MAIKO CKD pt 2 Flashcards
goal of CKD treatment
Address the inciting cause of CKF
* Ideal
* But primary cause????
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Detect and eliminate risk factors
* Stones
* Infection
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* ↓ renal workload
* Gain weight
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Slow progression of the renal dysfunction
* Fix anemia
* Control proteinuria
* Control BP
Hypokalemia with CKD
- common for who?
- Tx?
- goal?
- More common in cats
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Treatment - Diet higher in K
- Oral supplements
> Pill, powder, gel
> Potassium citrate or gluconate - Supplement in fluids
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Goal - Serum K>4mEq/L
- Don’t wait until K below normal (If acidotic, K cell depleted)
CKD-Mineral Bone Disorder
- pathogenesis
- control
“Renal secondary hyperparathyroidism” = CKD-MBD
* Decreased activation of Vitamin D3 (calcitriol)
* Normally inhibits parathyroid gland
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Control of phosphorus is key
* Decreases calcitriol activation
* Renal diets
* Phosphate binders
* Goal: low normal range
When to worry about phosphorus for CKD?
- Before it is even increased!!
- When P>1.45mmol/L
- Phosphorus > upper end when 75% ↓ in GFR
Management of Hyperphosphatemia in CKD
- Low phosphorus diet (kidney diet)
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Oral phosphate binders - Aluminiumhydroxide
- Lanthanum carbonate (Renalzin)
- Sevelamer (Renagel)
- Chitosan (Epakitin)
- Calcium carbonate (Viyo Renal)
- Calcium carbonate plus magnesium carbonate (Pronefra)
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Calcitriol - Evidence is weak in cats in particular
- Expensive, requires close monitoring
Phosphate Binders in CKD
- what do they do? how do they work?
- how to administer?
- Binds phosphate in GI tract
- Efficient only if animal eats
- Ideally with meals
- For grazer prefer powder or switch to 3 meals / day
- Calcium-based phosphate binders contraindicated if hypercalcemia
> Prefer calcimimetic drugs (Cinacalcet)
Radiographs for CKF - what might we see? limitations?
- Small and irregular kidneys
- Or 1 small and 1 enlarged kidney
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Limitations - Stones?
- Obstructions?
Urinary Tract Ultrasound for CKD - what might we see?
- Irregular shape and small size
- Hyperechoic renal cortices
- Loss of normal corticomedullar boundary
renal biopsy for CKD - should we do it?
NO - though we could do it and get information, we dont want to remove what little functional kidney the animal has left
Urine Culture - purpose for CKD
- To rule out urinary tract infection
- To treat adequately the patient
Hypertension and CKD
- how common?
- related to what in cats?
- consequences
- Check blood pressure!!!
- Hypertension in 20-65% cats, 31-54% dogs
- 65-100% cats with retinal detachment have CKD
- Etiology and relationship unclear (multifactorial)
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Consequences - Retinal damage, blindness
- Worsening of renal damage
- Exacerbating proteinuria
- Seizures, ischemic encephalopathy
When to treat ↑ blood pressure (related to CKD)?
goal?
- Hypertension ↑ risk of uremic crisis and death
- If blood pressure >150 mmHg, recheck BP 2-3 times
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TREAT If - BP»200mmHg
- Retinopathy/encephalopathy
<><> - GOAL: reduce BP to <150mmHg
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Otherwise - Follow the trend
- Fundic exam
- Recheck on 2-3 occasions
How to treat ↑ blood pressure with CKD patient?
- Calcium channel blockers (Amlodipine)
- Angiotensin-converting-enzyme inhibitors
(enalapril, benazepril) - +/- Angiotensin receptor blockers (telmisartan)
Angiotensine-converting enzyme inhibitor (ACE inhibitors)
- when do we use this?
- what does it do?
- important for what species?
- drugs?
- Treatment for high blood pressure
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Reduces: - angiotensine II production
- vascular resistance and volume retention
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1st line in dogs
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Calcium Channel Blocker - use of this type of drug? important in what animal?
- 1st line in hypertensive cats
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- Long acting Calcium blocker
- Causes vasodilation without cardiac effect
Telmisartan - what does this do?
