What is the appropriate hospitalized therapy for a dog with chronic kidney disease (CKD) or chronic renal failure (CRF)?

From the Guidelines

Dogs with chronic renal failure who require hospitalization should be treated with intensive supportive therapy, including intravenous fluid therapy and medications to manage electrolyte imbalances, vomiting, and gastric acid, as well as nutritional support and blood pressure management, with the goal of reducing uremic toxins and improving quality of life. The treatment plan should be based on the most recent and highest quality study, which recommends the use of dialysis solutions containing potassium, phosphate, and magnesium to prevent electrolyte disorders during kidney replacement therapy (KRT) 1.

Key Components of Treatment

• Intravenous fluid therapy using balanced electrolyte solutions like lactated Ringer's solution at 2-4 times maintenance rates to correct dehydration and improve kidney perfusion
• Medications to control vomiting, such as maropitant (1 mg/kg SQ once daily) or ondansetron (0.5 mg/kg IV twice daily)
• Gastroprotectants like famotidine (0.5-1 mg/kg IV twice daily) to reduce gastric acid
• Phosphate binders such as aluminum hydroxide (30-90 mg/kg/day divided with meals) to manage hyperphosphatemia
• Nutritional support with a kidney-specific diet low in phosphorus and protein but high in calories
• Blood pressure management with amlodipine (0.1-0.5 mg/kg orally once daily) if hypertension is present
• Potassium supplementation if hypokalemia develops during fluid therapy

Monitoring and Follow-up

• Regular monitoring of blood work, blood pressure, and body weight to adjust the ongoing management plan
• Follow-up appointments to assess the dog's response to treatment and make any necessary adjustments to the treatment plan

Prevention of Electrolyte Disorders

• Use of dialysis solutions containing potassium, phosphate, and magnesium to prevent electrolyte disorders during KRT 1
• Close monitoring of electrolyte levels to prevent hypophosphatemia, hypokalemia, and hypomagnesemia, which are common complications of KRT 1

From the FDA Drug Label

For adult patients with CKD on dialysis: • Initiate RETACRIT treatment when the hemoglobin level is less than 10 g/dL. • If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of RETACRIT. • The recommended starting dose for adult patients is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously For adult patients with CKD not on dialysis: • Consider initiating RETACRIT treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply: o The rate of hemoglobin decline indicates the likelihood of requiring a RBC transfusion and, o Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal • If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of RETACRIT, and use the lowest dose of RETACRIT sufficient to reduce the need for RBC transfusions. • The recommended starting dose for adult patients is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously.

The therapy for dog chronic renal failure is not directly addressed in the provided drug label. However, for adult patients with CKD, the recommended starting dose of erythropoietin is 50 to 100 Units/kg 3 times weekly.

• The decision to initiate erythropoietin therapy should be based on the hemoglobin level and the need for RBC transfusions.
• The dose of erythropoietin should be individualized and adjusted based on the patient's response to therapy.
• It is essential to monitor hemoglobin levels regularly and adjust the dose as needed to avoid RBC transfusions and minimize the risk of adverse reactions 2.

From the Research

Hospitalized Therapy for Dog Chronic Renal Failure

• The basic principles of fluid therapy should be used when constructing a plan for therapy in a dog with renal failure, with intravenous administration of fluids being almost always necessary 3.
• The choice of the type of fluid, solutes, and electrolytes to be administered is based on the predicted abnormalities associated with renal failure as well as the laboratory abnormalities in the dog 3.
• Careful monitoring of the patient and periodic assessment of various laboratory parameters are necessary in order to make appropriate adjustments in fluid therapy 3.
• Chronic renal failure (CRF) is the most common form of renal disease in dogs and cats, and its management involves diagnosis and conservative treatment 4.

Management of Chronic Renal Failure

• The management of CRF in dogs involves guidelines for diagnosis and conservative management, including the use of enalapril to reduce blood pressure and proteinuria 4, 5.
• Enalapril therapy has been shown to have a beneficial effect on renal function and proteinuria in patients with renal insufficiency, and can slow the progression of diabetic nephropathy 6, 7, 5.
• However, enalapril therapy can also cause hyperkalemia, particularly in the setting of salt/volume depletion, and clinical awareness of potential problems is important to assure optimal patient management 6, 7.

Renal Effects of Enalapril Therapy

• Enalapril therapy has been shown to maintain glomerular filtration rate, increase effective renal plasma flow, and reduce microalbuminuria and gross proteinuria in patients with renal insufficiency 7, 5.
• The renal effects of enalapril therapy differ from those of most other conventional antihypertensive medications, and enalapril can reduce blood pressure and proteinuria in hypertensive patients with chronic renal insufficiency 7, 5.