Chronic renal disease

From Dog
Macroscopic view of a kidney from a dog which died from chronic renal disease due to nephroliths[1]
Renal lymphoma, a slow-growing renal disease[2]
Tubulointerstitial nephritis in a dog which died from chronic renal disease associated with leptospirosis[3]

Chronic renal disease (CRD) is a common disease of the kidney characterized by progressive renal insufficiency due to glomerular loss. In most patients, chronic intermittent acute renal injury is an underlying inciting cause.

Although less frequently observed compared with cats, CRD is relatively common in older dogs and progress over months and years to the point of renal failure.

Chronic renal disease can also occur due to pre-renal causes (e.g. hypertension, thromboembolism, DIC, sepsis) or post-renal causes (e.g. urinary obstruction due to urolithiasis, cystitis, prostate diseases, hydronephrosis[4] or transitional cell carcinoma).

Chronic renal disease is equated with progressive nephron loss due to glomerulonephritis or interstitial nephritis, affecting the glomeruli, tubules, interstitial tissue or renal vasculature Irreversible damage to any portion of the nephron renders the entire nephron nonfunctional.

This insidious loss of nephrons has many underlying causes including:

- Amyloidosis
- Ectopic kidney
- Ureteral disease - ectopic ureter, ureteral stenosis[5], circumcaval ureter associated with portosystemic shunt[6], ureteral atresia, ureteral duplication[7], ectopic ureter[8]
- Fanconi's syndrome
- Polycystic kidney disease
- Renal agenesis
- Renal cysts
- Renal cystadenoma or cystadenocarcinoma[9] - associated with dermatofibrosis in German Shepherds
- Renal dysplasia
- Renal hypoplasia (Ask-Upmark kidney)[10]
- X-linked hereditary nephropathy - Cocker Spaniel
- Familial juvenile glomerulonephropathy (autosomal-recessive) - French Mastiff, Bull Terrier
- Chronic prostatitis
- Chronic cystitis
- Leptospira spp
- Pyelonephritis
- Balamuthia mandrillaris
- Dioctophyme renale
- Pearsonema plica
  • Inflammatory
- Glomerulonephritis
- Uroliths, ureteroliths, nephroliths
- Ureteral trauma during ovariohysterectomy[11]
- Renal transplantation
- Renal cystadenocarcinoma[12]
- Angiomyxoma
- Renal lymphoma
- Oncocytoma
- Urinary bladder transitional cell carcinoma
- Ureteral transitional cell carcinoma
  • Secondary renal disease
- Psychogenic polydipsia
- Diabetes insipidus
- Diabetes mellitus
- Hyperadrenocorticism
- Hypoadrenocorticism
- Nephrotic syndrome
- Prostatic disease

Disruption of the intrarenal renin-angiotensin system is correlated with the severity of kidney disease[13].

Clinically affected dogs present with varying degrees of hypertension, dehydration, metabolic acidosis, azotemia, hyponatremia, variable hyperkalemia and proteinuria.

Complications include chronic cystitis and renal secondary hyperparathyroidism.

Diagnosis can be established based on blood testing, which usually shows varying degrees of nonregenerative anemia (due to myelosuppression), uremia and elevated creatinine as well as radiographs which may reveal small, nodular kidneys and secondary pulmonary mineralization lesions[14].

A urinalysis and urine culture should always be performed to detect hematuria, glycosuria and the presence of bacteria or fungal elements.

Definitive diagnosis requires excretory urography and renal biopsy, with histological changes equating to primary diseases is often similar since the healing of irreversibly damaged nephrons occurs by replacement fibrosis (glomerulosclerosis)[15].

Staging of renal function is usually based on the International Renal Interest Society (IRIS) categories'

Stage Creatinine level Blood pressure Clinical signs
Stage 1 ≤ 140 μmol/L ≤ 160 mm Hg Asymptomatic
Stage 2 140 - 200 μmol/L ~160 mm Hg Asymptomatic
Stage 3 180 - 440 μmol/L ≥160 mm Hg Uremic breath, dehydration, vomiting, dehydration
Stage 4 ≥ 440 μmol/L ≥160 mm Hg Uremic breath, dehydration, vomiting, dehydration, moribund

Management of chronic renal disease in dogs is a multifactorial process. Although the disease is irreversible, the use of dietary and antihypertensive drugs such as benazepril[16] and amlodipine can decrease the progressive nature of canine CRD by reducing intrarenal hypertension and glomerular hyperfiltration[17].

