Oral Pathology in a Patient With Chronic Kidney Disease

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Image Source: The New England Journal of Medicine

A 26-year-old man presented to the emergency department with complaints of an altered taste sensation, painless sloughing of the tongue, malaise, weight loss, and muscle cramps for the past 2 months.

The patient had been advised to have dialysis and get evaluated for renal transplantation around 3 years back as he had chronic kidney disease secondary to vesicoureteral reflux, but he had been lost to follow-up.

On physical examination of the tongue showed white, sharply demarcated, adherent plaques on the sides (Panel A) and undersurface (Panel B) of the tongue.

Serology revealed a creatinine level of 22 mg per deciliter (reference range, 0.7 to 1.5) and a blood urea nitrogen level of more than 225 mg per deciliter (reference range, 9 to 20).

A diagnosis of uremic stomatitis was made, and hemodialysis was initiated.

After 3 sessions of hemodialysis, the lesions on the tongue resolved completely (Panels C and D). Owing to the response, hemodialysis is continued, and the patient is being evaluated for renal transplantation

In healthy individuals, urea is washed away in the urine, and the body maintains a normal level of urea. With renal dysfunction, urea fails to be excreted in the urine; therefore, it accumulates in the body. This excessive amount of urea in the blood can lead to complications. One such complication is uremic stomatitis, which is seen after long-standing uremia. With the advent of dialysis, this complication is rarely seen now.

The exact mechanism behind uremic stomatitis is still not clear; however, certain theories are suggesting the etiology, but none has been proven to be conclusive.

Usually, signs and symptoms of uremic stomatitis resolve once the dialysis is initiated. It takes a few days or may take up to 3 weeks to resolve completely with no additional treatment for stomatitis per se. On the contrary, some patients may be prescribed mild acidic mouth wash to resolve the lesions along with remedies to control pain, including ice chips or a topical anesthetics.

Although chronic renal disease can be fatal, uremic stomatitis per se doesn’t cause death in most of the cases. However, there has been a death reported secondary to the dislodging of the plaque, which obstructed the airway. Therefore, it is imperative to diagnose and understand oral pathologies and their associations.

References:

Sudarshan R, Annigeri RG, Mamatha GP, Vijayabala GS. Uremic stomatitis. Contemp Clin Dent. 2012;3(1):113-115. DOI:10.4103/0976-237X.94560

Mishaal Talish, M. B. (2020, June 25). Uremic Stomatitis. Retrieved from The New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMicm1914867

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Dr. Arsia Parekh
Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.

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