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CAM > IP9 Renal > Flashcards

IP9 Renal Flashcards

1
Q

Why are kidneys susceptible to injury?

A

Filter 25% of blood from each cardiac cycle
Medulla poorly perfused
Concentrates some drugs/ toxins

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2
Q

What are the main functions of the kidney?

A 
Maintain body water balance
(Concentrate urine)
Excrete waste products
Make hormones
erythropoietin, active vitamin D, renin/ angiotensin
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3
Q

What goes wrong in renal failure?

A

Kidneys can’t regulate water = dehydration
Can’t excrete waste = uremia
Can’t make hormones = anemia, renal secondary hyperparathyroidism

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4
Q

How do you diagnose renal failure?

A

Appropriate history and clinical signs

Concurrent azotemia and isosthenuria

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5
Q

What’s different when diagnosing RF in cats?

A

Can become azotemic before entirely losing urine concentrating ability

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6
Q

How does outcome and prognosis differ between acute (ARF) and chronic (CRF) renal failure?

A

Acute: Poor short term prognosis (Px) (~50% die), but can have better long-term Px if survive short-term
Chronic: Can remain compensated and respond to supportive therapy, but no cure long-term

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7
Q 
What is the definition of the following:
Anuria
Oliguria
Polyuria
Polydipsia
A

Anuria: No urine output ( 2 ml/kg/hr
Oliguria: 0.25 to 0.5 ml/kg/hr
Polyuria: 2 + ml/kg/hr
Polydipsia: 50-100 ml water consumption/ kg/day

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8
Q

Distinguishing features of ARF?

A

Recent (less than 7 d) onset illness
History: toxin, ischemic event, really uremic
Renal size: normal to large +/- painful
Anuria/ oliguria possible
+/- PU
Normal body condition score
Really “sick” (uremic) for degree of azotemia

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9
Q

Distinguishing features of CRF?

A

Signs for weeks to months
History: PU/PD, occasional vomiting, nausea
Renal size: small, irregular, asymmetrical
Usually polyuric
Usually thin, poor hair coat
May be anemic
Sometimes have remarkable azotemia but still feel OK and be eating

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10
Q

What stages are described in the Chronic Kidney Disease staging system?

A

Stages 1-4
Stage 1: Mild clinical signs, not yet azotemic
Stage 4: Severe renal disease (Creat > 5 mg/dl)

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11
Q

What causes Acute Renal Failure?

A

Toxin (Ethylene glycol, Lily, Raisins/ Grapes)
Drugs (Aminoglycosides, cisplatin, ampho B, NSAIDS)
Ischemia (Shock, Heat stroke, Addison’s, Hypotension, Systemic inflammatory response)
Hypercalcemia
Infections (Leptospirosis, Rocky Mountain spotted fever, Lyme disease [Borreliosis])
Immune-mediated disease, Neoplasia

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12
Q

What causes Chronic Renal Failure?

A 
Age-related
Congenital (renal dysplasia)
Cardiac disease (chronic low perfusion)
Inherited tubular disease (Fanconi’s)
Glomerular disease (Protein-losing nephropathy)
Chronic pyelonephritis
Ureteral obstruction 
Renal calculi
Recovered ARF
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13
Q

Following initial diagnosis with renal failure, how long do dogs and cats live? (In other words, what is the long-term prognosis?)

A

Can be widely variable for both.
Dogs: range of 100-300 days (some much less)
Cats: Depending on stage at diagnosis, can live for a relatively long time
Stage 4 – 30 days
Stage 1 – 1200+ days

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14
Q

Why does oliguria or anuria cause hyperkalemia?

A

The kidneys are the primary excretory mechanism for potassium.

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15
Q

What 2 factors independently reduce survival (shorten lifespan, reduce prognosis) in both dogs and cats with chronic renal failure?

A

Hypertension

Proteinuria

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16
Q

What are clinical manifestations of hyperkalemia?

A 
Cardiac abnormalities, weakness, death
Cardiac signs:
Bradycardia
Loss of P waves
Wide, bizarre QRS complexes
17
Q

How is hyperkalemia treated?

A

IV fluid therapy to rehydrate and improve urine output
Resolve any urinary obstruction or leakage
Drugs (all IV emergency drugs):
Regular insulin IV – shifts K+ into cells
Administer dextrose concurrently
Na Bicarbonate – shifts K+ into cells
Calcium gluconate – Protects myocardium until other treatments can work

18
Q

what signs are consistent with ethylene glycol toxicity, and how is it treated?

A

History of exposure or possible exposure
Erratic behavior (can seem “drunk” early in exposure)
Intense PD early on
Metabolic acidosis, hypocalcemia
Calcium oxalate crystalluria
ARF (Grave prognosis at this stage)
Tx: Fomepazole (dogs), Ethanol (dogs or cats), induce vomiting if recent exposure.

19
Q

What criteria do you use to decide between recommending in-hospital vs. at-home management of RF?

A 
Hospitalize if: 
ARF (or treating toxin to avoid ARF)
Dehydration
Hypercalcemia
Hyperkalemia
Significant uremia (vomiting, nausea)
At home therapy if: 
Eating, well hydrated, stable CRF
20
Q

How do you monitor an animal receiving intravenous fluid therapy?

A

Monitor catheter and delivery system (appropriate rate, catheter functioning normally)
Physical parameters: Body weight, heart rate, respiratory rate, skin turgor, mucous membrane moisture, body temperature, urine output
Laboratory parameters: PCV, total protein, sodium, potassium, chloride

21
Q

What is the fluid dose for hypovolemia?

