Vol. 92 No.
1 July 2001
ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY
MEDICAL MANAGEMENT UPDATE
Update on renal disease for the dental practitioner
A. Ross Kerr, DDS, MSD, New York, NY
NEW YORK UNIVERSITY
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:9-16)
The scope of this review will be limited to an update
of chronic renal disease (CRD). In contrast with
patients who have acute renal disease, most patients
with CRD progressively and irreversibly lose renal
mass and the ability to carry out critical renal func-
tions. If untreated, patients will have life-threatening
complications develop. Treatment modalities such as
dialysis and renal transplantation greatly reduce the
risk of such complications, although patients may have
a number of treatment-related complications develop.
Oral health care providers will encounter patients with
CRD and therefore should update their knowledge
about (1) the epidemiology, risk factors, and medical
management of CRD, (2) the myriad of complications
patients with CRD may experience, and (3) contem-
porary dental/oral management strategies for patients
with CRD. A discussion of renal transplantation has
been discussed elsewhere1 and is beyond the scope of
this review.
EPIDEMIOLOGY, RISK FACTORS, AND
MEDICAL MANAGEMENT
A patient’s renal reserve, or the capacity for struc-
tural and functional hypertrophy of surviving
nephrons, can compensate to a point at which less than
50% of renal function remains. Once the damage is
past the point of compensation, patients will begin to
experience the signs and symptoms of chronic renal
Director of Special Patient Care and Hospital Dentistry; Assistant
Professor, Department of Oral Medicine, New York University
College of Dentistry.
Received for publication Mar 12, 2001; accepted for publication Mar
22, 2001.
Copyright © 2001 by Mosby, Inc.
1079-2104/2001/$35.00 + 0 7/13/115976
doi:10.1067/moe.2001.115976
Editor: James R. Hupp
insufficiency (CRI) and, if left untreated, will progress
to a state of chronic renal failure (CRF). Ultimately,
such patients develop end-stage renal disease (ESRD),
an irreversible and potentially fatal condition unless
patients undergo dialysis or renal transplantation.
Serum creatinine and blood urea nitrogen levels are
considered crude measures of renal function and may
yield either false-positive or false-negative results.
Glomerular filtration rate (GFR) is the most valid para-
meter of renal function and is a useful marker in
gauging disease progression (Table I). The creatinine
clearance is a clinically acceptable approximation of
GFR. For a more sensitive calculation of GFR, there
are sophisticated—yet time-consuming—tests measur-
ing inulin clearance (the gold standard for GFR
measurement) and clearance of radioisotopes such as
125I-iothalamate, 51Cr-EDTA, or 99mTc-DPTA.
The NHANES III study2 from 1988-1994 screened
noninstitutionalized patients’ serum creatinine levels as
a crude measure of renal function and estimated that
more than 6 million Americans over the age of 12 years
had creatinine levels greater than or equal to 1.5
mg/dL. In 1998, 85,520 Americans were diagnosed
with ESRD, an incidence rate of 308 per million US
citizens. The prevalence of ESRD in 1998 was
323,821, a rate of 1160 per million US citizens. More
importantly, there has been a gradual and worrisome
increase in the incidence rates over the last decade,
reflected primarily in the increasing incidence of
diabetes mellitus—the single greatest cause of CRD—
in the United States. Table II stratifies these statistics
by age, sex, race, and cause.
In 1998, 71% of patients with ESRD were under-
going dialysis and 29% had functioning transplants.
Although chronic ambulatory peritoneal dialysis is still
prescribed, almost 90% of dialysis today is through
hemodialysis. Of the 63,000 deaths from ESRD
9
10 Kerr ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
July 2001

Table I. Measures of renal function Table II. Summary statistics on reported ESRD in the
Serum creatinine, United States (1998, compilation completed May
GFR, normal value: normal value: 0.6-1.3 2000)3
CRD stage 125 mL/min mg/dL (65-kg person) Incidence in Prevalence/
CRI 75-30 1.5 Characteristics million/year* million
CRF 29-10 2 Age (y)
ESRD <10 8 0-19 14 70
20-44 121 728
in 1998, more than 50% were from cardiovascular 45-64 606 2468
65-74 1314 4011
complications. Infections are the second most common
>75 1359 3279
cause of death in ESRD. Sex
The medical management of patients with CRD Male 370 1382
depends on the remaining renal function. As the GFR Female 261 977
drops, close monitoring of the following is indicated: Race
Whites 228 830
GFR, blood urea nitrogen, glycemic control in diabetic
Blacks 962 3854
patients, hypertension control, proteinuria (a significant Native Americans (Indians) 858 3075
risk factor for the progression of CRD), hyperlipidemia, Asian/Pacific Islander 394 1403
electrolyte derangements in CRD (metabolic acidosis, Cause
hypocalcemia, hyperphosphatemia, and hyperkalemia), Diabetic nephropathy 133 386
Hypertension 71 250
and smoking cessation compliance. Patients with CRI
Glomerulonephritis 38 221
or CRF may respond favorably to dietary interven- Other known causes 36 156
tions—particularly low-protein diets—although the Unknown causes 29 147
potential for malnutrition exists.4 Medications, particu- *Incidence: new patients who began ESRD therapy in 1998.
