Chronic Kidney Disease in Dogs

and Cats
Joseph W. Bartges, DVM, PhD

KEYWORDS
• Chronic kidney disease • Geriatric • Nutrition • Treatment
• International Renal Interest Society

KEY POINTS
• Chronic kidney disease occurs commonly in dogs and cats.
• Chronic kidney disease is progressive; however, management utilizing dietary modification
and pharmacologic agents may improve quality of life and survival.
• Management of dogs and cats with chronic kidney disease is directed at minimizing the
excesses and deficiencies that occur.
• Specifically, management is directed at providing nutritional support, treating hypokalemia
and metabolic acidosis, decreasing the degree of proteinuria, maintaining hydration,
decreasing retention of wastes such as nitrogen containing compounds, avoiding other
renal insults, improving anemia, minimizing renal secondary hyperparathyroidism and
hyperphosphatemia, and decreasing blood pressure if systemic arterial hypertension is
present.
• Serial monitoring of dogs and cats with chronic kidney disease is essential because of the
progressive nature of the disease.

Chronic kidney disease (CKD) occurs commonly in older dogs and cats and is the
most common renal disease occurring in elderly patients. It is defined as structural
and/or functional impairment of one or both kidneys that has been present for more
than approximately 3 months. In most patients, there is loss of function and structure
with CKD; however, degree of functional impairment does not always mirror loss of
structure. CKD implies irreversible loss of renal function and/or structure that remains
stable for some period of time but is ultimately progressive. In some patients, CKD
may be complicated by concurrent prerenal and/or postrenal problems that may
worsen the condition, but if managed, they may improve the situation.
CKD is considered a disease of older animals, although it occurs at all ages. The
estimated incidence of CKD in the general population of dogs and cats is 0.5% to

The author has nothing to disclose.

Department of Small Animal Clinical Sciences, College of Veterinary Medicine, The University of
Tennessee, 2407 River Drive, Knoxville, TN 37996-4544, USA
E-mail address: [email protected]

Vet Clin Small Anim 42 (2012) 669 – 692

http://dx.doi.org/10.1016/j.cvsm.2012.04.008 vetsmall.theclinics.com
0195-5616/12/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
670 Bartges

1.5%.1 At the University of Minnesota Veterinary Medical Center, more than 10% of
dogs and 30% of cats over 15 years of age are diagnosed with CKD.1 One
retrospective study reported that 53% of cats with CKD were over 7 years old, but
animals ranged in age from 9 months to 22 years.2 In a study on age distribution of
kidney disease in cats based on data submitted from 1980 to 1990 to the Veterinary
Medical Data Base at Purdue University, 37% of cats with the diagnosis of “renal
failure” were less than 10 years old, 31% of cats were between the ages of 10 and 15,
and 32% of cats were older than 15 years.3 Similarly, in a study of cats with CKD
reported in 1988, the mean age was 12.6 years with a range of 1 to 26 years.4 Mean
age among 45 control cats in this study was 10.0 years. During 1990, the prevalence
of kidney disease was reportedly 16 cases for every 1000 cats of all ages, 77 cases
per 1000 cats over age 10 years, and 153 per 1000 among cats older than 15 years.2
Maine coon, Abyssinian, Siamese, Russian blue, and Burmese cats were dispropor-
tionately reported as affected.
The kidneys are involved with whole body homeostasis; therefore, CKD affects many
organ systems, is associated with many metabolic derangements, and affects general
well-being. Glomerular filtration results in formation of urine in Bowman’s space except
for cells and protein-bound compounds; a small amount of albumin is filtered. Bulk
reabsorption of the filtrate occurs in the proximal tubule with additional secretion or
reabsorption of anionic and cationic compounds. The loop of Henle concentrates then
dilutes the filtrate through selective reabsorption of water and sodium. The distal
convoluted tubule and collecting ducts fine-tune the solute and moisture content of urine.
In addition to these processes, the kidneys are intimately involved in metabolic regulation
of acid-base status, have endocrine function (eg, erythropoietin and vitamin D), and have
a role in blood pressure regulation (eg, renin production and adrenal secretion of
aldosterone). Therefore, when renal function declines there is disruption of these normal
processes resulting in retention of compounds that should be excreted (eg, phosphorous
and creatinine) and loss of compounds that should be retained (eg, water and protein).

CLINICAL, BIOCHEMICAL, AND IMAGING FINDINGS WITH CKD

It is the retention or loss of compounds that results in clinical manifestations of CKD.

Many, but not all, patients show clinical signs of chronic disease such as loss of body
condition, BW, and muscle mass, and an unkempt appearance. Polyuria and
polydipsia occur because of an inability of the kidneys to regulate water balance.
Hyporexia/anorexia, vomiting, halitosis, and ulcerative stomatitis and gastroenteritis
may be present (Fig. 1). With CKD, the kidneys often palpate small and irregular, and
this is confirmed with abdominal radiography and ultrasonography. Occasionally,
renomegaly is present with CKD when there is renal neoplasia, pyelonephritis, or
ureteral obstruction present. Biochemically, azotemia with inappropriately dilute urine
(urine specific gravity ⬍1.030 in dogs and ⬍1.035 in cats), metabolic acidosis, and
hyperphosphatemia are present. Additionally, some patients may have hypokalemia
(seen more commonly in cats than in dogs), nonregenerative anemia, hypoalbumin-
emia, dyslipidemia, and bacterial urinary tract infection. Arterial systemic hyperten-
sion occurs in 40% to 80% of patients.1 Proteinuria may also occur and has been
associated with a poorer prognosis and more rapid progression of CKD than in
patients without proteinuria.5,6

TREATMENT OF CKD

Treatment of CKD is directed at correcting these imbalances and in slowing down

progression; it is lifelong because CKD is irreversible. Additionally, treatment is
 Chronic Kidney Disease in Dogs and Cats 671

Fig. 1. Uremic stomatitis and glossitis in a 20-year-old, spayed female domestic shorthair cat
with chronic kidney disease.

directed at ameliorating clinical signs of CKD and at correcting or controlling nonrenal

disease that may affect a patient with CKD. We developed an acronym to assist in
treating CKD based on excesses and deficiencies that occur: NEPHRONS.
N nutrition
E electrolytes
P pH of blood (acid-base status); proteinuria
H hydration
R retention of wastes
O other renal insults – avoid
N neuroendocrine function – hyperparathyroidism, hypoproliferative anemia,
and hypertension
S serial monitoring – CKD is irreversible and progressive

