Nursing the CKD Cat

Question 1

Define Chronic Kidney Disease.

Answer 1

Functional and/or structural disease of more than 3 months’ duration
Gradual, progressive, irreversible nephron loss

Question 2

What are the two possible CKD pathogenesis pathways?

Answer 2

Majority of cases due to chronic interstitial nephritis (inflammation of renal interstitium) - exclude treatable causes e.g. pyelonephritis/ureterolithiasis
Asymptomatic/undiagnosed initial insult = reduced GFR, compensatory hypertrophy of remaining nephrons = progressive nephron loss, progressive reduced GFR

Question 3

What should we discuss with owners if CKD is suspected?

Answer 3

Weight/condition changes
PUPD?
Appetite
Demeanour/activity levels
Vomiting, diarrhoea, haematemesis/malaena
Tolerant to medicate?

Question 4

What clinical signs might we see on examination of a CKD cat?

Answer 4

Hydration status (dehydration)
Weakness - neck ventroflexion = hypokalaemic myopathy
Uraemic ulcers +/- uraemic halitosis
Hypertensive retinopathy
Kidneys small/irregular on palpation
Rubber jaw = renal secondary hyperparathyroidism

Question 5

What tests can we run to diagnose CKD?

Answer 5

Urine specific gravity
Urine protein:creatinine ratio
Serum creatinine and urea
GFR (considered most sensitive)
SDMA
Imaging - ultrasound/radiography

Question 6

What can we see on these tests to confirm diagnosis of CKD?

Answer 6

Azotemia (increased urea and creatinine)
WITH inappropriately concentrated urine

Question 7

What are we looking for on ultrasonography and radiography of CKD patients?

Answer 7

Ultrasonography - renal size and architecture
Radiography - ureteroliths

Question 8

Describe hypertension as a complication of CKD.

Answer 8

Constant hypertension leads to organ damage, ocular/neuro/cardiac issues

Question 9

Describe renal secondary hyperparathyroidism as a complication of CKD.

Answer 9

CKD = increased serum phosphate
= parathyroid hormone (PTH) secretion to decrease phosphate (and increase calcium)
Ineffective as inadequate renal function to excrete excess phosphate
= progressive increasing phosphate = persistent PTH release
= bone resorption resulting from increased PTH activity
= rubber jaw (most recognised in renal dysplasia)

Question 10

Describe hypokalaemia as a complication of CKD.

Answer 10

Due to many causes e.g. inappetance, GI losses, urinary losses
Causes weakness (neck ventroflexion), inappetance
Supplement potassium for treatment

Question 11

Describe proteinuria as a complication of CKD.

Answer 11

More common in dogs
Need urineprotein:creatinine ratio (determine severity of protein loss in urine)

Question 12

Describe anaemia as a complication of CKD.

Answer 12

Multifactorial - lack of erythropoietin production, reduced RBC lifespan, GI losses?
Contributes to weakness, lethargy, inappetance

Question 13

What should be carried out in consult for CKD patients?

Answer 13

History - esp. appetite, drinking, GI signs
Weight, BCS
BP, retinal examination, PCV
Urea, creatinine, phosphate, calcium, electrolytes
Urinalysis
If stable, every 3-6 months - or more frequently as needed

Question 14

Describe IRIS staging.

Answer 14

Undertaken following diagnosis of CKD to facilitate appropriate treatment/monitoring
Once reversible problems have been addressed
Creatinine, substage by proteinuria, substage by blood pressure
IRIS treatment/monitoring recommendation for stage

Question 15

Describe a renal diet.

Answer 15

Restricted protein content
Low phosphate content
Antioxidants, essential fatty acids, added potassium, bicarbonate to prevent acidosis

Question 16

How can we manage hypertension due to CKD?

Answer 16

Calcium channel blockers e.g. amlodipine (cats)
ACE inhibitors (dogs)

Question 17

How do we manage hyperphosphataemia due to CKD?

Answer 17

Renal diet, phosphate binders

Question 18

How do we manage hypokalaemia due to CKD?

Answer 18

Renal diet, potassium supplementation

Question 19

How do we manage proteinuria due to CKD?

Answer 19

Renal diet, ACE inhibitors, omega 3 PUFAs, anti-platelets