Download Liver diease

Renal and Hepatic Disease
Claire Nowlan MD
Liver Function
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Secretion of bile for fat absorption
Short term sugar storage
Breakdown of aged red blood cells with
excretion of bilirubin
Synthesis of coagulation factors
Drug metabolism
Hepatitis
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Inflammation of the liver from any cause
Most common causes are viral & alcoholic
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Less frequent causes are mononucleosis, secondary syphilis,
TB, acetaminophen overdose, methotrexate, ketoconazole
Acute symptoms
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Abdominal pain, nausea, vomiting, fever, malaise, jaundice,
hepatomegaly, splenomegaly
In the recovery phase, hepatomegaly and abnormal liver
functions may persist
Symptoms of chronic liver disease
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May be asymptomatic for 10 to 30 years
Nonspecific signs
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Fatigue, weight loss, itchiness, right upper quadrant
pain
Hepatitis A
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Transmission - fecal-oral route
Sources - water, shellfish, restaurants
Incubation - 15-50 days
Serological evidence of infection in 40% of US
populations
No chronic carrier state
Vaccine and immunoglobulin available
Hepatitis B
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Transmission - percutaneous/permucosal
High risk groups
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healthcare workers, immigrants from Southeast Asia,
hemodialysis patients, IV drug users, recipients of blood
transfusions, unprotected sex (especially anal) with
multiple partners
Incubation - 45-180 days
Hepatitis B
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Risk of infection with needle stick injury 6-30%
Prevalence of infection in dentists 8%, oral
surgeons 21%
5-10% risk of becoming a chronic carrier
Carriers have increased risk of cirrhosis and
hepatocellular carcinoma
Vaccine and immunoglobulin available
Hepatitis C
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Transmission - mainly percutaneous. Very low
risk with sexual transmission
Incubation 14-180 days
Risk groups
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mainly IV drug users, and blood transfusion prior to
1992
Risk of infection with needle stick injury 2-8%
80-90% risk of becoming chronic carrier
Hepatitis C
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Risk of cirrhosis and hepatocellular carcinoma
No active or passive immunization available
Treatment is only suggested in certain
subgroups, but it is expensive, takes up to 1
year, has many side effects, and only 10-30%
are actually cured
Other Hepatitis Viruses
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Hepatitis D
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only occurs as a coinfection with B
transmitted both parenterally and sexually
Hepatitis E
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resembles hepatitis A, transmitted through the fecal
oral route
Dental management
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Difficult to identify all patients through history
Many acute cases of Hep B&C are mild
Must use infectious precautions for ALL
patients
Screening recommended for patients from high
risk groups
Guidelines for blood exposure
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From patients with Hep B
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determine titer of anti-HBs in the health care
professional
if adequate - no tx needed
if inadequate give HBIG
From patients with Hep C
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exposed professional gets baseline and f/u testing
for anti-HCV and liver enzymes
Alcoholic liver disease
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Only 10-15% of alcoholics develop cirrhosis
Early change - fatty liver
Second stage - alcoholic hepatitis
Final stage - cirrhosis
End stage liver disease
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Esophageal varicies
deficiency of Vit K dependant coagulation
factors
anemia, leukopenia, thrombocytopenia
esophagitis, gastritis
endocrine disturbances
encephalopathy
dementia
Laboratory abnormalities
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Increased
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AST
GGT
ALT
Bilirubin
Alk Phos
INR
Decreased
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albumin
RBC, WBC, platelets
Dental management - alcoholic liver
disease
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Beware a second addiction to pain medication
- no refills, avoid narcotics and sedatives if
possible
Patient may require more local anesthetic or
anxiolytic
Dental management - all liver
disease
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Screen for bleeding tendencies
Unpredictable metabolism of specific drugs
Renal function
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Control fluid volume
Acid-base balance
Controls secretion of K, Na, phosphate
Excrete wastes
Synthesize erythropoietin
Activates Vit D
Controls blood pressure by secreting renin
Metabolizes drugs
Chronic renal failure
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Irreversible destruction of the nephrons
The kidney can lose about 50% of the
nephrons and still maintain normal function
Progressive, most often caused by DM,
hypertension, Glomerulonephritis
Various grades of failure depending on GFR
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50-10 ml/min = moderate
< 10 ml/min = severe
Laboratory assessment
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Urinalysis
Increased creatinine
Increased BUN
Changes in Na, K
CBC, INR, PTT
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GFR = (140 - age) X lean wt in KG X.85 if female
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72 X serum creatinine
Chronic renal failure
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Problems
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CV - Fluid overload, hypertension
GI nausea, diarrhea
Neurologic “uremic encephalopathy”
Metabolic - Metabolic acidosis, uremia, hypokalemia
Hematologic - Anemia, platelet disfunction
Immunity - decreased
Dermatologic - yellow tinge to skin, pruritis, bruises
Renal rickets
Fatigue
Medical management
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Conservative care
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Hemodialysis
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Restrict fluid, K, Na, protein, phosphate
Tx DM, hypertension
Give recombinant human erythropoietin
Patients have arteriovenous shunt
Need heparin infusion during dialysis
Peritoneal Dialysis
Renal Transplantation
Dental management
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Screen for bleeding disorder before surgery
Avoid nephrotoxic drugs
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Decrease dosages of drugs mainly metabolized
through kidney
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NSAIDs – especially ASA
Acyclovir
High dose acetaminophen
Penicillins, erythromycin, opioids
Controversy whether antibiotic prophylaxis needed
Dental management - hemodialysis
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Be careful of arteriovenous shunt
Dental care on non hemodialysis days
Be aware of possible Hep B,C, HIV in these
patients