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• W2036630121 abstract "Note from Education Editor Scott Gilbert, MD: With this article, AJKD's Core Curriculum series, which provides readers with a basic analytical framework for approaching topics in clinical nephrology, changes from an outline to a narrative format. By using frequent headings and interspersed reading lists in a narrative presentation, the new format is intended to combine the convenient navigation of an outline with the clarity and flow of prose. As before, the feature is primarily intended for use by residency and fellowship program directors to develop educational programs. Note from Education Editor Scott Gilbert, MD: With this article, AJKD's Core Curriculum series, which provides readers with a basic analytical framework for approaching topics in clinical nephrology, changes from an outline to a narrative format. By using frequent headings and interspersed reading lists in a narrative presentation, the new format is intended to combine the convenient navigation of an outline with the clarity and flow of prose. As before, the feature is primarily intended for use by residency and fellowship program directors to develop educational programs. General medical care of the dialysis patient includes preventive care, health care counseling, and advance care planning. Because patients see their dialysis care providers regularly, coordinating medical care often falls to these clinicians. In some cases, for example, advance care planning, conditions of coverage under the US Centers for Medicare & Medicaid Services mandate that dialysis units and nephrologists provide some aspects of general medical care. Unique aspects of end-stage renal disease (ESRD), such as transplantation candidacy and high mortality, influence the appropriateness of some types of general medical care that will differ from the nondialysis population. This Core Curriculum outlines topics in preventive care, health care counseling, and advance care planning relevant to the care of dialysis patients. Because advance care planning depends on the competence of the patient, cognitive impairment and depression screening also are reviewed briefly. General medical care issues directly related to dialysis, for example, cardiovascular risk factors and specifics about bone and mineral metabolism, are not addressed in this Core Curriculum, but have been reviewed in other Core Curricula. An outline of topics covered, which could be treated as a rounding checklist, has been provided in Box 1.Box 1Overview of General Medical Care Issues in Dialysis PatientsPreventive Care •Immunizations ♢Hepatitis B♢Influenza♢H1N1♢Tetanus♢Pneumococcal♢Human papilloma virus♢Varicella zoster•Hearing and vision•Dental•Falls•FrailtyHealth Care Counseling •Exercise•Obesity and weight loss•Alcohol use•Tobacco use and cessation•Contraception and sexual dysfunctionScreening •Cancer•Cognitive impairment•DepressionAdvance Care Planning •Resuscitation status•Designated surrogate decision maker•Physician orders for life-sustaining treatment (when applicable) Preventive Care •Immunizations ♢Hepatitis B♢Influenza♢H1N1♢Tetanus♢Pneumococcal♢Human papilloma virus♢Varicella zoster•Hearing and vision•Dental•Falls•Frailty Health Care Counseling •Exercise•Obesity and weight loss•Alcohol use•Tobacco use and cessation•Contraception and sexual dysfunction Screening •Cancer•Cognitive impairment•Depression Advance Care Planning •Resuscitation status•Designated surrogate decision maker•Physician orders for life-sustaining treatment (when applicable) Immunization is an integral aspect of general medical care in dialysis patients. Dialysis patients exhibit a reduced response to immunizations and develop lower antibody titers and less sustained antibody responses. It is postulated that alterations in T lymphocytes and antigen-presenting cells are responsible for the impaired immunity. Nevertheless, the Centers for Disease Control and Prevention (CDC) recommends vaccinating dialysis patients, in part because in theory, patients may be effectively protected from infection despite low levels of measured antibodies, but also because the vaccinations limit transmissions of the virus in dialysis units. Altering immunization schedules, increasing vaccine doses, and adding adjuvants that attract antigen-presenting cells to the vaccination site and thereby stimulate cellular and humoral responses to immunization are all used to increase the immune response in dialysis patients. A beneficial synergistic effect of dual vaccination, noted with simultaneous tetanus and hepatitis B vaccination and pneumococcal and influenza vaccination, also has been observed. Table 1 lists the recommended immunizations for dialysis patients based on age and transplantation candidacy. Administering live vaccines is contraindicated in immunosuppressed and transplantation patients; therefore, any live vaccines indicated based on clinical circumstances (intranasal influenza, varicella, zoster, measles, mumps, rubella, yellow fever, BCG, and oral Salmonella typhi) should be given prior to transplantation despite the potential problem of impaired immunity.Table 1Recommended Adult Immunization Schedule for US Dialysis PatientsVaccineNotesInfluenzaAge ≥19 y, 1 dose trivalent vaccine annuallyTetanus, diphtheria, pertussis1-time dose of Tdap then boost with Td every 10 yVaricella2 doses if no evidence of immunityHuman papillomavirusFemale: 3 doses through age 26 y; male: 3 doses through age 21 yZosterAge >60 y, 1 doseMeasles, mumps, rubella1 or 2 doses if no evidence of immunityPneumococcal1 or 2 dosesHepatitis B40 μg of Recombivax HB on 3-dose schedule or 2 doses of 20 μg of Energix B on 4-dose scheduleMeningococcalOnly if other risk factor is presentHepatitis AOnly if other risk factor is presentNote: Based on Centers for Disease Control and Prevention Recommended Adult Immunization Schedule (http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.pdf), where further dosing information is available. Open table in a new tab Note: Based on Centers for Disease Control and Prevention Recommended Adult Immunization Schedule (http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.pdf), where further dosing information is available. Hepatitis B, a human viral pathogen transmitted by percutaneous inoculation through an exchange of contaminated blood, blood products, or body fluids, was responsible for outbreaks of infection in hemodialysis units in the 1970s and 1980s. Since that time, hepatitis B vaccination has been recommended for all dialysis patients. Only 34%-88% of dialysis patients develop seroprotective antibodies to hepatitis B, even when higher vaccine doses are administered. Improved, although variable, antibody response has been shown with vaccine manipulations, including intradermal injections, adjuvants, coadministration of immunomodulators, and combining hepatitis B and A vaccines. Current recommendations include administering an increased vaccine dose (40 μg) 3 or 4 times depending on which vaccine formulation is used. Patients who respond but lose antibodies over time should be given a booster vaccine. Patients who do not respond to an initial vaccine series should be administered an additional series in an attempt to induce a response. Subsequent vaccination strategies are unclear, as is the schedule for obtaining antibody levels. Vaccinating patients early in the course of their chronic kidney disease (CKD) is recommended because improved antibody production is seen in those with less severely decreased kidney function. Therefore, hepatitis B vaccination should be included in CKD care and not delayed until the initiation of dialysis therapy. Table 1 outlines the recommendations for hepatitis B vaccination in dialysis patients. As with other vaccines, dialysis patients develop variable responses to influenza vaccination, with 36%-90% of patients developing protective antibodies. Patient factors, as well as differences in the antigen immunogenicity of seasonal vaccines, likely account for the variability. Similarly, response rates to H1N1 vaccination vary among dialysis patients, ranging from 33%-64%. No serious adverse effects from the H1N1 vaccines have been observed. Because complications of influenza infection (notably hospitalization and development of pneumonia) are believed to be more common in dialysis patients and mortality from H1N1 infection is as high as 5% in dialysis patients, it has been recommended that dialysis patients receive the influenza vaccine yearly. However, conventional analyses examining vaccinated versus unvaccinated groups are prone to bias. A recent study looking at influenza illnesses, morbidity, and mortality that compared years using vaccines matched to circulating virus with a year in which a mismatched vaccine was used suggested only a small benefit of current influenza vaccine in dialysis patients. The authors suggested that it is premature to abandon yearly influenza vaccination in dialysis patients, but that alternate vaccination strategies to improve effectiveness (use of adjuvants, high vaccine doses, etc) should be investigated. Depending on the vaccine potency and adjuvant cost, administering adjuvanted influenza vaccines to all adult hemodialysis patients may be cost-effective. There are a few isolated studies examining dialysis patients' responses to tetanus and pneumococcal vaccination. As occurs with other vaccines, antibody development and maintenance are reduced in dialysis patients, but until there are more specific studies on the frequency of diseases that theoretically could be prevented by immunizing dialysis patients (as well as on the morbidity and mortality attributable to those diseases), the CDC recommends that all dialysis patients receive these vaccines (Table 1). A second dose of pneumococcal vaccine should be given 5 years after the initial dose if the patient was