CKD in Dogs and Cats

permanent and progressive condition characterized by any chronic change in kidney structure or function

chronic kidney disease (CKD)

non-regenerative anemia is more consistent with AKI or CKD?

CKD

1 multiple choice option

The underlying cause of CKD is most likely to be

renal or post-renal

3 multiple choice options

Secondary change as a result of CKD?

hypertension

Important lab values to evaluate for CKD?

Creatinine

SDMA

Phos

HCO3

Protein

BUN

K+

Alb

USG

FGF-23

most critical tests for CKD lab values?

Serum biochemistry

UA

should we use cutoffs or reference ranges for GFR markers such as creatinine, BUN and SDMA?

cutoffs

1 multiple choice option

if a patient has significant muscle wasting, is SDMA or creatinine a better indication of GFR?

SDMA

1 multiple choice option

if your patient is very young, is SDMA or creatinine a better indication of GFR?

both are likely inaccurate

3 multiple choice options

a primary regulator of phosphorous produced by osteocytes and is highly associated with outcome in CKD in cats and dogs

FGF-23 (fibroblast growth factor 23)

FGF-23 is a ? prognostic indicator of CKD in dogs and cats

negative

1 multiple choice option

moderately elevated FGF-23 and normal serum phosphorous indicate what stage of CKD?

early stage

1 multiple choice option

markedly elevated FGF-23 and high serum phosphorous indicate what stage of CKD?

late stage

1 multiple choice option

What is the system used to stage CKD?

IRIS

how many stages of CKD are there?

4

Benefits of staging CKD?

1. earlier recognition and response to CKD

2. better communication, records, and research

3. basis for published treatment recommendations

what is the underlying cause of most CKD cases?

idiopathic

use the IRIS ? for creatinine or SDMA

cutoff

1 multiple choice option

What are the key CKD parameters?

Creatinine/SDMA

Urine protein

BP

? measurements are critical for staging, monitoring, and evaluating response to tx

repeated

Goals for CKD tx?

-Good QOL

-Slow progression

-Delay onset of uremic crises

-Improved survival times

General principles for CKD tx?

1. Always try to find underlying disease

2. Discontinue nephrotoxic drugs

3. Pay attention to dose/frequency of medications that are eliminated by kidneys

4. Renal diet !!

prescription renal diets are recommended for what CKD patients?

stabilized CKD stages 2-4

What if a patient won't eat a renal diet?

balanced home-cooked diet is ideal

should you give AKI patients a renal diet in hospital?

no - can create food aversion

1 multiple choice option

? are important for supportive care of CKD patients

calories

What should you do if your CKD patient has inadequate caloric intake and is losing weight?

Experiment with palatability

Appetite stimulants

Treat nausea if present

Fluid recommendations for patient in uremic crisis?

IV fluids for replacement, maintenance and losses

Fluid recommendations for stable CRF patients?

Fresh drinking water always available

Serial measurements of body weight

Extra fluids as needed via SQ or E-tube

What are the phosphorous treatment goals for CKD pts?

at minimum, try to maintain within normal reference range but try to follow IRS guidelines

most thorough phosphorous treatment plan for cats?

regular phosphorous and FGF-23 monitoring

What is the baseline treatment to regulate phosphorous in CKD pts?

Kidney diet and adequate hydration

Effective and inexpensive drug most commonly phosphorous treatment if the kidney diet is not working?

Aluminum hydroxide

If for some reason a patient cannot have aluminum hydroxide, what is the next best drug for phosphorous regulation?

Calcium based (acetate, citrate, or carbonate)

Other drugs (not aluminum or calcium based) to control serum phosphorous?

Epakatin

Naraquin

Lanthanum

Sevelamer

Standard therapy for proteinuria?

RAAS inhibition with ACEi, and/or ARB

Diet

Thromboprophylaxis

Anti-hypertensive therapy

Hypertension control consists of

-Regular BP measurements at monitoring visits

-Anti-Hypertensive agents

When should you treat a CKD patient with anti-hypertensive agents?

-if SBP is repeatedly > 160

-if evidence of end organ damage

HCO3/TCO2 goal for dogs in stage 2 or greater CKD?

>18

HCO3/TCO2 goal for cats in stage 2 or greater CKD?

>16

treatments used to reach HCO3 target in CKD patients?

Oral bicarbonate

K+ citrate

Patients with CKD eventually develop ? anemia

non-regenerative

1 multiple choice option

If a CKD pt has non-regenerative anemia with normal morphology and Hct <25-30, what drugs can you consider?

Darbepoeitin

Molidustat

serum concentration ? potassium deficits

underestimates

most common K+ supplement for chronically hypokalemic CKD patients ?

K+ gluconate

Why do CKD patients generally "feel sick"?

Increased uremic toxins

Examples of advanced novel CKD treatments?

Transplant

Stem cells

Dialysis

It is recommended that CKD patients are seen for regular monitoring at least every ? months

6

What should you focus on monitoring in the CKD patient?

Phosphorous (diet)

Hydration

BP

Urine protein

There are many treatment options for CKD but evidence for many is _________

limited