Hemodialysis: A Case Presentation

Jason Yanich D.D.S. General Practice Residency The Ohio State University College of Dentistry 305 West 12th Avenue Columbus, Ohio 43210-1241 Phone: 614-292-2622 Fax: 614-292-4522

Introduction

Patient Information:
Andrew is a 37 yr old white male

requiring dental treatment prior to proposed kidney transplant.

Chief Complaint:
I need to get on the transplant list

Past Medical History (cont.)

Medical history:

25 yr hx of Diabetes Mellitus (type I) Chronic Renal Failure (CRF) With current dx of ESRD 2 to CRF Coronary Artery Disease (CAD) No hx of MI Cath w/ stent placed May 2001

Past Medical History (cont.)

Anemia (2 to ESRD) HTN (5 yr hx) Medically

controlled Hypercholesterolemia - treated Tobacco abuse

Past Medical history (cont.)

Left forearm venous anastamosis

(straight line graft) in April 2001. Hemodialysis began on July 2001. Surgical Hx includes several other procedures (cyst / tumor removal, artery repair, tendon / nerve surgery) with no complications.

Medications
Clonidine 0.2 mg TID Norvasc (Amlodipine) 10 mg QD Lopressor (Metoprolol) 50 mg BID Lasix (Furosemide) 80 mg BID Zocor (Simvastatin) 20 mg QD Phoslo (Calcium Acetate) 200 mg with meals ASA 325 mg QD NPH insulin 14 units Q am and 8 units Q pm Humalog insulin sliding scale

Social and Family Hx

Single, no children lives with parents Mother and father living with HTN Tobacco abuse

Allergies
Patient states allergies to morphine and codeine

Reactions:
Morphine n&v Codeine hearing s itchiness

Hemodialysis
Hemodialysis is performed by passing the patients blood through an artificial kidney. Special tubing carries the blood to and from the dialyzer. The dialyzer acts as a blood filter and should attempt to perform the same functions as the normal kidney.

Hemodialysis
The dialyzer is a device housing a semi permeable membrane and a special diasylate solution. Blood flows through the compartment of the membrane and is surrounded on the outside by the diasylate. Blood comes into contact with the diasylate through the membrane and materials in the blood and diasylate are exchanged by diffusion.

Extracorporeal Dialyzers Designs

Coil Dialyzer
1-2 long membrane tubes coiled around plastic core Older design Limited performance Limited surface area Lacked uniform flow of dialysate

Extracorporeal Dialyzers
Parallel Plate Dialyzer
Sheets of membrane mounted on support screens and stacked Multiple parallel channels of flow along membranes Increased performance / thinner channels of dialysate and blood Minimized blocking of flow and membrane stretching or deformation

Extracorporeal Dialyzers
Hollow Fiber (Capillary) Dialyzer
Most effective Allows Low volume / high efficiency with low resistance to flow Fibers create fiber bundle with is supported by polyurethane at each end Blood flows through the fibers, diasylate flows around outside

Capillary Dialyzer
Advantages:
Low priming volume and compliance Easier reuse

Disavantages:
Higher residual blood volume Potting compound retains residual ethylene oxide

Membranes
Cellulose Substituted cellulose (cellulose acetate) Cellulosynthetics (3 amino compound) Synthetics Polyamide, PMMA, polysulfone, PAN

diasylate
Bicarbonate containing Acetate containing Generates HCO3- by metabolism Both contain similar concentrations of: Na, K, Ca, Mg, and Cl

Vascular Access
Permanent Access:

Atriovenous fistula
Radial artery to cephalic vein Safest and longest lasting vascular access

Atriovenous graft
When poor veins exist or there is inadequate arterial system ( diabetes or atherosclerosis) Autogenous saphenous vein or PTFE (teflon)

Catheter

Catheter

Dental Exam

Extraoral:
Findings all WNL with exception of marked

skin pallor

Intraoral:
buccal mucosa shows bilateral leukoedema and

Fordyces granules present Tonsillar tissue still present, soft palate slightly erythematous Tongue is fissured and coated Generalized gingival erythema with recession

Panorex Note moderate to severe periodontal disease

Treatment Plan
Treatment in the OR under general anesthesia was rendered due to patients advanced periodontal disease, medical history, and moderate dental anxiety. Treatment consisted of full mouth extraction and alveoloplasty

Procedure
Antibiotic premed by anesthesia with Ancef (Cefazolin) General anesthesia via NETT Extractions performed: #s 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 Alveoloplasty all four quads

Complications of Renal Failure

Uremia leading to fluid overload, hypertension, and cardiac disease Azotemia (BUN), metabolic acidosis, and hyperkalemia Hematologic abnormalities incl. anemia and coagulopathy

Complications of Renal Failure

Decreased host defense and leukocyte abnomalities Cardiovascular disease and tendency to develop CHF Renal Osteodystrophy (with 2 hyperparathyroidism)

Complications of Chronic Hemodialysis

Altered serum [Ca2+] Over secretion of PTH Increased risks of Hep B and C and HIV Altered/abnormal bleeding & clotting

Management Considerations
General concerns:

Consultation with physician regarding control of disease, electrolyte balance, and 2 systemic diseases
Monitor BP Screen for coagulopathy Avoid nephrotoxic drugs Adjust dosage of drugs metabolized by kidney

Management Considerations
Dialysis concerns:

Provide treatment on days in between dialysis (avoid on day of tx) Use caution when taking BP (avoid area of fistula or graft) or giving IV meds Coagulation concerns Tx as potential carrier of HBsAg Drug dosing and intervals affected by dialysis

References
Http://www.kidneydoctor.com/ Http://www.multi-media.com/homehemotoday Http://www.niddk.nih.gov/health/kidney/summary/hemod ose/index.htm Http://www.kumc.edu/SAH/resp_care/cybercas.html

References
Replacement of renal function by dialysis / edited by C. Jacobs ... [et al.] Dordrecht, Netherlands ; Boston : Kluwer Academic, 1996 Replacement of renal function by dialysis : a textbook of dialysis / edited by John F. Maher Dordrecht ; Boston : Kluwer Academic Publishers, 1989 Essentials of anatomy & physiology / Rod R. Seeley, Trent D. Stephens, Philip Tate St. Louis : Mosby, 1996

References
Dental management of the medically compromised patient / James W. Little ... [et al.] St. Louis, Mo. : Mosby, 2002 Renal dialysis / edited by J.D. Briggs ... [et al.] London ; New York : Chapman & Hall Medical, 1994 Medical physiology : textbook study guide Garden City, N.Y. : Medical Examination Pub. Co., 1982 Poland, James L

References
Maher J. ed.: Replacement of renal function by dialysis, 3rd. Ed. 1989