Key Therapeutic Points

The kidneys are involved with homeostasis through filtration, reabsorption, secretion,
and metabolism of compounds. A conservative medical treatment of CKD consists of
supportive and symptomatic treatment designed to correct excesses and deficien-
cies that occur (NEPHRONS). Guidelines for managing dogs and cats with CKD have
been established by the International Renal Insufficiency Society (http://www.IRIS-
kidney.com). This staging system is designed for use with dogs and cats with CKD
(Table 1).7
A diagnosis of CKD is made first and staging is accomplished by evaluating (1) 2
serum creatinine concentrations when patient is well hydrated, (2) 2 or 3 urine
protein–to– urine creatinine ratios (UPCs), and (3) 2 to 3 indirect arterial blood pressure
determinations.1 CKD is staged by magnitude of renal dysfunction and further
modified (substaged) by presence or absence of proteinuria and/or hypertension.
Proteinuria ONLY refers to renal proteinuria and not prerenal (eg, hyperglobulinemia)
or postrenal (eg, urinary tract infection, hematuria, etc), and is based on UPC.8 Blood
pressure determination should be performed several times with an nonsedated and
calm patient that has acclimated to a quiet area using a standard protocol.9
672 Bartges

Table 1
International Renal Interest Society (IRIS) System
Stage of CKD based on serum or plasma creatinine concentration
Plasma Ccreatinine,
␮mol/L, mg/dL

Stage Dogs Cats Comments

1 ⬍125 ⬍140 Nonazotemic
⬍1.4 ⬍1.6 Some other renal abnormality present such
as inadequate concentrating ability
without identifiable nonrenal cause;
abnormal renal palpation and/or
abnormal renal imaging findings;
proteinuria of renal origin; abnormal
renal biopsy results
2 125–179 140–249 Mild renal azotemia [lower end of the
1.4–2.0 1.6–2.8 range lies within the reference range for
many labs but the insensitivity of
creatinine as a screening test means that
animals with creatinine values close to
the upper limit of normality often have
excretory failure]
Clinical signs usually mild or absent
3 180–439 250–439 Moderate renal azotemia
2.1–5.0 2.9–5.0 Many systemic clinical signs may be present
4 ⬎440 ⬎440 Severe renal azotemia
⬎5.0 ⬎5.0 Many extrarenal clinical signs present
Substage of CKD based on presence or absence of proteinuria determined by a UPC
UPC Value

Dogs Cats Substage

⬍0.2 ⬍0.2 Nonproteinuric
0.2–0.5 0.2–0.4 Borderline proteinuric
⬎0.5 ⬎0.4 Proteinuric
Substage of CKD based on presence or absence of systemic arterial hypertension and risk of
systemic arterial hypertension-related complications
Adaptation When
Systolic Blood Diastolic Blood Breed-Specific Reference
Pressure, mm Hg Pressure, mm Hg Range Is Available* Substage
⬍150 ⬍95 ⬍10 mm Hg above AP0: Minimal Risk (N)
reference range
150–159 95–99 10–20 mm Hg above AP1: Low Risk (L)
reference range
160–179 100–119 20–40 mm Hg above AP2: Moderate Risk (M)
reference range
⬎180 ⬎120 ⬎40 mm Hg above AP3: High Risk (H)
reference range

Courtesy of Novartis Animal Health, Inc, Basel, Switzerland, sponsor of the International Renal
Interest Society (IRIS), with permission.
 Chronic Kidney Disease in Dogs and Cats 673

Table 2
Body condition scoring systems
Descriptor Description 5 point 9 point
CACHECTIC Ribs are easily palpated with no fat cover; bony 1 1
structures are prominent and easy to
identify; muscle tone and mass often
decreased; little to no subcutaneous fat; hair
coat often poor; pronounced abdominal tuck
UNDERWEIGHT Ribs are easily palpated with little fat cover; 2 3
abdominal tuck present; bony structures are
palpable but not prominent; hair coat may
be poor; muscle tone and mass may be good
or slightly decreased
IDEAL Ribs are easily palpated, but fat cover is 3 5
present; hourglass shape present and
abdominal tuck is present, but not
pronounced; bony prominences are palpable
but not visible some subcutaneous fat, but
no large accumulations; muscle tone and
mass good; hair coat quality is good
OVERWEIGHT Ribs are difficult to palpate due to overlying fat 4 7
accumulation; hourglass shape is not
prominent and abdominal tuck is absent;
subcutaneous fat obvious with some areas of
accumulation; muscle tone and mass good;
hair coat quality may be decreased; cannot
identify bony prominences
OBESE Ribs are impossible to palpate due to overlying 5 9
fat; hourglass shape is absent and animal
may have a round appearance; subcutaneous
fat is obvious and accumulations are present
in the neck, tail-base, and abdominal
regions; muscle tone and mass may be
decreased; hair coat quality may be
decreased

N Nutrition
The main goal of nutritional support of any patient with a chronic disease is
maintenance of lean muscle mass and optimal body condition, and this is true of
patients with CKD. A thorough physical examination is performed and a body
condition score (BCS) and muscle condition score (MCS) are assigned.10 There are 5-
and 9-point BCS systems; either can be used.11–13 Assigning a BCS (Table 2)
provides more information than BW alone and estimates body fat content. The goal
for most pets is a BCS of 2.5 to 3 of 5 or 4 to 5 of 9.
An MCS may also be assigned and is an assessment of muscle mass and tone.10
Evaluation of muscle mass includes visual examination and palpation of muscles over
temporal bones, scapulae, lumbar vertebrae, and pelvic bones. Muscle condition is
an assessment of lean mass and loss of muscle mass may adversely affect strength,
immune function, wound healing, and ability to compensate for chronic conditions
such as CKD. A simple MCS has been suggested using a 0-to-3 scale where 0 ⫽
normal muscle mass and tone, 1 ⫽ slightly decreased muscle mass and tone,
674 Bartges

Table 3
Activity and life stage factors used to estimate MERs after RERs are estimated
Life Stage Canine Factor Feline Factor
Gestation 1.0–3.0 1.6–2.0
Dogs: first ½–2⁄3 1.0–2.0
Dogs: last 1⁄3 2.0–3.0
Lactation 2.0–8.0 1.0–2.0
Growth 2.0–3.0 2.0–5.0
Adult intact 1.8 1.4
Adult neutered 1.6 1.2
Senior 1.4 1.1
Work: light 2.0
Work: moderate 3.0
Work: heavy 4.0–8.0
Obese prone 1.4 1.0
Weight loss 1.0 0.8
Weight gain 1.2–1.4 ideal 0.8–1.0 ideal
Critical care (usually) 1.0 1.0

