The kidney patient is two patients

A referral that says "renal patient" describes two different patients, and the dental decisions follow which one is in the chair. The patient with advanced chronic kidney disease or on dialysis is at risk from the failing kidney itself: platelets that do not work properly in uraemia, heparin given during haemodialysis, drugs that the kidney no longer clears, blood pressure that is hard to control, bone changed by mineral disorder, and a degree of immune dysfunction — although in one small study of extractions in haemodialysis patients given no antibiotic prophylaxis, about one intervention in five bled beyond thirty minutes, all controlled with local measures, and no patient developed an infection, while a second small study could not link any laboratory test to bleeding. The patient with a working transplant is at risk from the drugs that keep the graft: immunosuppression, maintenance steroids and calcineurin inhibitors, of which ciclosporin causes gingival overgrowth more often than tacrolimus in cross-sectional studies, especially alongside calcium channel blockers. Two long-standing habits rest on thinner evidence than their ubiquity suggests: routine antibiotic prophylaxis for the dialysis access, which current endocarditis guidance does not list and for which a large matched database study found no endocarditis signal, though it did not measure infection of the access itself, and routine supplemental steroids for minor procedures under local anaesthesia, which a randomised trial in minor oral surgery and a systematic review do not support for patients who take their usual dose and do not have primary adrenal insufficiency. The pre-transplant clearance sits between the two patients — it is done on the dialysis patient, with dialysis-patient risks, for the benefit of the transplant patient — and the only systematic review of whether it changes transplant outcomes reads as support for it, on thin evidence.