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Small Animal Med. I > CRF & CKD - Green > Flashcards

CRF & CKD - Green Flashcards

1
Q

What two terms are also commonly used to describe

Chronic Kidney Disease (CKD)/Chronic Renal Disease?

A

Chronic Renal Insufficiency (CRI)

&

Chronic Renal Failure (CRF)

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2
Q

What CS will you see with Chronic Renal Insufficiency?

TQ

A

Isothenuric but not Azotemic

(patient has lost 2/3 of renal fxn)

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3
Q

What CS will you see with Chronic Renal Failure?

A

Isothenuric and Azotemic

(patient has lost 75% of renal mass)

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4
Q

When would a patient be considered to have CRF?

What does this result in?

A

When the kidneys are no longer able to maintain:

  • Excretory fxn
  • Regulartory fxn
  • Endocrine fxn

Resulting in:

  • Retention of nitrogenous waste
  • Derangement of fluids
  • Alterations in electrolytes & acid-base balance
  • Failure of hormone production
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5
Q

Are BUN and Creatinine sensitive indicators for the severity of renal disease?

TQ

A

NO!

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6
Q

Is renal disease more common in dogs or cats?

TQ

A

CATS!

(2x’s as often as dogs)

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7
Q

What is the number one cause of CRF in dogs?

TQ

A

Chronic tubulointerstitial nephritis of unknown cause

(Idiopathic interstitial nephritis)

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8
Q

What are some other causes of CRF in Dogs?

A
  • Chronic Pyelonephritis
  • Chronic Glomerulonephritis
  • Amyloidosis
  • Familial Renal Dz
  • Hypercalcemic Nephropathy
  • Chronic Obstruction
  • Sequele to acute renal disease (Lepto)
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9
Q

What is the number one cause of CRF in Cats?

A

Idiopathic Chronic Tubulointerstitial Nephritis

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10
Q

What are Clinical History findings in CRF?

(Findings are non-specific)

A
  • Polyuria/Polydipsia (common)
  • Vomiting (Dogs)
  • Inappetance/Anorexia
    • due to acidosis, ulcers, etc.
  • Weight loss
    • (chronic cases should have low BCS)
  • Lethargy
  • Small, Irregular, non painful kidneys
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11
Q

What are the PE findings you would see with CKD/CRF?

A
  • Weight loss/ low BCS
  • Poor Haircoat
  • Oral lesions
    • dogs > cats
  • Pale MM
    • from anemia associated w/ chronic renal dz.
  • Dehydration
  • Osteodystrophy
    • young dogs w/ familial renal dz.
  • + Small/irregular non-painful kidneys
  • + Ascites/edema (consider glomerular dz)
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12
Q

How does Renal 2° Hyperparathyroidism cause lesions?

TQ

A

P goes up → Ca2+ does down → Body produces PTH →

Ca2+increases at the expense of bone

(X-ray of skull shows teeth “floating” → Rubber jaw)

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13
Q

What are the laboratory findings you would see in a pt with CRF?

A
  • Non-regenerative anemia / lymphopenia
  • Isosthenuria (67% loss of nephrons)
  • Azotemia (75% loss of nephrons)
  • Hyperphosphatemia (85% loss of nephrons)
  • Decreased serum HCO3-
  • Variable serum Ca2+ (TQ)
  • Mild Hyperglycemia
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14
Q

What type anemia do you see with CRF?

A
  • Non-regenerative (normocytic, normochromic)
    • Variable in magnitude → correlates w/ severity of CRF (creatinine)
    • Serum EPO is low to normal, but inappropriate for the pt’s PCV
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15
Q

What is the trigger point theory of the pathophysiology of CKD/CRF?

A

Once intial critical mass of functioning nephrons are destroyed,

CKD/CRF will progress to End-Stage Renal Dz.

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16
Q

What mechanism contributes most to the progression of CKD?

A

Intraglomerular Hypertension

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17
Q

CKD/CRF is a self perpetuating dz due to Maladaption.

Explain this process.

