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HemodialysisHemodialysis: A Case Presentation: A Case Presentation
Jason Yanich D.D.S.General Practice Residency
The Ohio State University
College of Dentistry
305 West 12th Avenue
Columbus, Ohio 43210-1241Phone: 614-292-2622
Fax: 614-292-4522
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IntroductionIntroduction
Patient Information: Andrew is a 37 yr old white male
requiring dental treatment prior toproposed kidney transplant.
Chief Complaint: I need to get on the transplant list
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Past Medical History (cont.)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
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Past Medical History (cont.)Past Medical History (cont.)
Anemia (2 to ESRD) HTN (5 yr hx) Medically
controlled Hypercholesterolemia - treated
Tobacco abuse
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Past MedPast Medical history (cont.)ical 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.
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MedicationsMedications 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
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Social and FamilySocial and Family HxHx
Single, no children
lives with parents
Mother and father living with HTN
Tobacco abuse
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AllergiesAllergiesPatient states allergies to
morphine and codeine
Reactions:
Morphine n&v
Codeine hearing s
itchiness
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HemodialysisHemodialysis
Hemodialysis is performed by passingthe patients blood through an artificial
kidney. Special tubing carries theblood to and from the dialyzer. The
dialyzer acts as a blood filter and
should attempt to perform the same
functions as the normal kidney.
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HemodialysisHemodialysis
The dialyzer is a device housing a semi permeablemembrane and a special diasylate solution.
Blood flows through the compartment of the
membrane and is surrounded on the outside by thediasylate. Blood comes into contact with the
diasylate through the membrane and materials in
the blood and diasylate are exchanged bydiffusion.
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Extracorporeal DialyzersExtracorporeal Dialyzers
DesignsDesigns
Coil Dialyzer 1-2 long membrane tubes coiled around
plastic core Older design
Limited performance
Limited surface area
Lacked uniform flow of dialysate
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Extracorporeal DialyzersExtracorporeal Dialyzers
Parallel Plate Dialyzer Sheets of membrane mounted on supportscreens and stacked
Multiple parallel channels of flow alongmembranes
Increased performance / thinner channels of
dialysate and blood Minimized blocking of flow and membrane
stretching or deformation
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Extracorporeal DialyzersExtracorporeal Dialyzers
Hollow Fiber (Capillary) Dialyzer Most effective
Allows Low volume / high efficiencywith 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
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CapillaryCapillary DialyzerDialyzer
Advantages: Low priming volume and compliance
Easier reuse
Disavantages:
Higher residual blood volume
Potting compound retains residualethylene oxide
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MembranesMembranes
Cellulose Substituted cellulose
(cellulose acetate) Cellulosynthetics
(3 amino compound) Synthetics
Polyamide, PMMA, polysulfone, PAN
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diasylatediasylate
Bicarbonate containing Acetate containing
Generates HCO3-
by metabolism
Both contain similar concentrations of:
Na, K, Ca, Mg, and Cl
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Vascular AccessVascular 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 inadequatearterial system ( diabetes or atherosclerosis)
Autogenous saphenous vein or PTFE
(teflon)
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CatheterCatheter
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CatheterCatheter
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Dental ExamDental Exam Extraoral:
Findings all WNL with exception of markedskin pallor
Intraoral:
buccal mucosa shows bilateral leukoedema andFordyces granules present
Tonsillar tissue still present, soft palate slightlyerythematous
Tongue is fissured and coated
Generalized gingival erythema with recession
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Panorex Note moderate to severe periodontal disease
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Treatment PlanTreatment PlanTreatment in the OR under general
anesthesia was rendered due topatients advanced periodontal disease,
medical history, and moderate dentalanxiety.
Treatment consisted of full mouthextraction and alveoloplasty
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ProcedureProcedure
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
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Complications of RenalComplications of Renal
FailureFailure
Uremia leading to fluid overload,hypertension, and cardiac disease
Azotemia (BUN), metabolic acidosis,and hyperkalemia
Hematologic abnormalities incl.anemia and coagulopathy
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Complications of RenalComplications of Renal
FailureFailure
Decreased host defense and leukocyteabnomalities
Cardiovascular disease and tendencyto develop CHF
Renal Osteodystrophy (with 2hyperparathyroidism)
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Complications of ChronicComplications of Chronic
HemodialysisHemodialysis
Altered serum [Ca2+]
Over secretion of PTH
Increased risks of Hep B and C andHIV
Altered/abnormal bleeding & clotting
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Management ConsiderationsManagement ConsiderationsGeneral concerns:
Consultation with physician regardingcontrol of disease, electrolyte balance,
and 2 systemic diseases Monitor BP
Screen for coagulopathy
Avoid nephrotoxic drugs
Adjust dosage of drugs metabolized by
kidney
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Management ConsiderationsManagement ConsiderationsDialysis concerns:
Provide treatment on days in between dialysis
(avoid on day of tx)
Use caution when taking BP (avoid area offistula or graft) or giving IV meds
Coagulation concerns
Tx as potential carrier of HBsAg
Drug dosing and intervals affected by dialysis
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ReferencesReferences
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
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ReferencesReferences
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
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ReferencesReferences 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
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ReferencesReferences Maher J. ed.: Replacement of renal function by dialysis,
3rd. Ed. 1989
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