Pharmacologic considerations in the dental management of the patient with disorders of the renal system.

As reviewed in this article, the patient with ESRD presents a number of unique management challenges. A rapidly increasing number of patients are receiving renal transplants and undergoing dialysis, making it necessary for the dental practitioner to have a thorough understanding of the special treatment considerations that arise. Conservative medical management is designed to slow the progression of the disease and ameliorate the clinical consequences. Dialysis and transplantation provide renal replacement to sustain life and allow for the medical and social rehabilitation of the patient. When considering transplantation, oral examination is an essential part of the preoperative evaluation. Elimination of pathologic entities and restoring patient function are essential before the transplant and the immunosuppressive drug regimen. Any oral symptom or sign of infection must be examined immediately and treated aggressively in an immunosuppressed transplant recipient. Patients receiving hemodialysis and those with transplants should be considered for antimicrobial prophylaxis before dental treatment that induces bleeding to protect the function and patency of the vascular access site and the transplant. Drug therapy may need to be adjusted, depending on the degree of chronic renal failure, the patient's dialysis schedule, or the presence of a transplant. Therefore, the dentist must be familiar with the complexity of this interesting patient population and pay particular attention when prescribing and using various medications.

Where the kidney is concerned, how much mannitol is too much?

OBJECTIVE: To report a case of mannitol-induced acute renal failure (ARF). CASE SUMMARY: A 31-year-old woman who had been on long-term warfarin therapy for atrial fibrillation was admitted to the hospital with hemoptysis. Following reversal of her anticoagulation, she had a tonic-clonic seizure nine days after admission. An emergency computed tomography scan revealed cerebral edema, which was initially treated with hyperventilation and steroids. Two days later, a repeat scan showed progression of the cerebral edema with midline shift. Mannitol 550 g was infused over the next 28 hours, precipitating ARF. Despite prompt hemodialysis to reverse the renal failure, the patient died. This case of apparent mannitol-induced ARF illustrates several pathophysiologic effects of this agent. DISCUSSION: Case reports in the literature discussing mannitol-induced ARF are reviewed and compared. A relationship between dose and ARF and its reversal with hemodialysis is postulated. CONCLUSIONS: It is likely that sufficient doses of mannitol may lead to ARF. Limitation of dose may prevent and treatment with hemodialysis may reverse ARF in these instances.