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8

LIVER AND RENAL


DISEASE
Mike Escudier

Liver disease
The liver is the largest organ in the body and is involved with
almost all of the biochemical pathways that per-mit growth, ght
disease, supply nutrients, provide energy and carry out detoxication. Liver disease and its consequences can pose multiple problems in dental practice.

Anatomy
The liver gains 70% of its blood supply from the portal vein
and 30% from the hepatic artery. Almost all the nutrients
and drugs absorbed from the stomach and intestine are
directed to the liver for processing (Fig. 8.1). This so-called
rst-pass metabolism can be avoided when drugs are
given intravenously (IV) or sublingually.

Functions of the liver

Protein metabolism. Synthesis of all proteins apart from


gamma-globulins
Carbohydrate metabolism. Glucose homeostasis
Lipid metabolism. Metabolism of lipoproteins
Bile acid metabolism. Conjugation of bilirubin and
production of bile
Drug and hormone metabolism. Catabolism and
breakdown of a large number of drugs, hormones
and vitamins
Immunological. Kupffers cells act as a sieve for
bacteria and other antigens carried to it via the
portal system.

Epidemiology
Liver disease is relatively uncommon in the western
world. About 600 liver transplants are carried out per
year for end-stage liver disease in the UK. Two aspects

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Liver and renal disease

Liver

Bile duct
Stomach

Gall bladder
Hepatic portal
vein

Pancreas

Small bowel
(duodenum)

Fig. 8.1 Relationship of the liver to the gastrointestinal tract.


Note the hepatic portal vein transporting absorbed nutrients and
drugs to the liver for processing.

of liver disease are most important in relation to


dentistry:
1. Hepatitis
2. Cirrhosis.

Aetiology

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Alcohol consumption is the most common cause of liver


disease in the UK. Other less common causes are viral
infections, autoimmunity, prescription drugs and genetic
disease. The liver is also affected by disease of the biliary
tree, particularly gallstones.

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Clinical features

Fig. 8.2 Dupuytrens contracture affecting the ring and little


ngers. Notice the scar from attempted surgical correction.

Clinical features
The general features of liver disease that may be detected
in dental practice include:
Jaundice. This is a yellow pigmentation of the skin,
sclerae and oral mucosa due to deposition of bilirubin
in tissues. It is detectable when the bilirubin is above
3060 mmol/L.
Spider naevi. These small arterial dilations may be
detected in the skin of the face and neck.
Palmar erythema. Redness of the palms of the hand.
Dupuytrens contracture. Fixed exion of the little and
sometimes ring nger due to thickening of the
palmar fascia (Fig. 8.2).
Finger clubbing. Loss of the normal angle at the bed of
the nails.
Multiple bruises. These occur on areas exposed to
trauma due to the underlying clotting defect.
Delayed healing. This is due to the decreased synthesis
of protein and immunoglobulins.
Confusion. This may occur in severe cases due to
unmetabolised toxins reaching the CNS.

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Liver and renal disease

Hepatitis
This is inammation of the liver which may be acute or
chronic, causing enlargement, tenderness and deranged
function. Viral infection with hepatitis A, B, C, D or E is
the most common cause of inammation of the liver and
can present a signicant cross-infection risk as well as
liver damage. Other viruses, including CMV, EBV, Varicella, Rubella, Toxoplasma and Coxsackie virus and HIV
can also cause hepatits (cf. infectious disease section).
Alcoholic hepatitis can occur even with moderate intake
in susceptible individuals. In rare circumstances acute
hepatitis can lead to hepatic failure and death, for example
paracetamol overdose.

Cirrhosis
This results from necrosis of liver cells followed by brosis
and nodule formation. This causes disruption of blood
ow through the liver and loss of function. The diagnosis
is a histological one and requires a biopsy although the
severity of cirrhosis is determined clinically.
If the cirrhosis is asymptomatic the long-term prognosis
is usually good, provided the causative factor is under
control. Alcohol-induced cirrhosis has a worse prognosis.
Patients must abstain from alcohol whatever the cause of
their cirrhosis. In long-standing cases there is a small risk
of developing hepatocelluar carcinoma.
The liver has a huge reserve capacity and the ability to
regenerate so the effect of hepatitis or cirrhosis depends
on whether the liver is compensated (coping with reduced
capacity) or decompensated (not coping with reduced
capacity). Patients with decompensated disease are at a
greater risk from any intervention, including dental treatment. Signs of decompensated disease include jaundice,
ascites and neurological impairment.

Dental treatment in liver disease

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Most of the drugs administered during dental treatment


are metabolised by the liver and may affect liver enzyme
function (see Table 8.1).
In decompensated disease treatment should be postponed until the failure has been dealt with as there is a
high risk of accelerating the rate of failure.

