Lecture 6 Flashcards by Danika Boltz

What are the important roles of the kidney?

-water/fluid and electrolyte balance
-blood pressure regulation
-acid-base balance
-drug and toxin elimination
-Ca and P homeostasis/vitamin D
-RBC production

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What are the treatment goals for CKD?

-slow dz progression
-provide adequate nutrition
-minimize excesses and losses of electrolytes, vitamins, and minerals
-improve clinical signs

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What are the components of stage 1 CKD treatment?

-discontinue nephrotoxic drugs
-identify and treat pre-renal and post-renal abnormalities
-measure BP and UPC
-manage dehydration

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What are possible reversible diseases that could contribute to CKD that can be treated in patients?

-bacterial pyelonephritis
-leptospirosis
-chronic outflow obstruction
-renal neoplasia
-hypercalcemic nephropathy
-some immune-mediated diseases

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What are the characteristics of dehydration in CKD?

-occurs when water intake is less than water loss
-can have decreased/absent water intake, vomiting, diarrhea, and/or polyuric state
-more common in cats than dogs

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What are the effects of dehydration?

-predisposes to AKI
-hyporexia
-lethargy/weakness
-constipation

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How can water intake be maintained in CKD patients?

-provide clean, fresh water
-encourage drinking
-add water to food
-feed canned food
-add flavoring agents like broth
-feeding tube

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What are the additional treatment steps added for CKD stage 2 patients?

-consider feeding renal diet
-reduce phosphate intake
-treat dysrexia and nausea
-supplement potassium if hypokalemic

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What are the nutritional goals for CKD patients?

-maintain lean muscle mass and ideal BCS
-ensure adequate kcal intake; feed highly palatable, calorically dense foods with higher fat content

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Which components of a renal diet are higher than normal diets?

-calorie content/fat
-potassium
-pH (alkalinizing)
-omega-3 fatty acids
-B vitamins

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Which components of a renal diet are lower than normal diets?

-protein
-sodium
-phosphorus
-calcium

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When should protein vs phosphorus be the focus of dietary restriction?

Protein:
-protein-losing nephropathy
-advanced CKD (stage 3 or 4)

Phosphorus:
-non-proteinuric CKD

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What are the characteristics of protein restriction?

-improves clinical signs of uremia
-limits phosphorus intake
-reduces proteinuria
-significant restriction can lead to muscle wasting; poor BCS/MCS correlates with worse survival

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What are the characteristics of phosphorus restriction?

-improves survival
-slows decline of renal function

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What are the possible ways to restrict phosphorus?

-low phosphorus/protein diet
-phosphorus binders

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Which phosphorus binders are available in vet med?

-aluminum hydroxide
-calcium carbonate
-chitosin
-sevelamer

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How is FGF23 used to determine phosphorus restriction needs?

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-FGF23 is measured when phosphorus is in target range
-done as baseline at CKD diagnosis
-done in early (stage 1 and 2) CKD
-after initial dietary management

What are the options for treating dysrexia and nausea?

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anti-emetics/anti-nausea meds:
-maropitant
-ondansetron

appetite stimulants
-mirtazapine
-capromorelin

What are the specific GI manifestations of CKD?

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*tongue uremic ulceration
-acute or chronic dz
*uremic gastropathy
-edema
-vasculopathy
-glandular atrophy
-mineralization
-necrosis and ulceration uncommon
-no hyperacidity

What can cause hypokalemia in CKD?

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-activation of RAAS
-decreased intake
-transcellular shift
-excessive loss

What are the characteristics of hypokalemia in CKD patients?

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-seen in 20-30% of cats with stage 2 or 3 CKD
-not as common in dogs
-represents low whole body potassium content

What are the consequences of hypokalemia?

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-anorexia
-general weakness
-progression of CKD
-cardiac arrhythmias

What are the treatments for hypokalemia?

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-feline renal diets supplemented with potassium citrate
-additional PO or IV potassium supplementation

What are the therapies added for stage 3 CKD treatment?

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-feed a renal diet if pet is not already on one
-treat anemia
-treat metabolic acidosis

What is the classic pattern of anemia in CKD?

-normocytic -normochromic -non-regenerative

What effects of anemia are associated with CKD progression?

-decreased blood flow and oxygen delivery -oxidative stress -induction of fibrosis

How does hematocrit correlate with CKD survival?

increased survival if hematocrit is above 35%

What are the possible causes of anemia in CKD patients?

-poor nutrition -GI blood loss -reduced RBC lifespan -decreased erythropoietin

What are the characteristics of GI blood loss in CKD patients?

-common in patients -might not show overt GI signs or melena -may show disproportionate increase in BUN -can confirm with trial of omeprazole +/- sucralfate and iron supplementation -increase in hematocrit and/or appetite with treatment indicates positive response

What can cause a loss of erythropoietin-producing cells?

-fibrosis -uremic substances and oxidative stress -chronic inflammatory cytokines -impaired iron metabolism

What are the characteristics of anemia treatment in CKD patients?

-should consider if hematocrit is less than 20-25% despite optimal nutrition and treating GI hemorrhage -can give synthetic erythropoietin (darbepoetin); expensive option -can increase endogenous EPO with molidustat

How does molidustat work?

-inhibits prolyl hydroxylase to prevent breakdown of hypoxia-inducible factor -increased HIF leads to increased EPO transcription

What are the characteristics of metabolic acidosis in CKD patients?

-more common in patients with uremia -less than 10% of CKD stage 2 or 3 cats, but ~ 50% of uremic cats -acidic blood pH (<7.4) measured via blood gas or serum bicarb.

What causes metabolic acidosis in CKD patients?

-retention of organic acids -increased ammonia production -impaired bicarb. reabsorption

What are the consequences of metabolic acidosis?

-anorexia -weight loss -muscle weakness -progression of disease -bone demineralization -hypokalemia -nausea

What are the benefits of treating acidosis?

-improve clinical signs of uremic acidosis -minimize catabolic effects on protein metabolism -limit skeletal damage from bone buffering -avoid adverse effects of severe acidosis

When should acidosis be treated?

patients that are well hydrated and: -serum bicarb. < 18 mmol/L -blood pH < 7.10

What are the treatment steps for metabolic acidosis?

*avoid acidifying agents -protein restrict to decrease net acid production -can use renal diets *alkalinizing agents -potassium citrate supplemented in diet -sodium bicarb. (not ideal, Na load)

What are the additional treatment steps added for CKD stage 4?

-intensify efforts to prevent protein/calorie malnutrition -intensify efforts to prevent dehydration -consider dialysis and/or renal transplantation

What therapies can be implemented in CKD stage 4 patients?

*enteral nutrition support -food, medications, and water *SQ fluids -if chronic or recurrent dehydration -give balanced electrolyte fluids -not appropriate for every owner or patient

Lecture 6 Flashcards

(40 cards)