CKD Management

T/F: Long-term management should focus on quality over quantity, and should include hydration, diet/nutrition, phosphorus, potassium, blood pressure, proteinuria, and anemia assessment.

True!

You should be careful of —— overload when managing CKD cases.

Client

What is an extremely important diagnostic, even in CKD, to treat UTIs?

Urine culture and sensitivity

You should monitor urine with a culture every ———— when managing a CKD.

6 months

You should always make sure plenty of water is available for a CKD cat. What else can you do if they won't drink enough on their own?

SQ fluids (LRS or 0.9% NaCl)

In terms of hydration status, when are the TWO most appropriate times hospitalization may be needed?

1. Dehydration

2. Acute on chronic episode

What are FOUR major components to dietary therapy in a CKD animal? (KNOW THIS)

1. Low phosphorus

2. Low protein

3. Low sodium

4. High caloric density (helpful with poor appetite)

T/F: Omega-3s, essential amino acids, B-vitamins, and antioxidants are also important components of a renal diet.

True!

A renal diet should involve an (acidic/neutral/basic) acid-base.

Neutral

Why is phosphorus restricted in renal diets?

Aid control of hyperphosphatemia

What are TWO reasons controlling phosphorus in renal diets is helpful?

1. Decrease phosphate to decrease plasma PTH

2. Fewer signs of uremia

Why is protein restricted in renal diets?

Lowered BUN increased well-being

Name THREE reasons protein restriction is believed to delay progression of CKD.

1. Alterations in glomerular hemodynamics

2. Reduce renal ammoniagenesis

3. Ameliorate acidosis (reduce dietary acid load)

What kinds of high-quality protein is good to fulfill protein requirements in CKD animals?

Eggs, liver, cottage cheese, lean meats

Why is sodium restricted in renal diets?

1. Decreased blood pressure in hypertensive animals

2. Maintain blood pressure in normotensive animals

T/F: Low sodium diets in renal diets are truly low and therefore monitoring sodium levels is important.

False! Low sodium diets are NOT really "low sodium" and are still above AFCO minimum for Na.

Name at least FOUR reasons omega 3 polyunsaturated fatty acids are helpful in renal diets.

1. Lower mortality

2. Better renal function

3. Fewer renal lesions

4. Less proteinuria

5. Lower cholesterol levels

6. Glomerulosclerosis, tubulointerstitial fibrosis, interstitial inflammation lesions diminished

What are TWO reasons to provide essential amino acids in a renal diet?

1. Reduce muscle mass

2. Maintain lean body weight

What are TWO common reasons a patient will not accept a renal diet outside of preference?

1. Uremic ulcers

2. Nausea

Name at least FOUR strategies to help a patient eat a renal diet.

1. Change SLOWLY

2. Try different brands

3. Change BEFORE sick

4. Anti-emetics

5. Appetite stimulants

6. Place feeding tube

What are THREE anti-emetics that could be used to help patients with CKD?

1. Maropitant (Cerenia)

2. Ondansetron (Zofran)

3. Metoclopramide (Reglan)

What are TWO classes of antacids that can be used in GI complications?

1. H2 blockers (cimetidine, ranitidine, famotidine)

2. Proton pump inhibitors (omeprazole, pantoprazole, esomeprazole)

What gastroprotectant can be given that acts as a mucosal protectant, but can interfere with other drug absorption?

Sucralfate

Sucralfate needs a (acidic/basic) environment to activate.

Acidic

What major appetite stimulants can be used in dogs and cats, respectively?

Dogs: mirtazapine, capromorelin

Cats: mirtazapine, capromorelin, cyproheptadine

What are FIVE benefits to feeding tubes?

1. Nutrition support

2. Blenderized diet

3. Medication delivery

4. Water delivery

5. Can still eat by mouth

T/F: Esophagostomy tubes are quick to place and require a brief anesthesia (15 minutes).

True!

T/F: There are serious complications if an animal pulls out their esophagostomy tube, but can be maintained months to a year depending on the material if left in place.

False! There are NO serious complications, but can be maintained for months to a year depending on the material.

How is a gastrostomy tube placed?

Surgical/endoscopic

If a patient pulls out their gastrostomy tube in the first —- days after placement, this is a —————-.

10 days

Surgical emergency

Why is it a surgical emergency if a patient pulls out their gastrostomy tube in the first 10 days?

Stoma has not yet formed between gastric and body wall

T/F: Gastrostomy tubes are relatively easy to use and maintain, involve low-profile tubes available for long-term use, and can be maintained months to a year depending on the material.

True!

What is the relationship between GFR and phosphate?

Inverse (decreased GFR = increased phosphate)

If the calcium x phosphorus product is greater than —-, the result is —————————.

