**2. Main issues regarding the oral health in patients on hemodialysis and those with kidney transplant**

The primary role of the dental doctor consists of the early diagnosis or referral of the patient to the right specialist, as the most frequent renal disease a dentist may encounter is the chronic kidney disease [18, 39, 114].

The symptoms that may lead us to the conclusion of constrained renal function vary depending on the extent of the damage and the reaction to the suggested treatment, and are characterized with systemic as well as intraoral findings.

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**Table 1.** Symptoms at CKD [18, 125]

**Figure 1.** Brown coloring of nails

**Renal osteodystrophy or renal bone disease** is one of the most prominent signs of CKD and may occur in one or several combined forms. As a result of the increase of the level of phos‐ phates in blood plasma, the decrease of calcium in blood plasma and the failure of processing of 25-hydroxycholecalciferol into the active and necessary 1.25 dihydroxycholecalciferol, an increase of the parathormone (PTH) occurs. This leads to secondary hyperparathyroidism. Because of the increase of the non-mineralized bone matrix progressive bone changes may be observed - osteomalacia, lytic lesions followed by bone fibrosis. Renal osteodystrophy in kids leads to a delay in skeletal growth and a tendency for spontaneous fractures.

Most frequent orofacial signs of renal osteodystrophy are bone demineralization, lower trabeculation, lower density of the cortical bone, calcifications in soft tissues, radiolucent fibrocystic lesions, and complicated bone healing following extraction. Regarding the teeth and parodontal tissues we may observe delayed eruption, enamel hypoplasia (fig.2), loss of lamina dura, widening of the periodontal space, severe periodontal destruction, tooth mobility, denticles, obliteration of pulp chamber, and giant-cell lesions of the type "brown tumors"[78, 85].

**Figure 2.** Hypoplasia and open bite in a female patient on hemodialysis

**3. Common symptoms at CKD (Chronic Kidney Disease)**

**Gastrointestinal** – nausea, vomiting, anorexia, metal taste, malodor, oesophagitis, gastritis, gastrointestinal

**Neuromuscular** – headache, peripheral neuropathy, paralysis, sleep disturbances, numbness of limbs,

**Hematoimmunologic** – normocytic and normochrome anemia, coagulopathy, low resistance to infections, low

**Cardio vascular** – cardiomyopathy, arrhythmia, pericarditis, high blood pressure, difficulty in breathing,

**Renal osteodystrophy or renal bone disease** is one of the most prominent signs of CKD and may occur in one or several combined forms. As a result of the increase of the level of phos‐ phates in blood plasma, the decrease of calcium in blood plasma and the failure of processing of 25-hydroxycholecalciferol into the active and necessary 1.25 dihydroxycholecalciferol, an

hyperparathyroidism, disturbed growth, decreased libido, amenorrhea, thyroid dysfunction

pigmentation, uremic white spots, brown coloring of the nails- Fig.1, signs of water retention,

– paleness, itching, signs of scratching because of the itch, increased photosensitive

convulsions correlating with level of the azotemia

production of erythropoietin, lymphocytopenia

**Endocrine metabolic** – renal osteodystrophy (osteomalacia, osteosclerosis, fibrous cysts), secondary

**Disease Symptoms**

114 Updates in Hemodialysis

**Dermatologic**

**Table 1.** Symptoms at CKD [18, 125]

**Figure 1.** Brown coloring of nails

bleeding

congestive heart failure

limb heaviness, edema of the ankles

**Respiratory** – Kussmaul breathing because of acidosis, pulmonary edema, dyspnea

Nephrotic syndrome is observed in patients with glomerular diseases. It includes pro‐ teinuria (over 3.5 gr), hypoalbuminemia, hyperlipidemia, lipiduria, and edema. Causes may vary: sugar diabetes, chronic lupus erythematosus, or membrane glomerulonephri‐ tis. Increased level of blood coagulation factor VIII may lead to hypercoagulation and increased risk of thrombosis. Such patients may suffer catabolic processes, bacterial, fungal and viral infections [53, 66].

It should be noted that a significant part of the patients with renal disorders may also suffer from diabetes [14]. It is less probable for a dentist to diagnose diabetes, but patients whose dental status alters unexpectedly as rapidly as in progressive parodontitis, fungal eczemas, abscesses, high fluid intake, rapid weight loss, mouth dryness and halitosis [28, 29] may be suspicious. Those symptoms impose the appointment of definite examinations, which may help to set the latter diagnosis.

Renal disorders almost invariably cause anemia as a result of the kidneys' inability to produce erythropoietin. Fibrosis of marrow and the increased loss of erythrocytes are additional factors which increase the development of the disease. Anemia leads to fatigue, loss of concentration, tissue hypoxia, and paleness of the oral mucosa. In patients with advanced and untreated uremia, yellow-brownish coloring of the skin and mucosa because of the accumulation of carotene-like substances [4, 125] may be observed.
