Management of CKD (Quimby) Flashcards
In what specie is the following more likely to occur?
- NOT pro-thrombotic
- Slower progression
- Tubulointerstitial disease
- Hypertension: retinal damage
- Hypokalemia
Cats
In what specie is the following more likely to occur?
- Pro-thrombotic
- Faster progression
- Proteinuric glomerular disease
- Hypertension: hard to control
- Hypoalbuminemia
-HYPERkalemia
Dogs
(T/F) Calcium oxalate urolithiasis tends to end up in n the cat’s ureters
True
(T/F) Uremic gastritis is what causes inappetence in animals
False
- Activate the hunger center
- Ghrelin, NPY, ARP
Orexigenic
- Activate the satiety center
- Leptin, CCK, POMC/CART
Anorexigenic
Appetite compounds arise from CNS or GI
- Stimulates a meal
CNS
Appetite compounds arise from CNS or GI
- Terminate a meal
GI
What compounds override hunger stimulation in disease states such as CKD?
Anorexigenic
- Decreased uremic vomiting in cats
- Degree to which it helps with nausea is not known
Maropitant (NK-1)
- May decrease nausea and vomiting
Dolasetron and Ondansetron (5HT3)
- Stimulates appetite
- Increased weight and BCS
- Decreases vomiting
- Oral:
- 1.88 mg q 48h cats
- 1 mg/kg q 12h in dogs
Mirtazapine (5HT2c/H1/5HT3)
- Evidence is poor for benefit
Famotidine or Omeprazole
(Efficacy: Omeprazole > Famotidine)
- Approved for unintended weight loss in cats
- Achieves therapeutic serum concentrations
- Resulted in significant weight gain in comparison to placebo in a large efficacy trial
Transdermal Mirtazapine
- Capromorelin (grelin mimetic)
- Approved for both cats and dogs
- Somewhat bitter
- Careful monitoring in cats
- Bradycardia
- Hypotension
Entyce (Dogs) and Elura (cats)
When do we actively manage appetite?
- As soon as they develop a picky appetite e
- As soon as weight loss or muscle loss is seen
- To maintain caloric intake
- To get them to eat the diet you want
What are some known consequences of Hypertension?
- Retinal Damage, Blindness
- Worsening renal damage
- Proteinuria
(T/F) BP has to be sky-high for retinal damage to happen
False
Managing Hypertension:
- Calcium channel blocker
- First choice for cats, secondary for dogs
- Shown to effectively lower BP in cats
Amlodipine
Managing Hypertension:
- First choice if proteinuric (dogs)
- Dogs often require dual therapy
ACEI (Enalapril, Benazepril)
Managing Hypertension:
- Recently FDA approved for cats
- Only use when BP <200
- Takes a bit longer
- Also used in dogs
ARB (Telmisartan)
When managing Hypertension, when do we recheck?
In one week
- Increase dose if needed
- Add second med if needed (dog)
- ACEI + amlodipine or ARB + amlodipine
What can Hypokalemia cause?
- Polyuria
- Vomiting and diarrhea
- Anorexia
- Acidosis
What are some consequences of Hypokalemia in cats?
- Muscle weakness (neck and pelvic limbs)
- Delete in muscle even if serum K is normal - Constipation
- Anorexia
- Worsening renal disease
What is the Goal when treating Hypokalemia in cats?
- To get the serum K+ > 4.0 mEq/L
- Don’t wait until K+ is below normal
- Acidosis: shifts K+ out of cells
What are contributing factors of Hyperkalemia in dogs?
- ACEI therapy (most dogs)
- ARB therapy
- Kidney diets
What are some Effects of dehydration (physiologic)?
