Veterinary Medicine - December 2007 - (Page 796)

Chronic kidney disease O P E E R - R E V I E W E D approach may also be easier for clients. Because recent evidence suggests excessive sodium intake may harm the kidneys, recommendations for long-term sodium administration in any form should be carefully considered.9,10 AMELIORATE THE EFFECTS OF CHRONIC KIDNEY DISEASE Correct clinically apparent anemia. Treating anemia is indicated in a patient with chronic kidney disease stages 3 and 4 when the hematocrit declines below 20% and the patient has clinical signs attributable to anemia. The goal of treatment is increasing the hematocrit to about 30% to 40% in cats and 38% to 48% in dogs. Signs attributable to anemia may include impaired appetite, lethargy, #7 weakness, and decreased social interaction. Administering erythropoietin, either as recombinant human erythropoietin (Epogen—Amgen, Procrit— Ortho Biotech) or darbepoetin alfa (Aranesp—Amgen), is the only effective means of correcting anemia of chronic kidney disease. However, other factors that may exacerbate anemia, including blood loss, iron deficiency, poor nutrition, hyperparathyroidism, and infections, should be ruled out first. Anti-erythropoietin antibodies may develop in some patients, rendering them unresponsive to further recombinant human erythropoietin treatment. Immediately terminate therapy if antibody-associated anemia is suspected. Since canine and feline speciesspecific erythropoietin is not available, closely monitor patients treated with recombinant human erythropoietin for recurrence of anemia, which may herald the onset of anti-erythropoietin antibodies. A newer, longer-acting erythropoietin, darbepoetin, may be less likely to induce anti-erythropoietin antibodies, but experience with darbepoetin in dogs and cats is limited. Monitor dogs and cats treated with erythropoietin weekly until treatment targets have been achieved. Once therapeutic targets have been attained, the packed cell volume should be monitored at least monthly to detect development of anti-erythropoietin antibodies and to adjust dosages or provide supplemental iron as needed. Ameliorate gastrointestinal signs. Dogs and cats with stage 3 or 4 chronic kidney disease may #8 TABLE 4 Therapeutic Measures for Dogs and Cats with Chronic Kidney Disease Measure Feed a renal diet Place a gastrostomy or esophagostomy tube for feeding Initiate dietary phosphorus restriction Parameter or Sign and Kidney Disease Stage Serum creatinine concentration > 2 mg/dl (stages 3 to 4 in dogs and 2 to 4 in cats) Body condition score 4.5 mg/dl in stage 2 Serum phosphorus concentration > 5 mg/dl in stage 3 Serum phosphorus concentration > 6 mg/dl in stage 4 Serum phosphorus concentration > 4.5 mg/dl in stage 2, > 5 mg/dl in stage 3, or > 6 mg/dl in stage 4 despite four to eight weeks of dietary phosphorus restriction Serum potassium concentration persistently 6 mEq/L in any stage of the disease Blood bicarbonate concentration persistently < 18 mEq/L; total carbon dioxide concentration < 19 mEq/L in any stage of the disease Clinical evidence of dehydration and in stages 2 to 4; consider long-term fluid therapy if dehydration becomes persistent Hematocrit 2 in stage 1 Urine protein/creatinine ratio > 0.5 in dogs in stages 2 to 4 Urine protein/creatinine ratio > 0.4 in cats in stages 2 to 4 Administer a phosphate-binding agent Administer potassium Reduce potassium intake Administer sodium bicarbonate or potassium citrate Initiate subcutaneous fluid therapy Administer erythropoietin Administer an H2 blocker Administer an ACE inhibitor Administer amlodipine in cats or Blood pressure > 180/120 mm Hg and in stage 1 amlodipine and an ACE inhibitor in dogs Blood pressure > 160/100 mm Hg and in stages 2 to 4 Administer calcitriol (dogs only) Serum phosphorus concentration < 6 mg/dl and in stages 3 to 4; consider use in stage 2 796 December 2007 VETERINARY MEDICINE

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

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