Nursing the CKD cat Flashcards by Caitlin Holcombe

which species is more affected by chronic kidney disease?

cats (3x more prevalent than in dogs)

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what type of disease is chronic kidney disease?

functional and/or structural disease of >3 months duration

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what is the pathogenesis of chronic kidney disease?

gradual, progressive, irreversible nephron loss

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what is the aim of chronic kidney disease management?

reducing workload of the remaining nephrons and preventing further damage

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what is no nephron loss classed as?

normal kidney function

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what is the loss of 50% of nephrons classed as?

subclinical kidney disease

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what happens as a result of 67% kidney loss?

lose their concentrating ability

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what USG indicates the kidneys have lost concentrating ability?

<1.030 in dogs
<1.035 in cats

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at what percentage nephron loss do the kidney lose their concentrating ability?

67%

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what occurs when there is 75% nephron loss?

become azotemic

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at what nephron loss does the body become azotemic?

75%

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at what stage of nephron loss do clinical signs of kidney disease appear?

75%

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what occurs at 100% nephron loss?

incompatibility with life

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what are the 2 main causes chronic kidney disease?

chronic interstitial nephritis

asymptomatic/undiagnosed initial kidney insult

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what is chronic interstitial nephritis?

inflammation of the renal interstitium

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what are the treatable and/or (partially) reversible causes of chronic kidney disease?

pyelonephritis

ureterolithiasis

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what is pyelonephritis?

inflammation of the kidney and renal pelvis

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what might cause pyelonephritis?

FIP, FIV, leishmaniosis

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how can ureterolithiasis cause chronic kidney disease?

it is post-renal but causes renal damage

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how might an asymptomatic insult lead to chronic kidney disease?

upregulate GFR rate –> compensatory hypertrophy of remaining nephrons

over time –> progressive nephron loss, progressive decrease in GFR

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what are the main consequences of chronic kidney disease?

loss of water/electrolyte regulation

loss of acid/base regulation

failed excretion of uraemic solutes

impaired renal hormone synthesis

hypertension (cause vs consequence?)

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what is the clinical manifestation of loss of water/electrolyte regulation?

PUPD, dehydration

hypokalaemia

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what is the clinical manifestation of loss of acid/base regulation?

acidaemia - contributes to nausea, vomiting, inappetence

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what is the clinical manifestation of failed excretion of uraemic solutes?

azotemia, hyperphosphataemia - contributes to nausea, vomiting, inappetence

contributes to renal secondary hyperparathyroidism

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what is the clinical manifestation of impaired renal hormone synthesis?

lack of erythropoietin - anaemia

what is the clinical manifestation of hypertension?

end organ damage

which cats typically get chronic kidney disease?

mature-geriatric cats

when are young cats affected by chronic kidney disease?

due to congenital disorders (polycystic kidneys, malformation of kidneys)

when might we diagnose kidney disease in the sub-clinical phase

incidental finding - at time of pre-op profiles or geriatric wellness screening (bloods and urinalysis)

what should we discuss with the owner if kidney disease is suspected/diagnosed?

weight/condition changes - catabolic state drinking/urination, appetite demeanour, activity levels vomiting +/- diarrhoea +/- haematemesis/melaena signs associated with hypertension medication admin - ease/problems

why might cats with chronic kidney disease have constipation?

secondary to dehydration

what signs are associated with hypertension?

neurological signs blindness

why might we ask about drinking/urination?

to check for PUPD

what things should we be mindful of on assessment of a CKD cat?

hydration status weakness (neck ventroflexion) uraemic ulcers +/- halitosis hypertensive retinopathy small irregular kidneys on palpation 'rubber jaw'

why might a cat with CKD show neck ventroflexion?

hypokalaemic myopathy

why do cats with CKD get 'rubber jaw'?

due to renal secondary hyperparathyroidism

when might we have a clinical suspicion of CKD?

declining urinary concentration plus decline in weight

how do we diagnose CKD?

often combines diagnostic tools and functional tests

which tests may be undertaken for diagnosis of CKD?

