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Chronic Kidney Disease, Overt (Symptomatic) 171

insufficient, add angiotensin-converting Drug Interactions • Median survival times are approximately
enzyme (ACE) inhibitor (p. 501). • Phosphate binders can interfere with absorp- ○ 3 years in cats; 1 year in dogs with stage
VetBooks.ir istration. Dose is empirical, based on • Sucralfate works best in an acid environment ○ 2 years in cats; 6 months in dogs with Diseases and Disorders
○ Chronic dehydration: SQ fluid admin-
II CKD
tion of orally administered medications,
especially antibiotics and fat-soluble vitamins.
subjective assessment of the patient’s
stage III CKD
well-being, hydration status, and presence
stage IV CKD
minutes before antacid therapy if possible.
of other disorders (e.g., cardiac disease). and, if used, should be given at least 30 ○ 1 month in cats; 3 months in dogs with
Typically for cats without heart problems, • Nephrotoxic drugs (e.g., aminoglycosides)
100-150 mL isotonic replacement fluid or drug combinations (e.g., nonsteroidal PEARLS & CONSIDERATIONS
(e.g., lactated Ringer’s solution) SQ q antiinflammatory drugs [NSAIDs] plus
24-72h. Avoid giving glucose solutions ACE inhibitors) should be avoided whenever Comments
SQ. possible. • Therapeutic measures are seldom begun all
○ Proteinuria: ACE inhibition (e.g., benaz- • Drugs that undergo renal elimination at once, but instead added as appropriate
epril) or angiotensin receptor antagonists may need adjustment in dose strength or during disease progression.
(e.g., telmisartan) may reduce proteinuria frequency in animals with CKD. • Renal biopsy is rarely informative in cats
and convey renoprotection. These drugs with CKD (the inciting cause is rarely iden-
must be discontinued if dehydration or Possible Complications tified, unless neoplasia or feline infectious
hyperkalemia occurs (p. 167). • Anorexia, vomiting, hyperphosphatemia, peritonitis is present).
○ Management of renal secondary hypokalemia, acidosis, anemia, and hyperten- • At an early stage of decompensation, renal
hyperparathyroidism sion are common sequelae of CKD. transplant can be considered for otherwise
• Renal transplantation may be appropri- • Volume overload (pleural effusion, pulmo- healthy cats.
ate for some cats. May be preceded by nary edema, dyspnea, or peripheral fluid
hemodialysis. The highest likelihood of accumulation) is a concern at high rates of Technician Tips
a successful outcome occurs in mildly to fluid administration, particularly in anemic Technicians can be invaluable for teaching
moderately azotemic cats without concurrent animals or those with concurrent heart owners how to administer subcutaneous fluids.
illness or infection. Availability and success disease. They can also help to emphasize the importance
of renal transplantation is extremely limited • Platelet dysfunction in CKD increases risks of allowing the animal a constant source of
for dogs. of bleeding (gingival, GI, bruising, bleeding fresh water. The technician can help clients
• Chronic hemodialysis is costly and has limited after invasive procedures). develop a plan for a gradual transition from a
availability but can improve quality of life • ACE inhibition can result in exacerbated maintenance diet to a renal diet.
significantly in dogs without comorbidities azotemia/uremia and hyperkalemia when
(typically not recommended for cats). administered in volume-depleted or anorexic Client Education
patients. • CKD is a terminal condition in which treat-
Nutrition/Diet ments are aimed primarily at improving the
A restricted-quantity but high-quality protein Recommended Monitoring quality of life and delaying the progression
and restricted-phosphorus diet (i.e., renal diet) • Routine recheck, including physical exam, of disease.
slows progression of CKD and decreases severity weight, CBC (or packed cell volume), and • For pets with advanced CKD, the owners
of clinical uremia. biochemistry panel. Frequency depends on should be provided with realistic expectations
• Acceptance of diet changes can be problem- disease severity: for costs and inconvenience associated with
atic, particularly in uremic patients. ○ Stage I-II: recheck every 3-6 months potential treatments and prognosis.
• Maintaining adequate caloric intake to avoid ○ Stage III: recheck every 2-3 months • With successful renal transplantation in cats,
weight loss takes precedence over nutrient ○ Stage IV: recheck monthly intensive lifelong medication and frequent
composition of the diet. • Urinalysis +/− urine protein/creatinine ratio rechecks are required, but quality of life can
• Renal diets should be introduced when +/− urine culture should be performed at be excellent.
uremia (illness) is minimized and clinical least twice each year.
signs optimally controlled. • Blood pressure measurement at least every SUGGESTED READING
• Nutritional support occasionally requires 3 months or 1 week after antihypertensive Polzin DJ: Chronic kidney disease. In Ettinger SJ, et
appetite stimulation. drug dose adjustments. al, editors: Textbook of veterinary internal medicine,
○ Mirtazapine 1.88 mg/dose PO q 48-72h • Changes in clinical signs should prompt ed 8, St. Louis, 2017, Elsevier, 1938-1959.
(cats); 0.6 mg/kg PO q 24-48h (dogs) a recheck, regardless of predetermined
○ Capromorelin, a new ghrelin receptor schedule. AUTHORS: Catherine E. Langston, DVM, DACVIM;
Adam Eatroff, DVM, DACVIM
agonist, may be useful but experience EDITOR: Leah A. Cohn, DVM, PhD, DACVIM
very limited PROGNOSIS & OUTCOME
• Assisted feeding by an esophagostomy or
gastrostomy tube is often necessary to meet • Longevity is difficult to predict in an
caloric needs in cases of advanced (stage IV) individual patient, with a range of days to
CKD. years.

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