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Kidney: chronic kidney disease
Synonym(s): Chronic kidney failure, CKD
Introduction
- Gradual, progressive loss of renal tissue → inability of kidney to perform normal functions of waste excretion, fluid/electrolyte/acid-base homeostasis and endocrine functions.
- Cause: in younger animals usually either congenital or familial; in older animals usually acquired.
- Signs: often no clinical signs in the early stages. Weight loss and muscle loss, polyuria/polydipsia → uremia (vomiting, anorexia, oral ulceration) in late stages.
- Diagnosis: biochemistry, urinalysis, imaging, +/- histopathology.
- Treatment: dietary managment +/- phosphate binding agents; angiotensin receptor blocker (ARB) or ACE inhibitor; antiemetics, antinausea agents, appetite stimulants, +/- erythropoietin analogues; IV fluid therapy if dehydrated.
- Prognosis: mixed - early detection and management of CKD can ameliorate the signs of uremia and may slow down the progression of disease. Some cats demonstrate quickly progressive CKD and others have stable CKD for years. Print off the owner factsheet Kidney disease in your cat Kidney disease in your cat to give to your client.
Presenting signs
- May be no clinical signs.
- Weight loss or loss of muscle mass.
- Polyuria/polydipsia.
- Signs of uremia Uremia:
- Anorexia.
- Lethargy.
- Vomiting.
- Oral ulceration.
Acute presentation
- Acute decompensation of CKD can cause an uremic crisis (severe uremia, dehydration, collapse).
Age predisposition
- Depends on etiology (generally >9 years).
- Young animals 0-4 years for juvenile renal diseases.
- Usually older animals for acquired disease.
Breed/Species predisposition
- Often depend on underlying cause which may be breed specific.
- Abyssinian Abyssinian secondary to amyloidosis.
- Maine Coon Maine Coon.
- Siamese Siamese.
- Persian Persian longhair (secondary to polycystic kidney disease Kidney: autosomal dominant polycystic kidney disease).
- Russian Blue Russian Blue.
- Burmese Burmese.
- Balinese Balinese.
- Japanese Bobtail Japanese bobtail.
- Rex Cornish Rex Devon Rex.
Special risks
- Anesthesia since many anesthetic agents excreted through kidneys Anesthesia: in renal insufficiency and hypotension during anesthesia may contribute. Warn owner of risks associated with anesthesia.
- Increased risk of decompensation with heat stress or dehydration. Warn owner of risks of heat stress and/or dehydration.
Pathogenesis
Etiology
Young animals
- Juvenile renal diseases; renal cortical hypoplasia, renal dysplasia, hereditary nephritis, glomerulopathy, polycystic disease, familial amyloidosis, etc.
Older animals
- Most frequently idiopathic (chronic interstitial nephritis of unknown cause).
- Chronic pyelonephritis Pyelonephritis.
- Chronic glomerulonephritis Glomerulonephritis.
- Hypertension Hypertension.
- Infectious causes (FIP Feline infectious peritonitis).
- Polycystic kidney disease Kidney: autosomal dominant polycystic kidney disease.
- Renal pseudocyst.
- Renal amyloidosis Amyloidosis.
- Neoplasia (lymphoma Lymphoma).
- Following acute kidney injury Kidney: acute renal failure.
- Chronic generalized nephropathy.
- Nephrolithiasis/ureterolithiasis if cause post-renal AKI Nephrolithiasis.
Pathophysiology
- Damage to one component of nephron → generalized nephron failure → scarring and compensatory changes → chronic generalized nephropathy.
- Reduction of functional nephrons → loss of ability to concentrate urine and retention of waste products.
- Hyperfiltration of remaining nephrons → self-perpetuating destruction of remaining nephrons.
- Hyperphosphatemia, due to inability to excrete phosphate → hyperparathyroidism and CKD-mineral and bone disorder → osteodystrophy and nephrocalcinosis which increases renal damage.
- Lack of active vitamin D3 → initiates and exacerbates hyperparathyroidism.
- Metabolic acidosis → renal ammoniagenesis → toxic and inflammatory effect on renal interstitium.
