MAIKO CKD

Question 1

EXAM
Azotemia
- definition
- 3 origins

Answer 1

• ↑ urea nitrogen, creatinine, other non proteinaceous
  nitrogenous waste
• 3 origins:
• Pre-renal (dehydration)
• Renal azotemia (renal lesion)
• Post-renal (obstruction)

Question 2

Uremic syndrome
- what is it? clinical signs?

Answer 2

• Increased urea and other protein metabolism products
• Clinical signs (Gastro-intestinal, acidosis, pneumonitis, osteodystrophy, encephalopathy)

Question 3

urinalysis and USG interpretation
- renal vs pre-renal azotemia

Answer 3

If Azotemia and USG low> renal azotemia
If high> pre-renal
<><><><>
Normal USG in cats: 1,035-1,060

Question 4

uremic vs azotemic

Answer 4

uremic means there are clinical signs for sure

Question 5

International Renal Interest Society- IRIS Stages CKD
what are the stages?

Answer 5

Stage 1: no azotemia

Stage 2: mild azotemia

Stage 3 moderate azotemia

Stage 4: severe

Question 6

Prevalence of Kidney Disease

Answer 6

1 in 43 cats
1 in 285 dogs

Question 7

Chronic kidney disease pathogenesis

Answer 7

• injured kidney
  > decreased in number and function of nephrons
  > compensation by increasing size of remaining nephrons
  > if 2/3 of renal mass is lost due to damage > lower USG, kidney insufficiency
  > if 3/4 lost > azotemia, kidney failure
  > uremia

Question 8

CKD etiology, chronic vs acute

Answer 8

• Sustained functionnal +/- structural damage over >2-3 months or multiple AKI events
  <><>
  Decline in renal function
• Ischemic or toxic insult
• Leptospirosis
• Cellular injury, swelling, death
  <><>
• Reversible → Acute
• Irreversible → Chronic
  > Loss of 3/4 renal mass

Question 9

Causes of Chronic Kidney Failure

Answer 9

We wont know in most cases
<><>
* Sequel to acute renal failure
* Urinary outflow obstruction
* Neoplasia (“big kidney” CRF, mayoccur w/o CRF)
* Inflammatory or infectious causes (Pyelonephritis,leptospirosis)
* Immunologic disorders (Glomerular diseases, lupus erythematous, vasculitis-FIP)
* Nephrotoxicants
* Renalischemia
* Nephrolithiasis – cause and effect ?
* Inherited/congenitaljuvenilerenalfailure(polycystickidneys)
* Idiopathic

Question 10

Most Common reasons for CKD

Answer 10

• Sequel to acute renal failure
• Urinary outflow obstruction
• Nephrotoxicants
• Nephrolithiasis – cause and effect?
• Idiopathic

Question 11

Physical Examination for CKD findings

Answer 11

• Dehydration
• Pallor
• Poor body condition score
• +/- Oral ulcers
• +/- small irregular kidneys
• Assess muscle condition score!

Question 11

Risk Factors for CKD for Cats

Answer 11

• Poor body condition
• Periodontal disease
• Cystitis
• Being male neutered vs female spayed
• Anesthesia
• Documented dehydration in the preceding year

Question 12

How do you diagnose Kidney Disease?

Answer 12

• Essential: Creat/Urea and USG
  <><>
• History (+/- clinical signs)
• Persistent azotemia
• Inadequate urine concentrating ability
• +/- non regenerative anemia
• +/- abnormal sediment

Question 13

Biochemistry Profile
CKF lab results, and reasons

Answer 13

• Azotemia (↑ urea and creatinine)
• ↑ phosphorus > ↓ phophorus excretion
• ↑ total calcium > Complexed calcium
• Metabolic acidosis > ↓ ability to excrete hydrogen ions
  > Common complication of CRF in cats (60-80%)
  <><><>
  Low USG > Inappropriate
  > Lost ability of concentrating urine

