Renal and Hepatic Disease

Claire Nowlan MD

Liver Function

Secretion of bile for fat absorption Short term sugar storage Breakdown of aged red blood cells with

excretion of bilirubin Synthesis of coagulation factors Drug metabolism

Hepatitis

Inflammation of the liver from any cause Most common causes are viral & alcoholic

– Less frequent causes are mononucleosis, secondary syphilis, TB, acetaminophen overdose, methotrexate, ketoconazole

Acute symptoms– Abdominal pain, nausea, vomiting, fever, malaise, jaundice,

hepatomegaly, splenomegaly– In the recovery phase, hepatomegaly and abnormal liver

functions may persist

Symptoms of chronic liver disease

May be asymptomatic for 10 to 30 years Nonspecific signs

– Fatigue, weight loss, itchiness, right upper quadrant pain

Hepatitis A

Transmission - fecal-oral route Sources - water, shellfish, restaurants Incubation - 15-50 days Serological evidence of infection in 40% of US

populations No chronic carrier state Vaccine and immunoglobulin available

Hepatitis B

Transmission - percutaneous/permucosal High risk groups

healthcare workers, immigrants from Southeast Asia, hemodialysis patients, IV drug users, recipients of blood transfusions, unprotected sex (especially anal) with multiple partners

Incubation - 45-180 days

Hepatitis B

Risk of infection with needle stick injury 6-30% Prevalence of infection in dentists 8%, oral

surgeons 21% 5-10% risk of becoming a chronic carrier Carriers have increased risk of cirrhosis and

hepatocellular carcinoma Vaccine and immunoglobulin available

Hepatitis C

Transmission - mainly percutaneous. Very low risk with sexual transmission

Incubation 14-180 days Risk groups

– mainly IV drug users, and blood transfusion prior to 1992

Risk of infection with needle stick injury 2-8% 80-90% risk of becoming chronic carrier

Hepatitis C

Risk of cirrhosis and hepatocellular carcinoma No active or passive immunization available Treatment is only suggested in certain

subgroups, but it is expensive, takes up to 1 year, has many side effects, and only 10-30% are actually cured

Other Hepatitis Viruses

Hepatitis D– only occurs as a coinfection with B– transmitted both parenterally and sexually

Hepatitis E– resembles hepatitis A, transmitted through the fecal

oral route

Dental management

Difficult to identify all patients through history Many acute cases of Hep B&C are mild Must use infectious precautions for ALL

patients Screening recommended for patients from high

risk groups

Guidelines for blood exposure

From patients with Hep B– determine titer of anti-HBs in the health care

professional– if adequate - no tx needed– if inadequate give HBIG

From patients with Hep C– exposed professional gets baseline and f/u testing

for anti-HCV and liver enzymes

Alcoholic liver disease

Only 10-15% of alcoholics develop cirrhosis Early change - fatty liver Second stage - alcoholic hepatitis Final stage - cirrhosis

End stage liver disease

Esophageal varicies deficiency of Vit K dependant coagulation

factors anemia, leukopenia, thrombocytopenia esophagitis, gastritis endocrine disturbances encephalopathy dementia

Laboratory abnormalities

Increased AST GGT ALT Bilirubin Alk Phos INR

Decreased albumin RBC, WBC, platelets

Dental management - alcoholic liver disease

Beware a second addiction to pain medication - no refills, avoid narcotics and sedatives if possible

Patient may require more local anesthetic or anxiolytic

Dental management - all liver disease

Screen for bleeding tendencies Unpredictable metabolism of specific drugs

Renal function

Control fluid volume Acid-base balance Controls secretion of K, Na, phosphate Excrete wastes Synthesize erythropoietin Activates Vit D Controls blood pressure by secreting renin Metabolizes drugs

Chronic renal failure

Irreversible destruction of the nephrons The kidney can lose about 50% of the

nephrons and still maintain normal function Progressive, most often caused by DM,

hypertension, Glomerulonephritis Various grades of failure depending on GFR

– 50-10 ml/min = moderate– < 10 ml/min = severe

Laboratory assessment

Urinalysis Increased creatinine Increased BUN Changes in Na, K CBC, INR, PTT GFR = (140 - age) X lean wt in KG X.85 if female

72 X serum creatinine

Chronic renal failure

Problems CV - Fluid overload, hypertension GI nausea, diarrhea Neurologic “uremic encephalopathy” Metabolic - Metabolic acidosis, uremia, hypokalemia Hematologic - Anemia, platelet disfunction Immunity - decreased Dermatologic - yellow tinge to skin, pruritis, bruises Renal rickets Fatigue

Medical management

Conservative care – Restrict fluid, K, Na, protein, phosphate– Tx DM, hypertension– Give recombinant human erythropoietin

Hemodialysis– Patients have arteriovenous shunt– Need heparin infusion during dialysis

Peritoneal Dialysis Renal Transplantation

Dental management

Screen for bleeding disorder before surgery Avoid nephrotoxic drugs

NSAIDs – especially ASA Acyclovir High dose acetaminophen

Decrease dosages of drugs mainly metabolized through kidney

Penicillins, erythromycin, opioids

Controversy whether antibiotic prophylaxis needed

Dental management - hemodialysis

Be careful of arteriovenous shunt Dental care on non hemodialysis days Be aware of possible Hep B,C, HIV in these

patients