Chronic and Acute Kidney Dz

Question 1

Chronic kidney dz

Answer 1

Persists of >3m
Creat >1.5 and BUN >33
USG: 1.008 -1.030 (inappropriate, not actively diluting or concentrating urine)

Question 2

Non-azotemic kidney dz

Answer 2

Proteinuric (glo and tubular)
Structural (dysphagia, agenesis and vascular)
Pathophysiologic (degenerative, anomaly, metabolic, neoplasia, infection/inflamm, trauma/toxin, genetic)

Question 3

CS associated with chr. kidney dz

Answer 3

WL, PU/PD, ↓ appetite and old age
(more likely in cats)
↓ nutrition status and poor hair coat

Question 4

Dx chr. kidney dz

Answer 4

↑ azotemia and ↓ USG
Persistent glomerular proteinuria, non-regen anemia, and genetic biomarkers of inherited kidney dz
NEXT STEP: IRIS stage

Question 5

Anatomical kidneys signs associated with chr. kidney dz

Answer 5

Small kidneys, mineralization and cysts/ pseudocysts

Question 6

What are the stages of chr. kidney dz based on?

Answer 6

Elevated serum creatinine
1. Azotemia (if hydrated)- pre (non kidney), renal (kidney failure), post (obstruction)
2. Substage with proteinuria and hypertension

Question 7

Stage 1 of chr. kidney failure

Answer 7

Inadequate urine conc. ability (cats)
Progressive ↑ in creat/ SDMA
Renal abnorms (imaging)
Persistant renal proteinuria
↓ GFR

Question 8

How to tx stage 1 of chr. kidney failure

Answer 8

Tx underlying dz
Renal therapeutic diet (tx proteinuria)
Keep P (phosphate binder)
Fresh H20 available

Question 9

Stage 2 of chr. kidney failure

Answer 9

Mild (years survival)
Animal progresses

Question 10

How to tx stage 2 of chr. kidney failure

Answer 10

Renal therapuetic diet
Tx hypokalemia (cats)
Same as stage 1

Question 11

Stage 3 of chr. kidney failure

Answer 11

Moderate
Complication: hypertension
Anemia and poor appetite

Question 12

How to tx stage 3 of chr. kidnye failure

Answer 12

Keep P
Tx met. acidosis, anemia, V, inappetence and nausea
↑ fluids
Calcitriol tx (dogs)
Same as 2

Question 13

Stage 4 of chr. kidnye failure

Answer 13

Severe (week- month survival)
Creat >5 (bad CS)
Complication: infection

Question 14

How to tx Stage 4 of chr. kidnye failure

Answer 14

Feeding tube for nutrition and hydration
Same as 3

Question 15

What does progressive chr. kidney dz look like?

Answer 15

Glomerulosclerosis
Tubulointestinal injury
Cell death

Question 16

Mechanisms promoting progression

Answer 16

Hypoxemia, hyperphosphatemia, hypertension, renal proteinuria, persistence/ recurrence of initial or new cause, advancing age

Question 17

EG toxicity (acute kidney dz)

Answer 17

Once azotemic 100% die
Ca oxalate crystals in urine (death soon)
Severe met. acid and ↑ anion gap seen before azotemia and crystals

Question 18

Significance of EG

Answer 18

Dx b4 azotemia
Normal creat. doesn’t rule out AKI
Urinalysis in initial evaluation if you suspect kidney dz

Question 19

Acute kidney dz

Answer 19

Sudden and rapid decline in kidney function <1w

Question 20

Anion gap

Answer 20

Helps localize aciodsis
(Na + K) - (Cl +HCO3)
Norml: 15-25

Question 21

How to dx AKI

Answer 21

Historical data (EG, lilies, grapes, etc)
Clinical markers (renal pain, oliguric)
Lab data (↑ creat, cystatin B, UA, MDB)

Question 22

What can cause AKI

Answer 22

Hemodynamic (hypovelmia, hypotension, shock, anesthesia)
Infectious (lepto)
Nephrotoxicity (EG, grapes, NSAIDs)
Systemic Dz (sepsis)
Urinary obstruction (ureteral)

Question 23

CS associated with AKI

Answer 23

Oligonuria, kidney pain and enlargement
Lethargy, anorexia, V/D, PU/PD, WL

Question 24

Phase 1 of AKI: Initiation

Answer 24

GFR goes to 0 right away
Creatinine low or normal
Specific therapy can halt damage

Question 25

Phase 2 of AKI: Extension

Answer 25

Continues damage Specific/ supportive therapy can halt damage + permit renal repair

Question 26

Phase 3 of AKI: Maintenance

Answer 26

Measures ↓ kidney function 1-3w Oliguria Targeted supportive therapy (allows kidney time to repair)

Question 27

Phase 4 of AKI: Recovery

Answer 27

Renal repair, not all recover Weeks to months Urine output ↑ Consequences: CKD/ death (50%)

Question 28

Most important step for tx AKI

Answer 28

Correcting prerenal azotemia 1. Correct perfusion within first hrs to dx 2. Correct dehydration over 12-24 hrs

Question 29

What is the most common error when dx AKI?

Answer 29

Failure to perform the urinalysis

Question 30

Other ways to dx AKI

Answer 30

Glucosuria without hyperglycemia (tubular damage and proteinuria) ↓USG (with ↑ azotemia) Urine sediment

Question 31

What seen in a urine sediment of a pet dx with AKI

Answer 31

Acute tubular necrosis: granular casts (muddy brown) with epithelial cells and casts Ca oxalate crystals (EG, hypocalcemia) Glomerunephritis/ vasculitis: proteinuria, red cells and red cell casts Interstitial nephritis/ pyelonephritis: Polyuria and WBC casts

Question 32

How to tx AKI

Answer 32

Specific therapy: eliminate, remove underlying cause Supportive (water, electrolyte, calorie, acide/base correction, removal of retained wastes, endocrine) Symptomatic therapy: nausea and pain

Question 33

How to tx persistent oliguria

Answer 33

Patients remaining oliguric after complete rehydration Therapeutic trial with diuretics (don't give unless completely hydrated)

Question 34

What drugs to use for AKI

Answer 34

Mannitol (osmotic diuretic) Glucose (OD) Furosemide (loop diuretic) Fenoldopam/ dopamine (vasodilation ↑ renal blood flow and naturesis) Diltiazem (Ca channel blocker causing preglo vasodilation)

Question 35

Pathologic oliguria/anuria

Answer 35

Small urinary bladder, hyperkalemia, urinary obstruction and uroabdomen

Question 36

What does pathologic oliguria/anuria lead to?

Answer 36

azotemia, fluid overload, met acidosis

Question 37

Pathologic nonoliguria and polyuria

Answer 37

Large urinary bladder and hypokalemia

Question 38

What does nonpathologic oliguria/polyuria lead to?

Answer 38

Signals onset of recovery of AKI Dehydration and hypokalemia

Question 39

Leptospirosis

Answer 39

Common cause of AKI in dogs PCR accurate (abx and test timing disrupt) Confirm with convalescent Ab titer

Question 40

Indications for Renal Replacement Therapy

Answer 40

Fluid overload Unrelenting hyperkalemia acid/ base imbalance Inadequate urine production Progressive unrelenting azotemia Acute poisoning/ drug overdose