Monitoring Renal Disease Gary Coxon BVetMed MRCVS Veterinary Advisor Vetoquinol UK and Ireland.
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Transcript of Monitoring Renal Disease Gary Coxon BVetMed MRCVS Veterinary Advisor Vetoquinol UK and Ireland.
Monitoring Renal Disease
Gary Coxon BVetMed MRCVS
Veterinary Advisor Vetoquinol UK and Ireland
Agenda
• Consequences of renal failure• Aims of management• Medications and monitoring
IRIS (International Renal Interest Society)
• Website at www.iris-kidney.com• Group of specialists that have created guidelines for
• Staging kidney disease• Treatment at various stages of kidney disease in cats and
dogs• Good education section on proteinuria, urine collection, USG
etc
Renal Failure
• Multiple underlying causes with same outcome
• Progressive and dynamic condition• Clinical signs vary and only appear when 66-
75% of functional tissue has been lost• Replaced by fibrous or scar tissue• GFR no longer adequate
Diagnosis
• Clinical signs• Changes in urine specific gravity• Changes in blood levels (Urea / Creatinine)
Urine changes (specific gravity)
Blood changes (urea/creat)
¾ Loss
2/3 Loss
Clinical sign Proportion of cats affected Dehydration 67%Anorexia 64%Lethargy/depression 52%Weight loss 47%PU/PD 32%Vomiting 30%Macrorenale 25%Microrenale 19%Pale mucosae 7%Oral ulceration 5%Diarrhoea 4%Retinal detachment 4%Less common clinical signs Haematuria/dysuria, Poor
coat, Halitosis, Osteodystrophy,
Constipation
Management
• Directed at complications of decreased kidney function
• “Conservative medical management”• Needs to be monitored
Goals of Management
• Correct imbalances and deficits in fluids and electrolytes
• Limit progressive loss of functional tissue• Manage clinical signs• Ensure adequate but correct nutrition
Major Factors That Lead to Progression
1. Hyperphosphataemia and its consequences
• Controlling phosphate proven to increase life expectancy
• The earlier treatment is started the better the prognosis
• Prevent mineralisation and therefore prevent chronic inflammation
Renal secondary hyperparathyroidism
Phosphate Management
• Restrict dietary phosphorus• Decrease intake• Decrease absorption eg. Ipakitine
• Maintain phosphate in levels set out by experts• Gives extension to lifespan
Serum Phosphate
• Establish “stage” of renal failure• IRIS guidelines ( www.iris-kidney.com )
• Look up target phosphate level• Adjust phosphate binder and/or food
Target Phosphate Levels
“Normal” serum
phosphate ranges
recommended by
commercial
laboratories
and in-house
analyzers for cats
Survival of cats Median survival times of catswith serum phosphate outside orinside new stipulated phosphate
reference ranges2
Calcium carbonateCompound with proven phosphate binding properties
ChitosanDerived fromchitin, the main buildingmaterial ofthe exoskeleton of arthropods
Speci c molecular properties
Adsorbant in the intestines
PhosphatesSomeuraemic toxins
Ipakitine®
The original UK phosphate binderformulated speci cally for veterinary use
For cats and dogs
Tasteless powder for addition to food
Contents
Formulations
• 50g• 150g• 1g/5kg BID• MUST be added to food
2. Systemic Hypertension• May be a cause or consequence of renal disease• Occurs in up to 66% of cats with CRF• Causes end organ damage – renal, ocular, CNS• In the kidney persistent glomerular hypertension lead to
hypertensive damage and nephron death• Reduction in GFR Activation of RAAS Angiotensin II CO and peripheral vascular resistance BP
Treatment of Hypertension• Calcium channel blocker
• Amlodipine (Istin) 5mg tablets• Typical dose 0.625-1.25mg/cat SID• 1/8 – 1/4 tablet!• Aim to get BP<170mmHg• Adjust dose as necessary
• ACE inhibitors• Not the most effective for systemic hypertension• May be used if amlodipine alone isnt effective
3. Proteinuria• Is a marker of glomerular damage
• Glomerulonephritis• Glomerular hypertension• Amyloidosis
• Proteins directly damage the renal tubules causing further nephron loss
• Can be measured via• Dipstick• Urine Protein Creatinine Ratio (UP:C)
• Gives quantitative measure of protein and significance• Prognostic indicator• Treatment decisions• Monitor response to treatment
Treatment of Proteinuria
• Renal diet
• ACEi (if UP:C >0.4)
Tests• Haematology
• Anaemia• Biochemistry
• Urea, Creatinine, K+, Na+, Ca+, Phosphate, Proteins• Urinalysis
• USG/dipstick, Sediment, Protein (UP:C), C&S• Systolic BP
Case 1 – 13 y MN DSH • Clinical signs
• PUPD, Lethargy, weight loss• Bloods
• Urea – 14.3, Creatinine – 178, phosphate normal
• Urinalysis• USG- 1.024, rest including
UP:C normal• Blood pressure
• 225mmHg
Treatment??
•Renal diet•Amlodipine 1/8 tablet SID
•Aim to get BP<170mmHg
Case 2 – 8y MN Xbreed • Clinical signs
• PUPD, lethargy, weight loss• Bloods
• Urea-16.2, Creatinine-290, phosphate 2.3 (<1.61)
• Urinalysis• USG-1.016, rest including
UP:C normal• Blood pressure
• 145 mmHg
Treatment???
•Renal diet and retest phosphate 4w later
•Phosphate 4w later – 1.97•Add in Ipakitine and aim for <1.61
Case 3 – 14y FN DSH• Clinical signs
• PUPD, Lethargy, weight loss• Bloods
• Urea-19.1, Creatinine-279, Phosphate – 2.7 (<1.61)
• Urinalysis• USG 1.019, UP:C- 0.8
• Blood Pressure• 160 mmHg
Treatment???
• Renal diet•ACE inhibitor
•But wouldn’t eat food so Ipakitine added to normal food•Retest bloods(inc Phosphate) and UP:C in 4w
QUESTIONS?