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Renal disease

Table 8.1
Drugs to be avoided or altered during dental treatment of
patients with liver disease.
Drug name

Effect or alteration required

Paracetamol

Limit daily dose to 2 grams in


decompensated disease
Avoid in decompensated disease
No change
Reduce dose to 1/3 and frequency to once
daily in decompensated disease
Reduce dose
Avoid
Avoid
Avoid in decompensated disease
Avoid
Avoid as may cause coma

NSAIDs
Amoxicillin
Metronidazole
Clindamycin
Tetracycline
Miconazole
Lignocaine
Halothane
Midazolam

DENTAL RELEVANCE OF LIVER DISEASE

Post-operative haemorrhage due to deciency of clotting


factors
Altered drug metabolism (see Table 8.1 and check Appendix II
of the BNF)
Cross-infection risk in patients infected with hepatitis B, C and
HIV
Delayed healing due to protein and immunoglobulin deciency
Avoid intravenous sedation due to risk of coma
Liver transplant patients require antibiotic cover for invasive
dental procedures
Liaise with the physician concerned before treatment.

Renal disease
The kidneys receive approximately 25% of the cardiac output per
minute normally producing 12 litres of urine per day. Most
drugs along with other waste products are excreted by the kidneys
and they have an important role in homoeostasis and hormone
synthesis.

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Liver and renal disease

The functions of the kidney

Elimination of waste material


Maintenance of blood pressure
Maintenance of the composition of the body uid:
regulation of electrolyte balance
regulation of acidbase balance
regulation of calcium balance
Endocrine
erythropoietin secretion
reninangiotensin system
vitamin D metabolism.

Epidemiology
Renal disease is common within the population. The incidence of chronic renal failure increases with age; it is more
common in men and those of Asian or Afro-Caribbean
origin. 1700 renal transplants were carried out in the UK
in 2004. There are about 20 000 people in the UK with a
functioning renal transplant.

Aetiology
Diabetes is the main cause of end-stage renal failure
(ESRF) accounting for 40% of cases. The kidneys may also
be damaged by hypertension, ascending infection and
immunological mechanisms.
Three aspects of renal disease are most important in
relation to dentistry:
1. Renal failure
2. Dialysis
3. Transplantation.

Renal failure
This is said to occur when the kidneys fail to maintain
excretory function as a result of a reduced glomerular ltration rate. This may be acute or chronic.

Acute renal failure (ARF)


This is associated with a decline in renal function over a
few hours or days.

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Aetiology may be pre-renal (poor perfusion), renal (glomerulonephritis, SLE, acute tubular necrosis) or post-renal
(obstruction).

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Chronic renal failure (CRF)

Clinical features vary depending on the level of uraemia and


range from none, through oliguria (polyuria) to weakness,
fatigue, lassitude to pruritis, breathlessness and eventually confusion, ts and even coma.
Treatment is based on identication and treatment of the
underlying cause, careful maintenance of uid balance
and dialysis where the level of toxic wastes needs to be
reduced.

Chronic renal failure (CRF)


This represents end-stage renal disease.
Aetiology: diabetes (40%), hypertension (25%) and glomerulonephritis (12%).
Clinical features: patients may be asymptomatic but may
suffer from, anaemia, nausea, pruritis, hypertension, disturbed urine production, vomiting, oedema, dyspnoea,
neuropathy, confusion, ts and coma.
Oral manifestations:
Ulceration
Candidiasis
Parotitis
Fetor (ammonia-containing breath)
Lytic lesions in the jaw bone.
Drugs to be avoided or altered during dental treatment
of patients with renal failure are listed in Table 8.2.

Table 8.2
Drugs to be avoided or altered during dental treatment of
patients with renal failure.

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Drug name

Effect or alteration required

Paracetamol
NSAIDs
Amoxicillin
Metronidazole
Clindamycin
Tetracycline
Miconazole
Lignocaine
Halothane
Midazolam

Short courses only


Avoid if possible
Reduce dose
No change
No changes if short course
Avoid
Reduce dose
No change
No change
Avoid if possible, use lower dose

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Liver and renal disease

Fig. 8.3 An arterio-venous stula in a diabetic patient with


chronic renal failure. Note the scarring from multiple needle
insertions.

Treatment. Dialysis is often required with a view to


transplantation.
Dialysis allows removal of waste products from the blood
when the kidneys have failed. Toxins diffuse across a
semi-permeable membrane towards a low concentration
present in the dialysis uid. The two common techniques
are haemodialysis and peritoneal dialysis.
Haemodialysis requires a blood ow of 200 mL per minute
via a surgically created arterio-venous (AV) stula in the
forearm (see Fig. 8.3). The process takes 45 hours three
times per week during which the patient is heparinised to
minimise the risk of clotting.
Peritoneal dialysis may be either continuous ambulatory
(via a permanent catheter) or intermittent (patient remains
in bed) which is usually used in ARF. The most common
complication of both techniques is peritonitis.
Transplantation is the treatment of choice for end-stage
renal failure (see Ch. 17).

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Chronic renal failure (CRF)

DENTAL RELEVANCE OF RENAL DISEASE

Preventative dentistry, the key to management.


Minimise the drugs used and alter doses as required (see Table
8.2 for commonly prescribed drugs).
Treat under local anaesthetic.
Treat infections aggressively as patients are often
immunosuppressed by the disease or treatment.
High risk of hypertension and its complications.
Screen for bleeding tendencies in CRF before invasive dental
procedures.
Lytic lesions may occur in the jaw bones due to secondary
hyperparathyroidism.
Dialysis patients:
Treat on non-dialysis days to avoid bleeding tendency from
heparin administration
Antibiotic cover for AV stulas
Increased risk of hepatitis B, C and HIV carriage.
Transplant patients:
See Ch. 17.

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