larly angiotensin-converting enzyme inhibitors, are
commonly prescribed for the treatment of underlying
hypertension and proteinuria.5 The use of potentially patient population. This is hardly a surprising fact given
nephrotoxic medications in patients with compromised that almost 75% of patients have hypertension, 65% have
kidney function may be contraindicated. In patients diabetes, 34% have congestive heart failure, and 25% have
with ESRD who rely on dialysis, the benefit of dialysis a history of ischemic heart disease at the time they are diag-
outweighs the risk of life-threatening uremic complica- nosed with CRD. In addition, kidney failure leads to fluid
tions, but this modality can lead to numerous complica- overload, stimulation of the renin-angiotensin system, and
tions of importance to the dentist. other mechanisms, all of which cause secondary hyperten-
sion.6 A shutdown in renal erythropoietin production leads
COMPLICATIONS to anemia, putting additional stress on the cardiovascular
The kidneys perform a wide range of important func- system to meet oxygen demands, and, if untreated, will
tions, the prime function of which is to maintain a stable result in left ventricular hypertrophy and, ultimately,
composition of the fluid-bathing cells by selective reten- cardiac failure.7 Vascular disease (both arteriosclerosis and
tion and elimination of water, electrolytes, and other atherosclerosis) is progressive in renal failure,8 and hyper-
solutes. In addition, they are important sites for carbohy- kalemia increases the risk for dysrhythmias. Collectively,
drate, fat, and protein metabolism, and they play a role in these factors may lead to the development of potentially
the renin-angiotensin system and in the stimulation of red life-threatening cardiovascular complications, emphasizing
blood cell production. They also assist in the metabolism the need for the dentist to carefully assess the patient’s
and elimination both of drugs and of hormones. The cardiovascular status before proceeding with dental treat-
progressive loss of kidney function ultimately results in a ment.
clinical syndrome known as uremia, in which failure to A predilection for developing infective endocarditis
adequately perform essential functions leads to the build- (IE) and vascular access infections in this patient popula-
up of retained toxins and the development of a myriad of tion (particularly in those receiving hemodialysis) as the
potential problems affecting virtually every organ system. result of orally induced bacteremia has been suggested in
Which blend of complications a patient with CRD will the dental literature.9 Valvulopathies, particularly calcific
have develop will depend on the underlying cause of the valvular disease due to secondary hyperparathyroidism,
CRD, the remaining renal function, the success and are common in this population. A multicenter prospective
compliance of treatment, and individual variation. study in France revealed an incidence rate of 15 to 19
Cardiovascular complications are multifactorial in origin patients (per 10,000 dialyzed patients) with a severe
and cause the highest morbidity and mortality in this valvulopathy requiring surgical intervention,10 a clear
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 92, Number 1
Table III. Summary of the assessment and management of patients with CRD (continued)
Question
What is the overall
degree of CRD?
What is the cause of CRD?
What factors affect the
progression of CRD?
What is the medical management Physician (ie, nephrologist)
of CRD?
What is the hemodialysis regimen? Access type (arteriovenous
What medications is the patient
taking?
What is the cardiovascular
history?
Kerr 11
Potential concerns and
Consideration of assessment consideration of modifications to
Looking for before dental treatment dental treatment
CRI: GFR, 75-30 mL/min Renal function screening tests Defer elective dental treatment
CRF: GFR, 29-11 mL/min Serum creatinine until complete assessment has
ESRD: GFR < 10 mL/min Blood urea nitrogen been made and a medical treat-
GFR measures ment plan established.
Creatinine clearance Follow treatment modifications
Inulin clearance [gold standard] for patients with diabetes,
Radioisotope clearance hypertension, or SLE.