Dietary modification has been shown to increase survival and quality of life and involves more than protein restriction as diets modified for use with CRD are lower in phosphorous and sodium, potassium and B-vitamin replete, and alkalinizing, and they contain n3-fatty acids[18].

The addition of chitosan, calcium carbonate and potassium citrate have also been shown to improve azotemia in these patients and reduce the risk of hyperphosphatemia[19] and thus minimize the risk of secondary hyperparathyroidism.

The long-term prognosis for dogs with chronic renal disease is generally guarded in patients with stages 3 - 4, based on the International Renal Interest Society staging[20].

References

  1. Jeong WI et al (2006) Canine renal failure syndrome in three dogs. J Vet Sci 7(3):299-301
  2. Dog Health Guide
  3. Iowa State Uni
  4. Rigas JD et al (2012) Primary ureteral giant cell sarcoma in a Pomeranian. Vet Clin Pathol 41(1):141-146
  5. Lam NK et al (2012) Endoscopic placement of ureteral stents for treatment of congenital bilateral ureteral stenosis in a dog. J Am Vet Med Assoc 240(8):983-990
  6. Doust RT et al (2006) Circumcaval ureter associated with an intrahepatic portosystemic shunt in a dog. J Am Vet Med Assoc 228(3):389-391
  7. Esterline ML et al (2005) Ureteral duplication in a dog. Vet Radiol Ultrasound 46(6):485-489
  8. North C et al (2010) Congenital ureteral ectopia in continent and incontinent-related Entlebucher mountain dogs: 13 cases (2006-2009). J Vet Intern Med 24(5):1055-1062
  9. Zanatta M et al (2012) Nodular Dermatofibrosis in a Dog without a Renal Tumour or a Mutation in the Folliculin Gene. J Comp Pathol Aug 4
  10. Kolbjørnsen O et al (2008) End-stage kidney disease probably due to reflux nephropathy with segmental hypoplasia (Ask-Upmark kidney) in young Boxer dogs in Norway. A retrospective study. Vet Pathol 45(4):467-474
  11. Ruiz de Gopegui R et al (1999) Bilateral hydroureter and hydronephrosis in a nine-year-old female German shepherd dog. J Small Anim Pract 40(5):224-226
  12. Whitehead ML et al (2012) Elevated serum γ-glutamyltransferase associated with canine renal adenocarcinoma. Vet Rec 170(14):362
  13. Mitani S et al (2012) Association between the Intrarenal Renin-Angiotensin System and Renal Injury in Chronic Kidney Disease of Dogs and Cats. J Vet Med Sci Sep 14
  14. Le Boedec K et al (2012) Pulmonary abnormalities in dogs with renal azotemia. J Vet Intern Med 26(5):1099-1106
  15. Pomeroy MJ & Robertson JL (2004) The relationship of age, sex, and glomerular location to the development of spontaneous lesions in the canine kidney: analysis of a life-span study. Toxicol Pathol 32(2):237-242
  16. Pouchelon JL et al (2004) Long-term tolerability of benazepril in dogs with congestive heart failure. J Vet Cardiol 6(1):7-13
  17. Finco DR (2004) Association of systemic hypertension with renal injury in dogs with induced renal failure. J Vet Intern Med 18(3):289-294
  18. Bartges JW (2012) Chronic kidney disease in dogs and cats. Vet Clin North Am Small Anim Pract 42(4):669-692
  19. Zatelli A et al (2012) Effect of dietary supplements in reducing probability of death for uremic crises in dogs affected by chronic kidney disease (masked RCCT). Scientific World Journal 2012:219082
  20. Polzin DJ (2013) Evidence-based step-wise approach to managing chronic kidney disease in dogs and cats. J Vet Emerg Crit Care (San Antonio) Mar 7