Question 14

creatinine for CKD - use of this measure, what influences it, when increased

Answer 14

Influenced by muscle mass
* Increased in heavily muscled dogs (Greyhound)
* Decreased in dogs and cats with muscle loss
* Underestimation of azotemia in lean animals
<><>
Impacted by food
* Create level can ↑ by 20% after eating cooked meat
<><>
* ↑ when ≥75% reduction of renal mass

Question 15

how to interpret creatinine
- muscle mass considerations
- when to measure
- when can use as a sign of CKD

Answer 15

• Not reliable in very thin animals (overestimate
  kidney dysfunction)
• Ideally measurement in fasted animals
• Late marker of kidney dysfunction

Question 16

CREATININE
conventional markers of kidney function based on
Size of Dog- Reference Range (RR)

Answer 16

larger: 1/3 upper end of RR
mid size: 1/3 middle of RR
small: 1/3 lower end of RR

Question 17

creatinine - how do levels change based on GFR in early vs advanced renal failure?

Answer 17

X - blood creatinine
Y - GFR
> graph starts with steep negative slope, becomes shallower over time
<><><><>
- early renal disease - large changes in GFR have very little impact on blood creatinine
- advanced renal disease - small changes in GFR correspond to large changes in blood creatinine
> ie. we will see large changes in blood creatinine even when GFR changes a little bit in advanced renal disease

Question 18

creatine reference ranges - are they the same for everyone?

Answer 18

Not really
- Each Dog has its own “normal” Creat

Question 19

SDMA - what is it? what does it correlate with? values?

Answer 19

New Renal Biomaker
* Product of intranuclear protein metabolism
* Correlated with GFR strongly
* Correlated with creatinine and inulin clearance
* Cut off <14ug/dL IN ADULTS!
> higher for puppies

Question 20

SDMA
- effect of body mass
- sensitivity vs sCr
- correlation to renal function
- possible issues? when its ok to use

Answer 20

• Not affected by lean body mass
• More sensitive marker for kidney disease than sCr in dogs and cats
• Persistent increases in SDMA >14ug/dL suggestive of reduced kidney function
• But specificity??
• Use it on lean animals

Question 21

IRIS Classification staging - when should we stage an animal?

Answer 21

• Stage IRIS when animal stable (not in AKI)
• Wait for creatinine plateau before staging

Question 22

Urinalysis for CKD - what might we see?

Answer 22

• Impaired urine dilution and concentration
• +/- proteinuria and hematuria
• Sediment
  > Casts (tubular lesions)
  > Bacteria
  > Cylindruria

Question 23

Anemia of CKD
- characterize
- how common
- reasons

Answer 23

• Nornomocytic, normochromic, non regenerative
• 30-65% of cats with CKF
  <><><><>
  Reasons
• ↓ erythropoietin production
• ↓ RBC survival
• GI tract blood loss
• Uremic toxins ↓ erythropoiesis
• Poor nutrition
• Acidosis
• Iatrogenic
• Infection
• Medication (ACEI and aluminium hydroxide)

Question 24

Options to Treat Anemia of CKD?

Answer 24

* Address GI hemorrhage * Blood transfusion (if tachycardia, weakness) * AVOID Anabolic steroid (stanozolol) > Benefits questionable > Risk for hepatotoxicity in cats * Administration of erythrocyte-stimulating agents (ESAs)

Question 25

Darbepoetin for anemia in CKD - when should we consider it? outcomes? adverse effects?

Answer 25

* Consider once PCV < 20% (historic) * Consider once PCV < 25% (IRIS group) * Estimated success 60-65% > anecdotally higher * Target PCV 28-30% <><><><> Adverse Effects * Polycythemia * Hypertension <><> * Fever * Seizure * Arthralgia * Iron deficiency * Pure red cell aplasia

Question 26

darbapoietin - monitoring - expected response time

Answer 26

* Recheck weekly until target reached > PCV > Blood pressure (most common side effect hypertension) * Median response is 3 weeks > then can decrease injections (from weekly to every 2 weeks) > Recheck every 2 weeks until stable