Diabetes Control of these comorbid diseases
Hypertension
Glomerulonephritis
SLE
↑ Age Urine protein (measured over a
Sex (male > female) 24-hour period)
Race (black and Hispanic) Lipid profile (total cholesterol,
Proteinuria LDL, HDL, triglycerides)
Hyperlipidemia Blood pressure
Hypertension Smoking/cessation history
Smoking
Compliance issues (keeping Defer elective dental treatment
responsible for care appointments/drugs/diet/ in patients with compliance
Diet/risk-factor modification smoking) issues.
Medications
Renal replacement therapy
Hemodialysis (home vs center)
Peritoneal dialysis
Platelet count/INR/PTT Defer dental treatment on the
fistula, polytetrafluoroethylene day of hemodialysis.
graft, tunneled cuffed Do not take blood pressure on
catheters, others) arm with vascular access.
Use of antithrombotic agents Discuss controversy of antibotic
(including heparin and other prophylaxis with nephrologist.
agents) Possible adjustment of drugs
Schedule for dialysis (home vs prescribed in dentistry because
dialysis center) of hemodialysis clearance.
Antihypertensives Compliance issues Defer elective dental treatment
Antidiabetes drugs Adverse reactions/interactions in patients with compliance
Lipid-lowering drugs issues.
Anticoagulants Avoid interactions with drugs
Antiplatelet drugs prescribed in dentistry.
Erythropoietin Watch for adverse oral reactions
Phosphate binders by performing careful and
Iron supplements frequent oral examinations.
Dosage, schedule, route
Interactions with drugs
prescribed in dentistry
Adverse reactions of concern
with respect to dental treat-
ment
Hypertension History of recent cardiovascular Uncontrolled cardiovascular
Atherosclerosis emergency (<6 months) complications may lead to
Arteriosclerosis Cardiovascular symptoms (ie, medical emergencies in the
Ischemic heart disease headaches, shortness of breath, dental chair.
Stroke chest pain and/or left-sided pain, Follow treatment modifications
Dysrhythmia palpitations, fatigue, dizziness) for patients with cardiovascular
Valvulopathy Cardiovascular signs (ie, heart problems.
Infective endocarditis sounds/rate/rhythm, respiration
Cardiac surgery
sounds/rate, retinal changes,
Congestive heart failure
distended jugular veins, splinter
12 Kerr
Table III. continued
Question
What is immune status/
infection history?
Is there a history of anemia?
Is there a history of bone
involvement?
Is there a history of
abnormal hemostasis?
Is there a history of a psychiatric
disorder?
Looking for
Level of immunocompromise
Vascular access infections/IE
Tuberculosis
Bloodborne pathogens (HIV
and hepatitis C, B, and G)
Candidiasis
Renal anemia
Erythropoietin replacement
Iron-deficiency anemia
Secondary hyperparathyroidism
Osteitis fibrosa
History of parathyroidectomy
Vitamin D
Adynamic bone disease
Osteomalacia
History of bleeding
complications (gastrointestinal)
Medications interfering with
hemostasis
Renal anemia
Depression
Anxiety
Modality of treatment
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Consideration of assessment
before dental treatment
hemorrhage, Osler’s nodes,
pitting edema, clubbing,
cyanosis)
Blood pressure (not on access
arm)
Lipid profile (total cholesterol.
LDL, HDL, triglycerides)
Ejection fraction
Echocardiogram (transeso-
phageal is most sensitive)
Electrocardiogram
Perfusion scintigraphy
Angiography
Cardiac enzymes
Electrolyte changes
(Na, K, Cl, CO2, pH)
ANC and white blood cell indices
Echocardiography PPD/CXR/
Sputum smear/culture
HIV tests and disease indices
Hepatitis tests and disease indices
Fungal smear
Signs and symptoms of anemia
(ie, fatigue, pallor)
Hematocrit and red blood cell
indices
Serum iron, ferritin, total iron-
binding capacity
Signs and symptoms of bone change
(ie, macrognathia, open bite)
Calcium/phosphate/magnesium
levels
Serum parathyroid levels
Radiographic bony changes
Serum vitamin D levels
Skin/mucosal signs (ie,
ecchymosis, petechiae,
spontaneous gingival,
bleeding)
Bleeding time
Platelet count/INR/PTT
Hematocrit and red blood cell
indices
Control of condition
July 2001
Potential concerns and
consideration of modifications to
dental treatment
Immunocompromised patients
may be at risk for postoperative
infection, sepsis, or bleeding.
