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Acute-on-Chronic Kidney Disease in a Cat

Acute-on-Chronic Kidney Disease in a Cat

Marie A. Chartier, DVM, DACVIM, InTown Veterinary Group (IVG MetroWest)

Urology & Nephrology

|September 2014|Peer Reviewed

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Acute-on-Chronic Kidney Disease in a Cat

Harley, a 15-year-old domestic short-haired cat was hospitalized for acute-on-chronic kidney disease. On admission, he was receiving oral prednisone at 5 mg q24h for feline asthma, fluoxetine at 5 mg q24h for inappropriate urination, and amlodipine at 2.5 mg q24h for hypertension secondary to chronic kidney disease. Mild mature neutrophilia and moderate azotemia were evident on CBC and serum chemistry results, respectively. Remaining parameters were within normal limits. Urinalysis results showed isosthenuria, pyuria, and mixed bacteriuria; urine culture results were pending. Abdominal ultrasonography showed moderate bilateral renal pelvic dilation and subtle hyperechoic areas within the renal cortices. In addition, Harley was persistently hypertensive at 220 mm Hg systolic pressure as measured by Doppler ultrasound. Pyelonephritis was suspected.

Which of the following drugs could be safely administered?

Based on the information provided, how would you grade the following drugs and why? Please click on the red, yellow, or green buttons next to each drug name to indicate its level of safety.

Do Not Use Use Caution Safe

Acetaminophen

Correct ResponseDo Not UseAlthough this patient would most likely benefit from pain management, acetaminophen at any dose is contraindicated in cats. In cats, deficient acetaminophen glucuronidation results in toxic metabolites that may cause methemoglobinemia.

Amoxicillin-clavulanic acid

Correct ResponseSafeAntibiotics are indicated in cases of pyelonephritis, and pending urine culture results, amoxicillin–clavulanic acid is a safe, broad-spectrum antibiotic choice for this patient. Adverse GI effects can occur in cats but are usually minor.

Buprenorphine

Correct ResponseSafePatients with pyelonephritis may need some level of pain control, and buprenorphine is a safe analgesic for cats. Buccal administration is well tolerated and effective.

Cyproheptadine

Correct ResponseDo Not UseSee also mirtazapine for comparison
Cyproheptadine is a safe appetite stimulant for use as an alternative to mirtazapine; however, cyproheptadine is not a good choice in patients receiving fluoxetine because it may decrease or reverse the effects of selective serotonin reuptake inhibitors (SSRIs). It is a good antidote in cases of serotonin syndrome.

Enalapril

Correct ResponseUse CautionControl of hypertension is needed, but options better than enalapril are available. The elimination rate of enalapril may be affected in patients with kidney disease, as it is cleared primarily through renal excretion. A better option may be benazepril, which is cleared in part by the liver and does not accumulate in cats with mild-to-moderate renal insufficiency. Either drug may cause azotemia in some patients by adversely affecting the glomerular filtration rate (GFR). This patient should be monitored closely for worsening azotemia, hyperkalemia, or hypotension if any angiotensin-converting enzyme (ACE) inhibitors is given.

Enrofloxacin

Correct ResponseUse CautionIf urine culture and sensitivity results indicate use of a fluoroquinolone, enrofloxacin is not an ideal choice for kidney disease and, of the veterinary fluoroquinolones, carries the greatest risk for dose-dependent retinotoxicity. Marbofloxacin, pradofloxacin, and orbifloxacin have much lower risks at label doses.

Maropitant

Correct ResponseSafeCats with chronic kidney disease often develop signs of nausea, vomiting, and decreased appetite attributable to uremia. Maropitant is an approved antiemetic for use in cats and, if necessary, would have been a safe, effective choice for this patient. There is no evidence that the dose needs to be adjusted in cats with kidney disease. This neurokinin-1 receptor antagonist may also aid in treating visceral pain.

Meloxicam

Correct ResponseDo Not UseNSAIDs should not be used in cats that are dehydrated or have preexisting renal disease (ie, considerable risk for renal toxicity). NSAIDs should not be given with prednisone because the combination can exacerbate adverse GI effects (eg, ulceration).

Mirtazapine

Correct ResponseDo Not UseThe use of mirtazapine with fluoxetine, an SSRI, is contraindicated, as it can cause serotonin syndrome. In addition, mirtazapine should be used with caution in patients with reduced renal function, as drug clearance may be impaired.

Sucralfate

Correct ResponseSafeAlthough sucralfate administration is not contraindicated in this patient, the benefits are limited unless oral, esophageal, gastric, or duodenal ulceration is suspected. Sucralfate has a local rather than systemic effect, as it binds to ulcerated tissues. Sucralfate may also decrease absorption and efficacy of any aluminum-containing medications (eg, fluoroquinolones) that may be used in this patient.

References and Author Information

For global readers, a calculator to convert laboratory values, dosages, and other measurements to SI units can be found here.

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