A

Treat both dogs and cats to “end points”
Dogs:
Up to 80-90 ml/kg crystalloid or 20 ml/kg colloid rapidly IV – administer ¼ to 1/3 calculated dose and re-evaluate
Cats:
Up to 50-60 ml/kg crystalloid or 10-20 ml/kg colloid rapidly IV – administer ¼ go 1/3 calculated dose and re-evaluate

22
Q

What is the fluid dose for dehydration?

A

Various formulas are used for maintenance. Most involve BW x 45-60ml, administer over 24 hours
Formula:
Maintenance + Dehydration + Ongoing loss

Dehydration: (% Dehydr)(BW kg)(1000ml/kg)

Ongoing loss: “Guesstimate” – may not need this

23
Q

Clinical signs of hyperkalemia?

A 
Bradycardia (usually)
EKG changes in order: 
     Tall, tented T waves
     Diminished/ absent P waves
     Wide, bizarre QRS complexes
     Asystole
24
Q

Treatments for hyperkalemia? (Remember how potassium leaves the body?)

A

Increase K excretion:
IV fluid therapy
Establish/ insure urine output
Move K around (shift into cells):
Regular insulin IV + dextrose (2o hypoglycemia)
Sodium bicarbonate IV
Keep the dying heart happy until other drugs work:
Calcium gluconate (Reserve for severe EKG)

25
Q

Treatments for oliguria/ anuria

A
  1. Make sure hydration is appropriate!
  2. Stop M + D + OL fl plan
  3. New fluid plan: Ins and Outs
    20 ml/kg/day + additional fluid replacement to exactly match urine output
  4. Start drugs to increase urine output
26
Q

What drugs treatments are used to improve urine output?

A

Make sure hydration is appropriate before starting any of these!!!

  1. Mannitol (Osmotic diuretic)
  2. Furosemide (Loop diuretic)
  3. Low-dose dopamine (changes renal blood flow – may not work)
27
Q

What if animal remains oliguric/ anuric despite hydration and appropriate drug treatment?

A

Euthanasia vs. dialysis

28
Q

What is dialysis?
Does it cure ARF?
Who do I call?

A

Removal of uremic toxins by means other than renal filtration (hemo-, peritoneal dialysis)

Does not cure RF, but may provide time for kidneys to heal.

Very costly, complicated, not widely available.
Call your referral internist or criticalist if you think you have a case.

29
Q

Consequences of uremia (More severe = more consequences)

A

Oral: Ulcers (tongue, gums), tongue tip necrosis
GI: Gastritis, vomiting, ulcers (due to excess gastrin), colitis
CNS: Reduced mentation (dull, stupor, coma, seizure)
Respiratory: Uremic pneumonitis (ARDS)
Other oddities: Probably pancreatitis

30
Q

Uremia treatments

A

Oral: Good dental care, oral disinfectants
GI: Acid reducers (H2 blockers, Proton pump inhibitors), Antiemetics (Maropitant, metoclopramide)
CNS: Resole azotemia. Monitor carefully.
Respiratory: Resolve azotemia. Be careful with overhydration – at risk of ARDS

31
Q

What causes anemia of CRF? Treatment?

A

Absence of RBC progenitor stimulant: Erythropoietin
Treatment:
Look for other causes of anemia (avoid tunnel-vision)
Minimize blood draw volumes
Human recombinant erythropoietin (careful – side effects)

32
Q

When is outpatient SQ fluid therapy reasonable?

A

Cats, and occasionally small dogs (more painful!)
Use to maintain hydration if oral water intake not optimal (NOT a Tx for dehydration)
• Dose: ~ 1/3 of calculated maintenance dose
• Frequency: Usually daily to EOD
• Type: 0.9% NaCl or LRS, NOT P’lyte (pain)

33
Q

Dietary Management Principles in CKD

A

Renal-type diets increase survival and delay uremic episodes in CKD.
“Renal-type” = low protein, phosphorous, high omega-3 fatty acids
Won’t prevent CKD
Initiate diet change when the animal feels well to prevent “food avoidance”

34
Q

Managing hyperphosphatemia

A
  1. Maintain hydration
  2. Feed renal-type diet
  3. Phosphate binders:
    Aluminum hydroxide (antacids like Amphojel®)
    Calcium carbonate (Tums®)
    Veterinary product Epakitin® – CaCarbonate + chitosan
35
Q

Managing hypokalemia

A

CKD sometimes causes renal tubular potassium wasting, especially in cats.
Administer potassium supplementation (oral preferred)
KCl in IV fluids CRI (NOT bolus!!! Deadly!)
K Gluconate orally as needed

36
Q

Managing azotemia

A

Maintain hydration
“Enteric dialysis” – Azodyl® supposedly traps uremic toxins in the GI tract so they are not absorbed into the body.
Voodoo? Maybe – but seems to lower BUN and might help – won’t hurt

37
Q

Kidney Transplant does not cure kidney disease

A

Kidney transplant provides some functioning renal tissue to prolong quality and length of life, but does not “cure” CKD.
Cats can get transplant , but not dogs (rejection)
Expensive
Lifelong immunosuppression
MANY complications

38
Q

End-result of CKD

A

All CKD becomes end-stage at some point. Euthanasia appropriate if anuric, or if clinical signs of uremia cause a poor quality of life, or if client wishes to euthanize.

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