Patients with tuberculosis disease
are potentially infectious.
Patients with hepatitis
may have liver dysfunction.
Defer elective dental treatment
until complete assessment has
been made and a medical treat-
ment plan established.
Follow treatment modification
for patients with infectious
diseases or compromised
immune systems.
Patients with renal anemia may
be at increased risk for bleeding
(negative rheologic effect).
Patients with anemia may be
hypoxic.
Defer elective dental treatment
until complete assessment has
been made and a medical
treatment plan established.
Defer bony surgery or implants
in patients with uncontrolled
renal osteodystrophy.
Patients may be at risk for
bleeding. Follow treatment
modifications appropriate for
hemostatic abnormality.
Preoperative desmopressin
(short-term) or conjugated estrogens
(long-term) as indicated by
hematologist for surgical procedures.
Follow treatment modifications
appropriate for patients with
psychiatric disorders.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Kerr 13
Volume 92, Number 1

Table III. continued

Potential concerns and
Consideration of assessment consideration of modifications to
Question Looking for before dental treatment dental treatment

Is drug elimination or metabolism
affected?
What is the oral health status?
What types of dental procedures
are planned?
SLE, Systemic lupus erythematosus; INR, international normalized ratio; PTT, partial thromboplastin time; ANC, absolute neutrophil count; PPD, purified protein
derivative; CXR, chest x-ray; LFT, liver function test.
Degree of renal compromise GFR The prescription of certain
Hemodialysis regimen LFTs medications may lead to an
Drug pharmacokinetics Serum albumin overdose or be nephrotoxic.
Therapeutic index Plasma drug levels Customize prescription of anal-
Site of metabolism and active Nausea, vomiting gesics, antimicrobials, sedative
metabolites hypnotics, and anesthetic agents
Plasma protein binding depending on renal function.
Volume of distribution Avoid prescribing nephrotoxic
Absorption kinetics drugs.
Route of administration Avoid prescribing vancomycin
Hepatic/gastrointestinal disease because of risk of antibiotic
Volume status resistance.
Potential drug interactions
Soft tissue changes Intraoral examination Patients tend to have poor oral
Ecchymosis/petechiae Salivary flow tests (resting vs hygiene and an increased risk
Oral cancer/precancer stimulated) for xerostomia, candidiasis, and
Oral infections oral cancer.
Caries Perform regular extraoral/
Periodontal disease intraoral examinations.
Oral hygiene Maximize level of oral hygiene.
Salivary flow Eliminate all oral disease.
Emergency vs elective Defer elective dental treatment
Noninvasive vs invasive until complete assessment has
Surgical (soft tissue vs bone) been made and a medical treat-
Anesthesia/sedation ment plan established.
Postoperative analgesics Emergency treatment should be
Antibiotic therapy performed in consultation with
the nephrologist, particularly in
the case of an acute odonto-
genic infection.

underestimate of the number of patients with valvu-
lopathies for whom antibiotic prophylaxis would
normally be indicated before invasive dental procedures.
Widespread use of transesophageal echocardiography has
further raised the incidence rates of valvular disease in this
population.
Oral disease is prevalent in the renal disease population11;
2 recent studies have detected and implicated viridans strep-
tococci bacteremias as the cause both of vascular access
infections12 and of IE, although the source of the bacterial
organisms was not confirmed.13 However, most episodes of
bacteremia resulting in IE or vascular access infections are
caused by skin pathogens—predominantly Staphylococcus
aureus—associated with repeated vascular access for
hemodialysis. Arteriovenous fistulae are fraught with fewer
episodes of bacteremia and access infections than are pros-
thetic bridge grafts composed of polytetrafluoroethylene or
tunneled cuffed catheters.12,13
Bleeding in patients with uremia is primarily caused by
a qualitative platelet dysfunction, leading to faulty platelet
aggregation; such bleeding is aggravated by renal
anemia.14 Other than the cardiovascular benefits, patients
receiving recombinant human erythropoietin replacement
for the treatment of renal anemia were noted to have
fewer bleeding problems, explained by a normalization of
hematocrit that leads to margination of platelets and an
increased opportunity for vessel-wall contact.15 Although
gastrointestinal bleeding is the most common presenta-
tion, postoperative bleeding after dental care has been
reported. Desmopressin can temporarily reverse the
platelet dysfunction by increasing the release of von
Willebrand’s factor from storage. Conjugated estrogens
have also been shown to reverse the platelet dysfunction.
