Chronic Renal Failure Cases

1
Chronic Renal Failure Cases
2
Case
x

• 65 year old male who presents with a toothache
• PHM hypertension, kidney failure, itching
• Meds lisinopril, nifedipine, erythropoietin,
  calcitrol, sodium bicarbonate, multivitamins
• Diet high calorie, low protein, moderate Na
• VS BP 170/95 P 80

x
3
Lab Values

• BUN 50 mg/dL (6-20 mg/dL)
• Creatinine 2.5 mg/dL (0.7-1.3 mg/dL)
• GFR 50 ml/min (100-150 ml/min)
• HCT 30 (41.5-50.4)
• Phosphorus 10 mg/dL (2.3-4.7 mg/dL)
• Calcium 5 mg/dL (9.2-11 mg/dL)

4
What are the potential problems to consider in
this patient?

• Bleeding tendency
• Hypertension
• Anemia
• Intolerance to nephrotoxic drugs or drugs whose
  active metabolite is excreted by the kidneys
• Oral lesions or changes (stomatitis, mucosal
  pallor or yellow-brown coloration, unpleasant
  taste, ammonia-like breath odor, radiographic
  bone changes)

5
Medical Problem Worksheet
BP?
Hemostasis, anemia
6
Prescribing Drugs for Patients With Renal Failure

• Renal failure substantially slows drug
  biotransformation
• Many active or toxic drug metabolites depend upon
  renal function for elimination, thus many of the
  adverse drug reactions seen in patients with
  renal failure may be explained in part by the
  accumulation of active metabolites
• Drugs metabolized by the liver with inactive
  metabolites are of minimal concern
• The rate of elimination of drugs excreted by the
  kidneys is proportional to the glomerular
  filtration rate

7
GFR and Severity of Renal Failure

• Normal 100-150/ml/minute
• Mild 50-100ml/minute
• Moderate 10-50ml/minute
• Severe lt10ml/minute

8
Aronoff, GR, et al Drug prescribing in renal
failure, Amer Coll Phys, Phil, 1999.

• Antimicrobials
• Penicillin V (OK to use in normal dose and
  intervals)
• Amoxicillin (?dosing interval with increasing
  severity mild-q8h, mod-q8-12h, severe-q24h)
• Cephalexin (? dosing interval with increasing
  severity mild-q8h, moderate-q12h, severe-q12h)
• Erythromycin (Mild moderate-OK to use normal
  dose and intervals, severe-? dose by 25-50)
• Azithromycin (OK to use in normal dose and
  intervals)
• Clarithromycin (mild-OK to use in normal dose
  and intervals, mod-? dose by 25, severe-? dose
  by 25-50)
• Clindamycin (OK to use in normal dose and
  intervals)
• Metronidazole (mild moderate-OK to use in
  normal dose and intervals, severe-? dose by 50)
• Tetracycline (Avoid)
• Doxycycline (If necessary, OK to use in normal
  dose and intervals)
• Acyclovir (mild-5mg/kg q8h, moderate-5mg/kg
  q12-24 hr, severe- 2.5mg/kg q24h)

9
Aronoff, GR, et al Drug prescribing in renal
failure, Amer Coll Phys, Phil, 1999.

• Analgesics Hepatic metabolism eliminates most
  commonly used analgesics
• Acetaminophen (mild-OK to use in normal dose and
  intervals, mod- q6h, severe-q8h)
• Aspirin (mild-OK to use in normal dose and
  intervals, mod-q4-6h, severe-avoid)
• Ibuprofen (OK to use in normal dose and
  intervals)
• Codeine (mild-OK to use in normal dose and
  intervals, mod-? dose by 25, severe-? dose by
  50)

10
Aronoff, GR, et al Drug prescribing in renal
failure, Amer Coll Phys, Phil, 1999.

• Local Anesthetics Most local anesthetics are
  metabolized by the liver
• Lidocaine (OK to use in normal dose)
• Sedative/Hypnotics Use short term only
  metabolites can accumulate with chronic use
• Diazepam (OK to use in normal dose and intervals)
• Triazolam (OK to use in normal dose and intervals)

11
Case
x

• 48 year old Hispanic male school teacher presents
  to your office as a new patient for routine
  dental care
• PMH kidney failure, has been on hemodialysis for
  3 years, has 3 treatment sessions per week and is
  doing well
• VS BP 145/90, P 75
• Needs SRP, one extraction and a few fillings

x
x
12
What are the potential problems to consider in
this patient?(hemodialysis corrects many of the
complications of kidney failure)

• Bleeding tendencies
• Impaired drug excretion
• Hypertension
• Shunt/graft infections
• Hepatitis B or C
• Anemia
• Renal osteodystrophy

13
Medical Problem Worksheet
None required
Anemia, hemostasis
Treatment timing?
14
Case

• 47 year old female presents for routine dental
  care
• PMH chronic renal failure, kidney transplant 4
  years ago and doing well
• Meds prednisone, cyclosporine
• VS BP 145/87 P 70

x
x
15
What are the potential problems to consider in
this patient?

• Susceptibility to infection
• Management recommendations
• Consultation with physician/transplant
  coordinator
• Frequent recall and prophylaxis
• Daily antibacterial mouth rinses (chlorhexidene)
• Any indicated dental care
• Avoid NSAIDs (?bleeding with corticosteroids and
  potentiation of nephrotoxicity of cyclosporine
  and tacrolimus)
• Consider antibiotic prophylaxis for invasive
  procedures (controversial)
• Screen for head and neck cancers
• Consider need for supplemental corticosteroids
  (if patient is on or has recently discontinued
  taking corticosteroids