Chronic kidney disease

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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."[1]

These definitions are generally applicable in veterinary medicine. CKR is common among geriatric cats and dogs.

Classification

There are five stages:[1]

Classification may be improved by considering proteinuria.[2]

Etiology/cause

Bilateral renal artery stenosis (RAS) may cause 5% to 15% of cases of chronic kidney disease.[3]

Prevalence

Thirteen percent of adults in the United States of America have chronic kidney disease as defined by the Kidney Disease Outcomes Quality Initiative (KDOQI).[4] The prevalence is reduced to 11% if isolated microalbuminuria (CKD-1) is not included.[4] However, using otehr criteria, the prevalence is 2.9%.[5]

Routine reporting of the estimated glomerular filtration rate has increased the number of referrals to nephrologists[6]; however, the benefit is uncertain[7].

Signs and symptoms

Uremia, "the illness accompanying kidney failure", may have subtle manifestations when the glomerular filtration rate falls below 60 ml/min/1.73 m2.[8]

Anemia of chronic disease commonly coexists with CKD.

Medical treatment

The National Kidney Disease Education Program provides guidance on dosing drugs in patients with reduced glomerular filtration rate.[9]

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.[10]

Medications

Various drugs have been studied for slowing the progression of chronic kidney disease.[11][12][13]

Systematic reviews by the Cochrane Collaboration on treatments for chronic kidney disease
Treatment Setting Results
Protein restriction[11] Diabetic renal disease relative risk of end stage renal disease or death:
0.23
Protein restriction[12] Non-diabetic renal disease relative risk of renal death:
0.69
Angiotensin converting enzyme inhibitors[13] Diabetic renal disease  

Aldosterone antagonists

Aldosterone antagonists may reduce proteinuria according to a systematic review by the Cochrane Collaboration.[14]

Angiotensin inhibition

Angiotensin can be inhibited with either angiotensin-converting enzyme inhibitors[15] or angiotensin II receptor antagonists. These medications can help patients with an elevated creatinine,[16] including those with a creatinine of 1.5 to 5.0 mg per deciliter.[17]

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.[18] Adding an aldosterone receptor antagonist such as spironolactone may add further benefit, but presumably more hyperkalemia.[19]

Erythropoeitin

For more information, see: Erythropoeitin.


Secondary hyperparathyroidism

Clinical practice guidelines from the "Kidney Disease: Improving Global Outcomes (KDIGO)" address management of renal osteodystrophy.[20][21]

  • 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.[22]

Allopurinol

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."[23]

Treatment of associated diseases

Anemia

Clinical practice guidelines guide management for both adults[24] and children[25].

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.[26] However, the setting or target hemoglobin levels may increase adverse effects.[27]

Erythropoietin may increase hypertension patients with chronic kidney disease.[28] 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.[29]

In patients who require renal dialysis, iron should be given with erythropoietin.[30]

Coronary heart disease

Coronary heart disease is common among patients with chronic kidney disease.

Hypertension

AASK trial[31]
Patients Results at 3-6.4 yr
Intervention Control Hazard ratio
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)

Regarding which medication to add to add is angiotensin-converting enzyme inhibitors are not adequate:

Renal replacement therapy

For more information, see: Renal replacement therapy.

Veterinary treatment

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.

Prognosis

The estimated glomerular filtration rate and the urinary albumin/creatinine ratio can help predict who will progress to CKD5.[38]

References

  1. 1.0 1.1 Levey AS, Eckardt KU, Tsukamoto Y, et al (2005). "Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO)". Kidney Int. 67 (6): 2089–100. DOI:10.1111/j.1523-1755.2005.00365.x. PMID 15882252. Research Blogging.
  2. Tonelli, Marcello; Paul Muntner, Anita Lloyd, Braden J. Manns, Matthew T. James, Scott Klarenbach, Robert R. Quinn, Natasha Wiebe, Brenda R. Hemmelgarn (2011-01-04). "Using Proteinuria and Estimated Glomerular Filtration Rate to Classify Risk in Patients With Chronic Kidney Disease". Annals of Internal Medicine 154 (1): 12 -21. DOI:10.1059/0003-4819-154-1-201101040-00003. PMID 21200034. Retrieved on 2011-01-04. Research Blogging.
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