulting from blood loss
and ultimately helping prevent and manage potential complica- or impairment of iron absorption, hemolysis resulting from
tions resulting from CKD. In addition, patients in different CKD uremia, and loss of blood resulting from platelet dysfunction
stages require different management types, so dental practitioners contribute to anemia in patients with CKD. Common anemia
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must be aware of different management strategies for each patient. symptoms include dyspnea, fatigue, headaches, generalized
The purpose of this review is to: 1) provide a review of leading weakness, skin pallor, and tachycardia. Unlike the convention-
causes of CKD frequently encountered in a dental clinic - T2DM al treatment of anemia, treatment of anemia caused by CKD
and hypertension; 2) review common systemic complications of mainly focuses on improvement in renal function and increase
CKD seen in dental practice - anemia, renal osteodystrophy and in red blood cell production. The treatment often involves
renal hyperparathyroidism; 3) inform the reader of the appropri- erythropoiesis-stimulating agents (ESAs) such as recombinant
ate dental management of patients with CKD; and 4) increase the human erythropoietin (EPO) and iron supplementation. How-
awareness of underrecognized CKD patients. ever, due to the multifactorial nature of anemia of CKD, it is
imperative to understand that the treatment of anemia of CKD
Table 1. Classification of CKD by eGFR by KDIGO (Kidney Disease: is complex, and its prognosis is guarded. Thus, it is vital to
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Improving Global Outcomes) 2012. 4 monitor patients with CKD if they exhibit any signs or symp-
toms of anemia that can manifest in the oral cavity.
Stages of CKD eGFR (mL/min/1.73m )
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G1 (Normal or high) ≥90 Renal osteodystrophy
Renal osteodystrophy is a complication of CKD that involves
G2 (Mild decrease) 60 - 89 disturbances in the metabolism of minerals and bone and, ul-
G3a (Mild to moderate decrease) 45 - 59 timately, alteration in bone morphology. It leads to poor qual-
ity of life, increased morbidity and mortality in patients with
G3b (Moderate to severe decrease) 30 - 44 CKD. Although CKD patients with renal osteodystrophy are
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G4 (Severe decrease) 15 - 29 often asymptomatic, some may exhibit bone pain or fractures.
The treatment often involves strict regulation of calcium, phos-
G5 (Kidney failure) <15 phate, vitamin D, and parathyroid hormone (PTH) levels. 11
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