2 ⫽ moderately decreased muscle mass and tone, and 3 ⫽ markedly decreased

muscle mass and tone.14
Daily caloric requirements are determined by estimating resting energy requirement
(RER) using 1 of 2 equations15:
0.75
Exponential : 70 BWkg
Linear : 30共BWkg兲 ⫹ 70
The exponential equation is more accurate because energy requirements relate to
body weight (BW) in a parabolic fashion rather than a linear one. Once the RER is
estimated, the result is multiplied by an activity or life stage factor (Table 3) to
estimate the maintenance energy requirement (MER).15 These equations give only
estimates of daily energy requirements and energy intake should be adjusted based
on response to estimated energy requirements and through serial monitoring of BW,
BCS, and MCS.
Patients with CKD may exhibit some degree of anorexia depending on stage of
CKD. Causes of anorexia and nausea include retention of uremic toxins, dehydration,
biochemical alterations (azotemia, metabolic acidosis, electrolyte imbalances, and
mineral imbalances), anemia, renal secondary hyperparathyroidism, and uremic
gastroenteritis.16 Gastric ulcers occur less commonly in dogs and cats than in human
beings; however, many dogs and cats with CKD have gastric pathology including
vascular changes and edema17 and probable gastric hyperacidity associated with
hypergastrinemia from decreased renal excretion.
Feed a highly palatable diet or increase the palatability of diet by adding water to
dog food, using flavoring agents, and warming food to near body temperature.18
Consuming diets that are more calorically dense than maintenance adult foods
promotes adequate energy intake with less volume intake resulting in less gastric
distention and nausea. Because dietary fat is more calorically dense than dietary
protein and carbohydrates, diets formulated for patients with CKD are typically higher
 Chronic Kidney Disease in Dogs and Cats 675

in fat compared with maintenance adult foods. Available diets contain 12% to 30%
crude fat (dry matter basis).
Nausea and anorexia associated with chronic renal failure may also occur because
of hypergastrinemia and gastric hyperacidity.17 Dietary protein stimulates gastric acid
secretion; therefore, dietary protein restriction may decrease gastric hyperacidity.
Administration of histamine2-receptor antagonists (famotidine: dogs and cats, 1.1
mg/kg po q 12–24 hours; ranitidine: dogs and cats, 1–2 mg/kg po q 8 –12 hours)19 or
other antacids are beneficial in dogs and cats with CKD; many phosphate binders
also bind gastric acid and act as antacids. Sucralfate (dogs, 0.5–2.0 g po q 6 –12
hours; cats, 0.25– 0.5 g po q 6 –12 hours)19 is an aluminum-containing compound that
binds to exposed submucosal collagen in an acidic environment and may have
cytoprotectant effects via prostaglandin E2. It is used to treat active gastric ulcers, but
may also act as an antacid and phosphate binder. Maropitant (dogs and cats: 2– 8
mg/kg po q24h; although not recommended for more than 5 days)19 is an anti-emetic
that inhibits neurokinin-1; it is used for motion sickness but is effective with many
other causes of vomiting including uremic gastroenteritis. Mirtazapine (dogs, 15–30
mg po q 24 hours; cats, 1.875–3.75 mg po q 48 –72 hours)19 is a noradrenergic and
serotonergic antidepressant that stimulates appetite and has antiemetic properties. In
cats with CKD, it should be administered every 48 hours.20 Metoclopramide (dogs
and cats, 0.1– 0.5 mg/kg po q 6 –24 hours),19 an intestinal prokinetic agent that has
central antiemetic effects via dopamine receptor antagonism, may also be used
although it is less effective than serotonin receptor antagonists in uremic human
beings.21
In patients that are unwilling or unable to eat, nutrition may be provided by feeding
tubes including nasogastric, esophagostomy, and gastrostomy feeding tubes.22–26 A
study of 56 dogs with renal failure were managed with gastrostomy feeding tubes; 10
were low profile and 46 were standard mushroom-tipped tubes.27 Gastrostomy tubes
were used for 65 ⫾ 91 days (range, 1– 438 days). Eight dogs gained weight, 11 did not
have a change in BW, and 17 lost weight; information was not available for 20 dogs.
Mild stoma-site complications included discharge, swelling, erythema, and pain in 26
(46%) of dogs. Twenty-six gastrostomy tubes were replaced in 15 dogs; 11 were
replaced because of patient removal, 6 were replaced because of tube wear, and 3
were replaced for other reasons. Three dogs were euthanatized because they
removed their gastrostomy tubes, 2 were euthanatized because of evidence of tube
migration, and 1 died of peritonitis. Based on this report, gastrostomy tubes appear
to be safe and effective for improving nutritional status of dogs with renal failure. In
another report, 96% of owners of dogs or cats managed with gastrostomy feeding
tubes had a positive experience and would use a gastrostomy feeding tube again in
their pet if necessary.28
In addition to providing calories (energy), there are specific nutrients that may
alter progression of CKD in dogs and cats. With a decrease in numbers of
functioning nephrons, pressure inside remaining nephrons increased; this is
termed intraglomerular hypertension.29,30 The intraglomerular hypertension in-
creases the filtration rate in the remaining nephrons. The tradeoff of intraglomeru-
lar hypertension is damage to these nephrons over time. In dogs with induced
CKD, feeding diets containing omega-3 fatty acids has been shown to decrease
intraglomerular hypertension, maintain glomerular filtration rate, and increase
survival.31–34 In dogs fed omega-3 long chain fatty acids, renal function actually
increased and remained above baseline over 20 months of the study. Glomeru-
losclerosis, tubulointerstitial fibrosis, and interstitial inflammatory cell infiltrates
were less in dogs fed an omega-3 fatty acid–supplemented diet compared with
676 Bartges

dogs fed an omega-6 fatty acid–supplemented diet.32 Omega-3 fatty acids reduce
hypercholesterolemia, suppress inflammation and coagulation, lower blood pres-
sure, and improve renal hemodynamics. An omega-6 –to– omega-3 fatty acid ratio
of 3:1 to 5:1 appears to be beneficial and is present in many renal failure diets.
B vitamins are water-soluble vitamins and may be decreased with CKD due to the
polyuric state. B vitamin deficiency may be associated, in part, with hyporexia/
anorexia, which occurs commonly with CKD. A recent study showed that B vitamin
deficiency is not common in patients with CKD.35 Nonetheless, diets formulated for
CKD in dogs and cats are supplemented with B vitamins.
Oxidative stress may be an important component of CKD. Renal cells, particularly
renal tubular cells, are among the most metabolically active cells. The kidneys
maintain persistently high levels of mitochondrial oxidative phosphorylation and
arterial blood flow, making them an environment in which reactive oxygen species
formation occurs.36 Important factors in generation of reactive oxygen species
include angiotensin II, glomerular hypertension, hyperfiltration, tubular hypermetab-
olism, systemic arterial hypertension, anemia, regional hypoxia, and renal inflamma-
tion.37,38 The result of reactive oxygen species formation may be glomerulosclerosis
and interstitial fibrosis, thereby promoting progression of CKD. Renal oxidative stress
may be decreased by treating systemic arterial hypertension, correcting anemia,
providing omega-3 fatty acids, and treating with angiotensin-converting enzyme
inhibitors.37 In a study of cats with induced CKD, feeding a diet with vitamins C and
E and beta-carotene for 4 weeks decreased evidence of oxidative stress as measured
by serum levels of 8-hydroxy-2=-deoxyguanasine and comet assay parameters.38
Supplementation with omega-3 fatty acids and antioxidants has not been ade-
quately evaluated in cats. A retrospective study on the effects of several renal diets
did find that survival was greatest among cats fed the diet with the highest omega-3
fatty acid content.39 The study, however, was retrospective and it is not possible to
accurately assess effects of dietary omega-3 fatty acids from these data.
Recently, an extract of medicinal rhubarb (Rheum officinale) has become available
for dogs and cats with CKD. Experimentally, it decreases renal fibrosis in an induced
CKD model in rats.40,41 One study of cats with CKD showed no benefit when
administered alone or in combination with benazepril.42

