Affects: Cats
The chronic kidney disease of the cat (CKD or CNE)—also called chronic renal insufficiency (CRI or CNI) or chronic renal failure (CRF) in the older literature—is an incurable, progressive disease characterized by a gradual decrease in the nephrons and thus to a decreasing function (insufficiency) of the kidneys. It is one of the most common causes of death in older domestic cats. In current literature, the term "kidney disease" is preferred to the term "renal insufficiency" because the disease initially progresses without any measurable decline in kidney function. Due to the different type of diet and the resulting metabolic peculiarities, the clinical picture and treatment sometimes differ significantly from chronic renal failure in humans.
Chronic kidney disease occurs in cats as a result of inflammation of the renal tubules and the renal interstitial tissue without an identifiable cause (idiopathic tubulointerstitial nephritis). The main symptoms are a reluctance to eat, increased drinking, increased urine output, fatigue, vomiting and weight loss. Chronic kidney disease in cats is divided into four main stages based on the creatinine concentration in the blood plasma, which are further subdivided according to the protein-creatinine quotient in the urine and blood pressure. Treatment is mainly based on reducing the protein and phosphate content of the diet to the basic requirement ("renal diet"). In addition, the numerous secondary symptoms resulting from renal dysfunction, such as disorders of the water, electrolyte and acid-base balance, increased blood pressure, anemia and digestive disorders are treated with medication. If detected and treated early, the progression of the disease can be slowed, the quality of life improved and the life expectancy of the animals increased.
Symptoms: The main symptoms of chronic kidney disease in cats are lack of appetite (anorexia), increased drinking (polydipsia), increased urine output (polyuria), fatigue (apathy), vomiting and weight loss. In addition, diarrhea, inflammation of the oral mucosa (stomatitis) with the formation of ulcers (ulcera), increased salivation (hypersalivation) and bad breath may occur as a result of uremia. Increased blood pressure (arterial hypertension) with damage to the eye (fundus hypertonicus, hypertensive retinopathy), anemia (anemia), itching, dehydration, soft tissue calcifications, bleedings and accumulation of water in the tissues (oedemas) are also more frequent accompanying symptoms. In the case of severe uremia, neurological neurology manifestations such as apathy, seizures, delirium, coma, abnormal movements and muscle disorders (myopathies). Typically, the symptoms—in contrast to acute renal failure—occur gradually over weeks, months or even years, and the general condition is poor. In addition, acute kidney failure is initially characterized by reduced urine production. However, an existing mild or moderate chronic kidney disease is often suddenly worsened by an acute event ("exacerbation") and thus becomes conspicuous to the cat owner. This can be the case, for example, if one kidney has already become a non-functioning shrunken kidney due to urinary retention and the second suddenly swells acutely due to urinary retention (hydronephrosis) and is damaged ("large kidney-small kidney syndrome") or if hyperthyroidism is treated and the glomerular filtration rate is suddenly reduced as a result.
By palpation, the kidneys can be checked for pain, firmness (consistency), enlargement or reduction in size and changes in surface structure. A healthy kidney is about 4 cm long, 3 cm wide and 2–3.5 cm thick. In the most common form—CNE due to tubulointerstitial nephritis—the kidneys are usually reduced in size and have an irregular surface; in the case of tumors or pyelonephritis, they may be enlarged and sensitive to pain. Since the degree of protein loss via the urine is directly related to the increase in blood pressure, regular blood pressure measurement is advisable.
An X-ray examination can be used to detect changes in the size, density and position of the kidneys as well as some urinary stones (struvite and calcium oxalate stones are "radiopaque") and soft tissue calcifications. In severely emaciated cats or fluid accumulations in the retroperitoneal space, however, the kidney can only be visualized to a limited extent on the X-ray image due to the resulting reduction in contrast. Excretory urography, in which a radiopaque contrast medium (e.g. Iopamidol, Iohexol) is injected into the bloodstream and its excretion via the kidneys is recorded radiographically. This makes it possible to detect circulatory disorders, dysfunctions of the renal corpuscles and obstructions of the outflow pathways.