For longer-term control, hemodialysis in conjunction with
erythropoietin replacement will generally reverse uremic
bleeding, although the therapy to prevent vascular access
thrombosis (eg, heparin or other anticoagulants) can cause
a risk for bleeding, and platelet activation by the dialysis
membrane can also result in a risk for bleeding.
It is not uncommon for patients on erythropoietin
14 Kerr
replacement to develop iron-deficiency anemia because of
the depletion of their iron stores that are necessary to
produce more hemoglobin. Other adverse effects include
hyporesponsiveness to the recombinant erythropoietin as
well as hypertension.16
Patients with uremia are often immunosuppressed and
may demonstrate dysfunction of both the cellular and the
humoral arms of the immune system. Not only are patients
predisposed to bacterial infection, but they also may not
exhibit the signs and symptoms of severe infection, such as
an elevation in temperature. In patients receiving
hemodialysis, most infections are associated with the
breach of the mucosal immune system secondary to vascu-
lar access. Nosocomial transmission of bloodborne
pathogens (HIV and hepatitis B, C, and G) and tuber-
culosis have been reported in this population, and patients
should be evaluated for these diseases.
Safely prescribing drugs to this patient population
requires an understanding of drug pharmacokinetics.
Recent drug dosing guidelines have been published.17
During a patient’s progressive loss of renal function, drug
elimination becomes compromised. For drugs normally
eliminated in an unchanged form, reduced glomerular
filtration and tubular secretion rates can lead to toxic
plasma drug levels (particularly if the drug does not
undergo hepatic metabolism), mandating a change in the
dosing regimen. If rapid therapeutic drug levels are
required, the loading dose normally remains unadjusted
unless the patient is hypervolemic. For drugs with a large
therapeutic index and half-life—assuming the patient has
normal drug absorption and liver function—drug dosage
should be adjusted by increasing the interval between
doses while preserving dose size. Conversely, for drugs
with a narrow therapeutic index or a short half-life, or
when a constant blood level is desired, a reduction in dose
size while preserving the dose schedule is indicated.17
Gastrointestinal absorption is compromised by nausea,
vomiting, or changes in intestinal pH caused by uremia.
Medications, including cationic phosphate binders or iron
supplements commonly prescribed to these patients, can
also interfere with absorption. Low serum albumin levels
may impair plasma protein binding, and concomitant liver
dysfunction can lead to diminished drug metabolism.
The extent to which hemodialysis affects blood drug
levels primarily depends on when the drug is taken rela-
tive to the timing of the dialysis session and the membrane
pore size. With the evolution of dialysis technology, the
newer “high-flux” membranes have larger pores than
the conventional membranes, which may result in an
increased clearance of drugs during dialysis and a need
for supplemental dosing after dialysis.18
Despite the fact that most of the medications routinely
used in dentistry are relatively safe and are prescribed for
short-term use, some medications are nephrotoxic in this
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
July 2001
population. Numerous reports of nephrotoxicity in
patients receiving analgesics led the National Kidney
Foundation to develop recommendations for analgesic
use in patients with CRD.19 Aspirin and nonsteroidal
anti-inflammatory drugs (NSAIDs) are contraindicated
unless renal function is monitored. Acetaminophen, as a
single agent, remains the non-narcotic analgesic of
choice for episodic use. The major mechanism
explaining the nephrotoxicity of NSAIDs in patients with
CRD is a reversible inhibition of renal prostaglandin
synthesis resulting in vasoconstriction and reduced perfu-
sion to already compromised kidneys.20 Case reports
have demonstrated that cyclo-oxygenase 2 (COX-2)
inhibitors can also cause acute renal failure,21 although
additional studies are needed to ascertain whether these
agents have a different nephrotoxicity profile than other
NSAIDs.