younger than 65 years at the time of the initial vaccination. Repeated vaccinations are not advised due to the risk of developing immune tolerance. Outcome data are sparse, but one study suggested a small but significantly reduced mortality (hazard ratio, 0.73; 95% confidence interval, 0.68-0.78) in the 21% of 118,533 maintenance hemodialysis patients who received pneumococcal vaccination with or without influenza vaccine. In 2005, a tetanus, diphtheria, and acellular pertussis vaccine was licensed for use in the United States for those aged 11-64 years. A single booster dose of this vaccine is suggested for adults and may be given 2 years or less after the last tetanus vaccine in high-risk people. There is no information about varicella or human papillomavirus vaccines in dialysis patients. For dialysis patients on transplant waiting lists, the CDC recommends that appropriate individuals (women aged <26 years, girls aged 11-12 years, and probably also boys aged 11-12 years) receive a human papillomavirus vaccine. Varicella zoster infection is common in immunosuppressed and elderly individuals and may affect solid-organ transplant recipients. Because it is a live virus, it is contraindicated in immunosuppressed individuals. Some have suggested that potential kidney transplant recipients who have some immunity to varicella by antibody titer measurement be considered for varicella zoster immunization. However, there are no data for the efficacy and safety of this vaccine in dialysis patients. »Chow J, Golan Y. Vaccination of solid-organ transplantation candidates. Clin Infect Dis. 2009;49:1550-1556.»Danzinger-Isakov L, Kumar D. Guidelines for vaccination of solid organ transplant candidates and recipients. Am J Transplant. 2009;9(suppl 4):S258-S262.»Eleftheriadis T, Antoniadi G, Liakopoulos V, Kartsios C, Stefanidis I. Disturbances of acquired immunity in hemodialysis patients. Semin Dial. 2007;20:440-451.»Fuchshuber A, Kuhnemund O, Keuth B, Latticken R, Michalk D, Querfeld U. Pneumococcal vaccine in children and young adults with chronic renal disease. Nephrol Dial Transplant. 1996;11:468-478.»Gilbertson DT, Unruh M, McBean AM, Kausz AT, Snyder JJ, Collins AJ. Influenza vaccine delivery and effectiveness in end-stage renal disease. Kidney Int. 2003;63:738-743.»Kausz AT, Gilbertson DT. Overview of vaccination in chronic kidney disease. Adv Chronic Kidney Dis. 2004;13:209-214.»Lee BY, Stalter RM, Bacon KM, et al. Cost-effectiveness of adjuvanted versus nonadjuvanted influenza vaccine in adult hemodialysis patients. Am J Kidney Dis. 2011;7:724-732.»McGrath LJ, Kshirsagar AV, Cole SR, et al. Influenza vaccine effectiveness in patients on hemodialysis: an analysis of a natural experiment. Arch Intern Med. 2012;172:548-554.»Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among hemodialysis patients. MMWR Recomm Rep. 2001;50(RR-5):1-43.»Centers for Disease Control and Prevention. Recommended adult immunization schedule for United States 2011. MMWR Morb Mortal Wkly Rep. 2011;60:1-4. http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/mmwr-adult-schedule.pdf. Accessed March 27, 2012. Adult periodic health examinations typically include age- and sex-appropriate cancer screening. Recommendations for cancer screening are based on disease occurrence, risks of screening, sensitivity and specificity of screening tests, and ultimately, the reduced mortality observed if screening detects disease. Thus, the expected survival of the individual to be screened is an implicit aspect of cancer screening. The high mortality in dialysis patients makes routine cancer screening inappropriate for this population. Cost-effective cancer screening in dialysis patients depends on the patient's risk of developing the cancer (including his or her personal cancer risk factors), expected survival, and transplantation status. Hypothetical analyses have determined that typical cancer screening (for cervical, colon, breast, and prostate cancers) in dialysis patients would result in 5 or fewer days of life saved. Cancer screening in these analyses is least effective in dialysis patients who are aged 50-70 years, women, and/or white. Some cancers occur more frequently in the dialysis population, notably viral-mediated and urologic cancers. Acquired renal cystic disease also is more common in dialysis patients and is associated with a small incidence of renal cell adenocarcinoma. However, ultrasound or computed tomographic screening all dialysis patients for renal cell carcinoma is not cost-effective. Breast and colon cancer are not more common in dialysis patients. Table 2 lists cancer frequencies in dialysis patients based on registry studies. With the exception of prostate cancer, dialysis patients are not more likely to be given a diagnosis of late-stage cancers. Box 2 summarizes the recommendations for cancer screening in dialysis patients. In general, individualized decisions will direct appropriate cancer