- RAAS inhibitor
- Shown to efficiently lower BP
- Not assessed in cats BP>200
Tips for Hypertension Treatment for CKD patients?
- what is good for acute injury?
- Don’t use telmisartan and benazepril when the patient is in acute kidney injury (or acute on chronic)
- Use Amlodipine
- If using Telmisartan monitor more frequently as dosage decrease frequently needed over time
Hypertension Monitoring for CKD patient
Stage I-II moderate hypertension
* Recheck in 7-14 days
* Gradual adjustment of dose
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Stage III-IV disease
* Recheck in 3-5 days
* Particularly if on other drugs
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Telmisartan
* Longer onset of effect
* Potential need for dose decrease
Proteinuria in CKD
- effect on prognosis?
- how we detect?
- thresholds for dogs and cats?
- should we do anything?
- Associated with poorer prognosis, progression
> Most often develops with later stage CKD - Urine Protein/ Creatinine Ratio (UPCS)
- Dogs UPCR≥ 0.5 increased risk of uremic crises and death
- Cats UPCR≥ 0.4 predicts shorter survival
> Should be treated
> Close monitoring required
> CAUTION using ACEI/ARB in late stage disease
Proteinuria Approach in Non Azotemic Dogs or cats
- 0.5-1: Monitor
- 1.1-2: Investigate
- ≥2: Treat
Proteinuria Approach in Azotemic Dogs or cats
- ≥0.5 (Dogs): Treat
- ≥0.4 (Cats): Treat
Telmisartan (SEMINTRA)
- what does this drug do?
demonstrated to decrease proteinuria in CKD cats
GI signs associated with CKD
- Anorexia
- Picky appetite
- Nausea
- Vomiting
Maropitant use for CKD cats
Palliates Uremic Vomiting
* Significant decrease in vomiting
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* (No difference in weight, appetite scores after 2 weeks)
Mirtazapine use for CKD cats
- Significant increase in appetite
- Significant decrease in vomiting
> weight gain, vs weight loss without
> generally improvement of BCS
Clinical Effect of Dehydration
- Inappetence, lethargy, weakness = QOL * Constipation
- Increased susceptibility to uremic crisis * Exacerbate stone formation
- Increase occurrence of UTI
renal diet - what is different? 4 goals?
- Modified in protein, phosphorus, sodium and lipid composition
- Supplemented in Omega-3 fatty acids and antioxydants
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4 goals - Ameliorate or prevent clinical consequences of CKD and uremia
- Slow progression of CKD and/or prolong survival
- Minimize derangements of electrolyte, mineral and acid base balance
- Maintain adequate nutrition
<><><><><><><><> - Modified in protein, ↓ phosphorus
> If high phosphorus: diet low in P
> If protein losing nephropathy : focus on the proteins - Others: sodium and lipid composition
- +++ omega 3 fatty acids
effects of renal diets?
- ↓ uremic episodes (clinical signs)
- ↓ mortality rate
- ↓ renal causes of death by 69%
- ↓ risk for uremic crisis by 72%
- In cats and dogs with spontaneous renal failure
- Better than adult maintenance diet
Feeding a CKD patient - how to focus on weight? what is the priority?
- If BCS ≤ 4/9- try to put on weight
- Of if obese- try to weight loss until BCS of 7/9
- Priority: maintain muscle mass
- APPETITE STIMULANT!!!!
what stage of kidney disease is it best to start a renal diet at?
Stage 2
* More chance of being accepted
* If needed to achieve Phosphorus goals * If UPCR >0.4
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* Stage 4 – introduction new diet may be difficult- calories intake paramount
CKD prognosis
- Cats stage II and III: 1-3 years??
- Dogs stage III: 6-12 months
if a cat has an acute on chronic renal failure episode, and gradually improves from stage 4 renal failure, when can the cat go home?
- send the cat home when good appetite and energy back to normal
> will still show kidney failure, eg. stage 2, but the cat will plateau here and never go back to normal…
<><><><> - Eating well + creat plateau
- SC fluids 50-70ml every 2 days
- Recheck in 1 week (renal profile, PCV)
- Meds: cerenia, mirtazapine
