#8 Ameliorate gastrointestinal signs. Dogs and cats with stage 3 or 4 chronic kidney disease may have gastrointestinal complications including reduced appetite,
nausea, vomiting, uremic stomatitis and halitosis, gastrointestinal hemorrhage, diarrhea, and hemorrhagic colitis. Treatment
for these gastrointestinal signs largely focuses on ameliorating uremic gastritis (evidence grade 4) by
1. Limiting gastric acidity with H2 blockers (ranitidine, famotidine)
2. Suppressing nausea and vomiting with antiemetics (metoclopramide, 5-HT3 receptor antagonists such as ondansetron hydrochloride or dolasetron mesylate, or the neurokinin-1 receptor antagonist maropitant
[Cerenia—Pfizer]) or low doses of phenothiazine tranquilizers (prochlorperazine)
3. Providing mucosal protection with sucralfate.
Of these treatments, H2 blockers are most commonly used, and few adverse effects have been attributed to their use. Antiemetics are typically added
when anorexia, nausea, or vomiting persist despite the use of an H2 blocker. Sucralfate is added when gastrointestinal ulcers and hemorrhage are suspected.
PROVIDE RENOPROTECTIVE THERAPY TO SLOW DISEASE PROGRESSION
#9 Reduce the magnitude of proteinuria. Glomerular proteinuria should be reduced in dogs and cats with chronic kidney disease stages 1 through 4. Intervention is
indicated when the urine protein/creatinine ratio exceeds 2 in dogs and cats with stage 1 disease and when it exceeds 0.5
in dogs and 0.4 in cats with stage 2 through 4 disease.11
Proteinuria has been shown to adversely affect outcomes in people, dogs, and cats with chronic kidney disease, presumably
because proteinuria itself appears to injure the renal tubules, thereby promoting progression of chronic kidney disease.11-13 In people, it is well-established that reducing proteinuria by suppressing the renin-angiotensin system ameliorates the
adverse effects of proteinuria on the kidneys. Although qualitatively similar, evidence in dogs and cats is far less compelling.14,15 Studies on the long-term effects of angiotensin-converting enzyme (ACE) inhibitors on survival outcome in proteinuric dogs
have not been reported, and although such studies have been reported in cats, they have failed to yield statistically significant
evidence of enhanced survival. Nonetheless, an ACE inhibitor such as enalapril, benazepril, or lisinopril is recommended in
patients with chronic kidney disease that meet the above criteria (evidence grade 4).11 Ideally, proteinuria should be reduced below the therapeutic target. However, this is typically difficult and may require
higher doses of the ACE inhibitor or the addition of angiotensin II receptor blocking drugs (e.g. losartan or irbesartan). Losartan may be administered at a dose of 0.25 to 0.5 mg/kg/day while monitoring for any changes
in serum creatinine concentration. Dosages may be increased as needed up to 1 mg/kg every 12 hours.
Initially monitor a urine protein/creatinine ratio monthly to ascertain whether the treatment target of normalizing or at
least halving the urine protein/creatinine ratio has been achieved. Once therapeutic targets have been attained, monitor the
urine protein/creatinine ratio every three to four months to ensure continued compliance and therapeutic success at maintaining
#10 Minimize systemic hypertension. Drug therapy to lower blood pressure is indicated in dogs and cats with chronic kidney disease stages 2 through 4 when the
pressure exceeds 160/100 mm Hg and in dogs and cats with chronic kidney disease stage 1 when blood pressure exceeds 180/120
mm Hg.16 Unless hypertensive retinopathy or central nervous system signs are present or the systolic blood pressure remains above
200 mm Hg, determine blood pressure values on at least three separate clinic visits before establishing the need for therapeutic
intervention. The goal of therapy is to reduce blood pressure to below 160/100 mm Hg.
Amlodipine is the first-choice drug for managing elevated blood pressure in cats with chronic kidney disease (evidence grade
2).17 It is typically highly effective in reducing blood pressure in cats, often by as much as 20 to 50 mm Hg. Amlodipine is administered
at a dose of 0.625 mg/cat in cats less than 11 lb (5 kg) and 1.25 mg/cat in cats 11 lb or greater. The dose may be doubled
if response fails to meet treatment goals.