Page 394 - Cote clinical veterinary advisor dogs and cats 4th

170 Chronic Kidney Disease, Overt (Symptomatic)

Initial Database total T 4 is normal but hyperthyroidism ○ Other treatments described for chronic
• Assess hydration: azotemia may be exac- suspected. therapy may be applicable (see Chronic
VetBooks.ir azotemia may completely resolve with TREATMENT ○ Parenteral antimicrobial therapy should
Treatment section). Injectable forms are
erbated by dehydration. Hemodynamic
used until oral medications are tolerated.
intravenous fluid therapy.
• CBC: nonregenerative anemia (due to
The goals of treatment are to alleviate clinical
erythropoietin deficiency, gastrointestinal Treatment Overview be instituted if infection is present until
oral administration of drugs is tolerated.
[GI] bleeding, anemia of chronic disease, signs associated with uremia and slow pro- Avoid nephrotoxic drugs.
or a combination); severity varies. gression of kidney disease. A global approach
• Serum biochemistry profile: azotemia, hyper- to diagnosis and treatment is outlined on Chronic Treatment
phosphatemia, hypokalemia or hyperkalemia p. 1406. • Goals are delay of progression and optimiza-
(rare), total hypercalcemia or ionized hypo- tion of quality of life (p. 167).
calcemia (clinical signs of abnormal calcium Acute General Treatment • Additional therapies may be used, depending
concentrations are rare in the absence of Compensated state: see Chronic Treatment on presence of particular uremic signs.
concurrent diseases), hypercholesterolemia, Decompensated state (uremia; dehydrated, ○ Nausea/vomiting (see Acute General
and metabolic acidosis anorexic, vomiting) Treatment above)
• Urinalysis: usually isosthenuric (1.008-1.012) • Hospitalization is ideal because oral therapies ○ Hyperphosphatemia: dietary restriction ±
or minimally concentrated specific gravity often poorly tolerated. phosphate binders (must be given with
(dogs: 1.013-1.030; cats: 1.013-1.035). • Fluid therapy food to prevent absorption of phosphorus)
Active sediment may indicate urinary tract ○ Restoration of effective fluid volume over ■ Aluminum hydroxide or aluminum
infection (UTI). Proteinuria with inactive 4-12 hours is usually appropriate. carbonate 30-90 mg/kg/day PO with
sediment exam should be quantified by urine ■ Replacement intravenous (IV) crystal- food, divided and administered with
protein/creatinine ratio. loid fluid therapy (e.g., lactated Ringer’s meals; dose titrated based on serum
• Urine culture: indicated with active solution, Plasmalyte, 0.9% saline) phosphorus concentration
sediment to investigate for pyelonephritis. should be based on the patient’s pre- ■ Calcium acetate 60-90 mg/kg/day PO
Subclinical bacteruria can occur in cats with senting fluid deficit, as well as ongoing with food; hypercalcemia is a possible
CKD assessment of hydration status and side effect
• Thyroid hormone assay (elderly cats): rule acid-base/electrolyte status. ■ Chitosan (Epakitin) 1 g/5 kg twice
out hyperthyroidism as concurrent disorder ■ Fluid rate: replacement of dehydra- daily with food; contains calcium
(p. 503) tion (percent dehydration written as a carbonate
• Blood pressure (BP [p. 1065]): hypertension decimal [e.g., 10% = 0.1] × kg body ■ Lanthanum carbonate 30-90 mg/kg/
(systolic BP > 160-179 mm Hg, diastolic weight = liters deficit) plus ongoing day PO with food
BP > 95-119 mm Hg) often identified; may losses (estimated volume of polyuria, ■ Niacinamide 25-100 mg/kg PO q
cause end-organ damage (especially heart, vomiting) plus maintenance needs 12h, may promote gut excretion of