USG urine protein:creatinine ratio serum creatinine and urea GFR SDMA diagnostic imaging - U/S and radiography

what is the most indicative test of chronic kidney disease?

GFR

which parameters confirm reduced kidney function?

azotemia - increased urea and creatinine WITH inappropriately concentrated urine

which other test may be used to diagnose chronic kidney disease?

symmetric dimethylarginine (SDMA)

what is the advantage of testing SDMA?

may identify kidney disease earlier than elevated urea/creatinine when used appropriately

how can we looks for structural disease of the kidney?

u/s - renal size and architecture radiography - ureteroliths

what reversible causes of chronic kidney disease might we be able to see with imaging?

ureteric obstruction pyelonephritis lymphoma?

what is the most common cause of hypertension in cats and dogs?

chronic kidney disease

what is the target measurement for SBP?

<140mmHg

how many BP measurements should ideally be taken?

minimum 3, preferably 5-7 consecutive measurements

what can results from prolonged high BP?

ocular, target organ damage and neuro issues

how can we reduce the stress of taking blood pressure measurements in cats?

feline friendly room long appointment use headphones with doppler tail measurement feliway consider medication e.g. gabapentin

how does 'rubber jaw' occur in CKD patients?

due to renal secondary hyperparathyroidism

how does renal secondary hyperparathyroidism result in bone resorption?

kidneys failing to excrete phosphorous --> raised serum phosphate triggers increased PTH secretion to lower phosphate (ineffective as inadequate renal function to excrete phosphate efficiently anyway) persistent PTH release --> bone resorption resulting from increased PTH activity

when is rubber jaw clinically most recognised?

in renal dysplasia

what is the overall effect of excess PTH?

demineralisation of calcium to correct balance in blood (PTH increases calcium and decreases phosphate)

how does CKD result in hypokalaemia?

multiple factors - inappetence, GI losses, urinary losses

what does hypokalaemia cause?

weakness - neck ventroflexion inappetence

how do we treat hypokalaemia in CKD cats?

potassium supplementation

which species commonly gets proteinuria as a result of CKD?

dogs

how do we identify proteinuria?

need urine protein:creatinine ratio (dipstick not sufficient)

what value is classed as proteinuria?

UPC >0.4

why do cats with CKD get anaemia?

multifactorial - lack of erythropoietin production, reduced RBC lifespan, GI losses (?)

what does anaemia contribute towards in CKD cats?

weakness lethargy inappetence proportional to disease stage

what should be involved in the consultation for suspected CKD?

clinical history weight, BCS blood pressure, retinal exam PCV, urea, phosphate, calcium, electrolytes urinalysis

how often should CKD cats be re-seen?

every 3-6 months if stable more frequently (as needed) if unstable

when is staging of CKD undertaken?

after diagnosis, once reversible problems have been addressed

why do we stage CKD?

in order to facilitate appropriate treatment and monitoring of the patient

what is IRIS staging?

an internationally recognised set of guidelines to CKD staging and treatment

what are the factors which contribute to IRIS staging of CKD?

creatinine substage by proteinuria substage by blood pressure

what are the most important therapies for CKD?

maintenance of hydration feeding a renal diet

what is in a renal diet?

restricted protein content low phosphate content antioxidants essential fatty acids added potassium bicarbonate to help acidosis

how can we encourage water intake in CKD cats?

water fountains add water to food/feed wet food trying different shaped/material bowls multiple water bowls keep water away from food

how can we help transition a cat onto a prescription renal diet?

don't introduce in hospital heat up food mixing with existing diet, transition gradually stabilise first - more important they eat non-renal than not eat at all

how can we manage hypertension in CKD patients?

amlodipine in cats ACE inhibitors in dogs

how can we manage hyperphosphataemia in CKD patients?

renal diet phosphate binders

how can we manage hypokalaemia in CKD patients?

renal diet potassium supplementation

how can we manage proteinuria in CKD patients?

renal diet ACE inhibitors omega 3 PUFAs anti-platelets (for cardiac issues)