CKD in dogs - urgent help please!

Re: CKD in dogs - urgent help please!

Andrew Kent — Thu, 18 Sep 2014 20:38:24 GMT

[quote user="Rebecca Benge"]

Thanks for the prompt replies! I think I must have used benazepril previously, but then I wanted to double check and couldn't find much in my textbooks except for using in cases of hypertension. It also said use ACEi's with caution (monitor patient for worsening of azotemia or proteinuria), and then I got worried in case using an ACE inhibitor generally was the wrong thing!

So if you had a dog who's diet you couldn't easily change, would you start it on any drugs instead?

The elevated renal parameters were only uncovered on pre-op bloods, at which point the owners then thought to mention that yes he has been drinking more than usual recently... So he's not poorly with it at the moment, but is showing signs of PU/PD. Urinalysis showed SG of 1.016, +++ protein but also some blood and leucocytes. Haematology showed mild anaemia (WBCs not elevated - would you generally expect elevation with a pyelonephritis?).

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pyelonephritis is still possible without neutrophilia so if any doubt I would culture the urune or at least do a good sediment exam rather than dipstick. And UPC would be quite important before considering something like ACEi treatment so that you have a repeatable measure of proteinuria.

Re: CKD in dogs - urgent help please!

John Flynn — Thu, 18 Sep 2014 18:57:40 GMT

[quote user="Martin Atkinson"]

[quote user="John Flynn"]Is the general consensus to use ACEi/ARB in preference to amlodipine in CKD dogs with hypertension/proteinuria then?[/quote]Because the effects on the afferent arteriole different in dogs to cats amlodypine alone can cause decreased glomerular profusion so it is important to give an ACEi (benazepril is best because it is part eliminated via the liver) first to a quieten down the RAAS system and open up the efferent arteriole (or at least that's how I understand it but maybe a physiologist will be along to explain it better.

Anyway the bottom line is: ACEi before amlodypine in dogs, amlodypine is OK alone in hypertensive CKD cats that are non-proteinuric.

[/quote]

Thanks, Martin - that's very helpful.

Re: CKD in dogs - urgent help please!

Martin Atkinson — Thu, 18 Sep 2014 18:32:31 GMT

Anyway the bottom line is: ACEi before amlodypine in dogs, amlodypine is OK alone in hypertensive CKD cats that are non-proteinuric.

Re: CKD in dogs - urgent help please!

John Flynn — Thu, 18 Sep 2014 17:47:08 GMT

Is the general consensus to use ACEi/ARB in preference to amlodipine in CKD dogs with hypertension/proteinuria then?

Re: CKD in dogs - urgent help please!

Gareth Dowdeswell — Thu, 18 Sep 2014 17:40:54 GMT

My understanding from CPD a few years ago was that no one has shown that reducing proteinuria improves outcome, whilst renal diets have been shown to improve outcome.

Re: CKD in dogs - urgent help please!

Thomas Johnson — Thu, 18 Sep 2014 17:38:21 GMT

[quote user="Anthony Dennison"]

One of the vets I work with went one some CPD earlier this week and was told that ACEi's don't affect the outcome of renal disease, it is all down to the diet. How correct is this?

[/quote]

I went on some CPD earlier this year and the evidence presented was that in cats with CKD ACE inhibitors can improve appetite and quality of life, but not survival time.

Re: CKD in dogs - urgent help please!

Rory Bell — Thu, 18 Sep 2014 17:38:15 GMT

Agree with Andy's and Francisco's views above. Only slight difference in approach I might have would be to push the renal diet even in non hyperphosphatemic dogs as it is the one intervention we know will make a difference to survival. Maybe gradually weaning the dog onto the renal diet might be worth considering?

To Anthony: There is evidence that proteinuria and hypertension adversely affects survival in dogs with CKD, but not that treating those things improves survival. ACEi have been proved to improve survival in dogs with proteinuria, specifically Samoyeds with X linked hereditary nephritis. ACEi also improve survival, and can, over a long period of time, lead to an improvement in GFR in people with chronic kidney disease. So although we don't know if they affect survival, we do commonly use ACEi to in hypertensive or proteinuric CKD dogs. The lack of evidence is because the studies to examine this have not been done.

