Chronic kidney disease Flashcards
what is chronic kidney disease
Long-standing, irreversible damage to the kidneys that impairs their function
List 8 common presenting signs of CKD
PU/PD
Anorexia
Weight loss
Vomiting and diarrhoea
Dehydration
Pallor
Mucosal ulcers
Uraemic breath
describe how nephron damage gets worse and therefore irreversible
Nephron loss > other nephrons GFRs increased to compensate> more damage
how can reduced renal function lead to non-regenerative anaemais
reduced EPO production
what is a uraemic crisis
Build-up of urea and other toxins usually excreted in kidneys to intolerable levels.
list 3 conditions that can lead to uraemic crisis
End stage Chronic Kidney Disease
Acute Kidney Injury
Acute on Chronic Kidney disease
List 11 clinical signs of a uraemic crisis
VERY SICK
* Vomiting/nausea
* Anorexia
* Lethargy
* Depression
* Oral ulcers
* Melena (GI ulcers)
* Anaemia
* Weakness
* Hypothermia
* Muscle tremors
* Seizures
why should you not introdue a renal diet to a cat in hospital for renal disease
food aversion
offer when at home
describe the difference in duration of signs between CKD and AKI
CKD > 3 months
AKI <48 hours
what do we tend to find on clinical exam with CKD
BCS and coat quality reduced. Kidneys small and hard (enlarged possible dependant on cause e.g. PKD)
Describe stage 1 and 2 of IRIS STAGING
rarely picked up this soon
Abnormal renal imaging/ known insult OR
Persistent elevation/ increasing Creatine/ SDMA OR
Persistent renal proteinuria
Describe late 2 -4 stages of IRIS staging
consitent clinical signs
Azotaemia / persistently elevated creatinine/ SDMA
AND
USG <1.035 (cats) or <1.030 (dogs)
what is stage 1-4 of Iris staging based on
cratinine OR SDMA
consistent elevation in hydrated patient
what is substage of iris staging based on
proteinuria
systolic blood pressure
when does serum creatinine increase
when 75% of nephrons have been lost
when does SDMA increase
at 40% nephron loss
Describe how to treat CKD
treat underlying cause
mange risk factors to slow progression
renal diet
changes as it progresses
what is the problem with hyperphosphataemia with CKD
causes quicker progression of renal disease
can also lead to hyperparathyroidism –> Metabolic Bone Disease
Why do we get hyperphosphataemia in CKD
Phosphate –> filtered by kidneys so builds up in CKD
why is hypertension a concern
can cause end organ damage if susteined
describe how to diagnose hypertension
Based on repeated measurements of systolic blood pressure (SBP) - consistent technique and equipment
at what point do we treat hypertension
Treat if Systolic BP reliably and consistently >160 mm Hg
List 3 ways to treat renal hypertension
ACE inhibitor - e.g. Benazepril, Enalapril
Angiotensin receptor blockers (ARB) - e.g. Telmisartan, Spironolactone
Calcium Channel Blocker (CCB) - e.g. Amlodipine
how quick do you aim to reduce hypertension
Aim to reduce to <150mmhg over a few weeks – quicker (hours) if severe ocular / CNS signs
How do we treat CKD in dogs
aim to interfere with RAAS activation .
1st choice= Angiotensin receptor blockers (ARB) OR
ACE inhibitors (ACEi)
If needed can add in calcium channel blocker
How do we treat CKD in cats
start with Calcium Channel Blocker as more effective at reducing BP unless also proteinuria
can add angiotensin receptor blockers or ACEi to increase effect if needed
what should you do if urine dipstick +ve for protein
Urine Protein Creatinine Ratio
How do we treat proteinuria
RAAS inhibitor (ACEI or Angiotensin Receptor Blocker ) and feed a clinical renal diet
define pyelonephritis
bacterial infection of the renal pelvis and parenchyma
describe how to diagnose pyelonephritis
Very sick
haem- neutrophilia with left shift
U ltrasound - renal pelvis dilatation with hyperechoic mucosa, altered cortex/ medulla echogenicity.
NOT pyelocentesis as high risk- culture urine sample
Describe how to treat UTIs/ pyelonephritis
choose renally excreted drugs e.g. amoxycillin / amoxyclav
why should we avoid aminoglycosides in patients with CKD
can cause acute tubular necrosis
e.g. gentamycin
why should we avoid Enrofloxacin in patients with CKD
can cause renal damage in cats with reduced renal function at high
why do renal neoplasia generally not show signs of CKD
usually unilateral so other kidney compensates
Describe Polycystic Kidney Disease (PKD)
congenital disease
seen more in cats
Fluid filled cysts present from birth in the kidney–> Size and number gradually increase with age —> CKD
what do you find on clinical exam with
Polycystic Kidney Disease (PKD)
as CKD but large irregular kidneys
describe how to diagnose Polycystic Kidney Disease (PKD)
-ultrasound -hypo/anechoic spherical cavities
there is genetic testing- PCR for mutated gene (helps find animals we should not be breeding from)
describe Fanconi’s syndrome
Disease of proximal tubule > reduced resorption of solutes
Dogs
List the clinical signs of Fanconis syndrome
PU/PD
weight loss
signs or uraemia
describe how to diagnose Fanconi’s syndrome
Increased urinary fractional excretion of glucose, , Na+, K+, phosphorus & bicarbonate in urine despite normal plasma concs.
describe how to treat Fanconis syndrome
remove cause if possible
supplement electrolytes lost
List the indications of renal biopsy
Only if will alter patient management (generally not CKD) e.g.