70

Dystrophic mineralization

What are the TWO major treatments for hyperphosphatemia?

1. Increase GFR

2. Prevent intestinal absorption (low P diet or P binders)

Greater than or equal to what stage of CKD is the goal to maintain plasma phosphate between 4.6 mg/dL and 2/7 mg/dL?

Stage 2 CKD

What should you do first when trying to keep a Stage 2 CKD animal between 2.7-4.6 phosphate?

What should you use if phosphate still >4.6?

Dietary P restriction

Phosphate binders

What is a bone-derived hormone produced by osteocytes and osteoblasts that is an early biomarker of mineral and bone disease in CKD?

FGF-23 (Fibroblast growth factor 23)

Why is FGF-23 important?

Controls phosphate metabolism

FGF-23 can be chronically increased in CKD patients with what?

Metabolic bone disease

Should you measure FGF-23 when plasma P is < or > than 4.5 mg/dL?

What phosphate binder is dose titrated to effect and the liquid version is best?

How should it be administered?

What is one risk of using this?

Aluminum hydroxide (Amphojel)

With meals

Aluminum toxicity

What phosphate binder can avoid potential for aluminum toxicity?

What is its risk?

What should you avoid using it with?

Calcium carbonate

Hypercalcemia

Calcitriol

What adsorbent is often used in CKD animals that acts similar to charcoal?

Chitosan/Epakitin

What is calcitriol?

Active vitamin D

What are FOUR major reasons calcitriol is given to CKD animals due to their secondary hyperparathyroidism? Indicate which is most important.

1. Blocks PTH secretion

2. Lowers PTH set point

3. Reverses parathyroid hyperplasia

4. Increases GI calcium absorption (most important)

What is unique about the dose of calcitriol?

Dosed in ng/kg/day

You should NOT give calcitriol if a patient is —-.

Hyperphosphatemic

What is the major complication of giving calcitriol to a CKD animal with secondary hyperparathyroidism?

Hypercalcemia

T/F: Using calcitriol in a patient with secondary hyperparathyroidism prolongs survival in dogs (365 days vs 250 days).

True!

How do you treat hypokalemia in cats if clinical or severe?

IV KCl

What are the THREE oral supplementation methods K+ can be given to hypokalemic cats?

1. K gluconate powder/tablets (Tumil-K) most common

2. KCl solution (dilute 1:1 tap water to prevent vomiting)

3. K elixirs (dilute 1:1; cats do not like because flavored for humans)

T/F: Hypokalemic cats should have their K+ monitored every 1-2 weeks until a dose is determined, and renal function may improve after several months of supplementation.

True!

What drug may promote HYPOkalemia?

What drugs promote HYPERkalemia?

HYPOkalemia: Amlodipine

HYPERkalemia: ACEi and Angiotensin receptor blockers

ACEi or ARBs have a (minor/major) reduction in blood pressure when used to treat hypertension.

Minor (10-15 mmHg)

What is the major pro and con of using ACEi or ARBs to treat hypertension in a CKD animal?

Pro: treat concurrent proteinuria

Con: decrease GFR

What drug, used for hypertension, can relax arterial smooth muscle and decrease peripheral resistance?

What is the MOA?

Amlodipine

Ca2+ channel blocker

T/F: You should always identify and treat underlying disease if protein losing nephropathy (PLN) is possible.

True!

What are the TWO major treatment goals of PLN?

1. Reduce proteinuria (ACEi/ARBs or lower protein diet)

2. Control hypercoagulability (Clopidogrel/low dose aspirin)

What are the THREE major causes of anemia in a CKD animal?

1. Absence of native EPO

2. Chronic blood loss (most common)

3. Frequent phlebotomy

What TWO things can you do in an animal with CKD that has a severe and clinical anemia?

1. Blood transfusion

2. Recombinant EPO (Epogen/Darbopoetin)

What are the FOUR causes of Darbopoetin failure?

1. Functional or absolute iron deficiency

2. Anti-rHuEPO antibody formation

3. Ongoing GI blood loss or hemolysis

4. Concurrent inflammatory/malignant disease

What are the FOUR adverse effects of Darbopoetin therapy?

1. Systemic hypertension

2. Seizures

3. Local reactions at injection site

4. Development of antibodies directed at EPO (more common with EPO)

What must you always give concurrently with Darbopoetin?

Supplemental iron

What drug for anemia induces genetic transcription of EPO and is clinically MORE effective for a relatively MILD anemia?

What is the MOA?

Molidustat

HIF prolyl hydroxylase inhibitor

T/F: Enteric dialysis like Azodyl and probiotic kidney supplements are usually best reserved for early stages of disease.

True!