Advanced Education In General Dentistry

Patient Case: Renal Disease

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T.R. is a 55 year old man referred by his general dentist for maxillary alveoloplasty prior to denture fabrication. The patient wishes to have IV sedation because of previously unpleasant dental experiences.

PMHx: End Stage Renal Disease on Hemodialysis since 1997, Hypertension, Anemia
PSHx: AV Fistula Left Arm
Meds: Epogen, Norvasc, Phos Lo
Allergies: No Known Drug Allergies

Questions For The Patient

  1. What is your dialysis schedule?
  2. How long have you been on dialysis?
  3. Do you have any AV fistula?
  4. What is the underlying cause of your renal failure?
  5. Do you have any dialysis related diseases or complications?
  6. Are you fatigued, short of breath, have any chest pain at rest or with exertion?

Implications For Sedation

The sedation and procedure should take place the day following hemodialysis. This is the time that the patient's metabolic state is most optimal. Antibiotic prophylaxis is generally recommended for patients with an arterio-venous fistula. IV fluid should also be limited during the procedure to avoid volume overload. This is a risk becuase the patient cannot excrete excess fluid due to their renal dysfunction. It is also important to note that patients with renal failure will also have anemia secondary to a decreased erythropoetin production (Erythropoetin is made in the renal cortex). This anemia can cause fatigue, shortness of breath and chest pain. EKG monitoring in these patients is vital. Metabolic abnormailities combined with anemia can place a great deal of stress on the heart and thus should be monitored closely. It is also important to never take a blood pressure or start an IV in the patient's arm with the AV fistula. This could cause collapse of the fistula.

Summary Of Treatment

  1. Schedule procedure the day following dialysis
  2. Check post dialysis Labs: CBC and blood chemistry
  3. Supplemental Oxygen
  4. BP, EKG
  5. Avoid medications with renal metabolism
  6. No IV or blood pressure in arm with AVF
  7. Good local Anesthesia
  8. Limit IV fluid

<<Back to "Clinical Assessment and Guidelines: Special Cases to Consider"