1. Renal and Hepatic Disease Claire Nowlan MD

2. 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

3. 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

4. Symptoms of chronic liver disease May be asymptomatic for 10 to 30 years Nonspecific signs – Fatigue, weight loss, itchiness, right upper quadrant pain

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. End stage liver disease Esophageal varicies deficiency of Vit K dependant coagulation factors anemia, leukopenia, thrombocytopenia esophagitis, gastritis endocrine disturbances encephalopathy dementia

15. Laboratory abnormalities Increased AST GGT ALT Bilirubin Alk Phos INR Decreased albumin RBC, WBC, platelets

16. 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

17. Dental management - all liver disease Screen for bleeding tendencies Unpredictable metabolism of specific drugs

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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