In patients with CRD, the dosage of medications with
a narrower therapeutic index, such as narcotic analgesics
(eg, fentanyl, morphine, codeine, and hydrocodone)
should be reduced in proportion to the GFR. The primary
metabolite of meperidine, if not excreted normally, can
precipitate seizures. Correct dosing of antibiotics is
crucial to their efficacy, particularly in a population with
compromised immune function. To achieve therapeutic
levels quickly, volume status rather than renal function
should dictate the initial loading dose. Because most
antibiotics have a wide therapeutic index (with some
exceptions), spacing out the dosage schedule is prefer-
able for future dosing. Once a patient develops CRF
(GFR < 30 mL/min), with the exception of penicillin V
that requires no adjustment, dosages of penicillins and
cephalosporins including amoxicillin (with or without
clavulanic acid), ampicillin (with or without sulbactam),
and cephalexin should be spaced apart, with intervals
adjusted to GFR. The clinician should be aware that high
doses of penicillins can lead to drug accumulation risk
for seizures. Because these antibiotics are cleared during
hemodialysis, additional doses should be given during
and after dialysis. Approximately 10% of clindamycin is
eliminated unchanged and is not affected by hemodial-
ysis, allowing it to be prescribed in normal doses to
patients with CRD. Because of their reported ototoxicity
and nephrotoxicity, dosages of erythromycin and tetracy-
cline, respectively, should be adjusted in patients with
CRD. Benzodiazepines may be prescribed without
adjusting dosage, although excessive sedation is a possi-
bility in patients with ESRD.
Dysfunctional mineral homeostasis, known as renal
osteodystrophy, is common in patients with CRD; this
condition ranges anywhere from a high to a low state of
bone turnover. Secondary hyperparathyroidism, initiated
by the kidneys’ inability to secrete phosphate, is charac-
terized by increased osteoblastic and osteoclastic activity,
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 92, Number 1
leading to osteitis fibrosa in approximately 30% of
patients with ESRD.22 Parathyroidectomy and vitamin D
therapy lower parathyroid hormone levels and can reverse
secondary hyperparathyroidism. Among other factors, the
overuse of vitamin D or calcium-based phosphate binders
can lead to adynamic bone disease, a state of low bone
turnover occurring in approximately 30% of ESRD
patients (especially those patients who are receiving peri-
toneal dialysis).23 Aluminum accumulation puts patients
at additional risk for osteomalacia, a low state of bone
turnover characterized by defective mineralization.
Phosphate binders free of calcium and aluminum—
such as sevelamer—are now frequently prescribed.
Approximately 10% of ESRD patients show a mixture
both of high and of low bone turnover states. Albeit infre-
quent, there are reports of jawbone involvement, particu-
larly macrognathia24; thus, patients with renal disease
should be carefully screened for renal osteodystrophy
before performing surgical procedures involving bone—
particularly implant placement.25
The oral manifestations of uremia have been reported to
include xerostomia, candidiasis, metallic taste changes,
uremic odor, petechiae, ecchymoses, gingival bleeding,
and ulcerations (uremic stomatitis), although the preva-
lence of such manifestations has not been carefully
studied. A recent study26 of 60 patients with ESRD who
were undergoing hemodialysis reported that patients with
oral manifestations had significantly greater salivary
dysfunction (as measured by means of scintigraphy) than
did healthy control subjects or patients without oral mani-
festations.
MANAGEMENT STRATEGIES
The oral/dental management of patients with CRD has
3 components: (1) oral/dental and medical risk assess-
ment, including the identification of existing or potential
complications that could affect oral health or dental treat-
ment, (2) treatment modifications customized to amelio-
rate or prevent such complications, and (3) risk-factor
prevention. Furthermore, in patients with uncontrolled
diabetes or hypertension, oral health care providers are
advised to screen for renal dysfunction.
The oral/dental and medical risk assessment involves a
detailed history, intraoral/extraoral soft tissue and radio-
graphic examination, and consultation with a nephrologist
or other specialists (eg, endocrinologist). Important data to
collect include the following: (1) the degree of CRD,
cause, and factors associated with disease progression, (2)
the presence and control of comorbid medical conditions
such as diabetes, hypertension, and associated sequelae,
(3) the modalities of medical treatment, and (4) distant or
recent history of renal complications of particular impor-
tance to the proposed dental treatment plan, with cor-
roborating laboratory tests and/or signs and symptoms.
Kerr 15
A comprehensive risk assessment facilitates the treat-
ment plan. Because so many organ systems are potentially
affected by CRD, the reader is encouraged to review
suggested dental treatment modifications for patients with
cardiovascular disease, bleeding abnormalities, infections,
compromised immune systems, and others. Table III
summarizes the assessment and management of patients
with CRD. The prevention of risk factors, especially
tobacco use, is a responsibility the oral health care
provider should take seriously; reference materials about
tobacco cessation are available to help professionals
provide this service to their patients.
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16 Kerr ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
July 2001

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Reprint requests:
A. Ross Kerr, DDS, MSD
Department of Oral Medicine
New York University College of Dentistry
345 E 24th St
New York, NY 10010

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