Background and Aim: Chronic Kidney disease is a common condition seen in Juvenile diabetes with 90% of renal impairment patients displaying a wide spectrum of oral manifestations in the hard and soft tissues including changes of the salivary composition and flow rate. There is an increase in the serum cystatin-C, urea and creatinine levels in these patients, which is reflected in the saliva. This study was conducted to assess the changes in salivary levels of cystatin-C, urea, and creatinine as well as oral – Decayed, Missing and Filled Teeth Index (DMFT) and gingival indices in pediatric patients suffering from chronic renal disease and juvenile diabetes and compare them with healthy individuals.
Methods: Fifteen patients with juvenile diabetes suffering from chronic renal disease and 15 healthy controls aged 2-18 years were included in the study. Their saliva was analyzed for creatinine, cystatin-C and urea levels using an auto-analyzer and correlated with their existing serum levels. DMFT, gingival index, gingival bleeding and gingival enlargement indices were also assessed.
Results: Increased levels of salivary cystatin C, urea (p value <0.001) and creatinine (p value =0.001) were seen in the cases. The deft value was significantly lower (p value <0.001) while the gingival index, gingival bleeding index, and gingival enlargement index were significantly higher in the subjects with renal impairment.
Conclusion: Chronic Kidney disease results in many metabolic changes in the body, necessitating frequent biochemical blood analysis. Saliva, being a non-invasive, simple and rapid adjunctive tool, can be used for diagnosing and staging the disease and to check the progression of the condition.
Keywords: Chronic Kidney Disease; Renal Dysfunction; Saliva; Cystatin-C; Diagnosis.
Greenberg MS, Glick M, Ship JA. Burkets Oral Medicine Diagnosis and treatment, BC Decker Inc Hamilton, 11th ed;2008.
Picken M. Atlas of renal pathology. Arch Pathol Lab Med 2000;124:927.
Hovind P, Tarnow L, Rossing K, Rossing P, Eising S, Larsen N, Binder C, Parving HH. Decreasing incidence of severe diabetic microangiopathy in type 1 diabetes. Diabetes Care 2003;26:1258–1264
Kuravatti S, David MP, Indira A.P. Oral manifestations of chronic kidney disease-an overview. International Journal of Contemporary Medical Research 2016;3(4):1149-1152.
Johnson AC, Leway AS, Coresh J, Levin A, Lau J, Eknoyan G: Clinical practical guidelines for Chronic Kidney Disease in adults: Part I. Definition, Disease stages, Evaluation, Treatment, and Risk factors. American Family Physician 2004;70:869-876.
Floege J, Johnson R J, Feehally J. Comprehensive Clinical Nephrology 4th ed Elsevier Inc; 2010.
Gupta M, Gupta M , Abhishek. Oral conditions in renal disorders and treatment considerations – A review for pediatric dentist. The Saudi Dental Journal;2015: 27: 113–119
Mani MK. Prevention of chronic renal failure at the community level. Kidney Int.2003;83(63):S86–S89
Agarwal SK, Dash SC, Irsha DM. Prevalence of Chronic Renal Failure in adults in Delhi, India. Nephrol Dial Transplant.
Onopiuk A, Tokarzewicz A, Gorodkiewicz E. Cystatin C: A Kidney Function Biomarker Advances in Clinical Chemistry.2015; 68:57-69.
Rahime R. Can salivary creatinine and urea levels be used to diagnose chronic kidney disease in children as accurately as serum creatinine and urea levels? A case–control
Löe H, Silness J. Periodontal disease in pregnancy. Acta Odontologica Scandinavica, 1963;21:533-551, ISSN 0001-6357.
Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. International Dental Journal.1975;25(4):229-235, ISSN 1875-595X.
Ingles E, Rossmann JA, Caffesse RG, Dr Odont. New clinical index for drug-induced gingival overgrowth. Quintessence international;1997;30(7).
Patil S, Khandelwal S, Doni B, Rahman F, Kaswan S. Oral Manifestations in Chronic Kidney Disease Patients Attending Two Hospitals in North Karnataka, India; OHDM; 2009; 11:3: 100-106.
Nandan RK, Sivapathasundaram B, Sivakumar G. Oral manifestations and analysis of salivary and blood Urea levels of patients undergoing haemodialysis and kidney transplant. Indian J Dent Res 2005;16(3):77-82.