- Uremia → erythropoietin deficiency and a shortened RBC lifespan → normochromic, normocytic, non-regenerative anemia.
Timecourse
- Some animals can be stable for a long period, while others may decompensate and deteriorate rapidly (acute-on-chronic disease).
Diagnosis
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Treatment
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Prevention
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Outcomes
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Further Reading
Publications
Refereed papers
- Recent references from PubMed and VetMedResource.
- Jepson R E, Brodbelt D, Vallance C et al (2009) Evaluation of predictors of the development of azotemia in cats. J Vet Intern Med 23 (4), 806-813 PubMed.
- Roudebush P, Polzin D J, Ross S J et al (2009) Therapies for Feline Chronic Kidney Disease. What is the evidence? J Feline Med Surg 11 (3), 195-210 PubMed.
- Syme H (2009) Proteinuria in cats: Prognostic marker or mediator? J Feline Med Surg 11 (3), 211-218 PubMed.
- Boyd L M, Langston C, Thompson K et al (2008) Survival in cats with naturally occurring chronic kidney disease (2000-2002). J Vet Intern Med 22 (5), 1111-1117 PubMed.
- King J N, Tasker S, Gunn-Moore D A et al (2007) Prognostic factors in cats with chronic kidney disease. J Vet Intern Med 21 (5), 906-916 PubMed.
- King J N, Gunn-Moore D A, Tasker S et al (2006) Tolerability and efficacy of benazepril in cats with chronic kidney disease. J Vet Intern Med 20 (5), 1054-1064 PubMed.
- Hostutler R A, DiBartola S P, Chew D J et al (2006) Comparison of the effects of daily and intermittent-dose calcitriol on serum parathyroid hormone and ionised calcium concentrations in normal cats and cats with chronic renal failure. J Vet Intern Med 20 (6), 1307-1313 PubMed.
- Ross S J, Osborne C A, Kirk C A et al (2006) Clinical evaluation of dietary modification for treatment of spontaneous chronic kidney disease in cats. J Am Vet Med Assoc 229 (6), 949-957 PubMed.
- Syme H M, Markwell P J, Pfeiffer D et al (2006) Survival of cats with naturally occurring chronic renal failure is related to severity of proteinuria. J Vet Intern Med 20 (3), 528-535 PubMed.
- Elliott J, Rawlings J M, Markwell P J et al (2000) Survival of cats with naturally occurring chronic renal failure: effect of dietary management. JSAP 41 (6), 235-242 PubMed.
- Barber P J, Rawlings J M, Markwell P J et al (1999) Effect of dietary phosphate restriction on renal secondary hyperparathyroidism in the cat. JSAP 40 (2), 62-70 PubMed.
- Barber PJ & Elliott J (1998) Feline chronic renal failure- clinical findings in 80 cases diagnosed between 1992 and 1995. JSAP 39 (2), 78-85 PubMed.
- Barber P J & Elliott J (1998) Feline chronic renal failure- calcium homeostasis in 80 cases diagnosed between 1992 and 1995. JSAP 39 (3), 108-116 PubMed.
Other sources of information
- Sanderson S L (2009) Measuring glomerular filtration rate: practical use of clearance tests. In: Kirks Current Veterinary Therapy XIV, (ed) J Bonagura & D Twedt, Elsevier Saunders pp 868-871.
- Polzin D J, Osborne C A & Ross S (2009) Evidence-based management of chronic kidney. In: Kirks Current Veterinary Therapy XIV, (ed) J Bonagura & D Twedt, Elsevier Saunders pp 872-879.
- Elliott J & Watson A D J (2009) Chronic kidney disease: Staging and management. In: Kirks Current Veterinary Therapy XIV, (ed) J Bonagura & D Twedt, Elsevier Saunders pp 883-892
- Elliott J (2008) The role of phosphate in chronic kidney disease (CKD) progression: Part 1. UK Vet 13 (2), 23-28.
- Elliott J (2008) The role of phosphate in chronic kidney disease (CKD) progression: Part 2. UK Vet 13 (2), 37-41.
- International Renal Interest Society: www.iris-kidney.com