screening. Patients on transplant waiting lists and those with long expected survival will require more routine screening.Table 2Cancer Frequency in the ESRD PopulationCancerStandardized Incidence RatioRisk FactorsRenal cell3.6-24.1Acquired cystic diseaseBladder and ureter1.5-16.4Analgesic abuse, Balkan nephropathy, oral cyclophosphamideMultiple myeloma4.0—Cervical, uterine2.7-4.3Human papillomavirusLiver1.4-4.5Hepatitis B and CThyroid & other endocrine organs2.3—Tongue1.9Human papillomavirusProstate0.9-2.1— Open table in a new tab Box 2Cost-Effective Cancer Screening in Dialysis PatientsBreast •Mammogram yearly at age >40 and on transplant waiting list•Clinical breast examination yearly at age ≥40; every 3 y for those in 20s-30s•Screening in high-risk individuals with long expected survivalCervical •Yearly Papanicolaou test ∼3 y after beginning vaginal intercourse and no later than age 21; newer liquid-based Papanicolaou test can be done every 2 y•Consider testing for HPV DNA and administering HPV vaccine, especially in transplantation candidates•Yearly Papanicolaou test in those on transplant waiting list and those with risk factors and long expected survivalColon and Rectal •Starting at age 50 in average-risk patients, stool-based test, flexible sigmoidoscopy, or optical colonoscopy for those on transplant waiting list•No screening over age 75 or life expectancy <10 y•Screen high-risk individuals with long expected survivalRenal Cell •Yearly CT or MRI in patients on dialysis >3 y and on transplant waiting listProstate •Annual PSA and digital rectal examination beginning at age 50 for men on transplant listAbbreviations: CT, computed tomography; HPV, human papillomavirus; MRI, magnetic resonance imaging; PSA, prostate-specific antigen. Breast •Mammogram yearly at age >40 and on transplant waiting list•Clinical breast examination yearly at age ≥40; every 3 y for those in 20s-30s•Screening in high-risk individuals with long expected survival Cervical •Yearly Papanicolaou test ∼3 y after beginning vaginal intercourse and no later than age 21; newer liquid-based Papanicolaou test can be done every 2 y•Consider testing for HPV DNA and administering HPV vaccine, especially in transplantation candidates•Yearly Papanicolaou test in those on transplant waiting list and those with risk factors and long expected survival Colon and Rectal •Starting at age 50 in average-risk patients, stool-based test, flexible sigmoidoscopy, or optical colonoscopy for those on transplant waiting list•No screening over age 75 or life expectancy <10 y•Screen high-risk individuals with long expected survival Renal Cell •Yearly CT or MRI in patients on dialysis >3 y and on transplant waiting list Prostate •Annual PSA and digital rectal examination beginning at age 50 for men on transplant list Abbreviations: CT, computed tomography; HPV, human papillomavirus; MRI, magnetic resonance imaging; PSA, prostate-specific antigen. »Chertow GM, Paltiel AD, Owen WF, Lazarus JM. Cost-effectiveness of cancer screening in end-stage renal disease. Arch Intern Med. 1996;156:1345-1350.»Holley JL, Von Roenn J. Screening for breast cancer in women with CKD stages 4 to 5. Am J Kidney Dis. 2010;56:820-822.»Holley JL. Screening, diagnosis, and treatment of cancer in long-term dialysis patients. Clin J Am Soc Nephrol. 2007;2:604-610.»LeBrun CL, Diehl LF, Abbott KD, Welch PG, Yuan CM. Life expectancy benefits of cancer screening in the end-stage renal disease population. Am J Kidney Dis. 2000;35:237-243.»Maissoneuve P, Agodoa L, Gellert R, et al. Cancer in patients on dialysis for end-stage renal disease: an international collaborative study. Lancet. 1999;354:93-99.»Qassem A, Denberg TD, Hopkins RH Jr, et al. Screening for colorectal cancer: a guidance statement from the American College of Physicians. Ann Intern Med. 2012;156:378-386.»Taneja S, Mandayam M, Kayani ZZ, Kuo Y-F, Shahinian VB. Comparison of stage at diagnosis of cancer in patients who are on dialysis versus the general population. Clin J Am Soc Nephrol. 2007;2:1008-1013. Sensorineural hearing loss occurs significantly more often in dialysis patients than in the general population, occurring in 46%-77% of these patients. Higher rates of hearing loss occur in both children and adults treated with dialysis, although some have found less hearing loss in peritoneal dialysis patients compared with those on hemodialysis therapy. The kidney and cochlea share physiologic processes involving the active transport of fluid and electrolytes (by the glomerulus in the kidney and the stria vascularis in the cochlea). This function may account for the similar effects of some medications (eg, aminoglycosides), diseases such as vasculitis, and hereditary conditions such as Alport syndrome on the kidney and hearing. Etiologic factors that contribute to hearing loss in dialysis patients include electrolyte disturbances, hypertension, exposure to radiocontrast, use of ototoxic medications, and possibly vitamin