E Electrolytes
The kidneys are involved with regulation of electrolyte balance. Electrolytes are
filtered at the glomerulus, most of the filtered electrolytes are reabsorbed in the
proximal convoluted tubule, and the remainder of the nephron reabsorbs or secretes
electrolytes depending on status. A common electrolyte disturbance in cats and
occasionally in dogs with CKD is hypokalemia,43,44 which has been reported to occur
in 20% to 30% of cats with stage 2 or 3 CKD.2,4 Hypokalemia may occur because of
hyporexia or anorexia, excessive renal losses, transcellular shift due to chronic
metabolic acidosis, and activation of the renin-angiotensin-aldosterone system due
to dietary sodium restriction.45,46 Hypokalemia often manifests as polymyopathy.
Clinical signs include decreased activity and muscle weakness or classically as an
inability for the patient to lift its head while sitting sternally (Fig. 2). Additionally,
hypokalemia may result in hyporexia or anorexia and progression of CKD.2 The target
for plasma or serum potassium concentration should be in the middle to upper half of
reference range for the laboratory. Once hypokalemia is present, whole body
potassium content is low and it is difficult to replete in patients with CKD.47
Diets formulated for use in patients with CKD are supplemented with potassium,
typically using potassium citrate as it is a source of potassium and an alkalinizing
 Chronic Kidney Disease in Dogs and Cats 677

Fig. 2. Hypokalemic polymyopathy in an 18-year-old, castrated male domestic shorthair cat

with chronic kidney disease. Serum potassium concentration was 1.8 mEq/L.

agent. This is based, in part, on diets low in potassium and high in acid content being
implicated in impairing renal function and promoting development of lymphoplasma-
cytic tubulointerstitial lesions in cats.47–51 Potassium may be supplemented orally
using potassium gluconate or potassium citrate. If patients are receiving subcutane-
ously administered fluids, potassium may be added to the fluids up to 30 mEq/L as
potassium chloride.7 Irritation at injection site may occur with concentrations above
this. Potassium chloride may also be added to fluids administered intravenously
depending on blood potassium concentration (Table 4). Rate of administration should
not exceed 0.5 mEq/kg/h because cardiotoxicity may occur. Potassium may be
supplemented orally as well as gluconate or citrate salts; potassium citrate is used
more often as it provides alkalization as well. Potassium gluconate (dogs and cats, 2
mEq/kg po q 12 hours)19 or potassium citrate (dogs and cats, 75 mg/kg po q 12
hours)19 may be administered; dosage is adjusted to achieve a serum or plasma
potassium concentration in the middle to upper half of the reference range. If
hypokalemic polymyopathy is present, it usually resolves within 1 to 5 days after
initiating parenteral or oral potassium supplementation. Typical commercial modified
diets for CKD in dogs and cats contain 0.4% to 0.8% potassium on a dry matter basis
for dogs and 0.7% to 1.2% potassium on a dry matter basis for cats.52

Table 4
Suggested guidelines for intravenous potassium supplementation
Amount of Potassium to Add
Serum Potassium to Lactated Ringer’s Solution Maximum Fluid
(mEq/L) (mEq/L) Rate (mL/kg/h)
⬍2.0 80 6
2.1–2.5 60 8
2.6–3.0 40 12
3.1–3.5 28 18
3.6–5.0 20 25
678 Bartges

Blood sodium concentrations are typically normal in patients with CKD. Sodium
retention may occur with CKD because of intravascular volume contraction. This may
promote systemic arterial hypertension, in part; therefore, dietary sodium restriction
may be beneficial in patients with CKD. Furthermore, there is evidence that excessive
sodium intake may be harmful to the kidneys and excessive salt intake may impair
effectiveness of antihypertensive therapy.53 Excessive dietary sodium restriction may
be detrimental, however. In one study of experimentally induced CKD in cats, dietary
sodium restriction to 50 mg sodium/kg of diet promoted hypokalemia due to
activation of the renin-angiotensin-aldosterone system.46 Additionally, in one study,
dietary intake of sodium at 1.1% as fed was associated with increased azotemia in
cats with CKD54; however, other studies did not find this.55 Typical commercial
modified diets for CKD in dogs and cats contain 0.3% sodium or less on a dry matter
basis for dogs and 0.4% sodium or less on a dry matter basis for cats.52

P pH of Blood (Acid-Base Status)

Metabolic acidosis occurs commonly with CKD due to retention of acids that are
excreted normally by the kidneys. It has been reported that metabolic acidosis occurs
in less than 10% of cats with stage 2 or 3 CKD but in nearly 50% of cats with
uremia.56,57 With CKD, there is increased retention of metabolic acids, increased
production of ammonia, and decreased bicarbonate reclamation with CKD. Metabolic
acidosis is associated with hyporexia/anorexia, hypokalemia, and muscle weakness,
Bicarbonate therapy in human beings with CKD has been reported to slow progres-
sion and improve nutritional status.58 Transcellular shifting of potassium occurs with
metabolic acidosis because the increased hydrogen ion concentration in blood
results in movement of hydrogen ions into cells in exchange for potassium ions that
leave the cell and enter the circulation. Potassium is then excreted resulting, in part,
a propensity for hypokalemia. Acid-base status may be assessed by measuring blood
pH and bicarbonate concentration on an arterial or venous blood gas analysis.
Measurement of plasma or serum bicarbonate, also called total carbon dioxide, gives
a measure of acid-base status. The goal of treatment is to maintain a normal
concentration; in human beings with stage 3 or 4 CKD, a low or high serum
bicarbonate concentration is associated with increased mortality.59 There are several
treatments for metabolic acidosis. Many renal failure diets are formulated to contain
an alkalinizing agent usually potassium citrate, which is also a source of potassium.
Because metabolism of dietary protein results in production of organic acids, dietary
protein restriction decreases amount of organic acid that must be excreted by
kidneys. Supplemental alkalinizing agents may be administered including potassium
citrate or sodium bicarbonate. Potassium citrate (dogs and cats, 75 mg/kg po q 12
hours initially)19 is preferred because it provides potassium in addition to its
alkalinizing properties. Sodium bicarbonate (dogs and cats, 8 –12 mg/kg po q 8 –12
hours)19 administration provides alkalization but may worsen systemic arterial hyper-
tension and fluid retention due to the sodium load.

P Proteinuria
Proteinuria occurring in association with CKD in dogs and cats is associated with
progression.5,6,60 Proteinuria is considered a hallmark of glomerular disease; how-
ever, proteinuria appears to be nephrotoxic even without overt primary glomerular
disease.61 In humans with CKD, reducing proteinuria slows progression; however, no
such evidence exists for dogs and cats with CKD.62– 65 Proteinuria may promote
progressive renal injury by several mechanisms including mesangial toxicity, tubular
overload and hyperplasia, toxicity from specific filtered proteins (eg, transferrin), and
 Chronic Kidney Disease in Dogs and Cats 679

induction of proinflammatory molecules (eg, monocyte chemoattractant protein-1).

