Renal - Chronic Kidney Disease

Question 1

What is chronic kidney disease?

Answer 1

Structural/functional abnormalities of the kidney that have been present long-term

Question 2

CKD is typically reversible/irreversible and progressive/nonprogressive despite therapy.

Answer 2

Irreversible and progressive

Question 3

What is the pathophysiology of CKD?

Answer 3

Initial insult/disease process occurs and results in the loss of the majority of the nephrons

Question 4

What are the adaptive mechanisms to compensate for loss nephrons in CKD?

Answer 4

Increase single-nephron GFR (nephron hypertrophy)

Question 5

How do adaptive mechanisms effect CKD?

Answer 5

They result in damage of the remaining nephrons thus causing spontaneous, continued decline in renal function

Question 6

True or False: Anything that can cause AKI can cause CKD.

Answer 6

True

Question 7

What is often found on histopathology in CKD patients?

Answer 7

Tubulointerstitial nephritis and fibrosis

Question 8

What is the signalment for CKD?

Answer 8

Increasing prevalence with age, all ages can be affected, and all breeds can be affected

Question 9

What history/presenting complaints are associated with CKD?

Answer 9

PU/PD, gastrointestinal signs (decreased appetite, vomiting, diarrhea) and weight loss

Question 10

What will you find on PE in patients with CKD?

Answer 10

Weight loss; muscle atrophy
small, irregular kidneys
dehydration

Less commonly - uremic breath/oral ulceration and pale mucous membranes

Question 11

What will you find on CBC in CKD patients?

Answer 11

Normocytic, normochromic nonregenerative anemia

Question 12

What will you find on chemistry in CKD patients?

Answer 12

Azotemia, hyperphosphatemia, metabolic acidosis, and variable potassium (often normal to low)

Question 13

What USG is associated with CKD?

Answer 13

Isosthenuria is often present (1.008-1.012)

There is inadequate concentrating ability in the face of azotemia

Question 14

If no azotemia, persistent isosthenuria is suggestive of _____.

Answer 14

CKD

Question 15

What will the SDMA value be in patients with CKD (not a specific number)?

Answer 15

elevated

Question 16

When may be SDMA measurements be useful?

Answer 16

In cases of persistent isosthenuria/inappropriately concentrated urine when there is no azotemia

Question 17

What clinical characteristics are associated with IRIS stage I?

Answer 17

Non-azotemic; clinical signs absent other than possible PU/PD

Question 18

What clinical characteristics are associated with IRIS stage II?

Answer 18

Mildly azotemic; clinical signs absent other than PU/PD +/- mild appetite changes, weight loss

Question 19

What clinical characteristics are associated with IRIS stage III?

Answer 19

Moderately azotemic; clinical signs typically present, disease progressive

Question 20

What clinical characteristics are associated with IRIS stage IV?

Answer 20

Severely azotemic; clinical signs of uremia, disease progressive

Question 21

What is IRIS substaging based on?

Answer 21

The presence of proteinuria and/or hypertension

Question 22

What are the goals to managing patients with CKD?

Answer 22

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

Question 23

What is a therapeutic renal diet made up of?

Answer 23

Reduced phosphorus, added omega-3 polyunsaturated fatty acids, limited high-quality protein, and calorie dense

Question 24

What do you need to make sure to manage about the nutrition in CKD patients?

Answer 24

Maintain adequate calorie consumption because low BCS is associated with reduced survival

Question 25

Why does hyperphosphatemia occur in CKD patients?

Answer 25

There is decreased GFR which results in phosphorus retention

Question 26

What should you do first to manage hyperphosphatemia in CKD patients?

Answer 26

Dietary phosphorus restriction first Note: the IRIS scale for phosphorus supplementation recommends values below the normal RI for phosphorus

Question 27

What should you do second to manage hyperphosphatemia in CKD patients?

Answer 27

Add dietary phosphate binders - give with food to be effective

Question 28

Why are cats and dogs with CKD prone to dehydration?

Answer 28

because of polyuria

Question 29

What do you want to do to mitigate dehydration in CKD patients?

Answer 29

Promote compensatory polydipsia - free access to several water sources, water in food/canned food, carefully manage exacerbating factors

Question 30

In chronically dehydrated pets, what is the recommended fluid therapy?

Answer 30

SQ fluids or enteral hydration

Question 31

How do you manage vomiting in CKD patients?

Answer 31

antiemetics

Question 32

How do you manage uremic gastritis in CKD patients?

Answer 32

Acid suppression (proton-pump inhibitor) +/- sucralfate may be indicated in dogs

Question 33

If a patient with CKD has poor appetite, what should you give?

Answer 33

Mirtazapine or a feeding tube

Question 34

Is hypokalemia seen in CKD cats or dogs more commonly?

Answer 34

cats

Question 35

What is the most recognized clinical sign with hypokalemia?

Answer 35

muscle weakness

Question 36

How is potassium supplemented in CKD patients?

Answer 36

Parenteral (IV) supplementation if severe and/or symptomatic | Oral supplementation long-term

Question 37

When may hyperkalemia be seen in CKD patients?

Answer 37

in end-stage disease

Question 38

Why is hypertension problematic in CKD patients?

Answer 38

Because it contributes to further renal damage as well as damage to other organ systems

Question 39

What is the recommended treatment for hypertensive CKD cats?

Answer 39

amlodipine

Question 40

What is the recommended treatment for hypertensive CKD dogs?

Answer 40

Ace-inhibitors (benazepril or enalapril)

Question 41

Why is CKD sometimes accompanied by proteinuria?

Answer 41

Protein leakage into the urine is suspected to be damaging to the renal tubules

Question 42

How is it recommended to treat proteinuria in CKD?

Answer 42

with medication

Question 43

Why is anemia associated with CKD?

Answer 43

EPO deficiency develops as functional renal mass declines

Question 44

How is anemia managed in CKD patients?

Answer 44

Erythrocyte-stimulating agents - Darbepoetin alpha | Note: anti-EPO antibodies can develop

Question 45

What mineral and bone disorders can develop as a result of CKD?

Answer 45

Renal secondary HPTH, renal osteodystrophy, and soft tissue mineralization

Question 46

What should you do to manage mineral and bone disorders in CKD patients?

Answer 46

Reduce phosphorus | Maybe calcitriol therapy

Question 47

What diagnostic steps should be taken after CKD is diagnosed?

Answer 47

Measure BP Obtain urine culture Quantify urine protein Consider renal imaging

Question 48

What are the therapeutic steps to treating stage 1 CKD?

Answer 48

Avoid or discontinue any medications that may be nephrotoxic discuss hydration/lifestyle with owner identify and treat any complicating factors

Question 49

What are the therapeutic steps to treating stage 2 1CKD?

Answer 49

Same as stage 1 - introduction of a renal diet

Question 50

What are the therapeutic steps to treating stage 3 CKD?

Answer 50

Same as stage 1 + renal diet | +/- phosphate binder, GI symptomatic support as needed, and hydration support as needed

Question 51

What are the therapeutic steps to treating stage 4 CKD?

Answer 51

Same as stage 1 + renal diet +/- phosphate binder, GI symptomatic support as needed, and hydration support as needed +/- anemia management if indicated

Question 52

What is the prognosis for CKD?

Answer 52

variable - it depends on underlying etiology, complicating factors, stage and quality of management

Question 53

Do dogs or cats tend to live longer with CKD?

Answer 53

cats

Question 54

What are the poor prognostic indicators associated with CKD?

Answer 54

Degree of azotemia, phosphorus, anemia, proteinuria, and weight loss/body condition