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Y4 SA - Urogenital > Chronic kidney disease > Flashcards

Chronic kidney disease Flashcards

1
Q

Define chronic kidney disease

A

Structural or functional abnormalities of one or both kidneys that have been present for 3 months or longer

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2
Q

Describe the main features of damage in CKD

A
  • Compensatory/adaptive changes have already occurred
  • An irreversible, slowly progressive disease
  • After 3months have passed, you should not expect improvement in renal function
  • There is a permanent reduction in the number of functioning nephrons and reduced GFR
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3
Q

Define azotaemia

A

Azotaemia is an abnormal concentration of urea, creatinine and other nitrogenous compounds in the blood.
- Doesn’t mean abnormal renal function- there can be other causes

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4
Q

Define uraemia

A

The clinical syndrome that results from loss of kidney function, involving multiple metabolic derangements

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5
Q

List the congenital causes of CKD

A

Renal dysplasia - Dogs
Polycystic kidney disease - Persian
Amyloidosis
Fanconi-like syndrome

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6
Q

List some acquired causes of CKD

A

Idiopathic tubulointerstitial nephritis
Glomerular disease
Amyloidosis
Sequel to AKI
Lower urinary tract obstruction
Pyelonephritis
Hypercalcaemia
Renal neoplasia
Nephrotoxic drugs
Hypokalaemia in cats (controversial)
Hypertension (debated)

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7
Q

What happens in CKD once the active kidney disease stops?

A

Continues to progress

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8
Q

Why does CKD continue to progress?

A
  • Intraglomerular hypertension / ↑SNGFR (Increased single nephron GFR)
  • Systemic hypertension
  • Proteinuria
  • Precipitation of calcium phosphate in renal tubules - initiates inflammation, fibrosis and atrophy.
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9
Q

Describe an increase in single nephron GRF

A

A compensatory event aimed at maximising total GFR when the number of nephrons is reduced

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10
Q

Describe the 4 stages of IRIS CKD

A

1 = primary renal injury
2 = mild azotaemia, maladaptation’s
3 = uraemia, systemic complications
4 = end stage renal failure
GRF decreases over these 4 stages of CKD

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11
Q

List the clinical signs of CKD

A

Weight loss
Poor appetite
Dullness, lethargy, sleeping more
PUPD
Dehydration
Vomiting
Constipation
Poor hair coat
Neurological signs
Signs related to hypertension
Oedema/ascites in severe protein losing CKD

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12
Q

CKD is primary staged using?

A

Plasma creatine concentration

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13
Q

CKD is substaged using?

A

Proteinuria
Blood pressure - risk of organ damage

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14
Q

How is CKD stages from 1-4 using plasma creatine conc?

A

1 = some other renal abnormality present e.g. inadequate concentrating ability
2 = clinical signs usually mild (e.g. PUPD) or absent
3 = extra-renal signs present
4 = requires intensive treatment

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15
Q

When should creatine be measured to stage CKD?

A

Ideally two or more stable creatinine concentrations are used, obtained over days or weeks, when the pet is fasted and well hydrated

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16
Q

Describe the steps in the diagnostic approach to CKD

A

Determine diagnosis and stage
Identify any ongoing active renal diseases
Identify any complications
Identify concurrent conditions
CKD is not a single disease- all patients are individuals!

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17
Q

What do the levels of urea correlate with?

A

Clinical signs

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18
Q

What do the levels of creatinine correlate with?

A

GFR
Muscle mass

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19
Q

Describe the haematology seen in CKD

A
  • Normocytic normochromic non-regenerative anaemia can occur
  • Possible decreased albumin in protein losing enteropathy
  • Calcium levels vary
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20
Q

Why would you want to assess potassium levels in CKD patients?

A

Frequently low in cats with CKD
Increased in endstage CKD

21
Q

Why would you want to assess phosphorus levels in CKD patients?

A

Indicates secondary hyperparathyroidism and metastatic calcification
Linked to increased mortality and progression of CKD

22
Q

Describe urinalysis for CKD

A

May be normal if patient is hydrated
Is definitely abnormal in dehydration
Dipstick – check proteinuria
Sediment - WBC, RBC, casts, crystals

23
Q

What are the principles of treatment for CKD?

A
  • CKD is irreversible and usually progressive
  • There is no cure
  • Aim to provide good quality of life, reduce severity of c/s, minimise progression
24
Q

How is a uraemic crisis treated?

A
  • IVFT: Hartmann’s or 0.9% NaCl
  • Supply ongoing maintenance requirements
  • Monitor electrolytes and azotaemia
  • Reduce IVFT as animal starts eating and drinking
  • Don’t “flush” the kidneys!!
25
Q

When is an animal classified as stage 1 CKD?

A

For an animal to be classified in Stage I, some other abnormality must be detected to create the suspicion that a disease is present in kidney tissue

26
Q

List the abnormalities which may indicate stage 1 CKD?

