Chronic kidney disease
In medicine, chronic kidney disease (CKD) is defined as "kidney damage or glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) for 3 months or more, irrespective of cause. Kidney damage in many kidney diseases can be ascertained by the presence of albuminuria, defined as albumin-to-creatinine ratio >30 mg/g in two of three spot urine specimens."
These definitions are generally applicable in veterinary medicine. CKR is common among geriatric cats and dogs.
There are five stages:
- Stage 1 - glomerular filtration rate is 90 ml/min/1.73 m2 or more
- Stage 2 - glomerular filtration rate is 60-89 ml/min/1.73 m2
- Stage 3 - glomerular filtration rate is 30-59 ml/min/1.73 m2
- Stage 4 - glomerular filtration rate is 15-29 ml/min/1.73 m2
- Stage 5 - glomerular filtration rate is less than 15 ml/min/1.73 m2 or on renal dialysis; also callled end-stage renal disease (ESRD)
Thirteen percent of adults in the United States of America have chronic kidney disease as defined by the Kidney Disease Outcomes Quality Initiative (KDOQI). The prevalence is reduced to 11% if isolated microalbuminuria (CKD-1) is not included. However, using otehr criteria, the prevalence is 2.9%.
Signs and symptoms
Anemia of chronic disease commonly coexists with CKD.
Referral to a nephrologist
Clinical practice guidelines by the National Kidney Foundation recommend referral to a nephrologist when there is diagnostic uncertainty or the glomerular filtration rate is less than 30 30 mL/min/1.73 m2.
|Protein restriction||Diabetic renal disease||relative risk of end stage renal disease or death:|
|Protein restriction||Non-diabetic renal disease||relative risk of renal death:|
|Angiotensin converting enzyme inhibitors||Diabetic renal disease|
Angiotensin can be inhibited with either angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists. These medications can help patients with an elevated creatinine, including those with a creatinine of 1.5 to 5.0 mg per deciliter.
Combining angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists increases effect, but at uncertain increase in drug toxicity such as hyperkalemia according to a meta-analysis. Adding an aldosterone receptor antagonist such as spironolactone may add further benefit, but presumably more hyperkalemia.
- Phosphate binders (calcium carbonate 650 mg tabs three times - Calcichew™, Titrala™) or calcium acetate (Phosex™, PhosLo™) per day by mouth.
- Vitamin D preparations such as calcitriol (0.25-0.5 µg orally once per day) or intravenous paricalcitol (Zemplar™)are given once a patient has Stage 3 disease in order to prevent secondary hyperparathyroidism.
- Calcimimetic such as cinacalcet (Sensipar™) may help.
If hypercalcemia develops, guidelines are available for management.
A single randomized controlled trial found that giving allopurinol to hyperuricemic patients with chronic kidney disease had a relative risk ratio of 0.35 in the prevention of "significant deterioration in renal function and dialysis dependence."
Treatment of associated diseases
Anemia of chronic disease is associated with CKD, and may be directly regulated by hepcidin in human iron metabolism. In patients with chronic kidney disease, the goal hemoglobin should be 11.3 g per deciliter according to a randomized controlled trial of erythropoetin that found targeting a hemoglobin level of 13.5 g per deciliter increased adverse events. However, the setting or target hemoglobin levels may increase adverse effects.
Erythropoietin may increase hypertension patients with chronic kidney disease. The use of when the hemoglobin is less than 9 g per deciliter may increase the risk of stroke according to a randomized controlled trial.
Coronary heart disease
Coronary heart disease is common among patients with chronic kidney disease.
|Patients||Results at 3-6.4 yr|
|All patients||44%||46%||0.9 (0.8 - 1.1)|
|protein-to-creatinine ratio < 0.22||41%||36%||1.2 (0.9 - 1.5)|
|protein-to-creatinine ratio > 0.22||75%||85%||0.7 (0.6 - 0.9)|
- Intensive blood-pressure control had no effect on progression of kidney disease according to the AASK randomized controlled trial.
- Angiotensin-converting enzyme inhibitors may help according to the REIN trial.
- Thiazide may be as beneficial as angiotensin-converting enzyme inhibitors according to the ALLHAT trial. This trial excluded patients with a serum creatinine over 2.
Regarding which medication to add to add is angiotensin-converting enzyme inhibitors are not adequate:
- Aliskiren is an oral direct renin inhibitor that, according to a randomized controlled trial which added aliskiren to losartain, may have "renoprotective effects that are independent of its blood-pressure-lowering effect in patients with hypertension, type 2 diabetes, and nephropathy."
- Among patients already taking benazepril, amlodipine may be more effective than hydrochlorothiazide at preventing progression of renal disease.
- Angiotensin II receptor antagonists can be added to angiotensin-converting enzyme inhibitors to increase effect, but at uncertain increase in drug toxicity such as hyperkalemia, according to a meta-analysis.
- Aldosterone blocking agents may help as a second or even third medication.
Renal replacement therapy
One of the cornerstones of veterinary management of CKD is daily, or more frequent, administration of subcutaneous fluids. With proper technique, the loose skin of dogs and cats makes such administration quite comfortable; many owners combine it with grooming or stroking. Supplementary medications are less commonly used, possibly due to the difficulty of administration, but there is increasing use of bolus administration through the subcutaneous line, not even noticed by the patient.
Prepared low-protein foods are available by veterinary prescription, but protein restriction is more difficult in carnivores, especially obligate carnivores such as cats.
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