- Protein Losing Nephropathy – unexpected/doesn’t respond to treatment
- AKI- cause and prognosis
- Mass lesions
List 6 contraindications of renal biopsy
Late stage CKD
Severe anaemia/ azotaemia
Uncontrolled hypertension/ coagulopathy
Severe hydronephrosis/ many large cysts
Pyelonephritis/ perirenal abscesses
NSAIDs in last 5 days
what is nephrotic syndrome
Lost so much protein from blood–> no longer keep water in the blood so oedema formed
what is seen with nephrotic syndrome
Pitting oedema /ascites/ pleural effusion
Hypoalbuminaemia
Hyperlipidaemia (TGs and cholesterol)
Describe how to treat nephrotic syndrome
Antiproteinurics- ACE inhibitors
Anticoagulants - Aspirin or Clopidogrel- minimize spontaneous platelet aggregation
Fluid removal - if QOL decreasing as result
describe how to treat glomerular disease
If a cause of immune complex disease present – treat
Manage Nephrotic syndrome if present
Limit proteinuria - with ACE inhibitors
Monitor and manage CKD as per IRIS staging
List 5 things that decrease prognosis of CKD
Uncontrolled hypertension
Persistent ↑ Serum Phosphorus
Persistent Proteinuria
Unable to medicate/ switch to renal diet.
Can’t control underlying issue.
Describe how to treat CKD in cats
Treat underlying causes if possible
Discontinue nephrotoxic drugs- NSAIDS
Treatment as dogs/cats BUT dietary management different
2ndary hypertension common- diagnose as dogs/cats and treat with ACEi
List 7 potential underlying causes of CKD
Polycystic kidney disease
pyelonephritis
toxins
glomerulonephritis
neoplasia
amyloidosis
FIP
List 5 examples of nephrotoxic drugs that can cause CKD
NSAIDs
aminoglycosides
sulphonamides
polymyxins
chemotherapeutics
Why do we get renal hyperparathyroidism secondary to CKD
reduced metabolism and excretion of parathyroid hormone
How do we treat a uraemic crisis
IVFT- Hartmanns
Assess acidosis (blood gas analysis)
Treat nausea and GI ulceration (Maropitant, pain relief, omeprazole )
Nutritional support
Describe how we reduce phosphate levels
renal diet- low in phosphate
phosphate binders e.g. Aluminium hydroxide
What is a biomarker for cats at risk of hyperphosphataemia
FGF23
How can hypertension effect the kidneys
Faster decline of renal function
Increased proteinuria
More frequent uremic crisis
Higher mortality
How does CKD lead to proteinuria
Nephron loss => other nephrons GFRs increased to compensate => glomerular capillary wall damage and more plasma protein filtration => further glomerular and tubulointerstitial damage.
How do we monitor patients being treated for hypertension
Evidence of worsening EOD on exam
Marked increase in azotaemia
Evidence syncope/hypotension (SBP <120mmHg)
Describe how we treat pyelonephritis
Only if clinical signs
Choose renally excreted drugs e.g. amoxycillin/ amoxyclav - higher conc in urine
TMPS
Fluoroquinolones (not enroflocacin) - protected
List some nephrotoxin antibiotics
Aminoglycosides - can cause acute tubular necrosis
Enrofloxacin- can cause renal damage in cats with reduced renal function at high doses
what type of cancer can result in CKD
Lymphoma- multi centric
What testing can we do for polycystic KD before disease develops
Genetic testing - PCR for mutated PKD1 gene
List the clinical signs of glomerular disease
Signs consistent with CKD/ uraemia or can be non-specific weigh loss/ lethargy.
Describe how to diagnose glomerular disease
Haematology/ Biochem
- Likely as for CRF but may not be azotaemia
- Likely hypoproteinaemia
Urinalysis
- Proteinuria => always
- May still be able to concentrate urine
- Hyaline casts common as protein lines tubules
Renal biopsy - definitive diagnosis
Which part of the kidney would you biopsy for glomerular disease diagnosis
cortex only
which diuretic is potassium sparing
spironolactone
How do we diagnose CKD in rabbits
urinalysis
biochemistry
How do we get a urine sample in rabbits
Don’t cysto if possible
Free catch/express best option
Describe how to treat CKD in rabbits
Treat underlying causes if possible
Discontinue nephrotoxic drugs
Treatment as dogs/cats BUT dietary management different (see endocrine)
2ndary hypertension common- diagnose as dogs/cats and treat with ACEi