A
  • Inadequate urinary concentrating ability in the absence of an identifiable extra-renal cause,,
  • Detection of renal proteinuria
  • Abnormal size or shape of the kidneys on palpation, confirmed by diagnostic imaging
  • Abnormal kidney biopsy findings
  • Increasing creatinine concentrations (even if they remaining within the laboratory reference range) on serial sampling
27
Q

What is the immediate action needed in stage 1 CKD?

A
  • Stop all potentially nephrotoxic drugs.
  • Identify and eliminate any on-going specific diseases if present - Often none can be identified
  • Measure blood pressure and UPCR.
28
Q

What are the 3 main steps to managing stage 1 CKD?

A
  • Control dehydration
  • Control hypertension (Goal is to reduce SBP to < 160 mmHg)
  • Reduce proteinuria
29
Q

How is dehydration controlled?

A

Feed a wet diet
Supply drinking fountains/dripping taps
Give cats a large bowl and fill it right up
Can try chicken/fish flavoured water

30
Q

How is hypertension controlled?

A

ACEi
Telmisartan = Angiotensin receptor blocker
Amlodipine

31
Q

How can proteinuria be reduced?

A

If proteinuria >0.5, start ACE inhibitor (correct dehydration before using ACE inhibitor) and a renal diet
- RAAS inhibition plus dietary protein reduction
- Antiplatelet drugs (low-dose aspirin, or clopidogrel)
- NO ACE INHIBITOR IN DEHYDRATED OR HYPOVALEMIC PATIENT

32
Q

How is stage 2 CKD managed?

A

Same as Stage 1 plus the following:
- Start a renal diet
- Supplement potassium if needed
- Control phosphate to <1.5 mmol/l (diet, +/- phosphate binders to effect)

33
Q

Why are renal diets beneficial?

A
  • Protein restriction
  • Phosphate restriction
  • Ω-3 fatty acids
  • Fibre
  • ↓ sodium
  • Water soluble vitamins
34
Q

Why do you want to restrict protein in patients with CKD?

A

Ameliorates clinical signs
Reduced risk of uraemic crisis
Reduces proteinuria
Reduces PUPD
Reduces acid load

35
Q

Which stages of patients will benefit from renal diets?

A
  • Dogs in stage III and IV CKD
  • Cats in stage II, III and IV CKD
  • Dogs in stage II CKD when phosphate >1.5 mmol/L
  • All dogs with proteinuric CKD
  • Reduces c/s and prolongs life!
36
Q

How can you help increase acceptance of a renal diet?

A

Educate the owner
Implement early
Introduce slowly
Don’t introduce them during times of stress
Consider temperature, texture…
Add flavour enhancers
Try another brand

37
Q

How can you control the levels of serum phosphate in patients with CKD?

A

Reduce protein intake first (use a renal diet!)
Add phosphate binder if diet alone isn’t enough

38
Q

How can you avoid hypokalaemia in patients treated for CKD?

A

Supplement IVFT with KCl
Oral supplements
- Potassium gluconate
- Potassium citrate

39
Q

You’re treating a cat with CKD for a uraemic crisis. What food is best to offer the cat in hospital?

A

Any standard diet
Not a renal diet – this is for long term use, don’t want to cause food aversion by feeding in the hospital

40
Q

How is stage 3 of CKD managed?

A

Same as stage 2 plus:
- Control vomiting/nausea/poor appetite
- Manage anaemia

41
Q

How is vomiting/nausea/poor appetite controlled?

A
  • Antiemetics
  • Appetite stimulants (Mirtazapine, Capromorelin)
  • Reduce gastric acid secretion
  • Sucralfate
  • Consider a feeding tube
42
Q

How is anaemia managed in stage 3 CKD?

A
  • Avoid excessive blood sampling
  • Minimise GI blood loss (omeprazole/H2 antagonists/sucralfate)
  • Treat iron deficiency (oral ferrous sulphate)
  • Transfusions
  • EPO replacement
43
Q

What are the considerations/side effects of using EPO replacements?

A

Supplement iron if you give EPO
Side effects of EPO treatment: seizures, hypertension, local reactions, antibodies

44
Q

How is stage 4 CKD managed?

A

Same as stage 3 plus:
- Control phosphate to <1.9 mmol/l (higher levels more tolerated than stage 3)
- Intensify efforts to provide nutrition
- More likely to require extra fluids (SC or via tube)
- Consider euthanasia

45
Q

List the 4 steps involved in minimising progression of CKD

A
  1. Use a renal diet
  2. Control phosphate
  3. Control proteinuria
  4. Control blood pressure
46
Q

Describe giving a prognosis for CKD

A

Unpredictable time course of the disease.
Hard to give a Px- depends on rate of progression and animal’s ability to tolerate azotaemia.
Diet seems to be most important
Proteinuria = Risk factor for uraemia and death

47
Q

You’re monitoring a cat with CKD. What are your top 3 priorities to measure are ?

A

Creatinine
Phosphate
Potassium

48
Q

Which intervention is CONTRAINDICATED when managing a uraemic crisis?

A

ACE inhibitors

Y4 SA - Urogenital (12 decks)

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