Chronic Renal Failure

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Littman 3 hours

How does the prognosis for CRF differ in dogs and cats?

cats usually stay stable longer, dogs get progressive CRF

What determines the signs and treatment in CRF?

part of the nephron damaged

With tubular>glomerular disease or if there is whole nephron loss what will biopsy show?

chronic tubulointerstitial nephritis, lymphocytes, plasma cells, super nephrons

What kinds of diseases cause tubular>glomerular damage?

renal dysplasia, end-stage fibrotic with fetal glomeruli

In which species is glomerular>tubular damage more common? What is seen in urine? What happens first, azotemia or PU/PD? What might biopsy show?

dogs, proteinuria, azotemia, glomerulonephritis, glomerulosclerosis, amyloidosis

What are the renal reserve numbers for dogs?

50% normal clinically, 67% become PU/PD, 75% PU/PD and azotemia

What happened with feline renal mass reduction experiments?

After 1 and 5/6 kidney reduction creatinine still only 2.5 and could still concentrate urine (1.035)

What are some morphologic changes of surviving nephrons in CRF?

super nephrons become hypertrophied, hyperplastic

What are some function responses of nephrons in CRF?

increased single nephron GFR (but still summation decrease GFR), stop regulating BUN/creatinine, keep regulating electrolytes

Give an example of the trade off hypothesis in CRF.

Mild hypertension helps increase GFR but can cause organ damage (retinal detachment and stroke)

Why might increasing PTH in CRF end up being a bad thing?

increases serum Ca dn phosphorus excretion, but is a uremic toxin

What are the four stages of chronic kidney disease?

non-azotemic (may be PU/PD, decreaed GFR); mild (azotemia, mild or no signs), moderate (azotemic, signs, hyperphosphatemia), severe (end stage)

What are the borderline proteinuric and proteinuric levels (for UP/C ratio) in IRIS guidelines?

0.2-0.4 in cats and 0.2-0.5 in dogs; greater than either is proteinuric

What creatinine level is considered severe renal azotemia in the IRIS guidelines?

>5.0

What three things are used to stage renal failure patients with IRIS guidelines?

azotemia, UP/C, blood pressure

Name 3 vascular causes of CRF

emboli, infarcts, hypertension

Name 4 infectious causes of CRF

bacterial (pyelonephritis), spirochetes (Lyme, Lepto), rickettsial (RMSF), viral (FeLV, FIP)

Name 3 toxic causes of CRF

aminoglycosides, NSAIDs, cisplatin

Name 5 autoimmune causes of CRF

immune-mediated glomerulonephritis, lupus, lyme, HW (wolbachia), babesia

Name 2 metabolic causes of CRF

hypercalcemia, hyperthyroidism

Name two neoplastic causes of CRF (bilateral)

LSA, hemangiosarcoma

What are four things that contribute to the development of PU/PD in CRF?

osmotic diuresis (increased solute load), pressure diuresis (increased single nephron GFR), nephrogenic DI, medullary washout

Why is there anemia with CRF?

decreased EPO, GI ulcers, increased fragility of RBCs

What GI signs are seen with CRF?

vomiting/nausea (uremic toxins act on CRTZ), inappetance, ulcers (increased gastrin)

What happens with renal secondary hyperparathyroidism?

increased phosphorus causes increased PTH, and parathyroid hypertrophy and increased serum Ca++

What two processes happen to cause rubberjaw in young puppies?

decreased active vitamin D leads to hypocalcemia and decreased GFR leads to hyperphosphatemia, both lead to increased PTH levels

What Ca x Phos level can lead to soft tissue mineralization? Target organs?

70, renal tubules, gastric mucosa, small arterioles, aorta, CNS, lungs

How do the parathyroid glands change with renal failure?

no change if acute, large if chronic

How does CRF lead to hypertension?

kidney not able to excrete enough NA or RAA activation

What metabolic acid/base imbalance are CRF patients predisposed to?

metabolic acidosisj (can't excrete enough acid or resorb bicarbonate)

What is renal tubular acidosis?

Loss of bicarbonate ions

CRF patients may show peripheral _______ resistance.

insulin

What might the history of a CRF patient be?

decreased appetite, weight loss, PU/PD, vomiting

Two PE signs that might be seen with PLN?

edema and saddle TE

Chemistry changes with CRF? BUN? Creat? Phosphorus? Potassium?

all increased except potassium (can be high, low, normal)

Two chemistry changes with PLN?

hypoalbuminemia and hypercholesterolemia

CRF patients will be isosthenuris unless...

PLN

Ultrasound of ______ may be useful to determine ARF from CRF

parathyroids

What test is more sensitive than creatinine to show decreased GFR?

cystatin c

What plasma clearance tests can show decreased GFR in PU/PD cases before azotemia is present?

iohexol or inulin

When might you do an FNA on kidneys? Wedge biopsy?

big or LSA kidneys, renal dysplasia

If an animal is thin with small kidneys is it likely CRF or ARF?

CRF

What CBC/Chem result can help differentiate CRF from ARF?

anemia

Given the same degree of azotemia, which will feel better an ARF or CRF patient?

CRF

Two additional blood tests for differentiating ARF from CRF?

carbamylated hemoglobin or PTH/Vit D assay

In a renal biopsy to differentiate ARF from CRF what are you looking for?

fibrosis

Three things to look for in CRF diets?

low protein, low phosphorus, Omega 3 PUFA

Two types of diets to avoid in CRF?

salty and acidifying

Why be careful with Calcitriol treatment in CRF?

can cause soft tissue mineralization

Main medications to treat PLN?

ACE inhibitors

What home treatment is especially useful in cats?

SQ fluids

Name some classes of drugs that might be used to treat CRF?

Phosphate bindres, antiemetics, antacids, antiulcer meds, alkalizers, antihypertensives, K supplement (cats)

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