The ultrasound examination allows morphological changes in the kidneys in more detail. In addition to changes in size and shape, renal cysts, localized (focal) organ damage, water sac kidneys and urinary retention as well as tumors can also be visualized. Hardly defined (diffuse) organ changes are accompanied by changes in echogenicity, but can only rarely be assigned to defined diseases. Pulsed Wave Doppler" can also be used to detect circulatory disorders. Calcification (nephrocalcinosis) is also common in chronic kidney disease and can also be detected sonographically.
Renal biopsy is not routinely used, but may be indicated in certain preliminary reports—for example, young Abyssinian cats with symptoms of kidney disease for the detection of amyloidosis. Although computed tomography and magnetic resonance imaging have very good detail recognition, they only play a subordinate role in veterinary medicine due to their high costs and limited availability.
Pathophysiological Basics: Symptoms of the disease only appear at an advanced stage, when more than two-thirds of the original kidney function has already been lost. This is due to the body's own compensatory mechanisms and the kidney's reserve capacity, which can compensate for the reduced kidney function for a long time and maintain the excretion of urine-requiring substances. With the loss of functioning nephrons—the functional structural unit of the kidney—the filtering capacity of the renal corpuscles (glomerular filtration rate) decreases and with it the excretory capacity for urinary substances. Acute damage to the tubules can regenerate again if the basement membrane is preserved. However, if a section of the nephron is irreversibly damaged, the entire nephron dies.
The increased urea levels in the blood (uremia) lead to nausea and vomiting for various reasons. Firstly, they directly irritate chemoreceptors in the chemoreceptor trigger zone in the brain. Secondly, they increase gastrinsecretion and thus lead to an increase in gastric acid production and thus to hyperacidity of the stomach. Finally, they cause vascular inflammation (uraemic vasculitis), which leads to further damage to the digestive tract.
As a result of the accumulation of phosphate in the blood (hyperphosphatemia) and the reduced formation of calcitriol in the remaining main parts, there is a drop in the calcium blood level (hypocalcemia) and increased parathyroid hormone is released from the parathyroid gland. Chronic kidney disease leads to hyperparathyroidism in 84% of cases (secondary renal hyperparathyroidism). Among other things, the parathyroid hormone causes calcium and phosphate to be released from the bones, which ultimately leads to renal bone disorders and calcification of the kidneys, skin, heart and blood vessels. In the kidneys, this calcification contributes to further destruction of the kidney tissue. The reduced responsiveness of the parathyroid cells to calcium disrupts the negative feedback of parathyroid hormone secretion, so that parathyroid hormone continues to be secreted despite the increase in calcium levels. As less phosphate reaches the renal tubules due to the reduced filtration rate, the inhibitory effect of parathyroid hormone on reabsorption in the main body has only a minor effect on the blood phosphate level.
The loss of nephrons and the associated decrease in the number of sodium ion channels leads to a decrease in the concentration gradient in the kidney. However, this is the driving force for water reabsorption in the mid-piece and—in the presence of ADH—also in the collecting ducts. The result is a loss of water via the urine and thus drying out of the body, which is exacerbated by the loss of fluid during vomiting.
Treatment: The options for kidney replacement therapy are severely limited in cats, as kidney transplants and hemodialysis in veterinary medicine are only carried out in exceptional cases due to the high equipment, logistical and financial costs involved. The aim is therefore to detect chronic kidney disease at the earliest possible stage, when the kidneys still have sufficient reserve capacity. At the same time, attempts are made to reduce the amount of urinary substances—especially nitrogen compounds and phosphate—in the diet by means of dietary measures. Finally, metabolic imbalances and sequelae must be buffered. From a plasma creatinine level of [dose — ask your vet]/dL (618.8 μmol/L), however, drug therapy is not very promising.
Treatment Prospects: It is not possible to restore lost nephrons, so that all therapeutic measures only result in an increase in quality of life and lifespan. The treatment prospects is strongly dependent on the degree of azotemia, protein loss via the urine, hyperphosphatemia and uremia as well as the hematocrit. In stage 2, a low hematocrit and a high urine protein-creatinine ratio, and in stage 3 hyperphosphatemia are prognostic for progression of CNE. A new prognostic parameter is fibroblast growth factor 23, as it indicates an early derailment of mineral metabolism. The average survival time in a recent study was 1151 days in stage IIb cats, 778 days in stage III and only 103 days in stage IV. The consistent use of phosphate-reduced kidney diets shows quite good results up to stage III. If the measures taken do not work, the only option for advanced kidney disease is often euthanasia.