D and nerve conduction dysfunction. The hearing loss is primarily in the high frequencies and is not related to duration of ESRD or blood measurements such as serum urea nitrogen, creatinine, electrolyte, or hematocrit values. Some patients show retrocochlear auditory abnormalities (measured by brainstem audiometry). Vestibular dysfunction also has been reported in dialysis patients, especially those exposed to high total doses of aminoglycosides. Periodic auditory testing is recommended for all dialysis patients as part of general medical care depending on clinical status and results of screening for hearing loss. The primary treatment for hearing loss is amplification by hearing aids. However, significant barriers to hearing aid use exist, including accepting the need, selecting and purchasing the device, and getting used to the device. For dialysis patients, there are the added issues of scheduling appointments around dialysis treatments and, for some, the cost, because Medicare does not cover the cost of hearing aids. There is little information showing improvement in overall quality of life with hearing aids, but hearing and hearing-related quality of life are positively affected. Integrating hearing assessment into the overall health care of dialysis patients may lead to better treatments and outcomes. Compared with the general population, individuals with CKD are affected more commonly by ocular diseases, including cataracts, subconjunctival calcification, optic neuropathy, microvascular and diabetic retinopathy, and macular degeneration. Because the inner retina and glomerular filtration barrier share developmental pathways, capillary networks, and structural features, retinal disorders characterize a number of inherited kidney disorders. These include retinitis pigmentosa with nephronophthisis, drusen with Alport syndrome and dense deposit disease, crystal deposits with oxalosis and cystinosis, and vascular abnormalities with Fabry disease. Vision-threatening retinal abnormalities, such as diabetic and microvascular retinopathy and macular degeneration, also are more common in dialysis patients. Regular ophthalmologic monitoring may prevent complications such as retinal detachment or hemorrhage. Routine screening may detect retinopathy and macular degeneration, treatment for which may delay the loss of vision. Thus, all dialysis patients should undergo regular ophthalmologic examinations. Diabetic patients in particular should continue to have regular examinations for retinopathy; per the USRDS (US Renal Data Systems) annual data reports, this is an area of general medical care that deserves attention and improvement. Heparin anticoagulation during the hemodialysis procedure is considered safe; there appears to be no increase in retinopathy in hemodialysis patients receiving heparin compared with patients on peritoneal dialysis therapy. Although recent information suggests that significant changes in ocular perfusion pressure and intraocular pressure do not occur during normal hemodialysis treatments, there are cases in the literature of worsening intraocular pressure in patients with glaucoma who are undergoing hemodialysis. The rarity of this event necessitates communication between nephrologists and ophthalmologists. Mannitol and acetazolamide may be used, and one case report suggests that nocturnal home hemodialysis may be an effective therapy. »Barbosa CP, Stefanini FR, Penha F, et al. Intraocular pressure and ocular perfusion during hemodialysis. Arq Bas Oftalmol. 2011;74:106-109.»Deva R, Afzal A, Colville D, et al. Vision-threatening retinal abnormalities in chronic kidney disease stages 3 to 5. Clin J Am Soc Nephrol. 2011;6:1866-1871.»Evans RD, Rosner M. Ocular abnormalities associated with advanced kidney disease and haemodialysis. Semin Dial. 2005;18:252-257.»Karim MR, Balsam L, Rubinstein S. Permanent hearing loss with iopamidol following aortic angiography in a hemodialysis patient: a case report and review of the literature. Am J Kidney Dis. 2010;55:712-716.»Kocak H, Ly J, Chan CT. Improvement in open-angle glaucoma by nocturnal home hemodialysis. Nephrol Dial Transplant. 2006;21:2647-2649.»Pacala JT, Yueh B. Hearing deficits in the older patient: “I didn't notice anything.” JAMA. 2012;307:1185-1194.»Thodi C, Thodis E, Danielides V, Pasadakis P, Vargemizis V. Hearing in renal failure. Nephrol Dial Transplant. 2006;21:3023-3030.»Tzamaloukas AH, Leehey DJ, Friedman EA. Diabetes. In: Daugirdas JT, Blake PG, Ing TS, eds. Handbook of Dialysis. 