Lecture 6

Question 1

CKD vs CRF?

Answer 1

CKD= 66% loss
CRF= 75% loss

Question 2

Difference between CKD and AKI

Answer 2

CKD is permanent and progressive!

No recovery period like in AKI

Question 3

Other than GFR markers, what other information do you want from your patient?

Answer 3

Blood pressure
UPC

Possibly imaging, culture

Question 4

Underlying cause of CKD

Answer 4

Most are idiopathic (age related, accumulation of injuries)

Others might be toxicity, infection, cancer, obstructions

Question 5

Why is it so important to recognize AKI vs CKD

Answer 5

Because there will be significant differences in treatment and prognosis

Question 6

Compare/contrast AKI and CKD

Answer 6

History: Both have PU/PD, decreased appetite and vomiting. AKI might have oliguria/anuria but CKD is unlikely to have that

PE: Both have oral ulcers and hypertension. AKI does not have weight loss while CKD does. AKI does has large kidneys while CKD has small.

Lab: Both have high P, changes in Ca, low K, and active urine sediment. CKD will have anemia. AKI could have high K while CKD wont.

Imaging: CKD may have lost bone density. AKI has large kidneys while CKD has small.

Question 7

Describe IRIS staging

Answer 7

At risk
Stage 1
Stage 2
Stage 3
Stage 4

*substages- proteinuria, blood pressure

Question 8

Goals of treatment for CKD

Answer 8

No cure

Good quality of life, slow progression, delay onset of uremic crisis, improve survival times

*pay attention to any nephrotoxic drugs or drugs excreted by the kidneys

Question 9

Describe diet/nutrition for CKD pets

Answer 9

Renal diets are recommended for almost all patients- reduced P, omega 3 FA, vitamins

Good evidence for benefit in azotemic patients!
Still have questions about which diet and which cases/which to start?
General recommendation is to start when patient is stabilized and in stages 2-4

Even more important than renal diet though is that the patient is getting enough calories (appetite stimulants?). If won’t eat renal diet then feed them what you can

Question 10

Describe fluids in CKD patient

Answer 10

Need to maintain normal volume and hydration!

This supports GFR and uremic toxin clearance, prevents clinical signs, and minimizes progression

Question 11

Fluids for uremic crisis

Answer 11

IV fluids- replacement + maintenance + losses

Question 12

Fluids for stable CKD

Answer 12

Fresh drinking water always available
Serial measurements of body weight to identify need for additional fluids
Give extra fluids as needed via SQ or E-tube

Question 13

Disadvantages of feeding tubes

Answer 13

It keeps patients alive that maybe shouldn’t be alive anymore..can’t look at eating as a marker for quality of life

Question 14

Describe P requirements in CKD patients

Answer 14

Control serum P within normal range

More P -> decreased serum Ca ->increased PTH and decreased calcitriol-> secondary mineralization of soft tissue and demineralization of bone and secondary hyperparathyroidism

Question 15

How can you maintain normal phosphorus

Answer 15

Renal diets
Phosphate binders

Ideally you want to even be at low end of normal RI

Question 16

Aluminum vs calcium based phosphate binders

Answer 16

Aluminum- effective, inexpensive, potential for toxicity, complexed with hydroxide, oxide, and carbonate

Calcium- may help minimize secondary high PTH, potential for toxicity, complexed with acetate, citrate, and carbonate

Question 17

Describe control of hypertension in CKD patients

Answer 17

Incorporate BP measurements into regular diagnostics
Good evidence that controlling hypertension increases survival
Treat with anti-hypertensive if BP is greater than 160-170 or if evidence of end organ damage

Question 18

Ways to control hypertension

Answer 18

Dogs- Na restriction, ACEi and calcium channel blocker and hydralazine

Cats- Na restriction, CCB and ACEi

*watch for signs that you overcorrected!

Question 19

Describe proteinuria in CKD patients

Answer 19

Requires UPC measurements!

Treat with ACEi (enalapril, benzaepril)

Always treat this!

Question 20

What are some other (noncore) treatment strategies for CKD patients

Answer 20

Acid-base balance (use potassium citrate unless hyperkalemic)

High or low potassium (high in end stage, low before then)

Acid blockers for GI symptoms (new evidence suggests maybe there isn’t increased gastrin)

Anemia (not making enough EPO)

Calcitriol reduces PTH but there are potential complications and frequent monitoring is required

Azodyl- probiotic that is claimed to be enteral dialysis. No evidence