Patil S, Puranik S, Mallikarjun J, Vohra R, Shivhare P, Gujar P. Assessment of Salivary Urea in Different stages of Chronic Renal Failure Patients. Int J Oral Care Res. 2016;4(1):21-24
Arora R, Sarvaiya B. Estimation of salivary Urea levels and its relation with dental caries in children with chronic renal failure. J Oral Health Res. 2010; 1(2):72-74.
Higgins C.Urea and the clinical value measuring blood urea concentration. www.acutecaretesting.org July 2016.
Sans L, Radosevic A, Quintian C, Montañés R, Gràcia S, Vilaplana C, et al. Cystatin C estimated glomerular filtration rate to assess renal function in early stages of autosomal dominant polycystic kidney disease. PLoS ONE. 2017;12(3): e0174583
Filler G, Bokenkamp A, Hofmann W, Bricon T, Martinez-Bru C, Grubb A. Cystatin C as a marker of GFR- history, indications, and future research. Clinical Biochemistry; 2005;38:1-98.
Venkatapathy R, GovindarajanV, Oza N, Parameswaran S, Pennagaram B Dhanasekaran, Prashad KV, Salivary creatinine estimation as an alternative to serum creatinine in chronic kidney disease patients, Int. J. Nephrol. 2014:742724.
Ferguson TW, Komenda P, Tangri N. Cystatin C as a biomarker for estimating glomerular filtration rate. Curr Opin Nephrol Hypertens. 2015; 24:295–300
Keevil BG, Kilpatrick ES, Nichols SP, et al. Biological variation of cystatin C: Implications for the assessment of glomerular filtration rate. Clin Chem 1998;44:1535–1539.
Horio M, Imai E, Yasuda Y , et al. Performance of serum cystatin C versus serum creatinine as a marker of glomerular filtration rate as measured by inulin renal clearance. Clin Exp Nephrol 2011;15:868–876.
Demirtaş S, Akan O, Can M, Elmali E, Akan H. Cystatin C can be affected by nonrenal factors: a preliminary study on leukemia. Clin. Biochem. 2006; 39 (2): 115–118.
Peterson S, Woodhead J, Cram J.Caries Resistance in Children with Chronic Kidney Disease: Plaque pH, Salivary pH, and Salivary Composition.Pediatric Research;1985:19:8:796-799.
Al-Nowaiser A, Roberts GJ, Trompeter RS, Wilson M, Lucas VS (2003) Oral health in children with chronic renal failure. Pediatr Nephrol 18:39–45
Davidovich E, Schwarz Z, Davidovitch M ,Eidelman E, Bimstein E. Oral findings and periodontal status in children, adolescents and young adults suffering from renal failure. J Clin Periodontol. 2005;32:1076–1082
Skorecki K, Green J, Brenner BM. Chronic renal failure. 2005: In: Kasper, D.L., Braunwald, E., Fauci, A.S., Hauser, S.L., Longo, D.L., Jameson, J.L. (Eds.), Harrison´ s Principles of Internal Medicine. McGraw-Hill, New York. 1653–1663
Ellis JS, Seymour RA, Taylor JJ, Thomason JM: Prevalence of gingival overgrowth in transplant patients immunosuppressed with tacrolimus. J Clin Periodontol.2004; 31: 126–131.
Lucas VS, Roberts GJ. Oro-dental health in children with chronic renal failure and after renal transplantation: a clinical review. Pediatr Nephrol.2005: 20:1388–1394.
Boccardo P, Remuzzi G, Galbusera M. Platelet Dysfunction in Renal Failure. Seminars in Thrombosis And Hemostasis. 2004;30(5): 579-589.
Pari A, Ilango P, Subbareddy V, Katamreddy V, Parthasarthy H. Gingival Diseases in Childhood – A Review. J Clin Diagn Res. 2014; 8(10): ZE01–ZE04
Chabria D, Weintraub RG, Kilpatrik NM. Mechanisms and management of gingival overgrowth in pediatric transplant recipients:a review. Int. J. Pediatr. Dent.2003;13:220–229.
Proctor R, Kumar N, Stein A, Moles D, Porter S. Oral and Dental Aspects of Chronic Renal Failure.J Dent Res. 2005;84(3):199-208.
Doufexi A, Mina M, Ioannidou E. Gingival overgrowth in children: epidemiology, pathogenesis, and complications. A literature review.J Periodontol. 2005;76(1):3-10.