Excessive proteinuria may injure renal tubules via toxic or receptor-mediated path-
ways or an overload of lysosomal degradative mechanisms. The abnormally exces-
sive filtered proteins accumulate in proximal tubular lumens, are endocytosed into
proximal tubular cells, and contribute to tubulointerstitial injury through upregulation
of vasoactive and inflammatory genes and by secretion into peritubular tissue where
they incite inflammation.66 Additionally, components of complements may enter
filtrate and initiate interstitial injury, and filtered proteins may form casts obstructing
tubular flow.
Proteinuria is often detected by a positive semiquantitative test on routine urine
dipsticks. It is further localized to pre-renal, renal, or postrenal causes. The most
common causes of proteinuria are postrenal including urinary tract infection or
inflammation (exudation of plasma proteins into the urine) and hematuria (loss of
plasma proteins with red blood cells). Prerenal causes of proteinuria include hemo-
lysis (hemoglobinuria) and hyperglobulinemia (eg, plasma cell myeloma). Proteinuria
is localized to renal causes after prerenal and postrenal causes have been ruled out.
Renal proteinuria is often considered glomerular in nature; however, tubular disorders
(eg, Fanconi syndrome) and interstitial disorders result in proteinuria as well albeit to
a lesser degree. Once prerenal and postrenal causes have been excluded, verification
and quantitation of renal proteinuria are made by determining a UPC. Healthy dogs
and cats have a UPC less than 0.2; between 0.2 and 0.4 in cats and 0.5 in dogs is
borderline proteinuria, and greater than 0.4 in cats and 0.5 in dogs is abnormal. In
dogs and cats with CKD, treatment is indicated when the UPC is greater than 2.0
in stage 1 CKD and when the UPC is greater than 0.4 in cats and greater than 0.5 in
dogs in stages 2 through 4 CKD.8 In humans with CKD, reducing proteinuria slows
progression; however, no such evidence exists for dogs and cats with CKD.62– 65
Treatment of renal proteinuria involves decreasing filtration and loss of proteins,
principally albumin. Feeding a protein-restricted diet decreases the degree of renal
proteinuria.8,67 Angiotensin-converting enzyme inhibitors (enalapril and benazepril:
dogs and cats, 0.25– 0.1.0 mg/kg po q 12–24 hours)19 have also been shown to
decrease proteinuria in dogs and cats.62– 64 Benazepril has been advocated over
enalapril because benazepril’s biliary excretion may compensate for reduced renal
clearance in patients with CKD. Serum/plasma creatinine concentration should be
evaluated approximately 7 days after initiating therapy with angiotensin-converting
enzyme inhibitors. An increase of greater than 0.2 mg/dL indicates a decrease in
glomerular filtration rate secondary to therapy and the dosage should be adjusted.
Omega-3 fatty acids, specifically eicosapentaenoic acid (EPA) and docosahexaenoic
acid (DHA), are also beneficial with renal proteinuria.31–34 An omega-6 –to– omega-3
fatty acid ratio of 3:1 to 5:1 appears to be beneficial and is present in many renal
failure diets. Omega-3 fatty acids may also be supplemented to dogs and cats, if
necessary (300 mg of EPA ⫹ DHA per 10 –22 kg po q 24 hours). Immunosuppressive
therapy may be considered for dogs with primary glomerular proteinuria as approx-
imately 50% of evaluated renal biopsies from dogs with glomerular proteinuria have
an immune-mediated basis.

H Hydration
Patients with CKD are polyuric due to decreased ability to concentrate urine from
decreased nephron mass. Polyuria is offset by polydipsia. Because of polyuria,
dehydration may occur if water loss exceeds water intake. This occurs more often in
cats than in dogs with CKD. In patients that are dehydrated, parenteral fluid is
administered.68 Intravenous administration is preferred over other parenteral routes.
680 Bartges

Intravenous fluid therapy is composed of 3 components: amount necessary for

rehydration, maintenance fluid requirements, and amount to treat additional losses
(eg, vomitus, diarrhea, etc).
• Amount needed for rehydration in milliliters is estimated by multiplying esti-
mated percentage of dehydration by BW in kilograms and multiplying the
resultant product by 1000.
• Maintenance fluid requirements are estimated to be 2.2 mL/BWkg/h
• Amount necessary to replace fluid lost by other routes can be measured or
estimated to be 1.1 mL/BWkg/h.
Dehydration may be prevented by increasing oral water intake by having clean and
fresh water available at all times, by feeding canned formulated diets, or by adding
water to dry formulated diets. Cats may drink more if circulating water fountains are
used. In some patients, particularly cats, supplemental fluid may be provided by
subcutaneous route as they are unable to maintain hydration by oral intake.
Subcutaneously administered fluids are administered using a syringe or bag of fluids
with an extension set and a 20- or 22-gauge needle. The easiest site to administer
fluids subcutaneously is to insert the hypodermic needle in the loose skin located
along the dorsal aspect of the body between the scapulae. Cats that require
supplemental subcutaneously administered fluids often require 75 to 150 mL admin-
istered every 12 to 72 hours. Lactated Ringer’s solution is used most often; however,
other types of fluids may be used. Potassium as potassium chloride may be added to
fluids administered subcutaneously up to a concentration of 20 mEq/L; above this
concentration, administration of the fluid results in discomfort. Some patients do not
tolerate subcutaneously administered fluids. Feeding tubes, such as nasogastric or
more preferred esophagostomy or gastrostomy, may be placed and used. Esopha-
gostomy and gastrostomy feeding tubes include may also be used for diet delivery
and medication administration if the oral route is unavailable.

R Retention of Substances
With CKD, substances that are eliminated normally in urine are retained. These
substances include nitrogenous compounds (blood urea nitrogen and creatinine)
among others. Elimination of nitrogenous compounds is a major function of the
kidneys and retained nitrogenous compounds are associated with clinical signs of
CKD. Azotemia is a hallmark of CKD. Thus, restriction of dietary protein is logical.
Results of studies are contradictory concerning the influence of dietary protein
restriction on progression of CKD.69 –72 Restricting dietary protein may be associated
with a decreased degree of azotemia, decreased dietary phosphorous as meat-based
protein is also high in phosphorous, decreased metabolic acids generated from
dietary protein, and decreased stimulus for gastric hydrochloric acid production and
may reduce dosage of antihypertensive agents and decrease requirement for
erythropoietin.73 Modified diets for managing CKD in dogs and cats typically contain
14% to 20% protein on a dry matter basis for dogs and 28% to 35% protein on a dry
matter basis for cats.52
There are 3 studies of dietary intervention in dogs and cats with spontaneously
occurring CKD: 2 in cats and 1 in dogs.74 –77 In these studies, a diet formulated to
contain lower quantities of protein, phosphorous, and sodium and higher quantities of
potassium, B vitamins, calories, alkalization potential, and omega-3 fatty acids were
compared with a diet that was formulated to be similar to maintenance over-the-
counter adult dog or cat foods. Results of these studies showed benefit in dogs and
cats with CKD: patients lived longer, had fewer episodes of uremia, time to onset of
 Chronic Kidney Disease in Dogs and Cats 681

