Renal disease: chronic kidney disease Flashcards
(40 cards)
Chronic kidney disease refers to
● Structural and/or functional abnormalities of one or both kidneys that have been continuously present for ≥3 months.
● Is irreversible and progressive
● Concurrent prerenal/postrenal azotemia, “acute-on-chronic” kidney disease.
● More common in older animals
Causes of chronic kidney disease.
● Initial inciting cause of CKD is not usually determined, likely a series of renal
insults.
Causes of chronic kidney disease in dogs. (4-5)
● Familial, congenital, acquired conditions
● Juvenile nephropathy (renal dysplasia) - young dogs
● Tubulointerstitial nephritis - older dogs
● Glomerular disease - majority
- Immune-complex mediated glomerular nephritis, amyloidosis, non-immune complex glomerulonephritis conditions, infectious diseases (borreliosis, ehrlichiosis, anaplasmosis, babesiosis, leishmaniasis)
Causes of chronic kidney disease in cats. (2)
● Tubulointerstitial nephritis
- Age, viral infection, extrarenal diseases, environmental factors,
ischemia, hypoxemia
● Polycystic kidney disease (PKD)
In the context of kidney disease, what important question should not be forgotten during anamnesis?
potential toxin exposure (lilies, pest bait and poisons etc.)
Clinical signs in potential chronic kidney disease patients.
● Can be subclinical in early stage
● PU/PD, weight loss, decreased appetite, lethargy, dehydration, vomiting, halitosis
Physical exam findings in potential chronic kidney disease patients.
● Normal in early stage
● Later: palpable kidney abnormalities (e.g. unilateral compensatory hypertrophy), evidence of weight loss, dehydration,
pale mucous membranes, uremic ulcers, evidence of hypertension (retinal hemorrhages/detachment).
CKD - findings persistent, no pre/postrenal causes
For the diagnosis of chronic kidney disease, hematological changes.
anemia
CKD - findings persistent, no pre/postrenal causes
For the diagnosis of chronic kidney disease, blood biochemical changes. (7)
Azotemia,
SDMA,
hyperP,
hypo/hyperK,
hypo/hyperCa,
hypoalb,
metabolic acidosis
CKD - findings persistent, no pre/postrenal causes
For the diagnosis of chronic kidney disease, urine-analytical changes. (9)
Impaired urine concentration/dilution,
proteinuria,
cylindruria,
hematuria,
pyuria,
inappropriate urine pH,
inappropriate urine glucose,
cystinuria,
bacteriuria
CKD - findings persistent, no pre/postrenal causes
For the diagnosis of chronic kidney disease, imagine diagnostics may show what types of changes?
Abnormal renal size, shape,
echotexture, mineralization,
uroliths, absence of a kidney,
neoplasia
CKD - findings persistent, no pre/postrenal causes
Diagnosis of chronic kidney disease stage 1 and early stage 2
One or more of these findings should be present:
● Creatinine/SDMA increasing within the reference interval where no prerenal
cause is apparent.
● Persistent increased SDMA >14 µg/dL
● Abnormal kidney imaging
● Persistent renal proteinuria
● UPC >0.5 in dogs,
>0.4 in cats
Diagnosis of chronic kidney disease late stage 2-4.
Both of these diagnostic findings must be present:
● Increased creatinine and SDMA concentrations
AND
● USG <1.030 in dogs, <1.035 in cats
Describe staging of chronic kidney disease.
● Only once the diagnosis has been confirmed and the patient is stable.
● For developing treatment plan and establishing prognosis.
● IRIS Guidelines
Based on renal function:
● Creatinine
● SDMA
Substages based on:
● Proteinuria
● Arterial blood pressure
(as seen in attached table)
Treatment of chronic kidney disease.
● Medical management is to minimize metabolic complications, slow progression.
● Treatment is individualized based on stage of disease and
- Clinical and laboratory status of the patient
- Owner
● Is a progressive and dynamic disease and therapy modifications are based on serial
clinical and laboratory assessment.
CKD-MBD, RSHP stand for:
CKD-MBD = Chronic kidney disease–mineral bone disorder
CKD-RSHP = Chronic kidney disease-refractory secondary hyperparathyroidism
Treatment of CKD-MBD, RSHP options. (4)
Dietary PO4 restriction
Phosphate binders
Cinacalcet
Calcitriol?
Describe Dietary PO4 restriction
● Therapeutic goal based on the IRIS CKD stage
● PO4 assessed after 12 h fast
● PO4 rechecked after 4-6 weeks
● When in Target range: continue renal diet, check PO4 q3-6m
● When phosphate Not in the target range: add intestinal binding agent
Describe Phosphate binders
● Aluminum hydroxide, Ca based, lanthanum salts, sevelamer carbonate.
● Give With renal diet
● At or around meal time
● Dosed to effect, adjust q2-4w
● If necessary, add a binding agent with a different mechanism of action
● Ineffective in anorectic patients
● Unpalatable
● Avoid Ca based with hyperCa, calcification, avoid giving with calcitriol. Monitor ionizedCa.
renal osteodystrophy caused by
caused by disturbances in mineral metabolism that occur as a result of kidney dysfunction.
- In CKD, the kidneys lose their ability to excrete phosphorus properly. High phosphorus levels cause a reduction in blood calcium levels, leading to an increase in parathyroid hormone (PTH) secretion, a condition called secondary hyperparathyroidism.
- Diseased kidneys cannot efficiently convert vitamin D into its active form, calcitriol, which is necessary for calcium absorption from the intestines.
- secondary hyperparathyroidism is a compensatory response to the low blood calcium and high phosphorus levels. Over time, the parathyroid glands become overactive and produce excessive PTH, which causes excessive bone resorption.
- The imbalance in calcium and phosphorus metabolism causes alterations in bone structure and strength, leading to fibrous osteodystrophy and osteomalacia.
Most common phosphate binder product.
oral suspension pronefra (binds phosphate from food, not from in body)
Pronefra® is delicious and based on the interaction of four ingredients.
- calcium carbonate and magnesium carbonate bind phosphorus in the digestive tract, reducing its absorption;
- chitosan is known as a binder of uremic toxins in the digestive tract;
- oligopeptide of marine origin helps to maintain normal blood pressure.
Describe the use of Cinacalcet for the treatment of CKD-MBD, RSHP.
● Is a Calcimimetic, meaning it mimics the action of calcium on tissues. It reduces PTH secretion and serum Ca.
● Risk of hypoCa when using it.
● 0.5 mg/kg q24h, increased q2-3w until PO4 and Ca are controlled/max 3 mg/kg
● Well tolerated but common side effects include Nausea, vomiting.
Treatment of uremia?
Diet: Decreased protein has been speculated for this but isn’t backed by adequate evidence.
Some suggest it has to do with protein quality instead.
dysrexia =
abnormal appetite