To John: I've not used Telmisartan in dogs. There was an interesting talk on this subject at the recent ECVIM congress. There was experimental data to show that telmisartan was very effective at attenuating the hypertensive response to administration of angiotensin in healthy dogs, but at 3x the current recommended dose. At the standard dose, telmisartan was no more effective than benazepril. There was no data regarding its use in CKD dogs, but the speaker did say that they had used it digs with ACEi refractory proteinuria and had seen some good results.

You are of course correct that using AT1 receptor blockers avoids the 'breakthrough' effect of ACEi resistence seen in about 30% of people on long term ACEi therapy. By selectively blocking the AT1 receptor, these drugs theoretically stop the vasoconstriction and sodium retention mediated by the action of aldosterone at this receptor, but allow aldosterone to target the AT2 receptor which mediates vasodilation and natiuresis.

cheers

Re: CKD in dogs - urgent help please!

Francisco Gomez — Thu, 18 Sep 2014 17:34:34 GMT

[quote user="Rebecca Benge"]

Would starting him on a phosphate binder be worth doing instead, even if his phosphate levels are normal?

[/quote]

As far as I can remember, phosphate binders are used to avoid worsening of CKD because CKD animals struggle to get rid of phosphate. It accumulates in blood and estimulates secondary hyperparathyroidism, worsening the whole clinical picture. But I think that this is all that a phosphate binder will do, it won't reduce protein absorption etc, so a 'bad' diet with renal disease is not going to be a lot better with just a phosphate binder (i guess it is better than nothing tho).

Most phosphate binders are made with calcium, so it is advisable to monitor calcium levels when using these products.

In your case, I would try hard to assess which stage is your patient and how badly affected is your dog. If you are happy with your diagnosis of CKD, bear in mind that CKD dogs will have GI disturbances, so be aware of telling the owners that their dog' sickness and diarrhoea will worsen, and it is not because the diet you're prescribing, but because the disease is worsening!!

Re: CKD in dogs - urgent help please!

Rebecca MacMillan — Thu, 18 Sep 2014 17:30:14 GMT

So if you had a dog who's diet you couldn't easily change, would you start it on any drugs instead?

Re: CKD in dogs - urgent help please!

John Ellis — Thu, 18 Sep 2014 17:06:56 GMT

Further to Francisco's comment above, I agree the IRIS recommendations are really useful... they have published a consensus statement on the treatment of glomerular disease in dogs which I think is an interesting read...

"Consensus Recommendations for Standard Therapy of Glomerular Disease in Dogs"

Does anyone currently use ARB's with dogs? I use Semintra in cats frequently now, but have never used an ARB with a dog as of yet. I think one of the main benefits is that you can't get the 'escape' that you can get with and ACEi, which i'm pretty convinced I have seen in both the canine and feline renal patients I have treated.

I frequently use benazapril in dogs with protein uric renal disease.

Re: CKD in dogs - urgent help please!

Francisco Gomez — Thu, 18 Sep 2014 16:32:20 GMT

Hi Rebecca,

Nowadays, CKD had been well studied and its treatment is becoming more and more standarised.

Would suggest to visit http://www.iris-kidney.com/guidelines/staging.shtml for staging and treatment of CKD.

ACEi are good in certain occasions. They are advised if UPC is high, just because proteinuria is associated with poor outcome, but this doesn't necessarily mean it will always help. I do use it often when I find that most of dogs with CKD will have high BP and ACEi will help reduce this a bit. You're right to think that diet is the mainstream of CKD management.

Hope it helps

Re: CKD in dogs - urgent help please!

Anthony Dennison — Thu, 18 Sep 2014 16:23:33 GMT

One of the vets I work with went one some CPD earlier this week and was told that ACEi's don't affect the outcome of renal disease, it is all down to the diet. How correct is this?

Re: CKD in dogs - urgent help please!

Andrew Kent — Thu, 18 Sep 2014 16:16:42 GMT

Hi Rebecca,

Similar to cats, I would regard ACEi as being useful in the management of proteinuria +/- hypertension in CRF. However due to their potential negative effects on glomerular filtration I would make sure that the azotaemia is stable and document an elevated UPC with inactive sediment on a couple of samples prior to starting.

The main role of diet (without opening another can of worms) is in the phosphate restriction so if the dogs phosphate is normal (and that means low/mid normal not high normal) then you may be ok without. Longer term you could consider a home cooked renal diet if they are very committed and have a specific requirement.

Hope that helps,

Andy