Internal Medicine: Chronic Kidney Disease Flashcards
What is the definition of chronic kidney disease?
Structural or functional abnormalities of one or both kidneys that have been there for 3 months of longer
Is CKD more prevalent in cats or dogs?
Cats
increases with age but can affect young
What are congenital causes of CKD in dogs/cats?
- Renal dysplasia
- Polycystic kidney disease
- Amyloidosis
- Fanconi-like syndrome
What are acquired causes of CKD in dogs and cats?
- Idiopathic tubulointerstitial nephritis
- Glomerular disease
- Amyloidosis
- Sequel to AKI
- Lower urinary tract obstruction
- Pyelonephritis
- Hypercalcaemia
- Renal neoplasia
- Nephrotoxic drugs
- Hypokalaemia in cats
- Hypertension
How does CKD progress even in the absence of active kidney disease?
- Intraglomerular hypertension- increased single nephron glomerular filtration rate
- Systemic hypertension
- Proteinuria- glomerular diseases tend to progress more quickly than those affected
- Precipitation of calcium phosphate in renal tubules
What happens at each IRIS stage of CKD?
- Stage 1- primary renal injury
- Stage 2- mild azotaemia, maladaptions
- Stage 3- Uraemua, systemic complications
- Stage 4- End-stage renal failure
International renal intrest society
What are the clinical signs of CKD?
- Weight loss
- Poor appetite
- Dullness, lethargy, sleeping
- PUPD
- Dehydration
- Consitpation
- Poor hair coat
- Neurological signs
- Signs related to hypertension
- Oedema/ascites
What is used to stage CKD?
- Creatinine- stage
- Proteinuria- substage
- Blood pressure- substage
What is the upper boundary of stage 1, 2 and 3?
- Stage 1- 140 umol/l
- Stage 2- 250 umol/l
- Stage 3- 440 umol/l
Stable- creatinine not relevant if dehydrated etc
What is the optimal minimum databse in CKD?
- History- exposure to toxins/nephrotoxic drugs
- Physical examination- including eyes, thyroid in cat
- Haematology, biochem, urinalysis
- Blood pressure
- Abdominal radiographs
- Abdominal ultrasound
After diagnosis (bloods) of CKD what is the diagnostic approach?
- Determine diagnosis and stage
- Identify ongoing active renal diseases
- Identify any complications
- Identify concurrent conditions
What is important to check in haematology?
Haematocrit
Haemoglobin
RBC- most important
Anaemia may occur needs to be managed
What does urea and creatinine correlate with?
Urea
* correlated with clinical signs
Creatinine
* Correlates with GFR
* Muscle mass
What aboutthe following biochem should be checked?
1. Albumin
2. Potassium
3. Phosphorus
4. Calcium
- Decrease in PLN- protein losing nephropathy
- Frequently low- increase at end stage
- Initiated secondary hyperparathyroidism/metastatic calcification
- Increase, normal or decrease-
What may urinalysis show with CKD?
Isothenuric, moderately concentrated
- May be normal if patient hydrated
- Definetly abnormal in dehydration
When should UPCR be done for CKD?
If sediment is inactive
Urea protein creatinine ratio
How is a uraemic crisis treated?
- IVFT
- Hartmanns or Saline
- Supply ongoing maintenance
- Monitor electrolytes and azotaemia
- Reduce IVFT if animal starts drinking
How is stage 1 CKD treated?
- Stop all potentially nephrotoxic drugs
- Identify and eliminate any on-going specific diseases
- Measure blood pressure and UPCR
- Reduce proteinuria- RAAS inhibition and dietary reduction and antiplatelet drugs
-
Control hypertension- < 160
ACEi
Telmisartan
Amlodipine - Combat dehydration- wet diet, supply fountains/taps, large bowl, chicken flavoured water
When should ACE inhibitors not be used?
If dehydrated or hypovalaemic patient
When should a renal diet be started?
Stage 2 onwards
All dogs with proteinuric
How do renal diets differ?
- Protein restriction- reduces clin signs, stops uraemic crisis, reduces proteinuria, reduced PUPD, reduced acid load
- Phosphate restriction
- Omege 3 fatty acids
- Fibre
- Decreased sodium
- Water soluble vitamins
Other then renal diet what can help control phosphate?
What level are you aiming for?
Add phosphate binder it diet alone
Stage 2 < 1.5mmol/l
Stage 3 < 1.6mmol/l
Stage 4 < 1.9 mmol/l
How is hypokalaemia avoided?
- Supplement IVFT with KCL
- Oral supplements- potassium gluconate, potassium citrate
- Aim for > 4 mmol/l
Overall how is stage 2 treated?
- Control dehydration
- Control hypertension
- If proteinuric, start ACEi
- Start renal diet
- Control phosphate
- Supplement potassium
What additional treatments are recomended for CKD?
- Treat nausea and vomiting
- Consider EPO- erythropoetin (anaemia)
- Control metabolic acidosis
- Consider subcutaneous fluids
What can be used at stage 3 to control vomiting, nausea and poor appetite?
- Antiemetics
- Appetite stimulants- mitrazapine, capromorelin
- Reduce gastric acid secretion
- Sucalfate
- Consider feeding tube
How can anaemia be managed for stage 3?
- Avoid excessive blood sampling
- Minimise GI blood loss- ulcers
- Treat iron defiency
- Transfusions
- EPO replacement
What additional treatment can be added for stage 4 CKD?
- Control phosphate < 1.9 mmol/l
- Intensify efforts to provide nutrition
- More likely to require extra fluids
- Consider euthanasia
What can be used for a prognosis?
- IRIS stage at baseline
- Proteinuria- risk factor for uraemia and death