eyes, central nervous system, kidneys) ○ Maintain intravascular volume. phosphorus
• Abdominal radiographs and/or ultrasound: ■ Rate highly variable depending on ○ Hypokalemia (more likely in cats than
may further elucidate cause of or factors con- degree of polyuria, extrarenal losses, dogs)
tributing to CKD (e.g., partially obstructing and voluntary intake; 60-75 mL/kg/ ■ Potassium gluconate 2 mEq per 4.5 kg
nephroliths or ureteroliths, renal neoplasia, day is an appropriate starting point. PO per day
cystic disease, perinephric pseudocysts, Rate should be adjusted from this point ■ Potassium citrate 75 mg/kg PO q 12h
pyelectasia). Alterations of shape, size, and based on acute changes in body weight ○ Acidosis: consider treatment if total CO 2
echogenicity of kidneys are common. and acid-base/electrolyte status. < 16 mEq/L or pH < 7.2
■ Potassium supplementation of fluids ■ Potassium citrate 75 mg/kg PO q 12h
Advanced or Confirmatory Testing based on electrolyte measurement (do (also addresses hypokalemia)
• Glomerular filtration rate (GFR) measure- not exceed 0.5 mEq/kg/h [p. 516]) ■ Sodium bicarbonate 10 mg/kg PO q
ment: not useful when azotemia is present • Vomiting or anorexia 8-12h
• Urine protein/creatinine ratio: pathologic ○ Persistent nausea/vomiting ○ Anemia
proteinuria (urine protein/creatinine [UPC] ■ Maropitant 1 mg/kg SQ or IV or 2 mg/ ■ Transfusion based on clinical need
ratio > 0.5 in dogs, > 0.2-0.4 in cats; urinary kg PO q 24h for 5 days; approved for ■ Darbepoetin (Aranesp) 6.25 mcg/CAT;
sediment is inactive, and culture is nega- use in cats dogs 1 mcg/kg up to 25 mcg SQ q
tive) provides prognostic information and ■ Ondansetron 0.1-0.5 mg/kg IV or SQ 7 days until hematocrit rises; then q
a therapeutic target. q 8-12h; dolasetron 0.6-1 mg/kg IV or 14-21 days to maintain low-normal
• Renal biopsy: indicated primarily with SQ q 12-24h hematocrit. Risk of pure red cell aplasia
renomegaly (rule out lymphoma, feline ■ Metoclopramide 0.2-0.4 mg/kg SQ q from cross-reactive antibodies appears
infectious peritonitis, amyloidosis), persistent 6h or 0.04-0.08 mg/kg/h as constant- lower with darbepoetin compared to
proteinuria, or in cases for which CKD rate infusion human recombinant erythropoietin
cannot be otherwise distinguished from ○ Address stomach ulcers (rare but may (Epogen, Procrit).
acute kidney injury. contribute to anemia due to GI blood ■ Iron dextran 5-10 mg/kg IM q 2-4
• Although CKD in cats may complicate the loss) weeks. Necessary to restore deficient
diagnosis of concurrent hyperthyroidism ■ Proton pump inhibitors (e.g., iron stores for effective use of darbepo-
by suppressing total thyroxine (T 4) value, omeprazole 0.7 mg/kg PO q 24h or etin or erythropoietin, especially if red
advanced testing for hyperthyroidism is pantoprazole 1 mg/kg IV q 24h) blood cell transfusion (excellent source
usually withheld until the patient’s clinical ■ Histamine blockers (e.g., famotidine of bioavailable iron) not administered.
signs have been addressed. Thyroid scintig- 0.2-0.5 mg/kg IV, SQ, PO q 24h) Risk of acute hypersensitivity reaction
raphy or combined measurement of free but less effective acid suppression than exists.
T 4 with total T 4 +/− thyroid-stimulating proton pump inhibitors ○ Systemic hypertension: calcium channel
hormone is indicated to increase sensitiv- ■ Sucralfate 0.25-1.0 g (total dose) PO blockers recommended. If proteinuria
ity of diagnosis for hyperthyroidism if q 8h until signs resolve is present or calcium channel blocker is

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