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presence of immune complexes. The treatment goals are to decrease the magnitude of proteinuria and to prevent complications that may be associated with it (e.g., edema, decreased antithrombin concentration leading
to hypercoagulability). The treatment include dietary modification, ACEi/ARBs, and immunosuppression, if the process is immune mediated. ACEi and ARBs decrease proteinuria by decreasing the resistance of the afferent glomerular arteriole, and consequently decrease
the intraglomerular pressure. Thus, serum creatinine concentration should be monitored ~5 days following initiation of treatment to identify any decrease in GFR
in a timely manner. Low dose aspirin has also been recommended if albumin concertation is <2.0 g/dL. When histology supports presence of immune complexes, immunosuppression should be considered.
Hyperphosphatemia and Secondary hyperparathyroidism
Hyperphosphatemia and secondary hyperparathyroidism are inevitable consequences of CKD. Hyperphosphatemia and secondary hyperparathyroidism are controlled using phosphorus restricted diets and phosphorus binders. These drugs bind the phosphorus in the food, thus should not be administered without
it. The most commonly used phosphate binders
are aluminum based or calcium based. In Stage I-III, phosphorous concentration needs to be maintained at the range of 2.7-4.6 mg/dL, and at stage III and IV <5.0 mg/dL and <6.0 mg/dL, respectively. Evidence suggests that judicious use of calcitriol (1.5 to 3.5 ng/kg), prolongs survival in dogs in Stage III when phosphate is controlled and ionized calcium and PTH are monitored.
Anemia is evident mostly in animals in Stage III CKD. There are many potential causes for anemia in patients with CKD, including decreased erythropoietin production, bleeding (mostly to the gastrointestinal tract) and bone marrow dysfunction. The timing for treatment initiation is determined by the severity of the anemia, the degree of clinical signs associated with it, and when the clinician
is convinced that its origin is erythropoietin deficiency.
In most animals anemia is treated when hematocrit is <20%. The two common therapies include erythropoietin and blood transfusions. The latter are used mainly in crisis or when a rapid response in needed. The main complication of erythropoietin treatment is antibody production.
Metabolic acidosis
Metabolic acidosis is a common complication of CKD and is to be expected in late Stage III and Stage IV CKD. The diagnosis of metabolic acidosis is based on total venous CO2 or bicarbonate concentration. Treatment of metabolic acidosis is to be initiated when bicarbonate
is < 18 mmol/L and includes administration of sodium
bicarbonate or potassium citrate.
The main goal of subcutaneous fluid administration
is to prevent dehydration. It is likely that patients that maintain hydration status by drinking enough water to compensate for their fluid losses do not benefit from subcutaneous fluids. Moreover, fluid administration should not be regarded is risk free. Potential side effects of subcutaneous fluids include hypernatremia and worsening pre-existing hypertension, negative effect
on the owner-pet interaction and decrease the patient quality of life. In animals that tend to get dehydrated (especially cats), subcutaneous fluid administration is beneficial and thus might be used on a regular basis. As the disease progresses, this treatment becomes more and more common both in dog and cats.
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