A
  • Increased glomerular Pressure = Increased glomerular volume
    • due to less functional glomeruli filtering the same amount of blood.
  • Increased protien traffic
    • → mesangial ractions → Glomerulosclerosis → reduced GFR → systemic hypertension → Repeat
    • → increased tubular processing → tubulo-interstitial nephritis → decreased GFR → systemic hypertension → Repeat
  • Snowball effect as more nephrons die
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18
Q

What are the biggest factors in the progression of CRF?

A
  • Intraglomerular HYPERtension (SNGFR)
  • Systemic HYPERtension
  • Renal 2° HYPER-PTH
    • PTH = biggest uremic toxin & is present at toxic levels during CRF
  • Renal mineralization (product of Ca + P)
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19
Q

The International Renal Interest Society (IRIS) has classified canine CKD.

What are the stages and substages based on?

A
  • Stages
    • Creatinine (serum CRE when the animal is relativley stable)
  • Substages
    • Degree of proteinuria & magnitude of systemic HYPERtension
      • Substages do NOT use serum P or PTH
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20
Q

In the IRIS Classification of K9 CKD:

What stages are silent?

What stages are clinically apparent?

A
  • Stage 1 & 2 are silent
  • Stage 3 & 4 are clinically apparent
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21
Q

What are the parameters for the different IRIS Stages of K9 CKD?

A
  • Stage 1 - Non Azotemic CKD, Serum CRE < 1.4
  • Stage 2 - Mild Renal Azotemia, Serum CRE 1.4 - 2.0
  • Stage 3 - Moderate Renal Azotemia, Serum CRE 2.1 -5.0
  • Stage 4 - Severe Renal Azotemia, Serum CRE > 5.0
22
Q

What is the prognosis of lifespan once CKD is clinically apparent (stage 3/4) in dogs?

A

6 m - 1 yr

23
Q

IRIS classification states that most dogs are diagnosed in what stage of CKD?

A

Stage 3 - 46.5%

&

Stage 4 - 34.6%

24
Q

IRIS Classification parameters for the stages of FELINE CKD:

