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Practitioner reality – How I deal with chronic renal insufficiency (Proceedings)

April 1, 2009
Renee Rucinsky, DVM, DABVP

Chronic renal insufficiency involves the permanent damage to any part of the nephron.

  • Permanent damage to any part of the nephron

  • Multiple possibilities for inciting cause

  • Any age or sex cat, more common in older cats

  • Progressive disease
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Signalment

  • History of polyuria/polydipsia

  • Usually weight loss

  • Anorexia

  • +/- vomiting

  • Bad breath

  • Lethargy

Physical exam findings

  • Dehydration

  • Unkempt cat

  • Kidneys may palpate small and irregular, occasionally large. Usually not painful upon palpation

  • Uremic breath, ulcers present in cats usually only end-stage

Diagnosis

  • Elevated BUN, Creatinine

  • Hypokalemia

  • Hyperphosphatemia

  • +/- anemia

  • Isosthenuria

  • +/- hypertension

Differential diagnosis

  • Prerenal azotemia – dehydration, high protein diet

  • Renal azotemia

o ARF

o CRF

o Diabetes

o Diuretics

  • Postrenal azotemia

IRIS staging

  • Stage 1: USG <1.030 with proteinuria or <1.025 without proteinuria, no azotemia, creatinine <1.6

  • Stage 2: Mild azotemia, creatinine 1.6-2.8, PU/PD and other clinical signs absent or minimal

  • Stage 3: Moderate azotemia, creatinine 2.8-5, clinical signs generally present

  • Stage 4: Severe azotemia, uremic syndrome, creatinine >5

Treatment

  • Fluids

  • Control vomiting/nausea

  • Dietary therapy

  • Phosphorus binders

  • Potassium supplements

  • Appetite stimulants

  • Manage anemia

  • Manage hypertension

  • Manage proteinuria

  • Calcitriol?

Practical management

  • Stage 1: Full bloodwork, BP, UA, +/- urine P/C ratio, +/- urine culture. Phosphorus binder if phosphorus over 3 (want to keep under 4), start dietary therapy? Recheck every 6 months with weight, UA, bloodwork

  • Stage 2: As above, but definite UP/C. Recheck every 4 months with weight and UA, Electrolytes +/- bloodwork as determined by history and PE, BP every 6 months

  • Stage 3: As above, recheck every 3 months. UA every visit +/- urine culture prn, culture every 6-9 months if otherwise stable. Bloodwork and BP every 6 months.

  • Stage 4: Hospitalize and stabilize, recheck monthly.

Generalizations

  • Start potassium supplementations if serum K <4.2

  • Start sq fluids at stage 3-4, or when appetite starts to decrease

  • Start H2 blockers when appetite starts to decrease

  • Start epogen if pcv <14%

  • Keep phosphorus <4 (<5 if stage 3-4)

UP/C in CRI cats – helps classify the proteinuria

  • < .2 = normal

  • .2 - .4 = borderline

  • .4 – 2 = glomerular or tubular

  • >2 = glomerular

The higher the number, the faster the progression of the disease. Will start ACE inhibitor if over .3.

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