Liver & Renal

Question 1

What are possible reasons for inability to achieve haemostasis?

Answer 1

• inherited/congenital bleeding disorders
  
  • haemophilia A (factor VIII) and B (factor Xa)
  • Von Willebrand’s disease
• medication induced
  
  • antiplatelets
    - aspirin
    - clopidogrel
  • anticoagulants
    - heparin
    - warfarin
  • DOAGs (thrombin, factor Xa)
    - apixaban
    - rivaroxaban
  • other
    - antimicrobials (rifampin)
    - anti- seizure (phenytoin, valproic)
    - quinine
• haematological disease
  
  • leukemia
  • myeloma
  • immune thrombocytopenia purpura (ITP)
• infection
  
  • HIV
  • hepatitis C
• liver diseases
  
  • alcoholic liver disease
  • liver cirrhosis
  • hepatitis B or C
  • primary biliary cirrhosis
  • hepatocellular carcinoma

Question 2

How does liver disease result in coagulation issues?

Answer 2

• hepatic synthesis altered
  
  • clotting factors and proteins involved in fibrinolytic system
  • vitamin K dependent coagulation factor proteins
    - factor II
    - factor VII
    - factor IX
    - factor X

Question 3

How does renal disease result in coagulation issues?

Answer 3

• abnormalities in platelet function
  
  • thought to be due to adhesion, secretion and storage

Question 4

How is challenge to achieve haemostasis managed in

Answer 4

• apply pressure to socket with gauze
  
  • can soak gauze in local anaesthetic
• pack socket with suitable material
  
  • oxidised cellulose
  • collagen sponge
• suture surgical site
• re-evaluate medical history
• tranexamic mouthwash
• cautery
  
  • sliver nitrate sticks
• bone wax

Question 5

At what point does anti-platelet medication need to be altered for dental treatment?

Answer 5

• when patient is taking 3 routine should be altered
• aspirin has effects for 7-10 days

Question 6

What is a normal platelet count and what levels can be treated in dental practice?

Answer 6

• 150x10^9/l - 400x10^9/l
• dental practice
  
  • > 100x10^9/l
• hospital
  
  • <50x10^9/l
  • supplements required

Question 7

What is UKELD?

Answer 7

• United Kingdom model for End stage Liver Disease
  
  • 49% minimum level for transplant assessment

Question 8

What are the features of a patient with liver disease?

Answer 8

• jaundice
• leukonychia
• clubbing
• palmar erythema
• spider naevi
• oesophageal varices
• ascites
• peritonitis
• tremors (alcohol related)
• congenital impairment (alcohol related)

Question 9

What are the causes of liver disease?

Answer 9

• infective
  
  • hepatitis A, B, C and D
• non-infective
  
  • auto-immune (primary biliary cirrhosis)
  • alcohol related
  • non-alcohol fatty liver disease
  • haemochromatosis
  • drug induced
  • hepatocellular carcinoma

Question 10

What are the basic stages of liver disease?

Answer 10

• hepatitis
  
  • inflammation of the liver
  • may be reversible
• liver cirrhosis
  
  • irreversible liver necrosis and fibrosis
• liver failure
  
  • failure of normal liver function

Question 11

How does local anaesthetic affect the liver?

Answer 11

• lignocaine is fully metabolised in the liver
• articaine goes through 5-10% metabolism in the liver
  • remaining metabolised by the plasma

Question 12

Why are NSAIDs avoided for all but the most mild cases of liver disease?

Answer 12

• can increase bleeding risk
• can inhibit prostaglandins
  • reduced renal perfusion
  • reduced glomerular filtration rate and sodium retention
  • hepatorenal syndrome

Question 13

How can treatment be facilitated for patients with liver disease?

Answer 13

• delivery of products
  
  • vitamin K replacement
  • FFP transfusion
  • +/- platelet transfusion

Question 14

What factors are produced by the liver?

Answer 14

• factor I
• factor II
• factor VII
• factor IX
• factor X
• factor XI