A
  • Stage 1 - Non Azotemic CKD, Serum CRE < 1.6
  • Stage 2 - Mild Renal Azotemia, Serum CRE 1.6 - 2.8
  • Stage 3 - Moderate Renal Azotemia, Serum CRE 2.9 - 5.0
  • Stage 4 - Severe Renal Azotemia, Serum CRE > 5.0
25
What stage are most CATS identified in using the IRIS system?
_Stage 1_ - 33.6% & _Stage 2_ - 37.2%
26
Why are cats in CKD caught at earlier stages than dogs?
Because the dz progresses much slower in cats and is caught on routine geriatiric blood work or when owner brings in for PU/PD
27
In dogs, what are the IRIS substaging catagories of Proteinuria (based on the UPC)?
* Non-Proteinuric UPC = 0 - 0.2 * Borderline Proteinuric UPC= 0.2 - 0.5 * Proteinuric UPC = 0.5 - 0.6+
28
What 2 parameters does the IRIS base its substages on?
* Level of Proteinurea * Systolic blood pressure
29
Is prognosis better or worse in an animal with CKD and proteinuria?
Worse! | (even just a little proteinuria is bad)
30
**What type of food should be fed to CRF patients?**
* Canned or water soaked kibble * **High in Energy** * **LOW in phosphorus** * **LOW/Mod Protein** * High potasium (loose via kidneys) * Restricted sodium
31
What is the most important dietary restriction for patients with CRF?
Phosphorus! (When you restrict protein, you are also restricting phosphorus)
32
What are the goals of treating a CRF Uremic patient?
* Make animal feel better * Reduce Uremic Lesions * Prevent (or slow) further loss of renal function
33
What are the general principles of managing a patient with CRF?
* Search for a reversible cause * Pyelonephritis * Obstruction (uroliths, neoplasia) * **HYPER**calcemia * Persistantly isosthenuric check for cause of PUPD * Image kidneys * Check BP * Wait to pass judgement on patient prognosis until on fluid therapy for several days (for animals w/ decompesated CRF)
34
Why should you wait until patient has been on fluids for several days to judgeprognosis on CRF patients?
Fluids will remove any pre-renal component of azotemia & may reduce serum CRE
35
What should you do initially to medically manage pts w/ CRF?
* **Dietary Phosphorus Restriciton** * **Intestinal Phosphate Binders** * Dietary protein restriction * H-2 receptor blockers
36
What should you do secondarily for conservative medical managment of pts with CRF?
* _Control of Renal 2° **HYPER**-PTH_ * ACE inhibition w/ or w/o **HYPER**tension * Control **HYPER**tension * Control metabolic acidosis * EPO
37
What are the only good renal diets?
The ones the pet will eat! (got to feed pt! If they won't eat renal diet, feed them something else)
38
When should you intervene dietarily in a CRF patient?
* Before they are obviously sick * may increase interval till uremic crisis
39
Can you give oral valium to a cat?
NO! WIll cause death by acute hepatic failure
40
What can you do to stimulate the appetite of CRF patients?
* H2-receptor blockers (Famotidine®) * Metoclopramide * Chemical stimulation * Cyproheptadine, Valium (cats), Mirtazapine * NG- Tube Feeding * Decrease BUN (fluids) * Alter food warm/broth/fat
41
What do you see in CRF patients with Uremic Gastroenteritis?
* Plasma gastrin concentrations are high (H-2 blockers will reduce) * Degree of **hyper**gastrinemia correlates w/ severity of CRF * Potential C/S: * Anorexia (cats common) * Vomiting (more in dog) * GI Bleeding
42
Why is P restriction so important in CRF patients?
* Dogs → Slows down the progression of Dz * Cats → Decreases mineralization & Fibrosis
43
When should you instruct clients to give phosphate binders to the patient? (How do they need to give it?)
At meal time
44
What are some phosphate binders used in vet med?
* Aluminum Salts (Aluminum Hydroxide) * Most common & cheapest w/ good Pi binding * Constipation common SE * Calcium Carbonate * Less P binding than aluminum * Must be careful w/ **HYPER**calcemic pt's * Calcium Acetate * PhosLo = binds 3x's better than calium carbonate * Less risk of **HYPER**calcemia * Epakitin - chitosan based supplement * NO taste aversion * Renalzin - not available USA & expensive * Sevelamer HCI (Renagel) * Expensive, high dose interferes w/ GI absorbtion of folic acid, Vit. D & Vit. K * Lanthanum Carbonate (Fosrenol) * Not absorbed in the GI, but found in bone & liver (trace) & is nontoxic
45
What are the advantages of hormonal replacement of EPO (human recombinant product) in animals with CRF?
* Resolves Anemia * Weight gain * Improves: * Appetite * Haircoat * Alertness * Activity
46
When do you replace EPO in CRF pt's?
When their PCV is \< 20%
47
What are the adverse effects of EPO replacement?
* Antibody formation (high risk 50% 30-160d after start) * Vomiting * Seizures * **HYPER**tension * Uveitits * Hypersysitivity reaction (mucocutaneous)
48
When do you use hormonal Calcitriol replacment in CRF patients?
* Only once **HYPER**phosphatemia is controlled * Rapidly lowers serum PTH levels (monitor levels) * Watch for hypercalcemia (especially w/ Ca2+ phosphate binders) FYI: Use extremely low doses & must be made by compounding pharmacy
49
What is important when monitoring BP in a patient with CRF?
* Have a well trained technician * Quiet, undisturbed environment * Sufficient time for acclimation * Correct Cuff size! * Several sequential measurements (do 3 & take avg)
50
When shoud you treat **Hyper**tension in CRF patients?
* BP consistently \> 160mmHg * High BP can lead to fundic lesions: * Retinal hemmorrhage * Vascular tortuosity * Retinal edema * Intra-retinal transudate * Retinal detachment
51
How do you treat **Hyper**tension in animals with CRF?
* Dietary salt restriction * Diuretics * Often not used b/c animal is on the verge of dehydration any way
52
What are some CRF findings that are indicative of a poor prognisis?
* **Sever intractable anemis** * **Inability to maintain fluid balance** * **Progressive weight loss** * Advanced osteodystrophy (w/ younger familial animals) * Progressive azotemia despite treatment * Severe end-stage renal lesions on biopsy

Small Animal Med. I (18 decks)

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