- Stimulation of vasopressin (ADH) release
- Stimulation of RAAS
- Poor perfusion – can exacerbate hypoxia
(T/F) Erythropoietin stimulates RBC production
True
(T/F) Erythropoietin comes from the kidney and thus production is decreased in CKD
True
Causes of Anemia of CKD
*Lack of erythropoietin
*Inflammatory cytokines
*Absolute iron deficiency
*Functional iron deficiency
*Uremic toxins
*ACE inhibitors, Angiotensin receptor antagonists
*Hyperparathyroidism
*Marrow fibrosis/infiltration
Decreased Erythropoiesis
Causes of Anemia of CKD
*Uremic toxins
*Hemolysis
*Premature removal
Shortened RBC Survival
Causes of Anemia of CKD
*Thrombocytopathy
*Gastrointestinal ulcers
*Blood sampling
Increase RBC Loss
What are ways to manage anemia?
- Blood transfusion
- Erythropoiesis-stimulating agents
Erythropoiesis-stimulating agents
* Given three times weekly
* Effective for increasing PCV in cats
* Potentially ~33% antibody formation
Epoetin (Epogen, Procrit)(historic)
Erythropoiesis-stimulating agents
* Current treatment of choice**
* 0.5-1 mcg/kg subcutaneously
* Given once weekly until normal PCV
* Monitoring BP and PCV required
* No antibody problems noted
Darbepoetin alpha (Aranesp)
(T/F) Uremic toxins come from colonic metabolism of proteins
True
(T/F) Uremic toxins have multiple negative effects and are associated with progression
True
CKD cats have increased uremic toxins:
- Indoxyl sulfate**
- P-cresol sulfate
What are some things we can do to address Uremic Toxins?
- Diet (highly digestible)
- Azodyl (commonly given, but low on the list)
- Porus One
- Absorbent binds indoxyl sulfate
- Mixed in food
Hyperphosphatemia
* Decreased activation of Vitamin D3 (calcitriol) in CKD
* Normally inhibits parathyroid gland
* ↑Phos further decreases calcitriol activation
Renal secondary hyperparathyroidism (CKD-MBD)
Therapy for Canine PLN:
- Kidney diet
- ACE inhibitors
- Angiotensin Receptor Blockers
- Anti-thrombotic therapy
- Omega 3 Fatty Acids
- +/-Immunosuppression
Proteinuria in Feline CKD:
- Associated with poorer prognosis, progression
* Few cats are profoundly proteinuric
* Most often develops with later-stage disease - Cats with UPC repeatedly > 0.4 should be treated
* NOT recommended for all cats with CKD
* Close monitoring is required
* CAUTION using ACEI in late-stage disease - Several studies examine benazepril therapy
What is a good treatment for proteinuria in cats is more effective than benazepril?
Telmisartan (Semintra®)
- Angiotensin receptor blocker (ARB)
- Demonstrated decreased blood pressure in cats
- Demostrated to decrease proteinuria in cats
- Need more info about effects in CKD cats
(T/F) 50-72% of profoundly proteinuric cats have immune-mediated glomerular disease
True
Match the following conditions with the medication that you would prescribe to address that problem:
Hypertension (cat)
Amlodipine or Telmisartan (Semintra)
Match the following conditions with the medication that you would prescribe to address that problem:
Hyperphosphatemia
- Renal Diet
- Then Phosphate Binder
Match the following conditions with the medication that you would prescribe to address that problem:
Anemia
Darbepoetin
Match the following conditions with the medication that you would prescribe to address that problem:
Poor appetite
Mirtazapine (Mirataz)
Match the following conditions with the medication that you would prescribe to address that problem:
Vomiting
Maropitant (Cerenia)
Match the following conditions with the medication that you would prescribe to address that problem:
Proteinuria (Cat)
Telmisartan (Semintra)
Match the following conditions with the medication that you would prescribe to address that problem:
Hypokalcemia
Potassium gluconate or potassium citrate
Match the following conditions with the medication that you would prescribe to address that problem:
Dehydration
Increased water ingestion, then subcutaneous fluids
Match the following conditions with the medication that you would prescribe to address that problem:
Hypertension (Dog)
Telmisartan or ACEI or amilodipine or combo
If a cat has a UTI, which antibiotic would be the least ideal choice for a cat with CKD?
Enrofloxacin
