Chronic Kidney Disease

What are causes of chronic kidney disease?

Prior AKI

Familial or breed disposition

Glomerular disease

Amyloidosis

Tubulointerstitial nephritis

How do you stage CKD?

Based on creatinine and SDMA then substaged based on proteinuria and blood pressure

Describe stage 1 ckd

Non-azotemic. may have changes in CKD

Describe stage II CKD

mild azotemia but minimal or no systemic signs

Describe stage III CKD

Moderate azotemia with systemic signs

Describe stage IV CKD

Severe azotemia with systemic signs

May be uremic

What is a proteinuric UPC for a cat?

>0.4

What is a proteinuric UPC for a dog?

>0.5

What are the target organs of hypertension?

Kidney, brain, retina, heart

What does a sys BP <140 mean?

normotensive

What does a sys BP of 140-159 mean?

Prehypertensive with low risk of target organ damage

What does a sys bp of 160-179 mean?

Hypertensive with moderate risk of target organ damage

What does a sys BP >180 mean?

Severely hypertensive with high risk of target organ damage

Understand how to classify and stage CKD

OK

What are the goals of CKD treatment?

Slow progression and preserve remaining kidney function

Maintain quality of life by managing clinical signs

What is the NEPHRONS acronym?

Nutrition

Electrolytes

Phosphate, proteinuria, pressure, pH

Hydration status

Retention of wastes

Other renal insults to avoid

Neuroendocrince changes

Serial monitoring

What is a diet good for CKD?

Caloric dense. High quality and easily digestible protein, low phosphorus, increased fat, high potassium and lower sodium

Why is nutrition so important with CKD?

You need to feed you pet ENOUGH and if they are still losing weight than use assisted feeding

What is the main electrolyte concern with CKD?

Hypokalemia

What species gets hypokalemia more with CKD?

Cats

How do you treat hypokalemia?

Potassium citrate or potassium gluconate

Why is hypokalemia rare in dogs?

They get ACE inhibitors for management

What stage of CKD get hyperkalemia?

Stage IV

What does hyperphosphatemia mean?

Progression of CKD and poor outcomes

Why do you gives phosphate binders with every meal for a patient with CKD?

To prevent hyperphosphatemia

How do you treat proteinuria?

ACEi or ARBs and antithrombotic therapy

What is the goal for proteinuria treatment?

Decrease UPC by at least 50% from baseline

Why do patients with proteinuria throw clots?

Because prothrombin is lost in urine

What do ACEi and ARBs do to azotemia?

Make it worse

What is the goal when managing BP during CKD?

Keep it under 160mmHg

How often do you need to recheck BP after hypertension develops?

Every 3 months

How do you treat high blood pressure?

ACEi or ARB and if he does not get under 160mmHg then add on Ca channel blockers

How do you prevent metabolic acidosis with CKD?

Renal diets

Potassium citrate

Sodium bicarbonate

When do you need to recheck after managing metabolic acidosis?

10-14 days

How can you improve hydration status of CKD?

Have fresh water available in different forms

Feed wet or canned food

SQ fluid

Via feeding tube if necessary

How do you limit the retention of wastes during CKD?

Renal diet and fermentable fibers

What are signs of retention of wastes?

Nausea, inappetence and weight loss

How can you stop the animal from feeling sick due to retention of wastes?

Antiemetics or appetite stimulants

What renal insults do you need to avoid during CKD?

Nephrotoxic drugs

Pre-renal insults

Post-renal insults

Infections (pyelonephritis is bad UTIS are not a concern)

What anemia is seen during CKD?

Normocytic, normochromic and non-regenerative

What can untreated anemia cause?

Impact quality of life

Contribute to renal hypoxia

Further upregulate RAAS

What are some underlying causes of anemia from CKD?

GI bleeding

Underlying infections

Nutritional deficiencies

How do you treat a CKD anemia?

Underlying cause

Erythropoietin and iron supplementation. Vit B supplementation can help

What is a risk of EPO suplumentation?

Development of anti EPO antibodies and hypertension

What is molidustate?

Inhibits hypoxia inducible factors degradation enzyme to increase RBC count ONLY IN CATS

What parameters do you need to monitor long term with CKD?

Body weight and muscle condition score

PCV/TP or CBC

Urea/creatinine

Electrolytes

BP

Urinalysis with UPC

What is the prognosis of CKD?

Depends on stage and comorbidities

Progresses slower in cats

Congenital in dogs

What is the estimated survival time of stage II in cats?

3 years

What is the estimated survival time of stage III in cats?

2 years

What is the estimated survival time of stage IV in cats?

35 days

What is the estimated survival time of stage II in dogs?

15 months

What is the estimated survival time of stage III in dogs?

11 months

What is the estimated survival time of stage IV in dogs?

2 moths