first uremic episode was longer, and owners perceived quality of life was better.
Although diets formulated for renal failure are lower in protein than over-the-counter
maintenance adult foods, they are still adequate and typically contain higher biologic
value protein.
Prebiotics and probiotics have been suggested to redistribute a small amount of
nitrogen into the gastrointestinal tract for elimination, thus decreasing the degree of
azotemia. Prebiotics are dietary fiber, typically soluble fiber that promotes prolifera-
tion of beneficial bacteria in the colon that metabolizes nitrogen and urea intraluminal.
The proliferation of bacteria also promotes uptake and utilization of intraluminal
nitrogen by the bacteria resulting in less absorption from the colon. Probiotics are live,
nonpathogenic bacteria that are presumed to populate the gastrointestinal tract,
providing the same benefit. One such probiotic (Azodyl; Vetoquinol, Lure Cedex,
France) is commercially available and marketed as “enteric dialysis.” A small
uncontrolled study showed decreased degree of azotemia; however, a controlled
study evaluating administration of the probiotic with and without food failed to show
a benefit.78

O Other Renal Insults—Avoid

Circumstances, drugs, toxins, and infections may compound CKD by inducing a
prerenal azotemia (dehydration) or by affecting remaining nephrons. Dehydration due
to any cause not only is associated with worsening azotemia (prerenal) but may also
precipitate acute kidney injury resulting in progression of CKD. Patients in CKD are
less tolerant of dehydration. Drugs, such as aminoglycosides, urinary acidifiers,
amphotericin, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme
inhibitors, and catabolic drugs (eg, glucocorticoids and immunosuppressive drugs)
may be nephrotoxic. These should be used cautiously or not at all in patients with
CKD. Patients with CKD have a higher incidence of bacterial urinary tract infections,
which has been reported to be 20%. There are several reasons for increased risk of
bacterial urinary tract infections with CKD including dilute urine, premature apoptosis
of white blood cells, decreased white blood cell recruitment and function, and
decreased immunoglobulin concentration in urine. Clinical signs of bacterial urinary
tract infection may be absent. If the infection ascends from the urinary bladder to the
kidneys, it may promote progression of CKD. Prophylactic antimicrobial therapy
should be avoided, if possible, as it may select for multidrug resistant microorgan-
isms. Some antimicrobial agents (eg, aminoglycosides) may be nephrotoxic and many
are excreted renally; therefore, pharmacokinetic parameters may be altered. Addi-
tionally, some antimicrobial agents may cause hyporexia/anorexia, vomiting, and/or
diarrhea that can induce dehydration. Many active bacterial urinary tract infections in
patients with CKD are not associated with pyuria or hematuria; therefore, aerobic
microbial culture of urine collected by cystocentesis may be necessary to document
an active bacterial urinary tract infection.

N Neuroendocrine Function
There are 3 abnormalities of neuroendocrine function that may occur with CKD:
renal secondary hyperparathyroidism, hypoproliferative anemia, and systemic
arterial hypertension.

Renal secondary hyperparathyroidism

Renal secondary hyperparathyroidism occurs commonly with CKD, and the more
advanced the CKD, the more advanced is the renal secondary hyperparathyroid-
ism.76,79 – 84 In extreme cases, renal secondary hyperparathyroidism results in fibrous
682 Bartges

Fig. 3. Renal secondary hyperparathyroidism and fibrous osteodystrophy in an 8-year-old

castrated male Dalmatian with CKD. (A) The maxilla and mandible are enlarged and the
patient cannot close his mouth. (B) Excessive fibrous tissue replacing bone in the maxilla and
mandible in the patient.

osteodystrophy, particularly of the mandible and maxilla; this occurs more commonly
in dogs with congenital or juvenile-onset CKD but may occur in adult patients (Fig. 3).
It occurs, in part, because of phosphorous retention and decreased calcitriol
(1,25-dihydroxy vitamin D3) metabolism. Renal tubular cells contain 1␣-hydroxylase,
which is the enzyme that converts 25-hydroxyvitamin D to the active 1,25-dihy-
droxyvitamin D3. Calcitriol stimulates gastrointestinal absorption of calcium and
phosphorous and inhibits parathyroid hormone production. Parathyroid hormone
stimulates renal reabsorption of calcium and excretion of phosphorous, stimulates
calcium and phosphorous release from bone, and stimulates calcitriol production.
With CKD, there is decreased enzyme activation of calcitriol. In response to
decreased calcitriol, parathyroid hormone production and secretion are increased.
Parathyroid hormone may be considered a uremic toxin. With decreased glomerular
filtration rate, hyperphosphatemia occurs, which may result in dystrophic mineraliza-
tion and progression of CKD and further inhibits calcitriol production. Hyperphos-
phatemia is associated with progression of CKD and shortened survival.
 Chronic Kidney Disease in Dogs and Cats 683

