Diagnosing, Staging,

and Treating Chronic Kidney

Disease in Dogs and Cats
Chronic kidney disease (CKD) is diagnosed based
on evaluation of all available clinical and diagnostic
information in a stable patient. Following diagnosis
of CKD, the IRIS Board recommends using serum
creatinine or SDMA (ideally both) to stage CKD with
substaging based on assessment of arterial blood
pressure and proteinuria.
Step 1: Diagnose CKD Step 2: Stage CKD
Clinical signs and physical Clinical presentation Physical examination findings
examination findings worsen Consider age, sex, breed predispositions, and relevant Can be normal in early stage CKD. Findings
historical information, including medication history, may include palpable kidney abnormalities,
with increasing severity of toxin/toxicant exposure, and diet. evidence of weight loss, dehydration,
kidney disease Can be subclinical in early stage CKD. Signs may include pale mucous membranes, uremic ulcers,
polyuria, polydipsia, weight loss, decreased appetite, evidence of hypertension, i.e., retinal
lethargy, dehydration, vomiting, and bad breath. hemorrhages/detachment.

Stage 1 Stage 2 Stage 3 Stage 4

To diagnose Stage 1 and early Stage 2 CKD OR To diagnose more advanced CKD (late Stage 2–4)
No azotemia Mild azotemia Moderate azotemia Severe azotemia
One or more of these diagnostic findings: Both of these diagnostic findings: (Normal creatinine) (Normal or mildly
elevated creatinine)
1 Creatinine SDMA
Increased creatinine and SDMA concentrations 1 Creatinine in mg/dL Less than Greater than

1.4 1.4–2.8 2.9–5.0 5.0

reference interval

reference interval

Creatinine SDMA Creatinine

increasing within the increasing within the Stage Canine (125 µmol/L) (125–250 µmol/L) (251–440 µmol/L) (440 µmol/L)
reference interval where no reference interval where no SDMA based on

plus
prerenal cause is apparent prerenal cause is apparent stable creatinine Less than Greater than
Jun ’11 Jun ’12 Jun ’13 June July Aug Sept Results of both tests should be interpreted
in light of patient’s hydration status. Feline 1.6 1.6–2.8 2.9–5.0 5.0
(140 µmol/L) (140–250 µmol/L) (251–440 µmol/L) (440 µmol/L)
2 Persistent increased SDMA* >14 µg/dL
SDMA* in µg/dL Less than Greater than
3 Abnormal kidney imaging Canine 18 18–35 36–54 54
Stage
Urine  Urine  based on
specific gravity specific gravity 2 stable SDMA Less than Greater than

<1.030 <1.035†
Feline
18 18–25 26–38 38
UPC ratio
Substage Canine Nonproteinuric <0.2 Borderline proteinuric 0.2–0.5 Proteinuric >0.5
based on
proteinuria Feline Nonproteinuric <0.2 Borderline proteinuric 0.2–0.4 Proteinuric >0.4
4 Persistent renal proteinuria
UPC >0.5 in dogs; UPC >0.4 in cats Systolic blood
pressure in mm Hg Normotensive <140 Prehypertensive 140–159
Substage based on _180
Hypertensive 160–179 Severely hypertensive >
0.6 0.7 1.0 blood pressure
1.030 Canine 1.008
Sept ’15 Oct ’15 Nov ’15
Urine protein to creatinine (UPC) ratio
1.035 Feline 1.008 Note: In the case of staging discrepancy between creatinine *SDMA = IDEXX SDMA® Test See www.iris-kidney.com for more
and SDMA, consider patient muscle mass and retesting detailed staging, therapeutic, and
See www.iris-kidney.com for more detailed staging, Note that some cats can produce hypersthenuric
† both in 2–4 weeks. If values are persistently discordant, management guidelines.
therapeutic, and management guidelines. urine in the face of renal azotemia. consider assigning the patient to the higher stage.
Step 3: Treat CKD

Stage 1 Stage 2 Stage 3 Stage 4

Treatment Use nephrotoxic drugs Same as Stage 1 Same as Stage 2 Same as Stage 3
recommendations with caution
Renal therapeutic diet Keep phosphorus Keep phosphorus
Correct prerenal and <5.0 mg/dL <6.0 mg/dL
Treat hypokalemia in cats
postrenal abnormalities (<1.6 mmol/L) (<1.9 mmol/L)
Fresh water available at Treat metabolic acidosis Consider feeding tube for
all times nutritional and hydration
Consider treatment
support and ease of
Monitor trends in creatinine of anemia
medicating
and SDMA to document
Treat vomiting,
stability or progression
inappetence, and nausea
Investigate for and treat
Increased enteral or
underlying disease and/or
subcutaneous fluids may
complications
be required to maintain
Treat hypertension if systolic hydration
blood pressure persistently
Consider calcitriol therapy
>160 or evidence of
in dogs
end-organ damage
Treat persistent proteinuria
with renal therapeutic diet
and medication
(UPC >0.5 in dogs;
UPC >0.4 in cats)
Keep phosphorus
<4.6 mg/dL (<1.5 mmol/L)
If required, use renal
therapeutic diet 
plus phosphate binder

See www.iris-kidney.com for more detailed staging, therapeutic, and management guidelines.