Page 17 - GP spring 2023

Severe skeletal changes of hyperparathyroidism are well doc- tion. Active oral infections need to be eliminated and man-
umented, but they are rarely seen today because laboratory aged aggressively before the transplant to avoid any poten-
tests usually diagnose the disease before macroscopic skel- tial complications during the transplant process. During the
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etal abnormalities develop. Some of those skeletal changes early post-transplantation phase (the first six months after the
might affect the facial bones. 12 transplant), patients will take the highest dosage of immuno-
suppressant and thereby will be at the greatest risk of infec-
Renal hyperparathyroidism tion or complication. Any elective dental treatments should
Hyperparathyroidism secondary to CKD results from defec- be postponed, and only emergency treatment should be per-
tive activation of vitamin D leading to hypocalcemia and hy- formed. Only palliative and preventive dental treatments are
perphosphatemia, which can further lead to an increase in the recommended during this phase. Elective dental treatment
production of PTH and in the number of parathyroid gland can be safely implemented during the stable post-transplant
cells. Symptoms and signs of renal hyperparathyroidism in- phase (6 months after the transplant). The risk of infection
13
clude muscle as well as bone pain and bone fractures. Treat- and complications is much lower during this phase. However,
14
ment of renal hyperparathyroidism revolves around strict it is critical that dental professionals continue to coordinate
regulation of serum PTH, calcium, phosphorus, and vitamin well with nephrologists or physicians and monitor any oral
D levels. complications or malignancies that may have arisen from
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immunosuppressive therapy. 19
Management of patients with CKD
In case of rejection after the transplant, only emergency treat-
Routine monitoring of vital signs ment can be performed since patients will be immunocom-
As aforementioned, hypertension is both the cause and effect promised during this phase. Constant communication and co-
of CKD. About 35.8% of patients with CKD in the United ordination with nephrologists or physicians are also critical
States have hypertension. It accelerates the rate of CKD during this phase. 19
15
progression to ESRD and increases the risk of the develop-
ment of cardiovascular diseases. Thus, routine monitoring of Antibiotic prophylaxis
a patient’s vital signs is of grave importance. The American Heart Association does not recommend anti-
biotic prophylaxis for invasive dental procedures for patients
In addition, since the early stages of CKD and hypertension with peripheral vascular grafts used for hemodialysis. 20
are often asymptomatic, early detection of hypertension
would enable dental professionals to help reduce the risk of Conclusion
potential systemic complications related to both CKD and Given the increasing prevalence of CKD, it is critical that
hypertension and ultimately reduce morbidity and mortality dental professionals understand the current burden of CKD
related to them. Blood pressure measurement is an important and its related complications. In addition, since the early
screening tool for dental patients. 16 stages of CKD and most complications of CKD are often
asymptomatic, being aware of appropriate management strat-
Bleeding Risk egies for patients with CKD is incumbent on all dental pro-
Early stages of CKD (stages 1 to 2) do not require any adjust- fessionals. Dentists can help lessen the socioeconomic bur-
ments or deferral of elective dental treatment regarding the den of CKD by monitoring patients for signs and symptoms
risk of bleeding. However, advanced stages of CKD (stages 4 of CKD, enabling early detection of CKD, and ultimately
and 5) may require special considerations regarding bleeding promoting patient-centered care.
risk.
References
Platelet dysfunction in patients with severely decreased 1. Kovesdy, Csaba P. “Epidemiology of chronic kidney disease: an up-
glomerular filtration rate (GFR) may manifest as abnormal date 2022.” Kidney international supplements vol. 12,1 (2022): 7-11.
bleeding involving the skin, resulting in easy bruising in doi:10.1016/j.kisu.2021.11.003.
the oral and nasal mucosa, gastrointestinal (GI), and urinary 2.Centers for Disease Control and Prevention. Chronic Kidney Disease
tracts. 17 in the United States, 2021. Atlanta, GA: US Department of Health and
Human Services, Centers for Disease Control and Prevention; 2021.
https://www.cdc.gov/kidneydisease/publications-resources/ckd-nation-
Patients with stage 4 or 5 CKD undergo renal replacement al-facts.html. Accessed 12/05/2022.
therapy, which includes peritoneal dialysis and hemodialysis. 3. Nicoll, Ruairidh et al. “Models of care for chronic kidney disease: A
Although peritoneal dialysis does not pose a risk of bleeding, systematic review.” Nephrology (Carlton, Vic.) vol. 23,5 (2018): 389-
hemodialysis poses some degree of risk of bleeding since he- 396. doi:10.1111/nep.13198.
modialysis requires anticoagulants such as heparin to prevent 4. Chen, Teresa K et al. “Chronic Kidney Disease Diagnosis and Manage-
clotting and facilitate unobstructed filtration of toxic com- ment: A Review.” JAMA vol. 322,13 (2019): 1294-1304. doi:10.1001/
pounds in the blood (i.e., urea). Thus, any invasive dental jama.2019.14745.
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treatments should be performed on non-dialysis days when 5. Vaidya, Satyanarayana R. and Narothama R. Aeddula. “Chronic Renal
anticoagulant effects are absent. Failure.” StatPearls, StatPearls Publishing, 10 August 2022.
6. Bello, Aminu K et al. “Complications of chronic kidney disease: cur-
rent state, knowledge gaps, and strategy for action.” Kidney international
Transplant supplements vol. 7,2 (2017): 122-129. doi:10.1016/j.kisu.2017.07.007.
The terminal stage of CKD, also known as ESRD, necessitates 7. Bonner, Ryan et al. “Diabetic Kidney Disease.” Primary care vol. 47,4
a kidney transplant. Thus, it is imperative that dental profes- (2020): 645-659. doi:10.1016/j.pop.2020.08.004.
sionals communicate and coordinate well with nephrologists 8. Portolés, Jose et al. “Anemia in Chronic Kidney Disease: From Patho-
or physicians before, during, and after kidney transplanta- physiology and Current Treatments, to Future Agents.” Frontiers in med-
www.nysagd.org l Spring 2023 l GP 17