Renal - Chronic Kidney Disease Flashcards
What is chronic kidney disease?
Structural/functional abnormalities of the kidney that have been present long-term
CKD is typically reversible/irreversible and progressive/nonprogressive despite therapy.
Irreversible and progressive
What is the pathophysiology of CKD?
Initial insult/disease process occurs and results in the loss of the majority of the nephrons
What are the adaptive mechanisms to compensate for loss nephrons in CKD?
Increase single-nephron GFR (nephron hypertrophy)
How do adaptive mechanisms effect CKD?
They result in damage of the remaining nephrons thus causing spontaneous, continued decline in renal function
True or False: Anything that can cause AKI can cause CKD.
True
What is often found on histopathology in CKD patients?
Tubulointerstitial nephritis and fibrosis
What is the signalment for CKD?
Increasing prevalence with age, all ages can be affected, and all breeds can be affected
What history/presenting complaints are associated with CKD?
PU/PD, gastrointestinal signs (decreased appetite, vomiting, diarrhea) and weight loss
What will you find on PE in patients with CKD?
Weight loss; muscle atrophy
small, irregular kidneys
dehydration
Less commonly - uremic breath/oral ulceration and pale mucous membranes
What will you find on CBC in CKD patients?
Normocytic, normochromic nonregenerative anemia
What will you find on chemistry in CKD patients?
Azotemia, hyperphosphatemia, metabolic acidosis, and variable potassium (often normal to low)
What USG is associated with CKD?
Isosthenuria is often present (1.008-1.012)
There is inadequate concentrating ability in the face of azotemia
If no azotemia, persistent isosthenuria is suggestive of _____.
CKD
What will the SDMA value be in patients with CKD (not a specific number)?
elevated
When may be SDMA measurements be useful?
In cases of persistent isosthenuria/inappropriately concentrated urine when there is no azotemia
What clinical characteristics are associated with IRIS stage I?
Non-azotemic; clinical signs absent other than possible PU/PD
What clinical characteristics are associated with IRIS stage II?
Mildly azotemic; clinical signs absent other than PU/PD +/- mild appetite changes, weight loss
What clinical characteristics are associated with IRIS stage III?
Moderately azotemic; clinical signs typically present, disease progressive
What clinical characteristics are associated with IRIS stage IV?
Severely azotemic; clinical signs of uremia, disease progressive
What is IRIS substaging based on?
The presence of proteinuria and/or hypertension
What are the goals to managing patients with CKD?
Deal with any active or exacerbating sources of kidney injury
Slow progression of renal function loss
Minimize clinical signs of uremia
Manage complications and comorbid conditions
What is a therapeutic renal diet made up of?
Reduced phosphorus, added omega-3 polyunsaturated fatty acids, limited high-quality protein, and calorie dense
What do you need to make sure to manage about the nutrition in CKD patients?
Maintain adequate calorie consumption because low BCS is associated with reduced survival
Why does hyperphosphatemia occur in CKD patients?
There is decreased GFR which results in phosphorus retention
What should you do first to manage hyperphosphatemia in CKD patients?
Dietary phosphorus restriction first
Note: the IRIS scale for phosphorus supplementation recommends values below the normal RI for phosphorus
What should you do second to manage hyperphosphatemia in CKD patients?
Add dietary phosphate binders - give with food to be effective
Why are cats and dogs with CKD prone to dehydration?
because of polyuria
What do you want to do to mitigate dehydration in CKD patients?
Promote compensatory polydipsia - free access to several water sources, water in food/canned food, carefully manage exacerbating factors
In chronically dehydrated pets, what is the recommended fluid therapy?
SQ fluids or enteral hydration
How do you manage vomiting in CKD patients?
antiemetics
How do you manage uremic gastritis in CKD patients?
Acid suppression (proton-pump inhibitor) +/- sucralfate may be indicated in dogs
If a patient with CKD has poor appetite, what should you give?
Mirtazapine or a feeding tube
Is hypokalemia seen in CKD cats or dogs more commonly?
cats
What is the most recognized clinical sign with hypokalemia?
muscle weakness
How is potassium supplemented in CKD patients?
Parenteral (IV) supplementation if severe and/or symptomatic
Oral supplementation long-term
When may hyperkalemia be seen in CKD patients?
in end-stage disease
Why is hypertension problematic in CKD patients?
Because it contributes to further renal damage as well as damage to other organ systems
What is the recommended treatment for hypertensive CKD cats?
amlodipine
What is the recommended treatment for hypertensive CKD dogs?
Ace-inhibitors (benazepril or enalapril)
Why is CKD sometimes accompanied by proteinuria?
Protein leakage into the urine is suspected to be damaging to the renal tubules
How is it recommended to treat proteinuria in CKD?
with medication
Why is anemia associated with CKD?
EPO deficiency develops as functional renal mass declines
How is anemia managed in CKD patients?
Erythrocyte-stimulating agents - Darbepoetin alpha
Note: anti-EPO antibodies can develop
What mineral and bone disorders can develop as a result of CKD?
Renal secondary HPTH, renal osteodystrophy, and soft tissue mineralization
What should you do to manage mineral and bone disorders in CKD patients?
Reduce phosphorus
Maybe calcitriol therapy
What diagnostic steps should be taken after CKD is diagnosed?
Measure BP
Obtain urine culture
Quantify urine protein
Consider renal imaging
What are the therapeutic steps to treating stage 1 CKD?
Avoid or discontinue any medications that may be nephrotoxic
discuss hydration/lifestyle with owner
identify and treat any complicating factors
What are the therapeutic steps to treating stage 2 1CKD?
Same as stage 1 - introduction of a renal diet
What are the therapeutic steps to treating stage 3 CKD?
Same as stage 1 + renal diet
+/- phosphate binder, GI symptomatic support as needed, and hydration support as needed
What are the therapeutic steps to treating stage 4 CKD?
Same as stage 1 + renal diet
+/- phosphate binder, GI symptomatic support as needed, and hydration support as needed
+/- anemia management if indicated
What is the prognosis for CKD?
variable - it depends on underlying etiology, complicating factors, stage and quality of management
Do dogs or cats tend to live longer with CKD?
cats
What are the poor prognostic indicators associated with CKD?
Degree of azotemia, phosphorus, anemia, proteinuria, and weight loss/body condition