Treatment of renal secondary hyperparathyroidism is aimed at decreasing serum

phosphorous concentrations and possibly parathyroid hormone concentrations. The
goal is to achieve a serum phosphorous concentration of less than 4.5 mg/dL with
stage 2, less than 5.0 mg/dL with stage 3, and less than 6.0 mg/dL with stage 4.
Serum phosphorous concentration may be decreased by feeding a low phosphorous
diet, administering phosphate binders, and possibly administering calcitriol. Typical
commercial modified diets for CKD in dogs and cats contain 0.2% to 0.5%
phosphorous on a dry matter basis for dogs and 0.3% to 0.6% phosphorous on a dry
matter basis for cats.52
There are several phosphate binders that may be used. Conventionally, aluminum
hydroxide (dogs and cats, 30 –100 mg/kg po q 24 hours divided and administered
with meals)19 has been used. Primary side effects are constipation and anorexia,
although aluminum toxicity has been reported with very high dosage. Calcium-
containing phosphate binders, such as calcium acetate (PhosLo; Nabi Biopharma-
ceuticals, Rockville, MD; dogs and cats, 60 –90 mg/kg po q 24 hours divided and
administered with meals)19 and chitosan with calcium carbonate (Epakitan; Veto-
quinol; dogs and cats: 200 mg/kg po mixed with meals)19 may be used. The chitosan
with calcium carbonate phosphate binder has been shown to decrease serum
phosphorous concentrations in cats with spontaneously occurring CKD.85 In addition
to the aforementioned side effects, hypercalcemia may occur particularly if used in
association with calcitriol. Non– calcium- and non–aluminum-containing phosphate
binders include sevelamer hydrochloride (Renalgel; Genzyme, Cambridge, MA, USA;
dogs and cats, 400 –1600 mg po q 8 –12 hours)19 and lanthanum carbonate (Fosrenal;
Shire, Wayne, PA, USA, and Renalzin; Bayer, Newbury, UK; dogs and cats, 30 –90
mg/kg po divided and administered with meals).19 Both of these appear to have
minimal side effects in dogs and cats; however, they have not been evaluated in a
controlled fashion.
Hypovitaminosis D occurs in dogs and cats with CKD, but not until an advanced
stage (stages 3 and 4).80 Benefits of calcitriol therapy in patients with CKD has been
thought to be mediated by its effects on parathyroid hormone and mineral metabo-
lism86; however, other beneficial renal effects have been recognized including
suppression of activity of the renin-angiotensin-aldosterone system, systematic
activation of vitamin D receptors, and reducing podocytes loss associated with
glomerular hypertrophy.87–90 Calcitriol supplementation (dogs and cats: initial dose of
2.0 –2.5 ng/kg po q 24 hours, increase if parathyroid hormone concentrations do not
normalize and decrease if hypercalcemia occurs; do not exceed 5 ng/kg po q 24
hours)7,19 may help decrease serum phosphorous concentration and parathyroid
hormone concentration. Because calcitriol enhances intestinal absorption of calcium
and phosphorous, it should not be given with meals; administration in the evening on
an empty stomach reduces the risk of hypercalcemia.7 When calcitriol therapy is
associated with hypercalcemia, the daily dose may be doubled and given every other
day reducing calcitriol-induced intestinal absorption.91 Calcitriol supplementation
may increase appetite, activity, and quality of life.86 To date, it has been shown to
improve survival in dogs with stage 3 or 4 CKD, but not in stages 1 and 2, and it has
not been shown to be beneficial in cats with any stage CKD.1
Hypoproliferative anemia. A normocytic, normochromic, nonregenerative anemia
often occurs in patients with CKD. Causes of the anemia include decreased renal
production of erythropoietin, nutritional imbalances because of hyporexia/anorexia,
reduced red blood cell life span, and blood loss due to uremic gastroenteritis.92,93
There is evidence that anemia may be associated with progression of CKD due to
decreased blood flow and oxygen delivery, oxidative stress, and induction of
684 Bartges

fibrosis.94,95 It has been shown that patients with CKD have increased survival if the
hematocrit is above 35%. Treatment includes maintaining good nutritional status,
minimizing gastrointestinal blood loss, and stimulating red blood cell production.
Patients with CKD may have blood loss due to uremic gastroenteritis. Hypergas-
trinemia occurs with CKD and gastrin stimulates hydrochloric acid production by
gastric parietal cells resulting in gastric hyperacidity.18,96 Histamine2-receptor– block-
ing agents may be beneficial in decreasing gastric acid production, although they are
not potent and the effect may be transient. Proton pump inhibitors (dogs and cats,
omeprazole: 0.7–2.0 mg/kg po q 12–24 hours; esomeprazole: 0.7 mg/kg po q 12
hours)19 decrease gastric acid secretion by inhibiting the potassium-hydrogen pump
located in the cell membrane; they are the most potent antacids. Sucralfate is also an
antacid that has phosphate binding properties and is used to treat active gastric ulcer
disease.
Red blood cell production by bone marrow may be stimulated pharmacologically.97
Anabolic steroids have been used to stimulate red blood cell production and to
stimulate appetite. While they may stimulate appetite and increase lean muscle mass,
they have minimal effect in promoting red blood cell production and may induce
hepatopathy. In addition to anabolic steroids, other hormones may be supplemented
including erythropoietin (dogs and cats, initial dose of 100 IU/kg subcutaneously 3
times per week and adjust based on hematocrit)19 and darbepoetin, a longer-acting
form of erythropoietin (induction phase: 1.5 ␮g/kg subcutaneously q 7 days and when
desired target hematocrit is reached the dosage is decreased to q 14 days; frequency
or amount of dosage is adjusted depending on response).7,97–99 Studies with
erythropoietin have shown that dogs and cats with CKD feel better even before
hematocrit is increased. The main limitation of erythropoietin administration is
development of antierythropoietin antibodies, which occurs in 20% to 70% of
patients.98,100 There have been no controlled studies with darbepoetin. Because of
antibody production, it has been recommended to begin erythropoietin therapy when
the hematocrit is less than 20% or in patients that do not feel well that are anemic but
not to that degree. Darbepoetin may be started at a lesser degree of anemia because
of the decreased risk of antibody production. Because uremic gastroenteritis is
common, iron should be supplemented to offset the iron deficiency associated with
blood loss (ferrous sulfate: dogs, 100 –300 mg po q 24 hours; cats, 50 –100 mg po q
24 hours; iron dextran: dogs, 10 –20 mg IM q 3– 4 weeks; cats, 50 mg intramuscularly
q 3– 4 weeks).19 Additionally, infections should be treated to minimize iron seques-
tration that may result in decreased effectiveness of erythropoietin and darbepoetin
administration. It is the author’s opinion that a hematocrit of 35% to 40% is the goal.
This is based on results of a study in cats with CKD where the median packed cell
volume in the group with progressive disease was 32% (interquartile range of
29%–36%) compared with the group with nonprogressive disease where the median
packed cell volume was 36% (interquartile range of 34%– 41%).101 Once the target is
reached, the dosage can be slowly decreased to find the lowest amount necessary to
control anemia. Complications of administration may include irritation at injection site,
systemic arterial hypertension, and polycythemia.97 In patients that initially respond
but in whom the hematocrit begins to decline, suspect antibody production against
the recombinant human erythropoietin. Additionally, ensure iron deficiency has not
occurred, which would result in decreased red blood cell production.
Systemic arterial hypertension. Systemic arterial hypertension has been reported to
occur in up to 65% to 75% of dogs and cats with CKD.102 It occurs, in part, because
of activation of the renin-angiotensin-aldosterone system, increased vasopressin
(antidiuretic hormone) levels, and increased sympathetic tone. Indirect determination
 Chronic Kidney Disease in Dogs and Cats 685

Fig. 4. Hypertensive retinopathy and blindness in a 14-year-old, spayed female domestic

shorthair cat with CKD. (A) The right pupil is dilated due to retinal detachment and hyphema
is present in the left eye. (B) Fundic examination of the right eye shows retinal detachment
and retinal hemorrhage.

