Veterinary Medicine - December 2007 - (Page 795)

The evidence-based medicine hierarchy Because all evidence is not created equal, a four-point system of grading the quality of evidence is used in this manuscript. The grade or score defines the strength and quality of the recommendation. Grade 1, the highest quality evidence, is obtained from at least one properly randomized controlled clinical trial or a meta-analysis of multiple randomized controlled clinical trials. Because such studies likely provide a strong estimate of effectiveness of the treatment when applied to patients in a clinical setting, they provide strong support for a recommendation. Grade 2 evidence derives from studies performed using acceptable laboratory models or simulations in the target species. Because these studies examine the effect of the treatment in an idealized setting, they may or may not represent the true efficacy when applied clinically. Grade 3 evidence involves data obtained from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies, or from uncontrolled studies in which dramatic results are obtained. Grades 2 and 3 evidence provide moderate support for a recommendation. Grade 4 evidence includes recommendations of experts derived from clinical experience, descriptive studies, studies in other species (e.g. people and rodents), pathophysiologic justification, and reports of expert committees; such evidence provides weak support for a recommendation. quate correction of hypokalemia may exceed the citrate dose required to correct acidosis, there is a risk of excessive alkalinization. Starting doses of 40 to 60 mg/kg given orally every eight to 12 hours are recommended. Once therapeutic targets have been attained, re-evaluate dogs and cats receiving alkalinizing therapy every three to four months to ensure continued compliance and therapeutic success at maintaining the target. Maintain hydration. Intervention to correct and prevent dehydration is indicated in dogs and cats with chronic kidney disease stages 2 through 4 with clinical evidence of dehydration. Maintaining hydration in patients with chronic kidney disease depends on adequate compensatory polydipsia. Cats with chronic kidney disease appear to be particularly susceptible to chronic dehydration, perhaps because the magnitude of compensatory polydipsia is inadequate. However, lack of adequate access to good quality drinking water, certain environmental conditions, and intercurrent illnesses that limit fluid intake or promote fluid losses (e.g. pyrexia, vomiting, diarrhea) #6 may lead to dehydration. The clinical consequences of chronic dehydration include decreased appetite, lethargy, weakness, constipation, prerenal azotemia, and predisposition to acute kidney injury. Additional loss of kidney function due to acute kidney injury is a potentially important cause of progression of chronic kidney disease. The goal of therapy is to correct and prevent dehydration and its clinical effects. In patients with signs consistent with chronic or recurrent dehydration, longterm subcutaneous fluid therapy may be considered (evidence grade 4). Typically, a balanced electrolyte solution (e.g. lactated Ringer’s solution) is administered subcutaneously every one to three days as needed. The volume administered depends on the patient’s size, with a typical cat receiving about 75 to 100 ml per dose. If the patient’s clinical response is suboptimal, the dose can cautiously be increased. However, it is possible to induce fluid overload with excessive fluid administration. In addition, sodium-containing fluids used for subcutaneous therapy do not provide electrolyte-free water. A more physiologically appropriate approach is to provide water through a feeding tube. This VETERINARY MEDICINE December 2007 795 http://virbacvet.com http://virbacvet.com

Table of Contents Feed for the Digital Edition of Veterinary Medicine - December 2007

Veterinary Medicine - December 2007 Contents Letters Editors' Guest Thanking Our Valued Reviewers The Veterinary Medicine Interview: Dr. Joseph Harari Clinical Exposures Idea Exchange Answers to Three Commonly Asked Questions About Lyme Disease Practical Ideas for Managing Common Internal Medicine Problems A Tip for Interpreting Leptospira Species Titers Investigating Proteinuric Kidney Disease Counseling New Puppy Owners: Normal Play vs. Aggressive Tendencies 11 Guidelines for Conservatively Treating Chronic Kidney Disease CE Form Product Preview Advertiser Index Marketplace/Classifieds Mind Over Miller Merial Insert

Veterinary Medicine - December 2007

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.