4th ed. Philadelphia, PA: Lippincott, Williams, & Wilkins; 2007:503-504. A variety of dental conditions are more common in CKD and dialysis patients than in the general population. These include periodontal disease, enamel abnormalities, narrowing of the pulp chamber, premature tooth loss, and xerostomia. In addition, the salivary glands, bone, mouth cavity, tongue, and temporomandibular joint may be affected by CKD and its complications. Consequences of poor dental health may include increased mortality and systemic inflammation (associated with periodontal disease), protein-energy wasting (attributed in part to poor oral intake and inflammation associated with periodontal disease), and atherosclerotic complications (as a result of increased inflammation primarily due to periodontal disease). Manifestations of renal osteodystrophy in the mandible, maxilla, and oral cavity may include demineralization, metastatic soft-tissue calcifications, tooth mobility, malocclusion, enamel hypoplasia, and pulp stones. Retrograde parotitis also appears to be more common in patients with CKD, likely as a result of direct gland involvement, chemical inflammation, dehydration, mouth breathing, and side effects of medications. Xerostomia, or dry mouth, may predispose to caries and gingival inflammation, as well as contribute to problems with dental retention, mastication, speech difficulties, dysphagia, sore mouth, infection, and loss of taste. Reduced salivary flow may be caused by medications (antidepressants, antiemetics, antihistamines, antipsychotics, and antihypertensives, notably β- and α-blockers and diuretics) and increasing age. Gingivitis and periodontitis (inflammation of the gingiva and supporting tissues of the teeth) are common manifestations of poor dental health and occur more frequently in dialysis patients. Periodontitis is a potential source of inflammation because organisms colonize periodontal pockets, which recruits inflammatory cells, leading to secretion of proinflammatory mediators. Some have suggested that periodontitis therefore may contribute to higher dialysis patient mortality and cardiovascular disease through inflammatory pathways. Atherosclerotic vascular disease and periodontal disease have several risk factors in common, such as cigarette smoking, age, and diabetes mellitus. Observational studies indicate that atherosclerotic vascular disease and periodontal disease are associated independently of known confounders, but a causal relationship is not supported to date. The cause of periodontitis in dialysis patients is not clear, but disturbed humoral defenses and repeated anticoagulation with heparin, which may predispose to gingival bleeding and consequent bacterial colonization, have been postulated. In addition, routine dental care (flossing, brushing, use of mouthwashes, and preventive care by dentists) is less common in dialysis patients. Tooth brushing, flossing, and mouthwashes may reduce gingivitis. Regular dental hygiene care with mechanical debridement and surgery when needed may prevent the start and progression of periodontal disease. Xerostomia can be reduced by avoiding mouth breathing; using a humidifier; avoiding use of tobacco, alcohol, and/or mouthwashes containing alcohol; and using saliva substitutes and sugar-free gum to stimulate salivary flow. Avoiding medications that contribute to dry mouth also may be helpful. Calcium channel blockers can cause gingival hyperplasia and thereby contribute to periodontal disease; therefore, their use should be limited in select patients. For dialysis patients, being aware of the importance of dental health may lead to fewer dental complications and possibly reduce opportunities for systemic inflammation. »Akar H, Akar GC, Carrero JJ, Stenvinkel P, Lindholm B. Systemic consequences of poor oral health in chronic kidney disease patients. In depth review. Clin J Am Soc Nephrol. 2011;6:218-226.»Borawski J, Wilczynska-Borawska M, Stokowska W, Mysliwiec M. The periodontal status of pre-dialysis and chronic kidney disease and maintenance dialysis patients. Nephrol Dial Transplant. 2007;22:457-464.»Klassen JT, Krasko BM. The dental health status of dialysis patients. J Can Dent Assoc. 2002;68:34-38.»Loxkhart PB, Bolger AF, Papapanou PN, et al. AHA Scientific Statement. Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association? Circulation. 2012;125:2520-2544. Fractures occur in 10%-40% of dialysis patients and ∼50% of dialysis patients older than 50 years. Hip fractures are 4 times more frequent in dialysis patients and increase mortality substantially. The complex abnormalities of bone and mineral disorders in CKD contribute to inadequate understanding, diagnosis, and management of this problem. For example, bone density measurements in the general population predict fracture risk, but bone density in dialysis patients has limited fracture prediction. In patients with CKD stages 4 and 5, bone mineral density of the hip and radius generally are lower than in the general population, but in the lumbar spine, it is similar. Bone density also does not predict the type of renal osteodystrophy. There are no longitudinal studies of bone mineral density in patients with CKD, and the association of parathyroid hormone and bone mineral density is variable in CKD. For these reasons, routine bone d" @default.
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