of systemic arterial blood pressure is indicated in all patients diagnosed with CKD and
is used to substage CKD. Systemic arterial hypertension may promote progression of
CKD and proteinuria; result in left ventricular hypertrophy and possibly left-sided heart
failure; neurologic signs such as ischemic encephalopathy, seizures, and death; and
ocular disease such as retinal vascular tortuosity and hemorrhage, hyphema, and
blindness (Fig. 4). The risk is moderate to high with a systolic blood pressure greater
686 Bartges

than 160 mm Hg. Diagnosis is made by indirect measurement of systemic arterial

blood pressure, although direct measurement can be performed by cannulation of the
femoral artery. Arterial blood pressure can be determined indirectly using Doppler or
oscillometric instruments. Doppler monitors use the Doppler effect to determine
systolic blood pressure. Although mean and diastolic blood pressures may be
determined using Doppler instruments, they are difficult and inaccurate. Oscillometric
instruments measure systolic, mean, and diastolic blood pressures by detecting
vibrations of the vascular wall. They are easy to use but require good technique.
Indirect blood pressure is usually determined from the palmar, plantar, or coccygeal
arteries.
Unless there is evidence of retinal lesions, neurologic signs, unexplained progres-
sion of CKD, or systolic blood pressure is greater than 180 mm Hg, the decision to
begin antihypertensive therapy is not an emergency. Patients with CKD stages 2 to 4
having arterial systolic blood pressures persistently above 160 mm Hg (AP2; see
Table 1) or patients with CKD stage 1 with arterial systolic blood pressures
persistently exceeding 180 mm Hg (AP3; see Table 1) are candidates for treatment.7
The goal of treatment is to achieve a systolic blood pressure less than 150 mm Hg.
Dietary sodium restriction may aid in decreasing systemic arterial blood pressure and
may potentiate effects of antihypertensive medications. Calcium channel blockers
(amlodipine: dogs, 0.25– 0.5 mg/kg po q 12–24 hours; cats, 0.625–1.25 mg po q
12–24 hours)19 are the most effective antihypertensive drugs used in dogs and cats
with CKD. They decrease systemic arterial blood pressure by inducing arterial
vasodilation and on average decrease arterial systolic blood pressure by 50 mm
Hg.103 Additionally, they may help to decrease degree of proteinuria, but are not as
effective as angiotensin-converting enzyme inhibitors for this. Amlodipine appears
safe with few side effects. Angiotensin-converting enzyme inhibitors (enalapril: dogs
and cats, 0.25–1.0 mg/kg po q 12–24 hours; benazepril: dogs and cats, 0.25– 0.5
mg/kg po q 12–24 hours)19 decrease enzymatic metabolism of angiotensin I to
angiotensin II, resulting in vasodilation and decreased aldosterone production. They
are more effective to decrease degree of proteinuria but on average reduce arterial
systolic blood pressure by 10 mm Hg.104 Administration of angiotensin-converting
enzyme inhibitors may be associated with an increase in the degree of azotemia and
potassium. Laboratory evaluation should be performed 7 to 10 days after initiation or
adjustment of angiotensin-converting enzyme therapy. Angiotensin-converting en-
zyme inhibitors have not been shown to slow down progression of CKD in cats except
in patients with UPC greater than 1.0. Calcium channel blockers and angiotensin-
converting enzyme inhibitors may be used together. Other treatments for systemic
arterial hypertension that may be used include angiotensin receptor blockers (ARBs;
irbesartan: dogs, 5 mg/kg PO q 12–24 hours; or losartan: dogs: 1–5 mg/kg PO q
12–24 hours),19 beta-blockers (atenolol: dogs, 0.25–1.0 mg/kg po q 12–24 hours;
cats, 0.5–3.0 mg/kg po q 12–24 hours),19 alpha-blockers (prazosin: dogs, 1 mg/15 kg
po q 12–24 hours; cats: 0.25– 0.5 mg po q 12–24 hours),19 direct arteriolar vasodila-
tors (hydralazine: dogs, 0.5–2.0 mg/kg po q 12 hours; cats, 2.5 mg po q 12–24
hours),19 and aldosterone receptor antagonists (spironolactone: dogs and cats, 1–2
mg/kg po q 12 hours).19

S Serial Monitoring
Because CKD is dynamic and progressive, serial monitoring should be performed on
all patients with CKD in order to adjust treatment. Monitoring should include body
condition, BW, muscle condition, thoracic auscultation, assessment of hydration
status, indirect measurement of systemic arterial blood pressure, complete blood
 Chronic Kidney Disease in Dogs and Cats 687

count, biochemical analysis, urinalysis, and possibly aerobic microbial culture of urine
collected by cystocentesis. Frequency and extent of monitoring depend on how
rapidly CKD is progressing, any nonrenal influences that may affect renal function,
and owner satisfaction and finances.

HOW CAN TREATMENT OF CKD BE IMPROVED?

Early detection of CKD in patients may be an important factor on response to

treatment. It may be worthwhile to determine serum creatinine concentration and
urine specific gravity at 1 to 2 years of age and yearly beginning at 5 to 10 years of
age. This may provide detection of CKD at an early stage and intervention at this point
may provide better quality of life and longer quantity of life. It is important to keep in
mind that the diagnosis of azotemia using the International Renal Insufficiency Society
system may be different than the normal reference ranges used by your laboratory. It
is recommended to use the values in the International Renal Insufficiency Society
staging system where a serum creatinine greater than 1.6 mg/dL in cats and greater
than 1.4 mg/dL in dogs is considered azotemic. Analytical techniques used to
measure creatinine are consistent across laboratories; therefore, a change in 0.2
mg/dL is considered significant. Also, significant renal disease may be present
without azotemia being present (stage 1). Whenever measuring serum creatinine
concentration, a urine specific gravity must be determined at the same time in order
to interpret the serum creatinine concentration. A complete urinalysis provides much
information concerning urinary tract health and should be collected as part of a
minimum database. Use of the International Renal Insufficiency Society staging
system is important to guide therapy and monitoring and to permit comparison of a
patient’s disease with others. However, treatment should be individualized to the
patient and owners but avoid overtreatment. Minimize or eliminate nonrenal influ-
ences that may affect renal function.
Despite appropriate treatment and monitoring, CKD is ultimately a progressive
disease. Early identification and treatment may modify the rate of progression and
provide for a better quality and longer quantity of life for the patient. Owners can be
educated to evaluate disease by observing changes in water intake, urine volume,
food intake, BW, body and muscle condition, activity, and behavior.

WHEN SHOULD DIET BE CHANGED IN A PATIENT DIAGNOSED WITH CKD?

Dietary modification is an important component of treating patients with CKD. Dietary

modification can be used to offset many deficiencies and excesses that occur with
CKD. It is more than protein restriction as diets formulated for use in patients with
CKD are calorically dense, phosphorous and sodium restricted, have increased
potassium and B vitamins, contain omega 3 fatty acids, contain soluble fiber, and are
alkalinizing. Dietary modification has been shown to increase quality and quantity of
life in dogs and cats with azotemic CKD (stage 2 or higher), but there are no studies
evaluating dietary modification in patients with stage 1, non-proteinuric CKD. None-
theless, in most patients the diet should be changed at the time of diagnosis of CKD.
Furthermore, it is easier to introduce a therapeutic diet when the patient feels good
rather than waiting until the disease process has progressed and introduction of a
therapeutic diet is not possible.

SUMMARY

Many strides have been made in diagnosing and treating dogs and cats with CKD
including dietary modification and pharmacologic therapy. Use of the International
688 Bartges

Renal Insufficiency Society staging system provides a basis for diagnosis and
management and for assessing response to treatment as well as comparison of
results of studies for application to patients.

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