网页内容摘要

这篇文章是美国兽医内科学院(ACVIM)心脏病专科共识小组关于犬只慢性瓣膜心脏病(CVHD)的诊断和治疗指南。CVHD是北美兽医实践中约75%的犬心脏病例的主要原因，主要影响左房室或二尖瓣，约30%的病例也涉及三尖瓣。该病在雄性犬中的发病率比雌性高1.5倍，在小型犬(<20kg)中更为普遍。文章介绍了一个新的心脏病分类系统，将犬心脏病分为四个阶段：A阶段(高风险但无结构异常)、B阶段(有结构异常但无临床症状，进一步分为B1和B2)、C阶段(有过去或当前心力衰竭临床症状)和D阶段(终末期疾病，对标准治疗无反应)。文章详细讨论了每个阶段的诊断标准和治疗建议，包括药物治疗、饮食管理和监测策略，并特别区分了急性住院治疗和慢性家庭管理的不同方法。

与犬只心脏病的钠摄入限制相关的信息

在网页内容中，关于犬只心脏病的钠摄入限制的建议主要出现在B2阶段的饮食治疗部分。对于B2阶段(有血流动力学显著的二尖瓣反流并伴有心脏重塑)的犬只，大多数专家小组成员推荐进行饮食治疗，尽管有少数专家不建议改变饮食。

饮食治疗的指导原则包括：

1. 轻度限制饮食中的钠含量
2. 提供高适口性的饮食
3. 确保足够的蛋白质和热量以维持最佳体况

这些饮食建议适用于小型犬和大型犬。文章指出，在B2阶段，饮食治疗的重点是轻度限制钠摄入，同时确保充足的蛋白质和热量摄入。

值得注意的是，文章中没有提供具体的钠限制量或详细的饮食配方指南，只是提出了一般性的原则。此外，这些建议仅适用于B2阶段的犬只，对于其他阶段(如A、B1、C或D阶段)的犬只的钠摄入限制建议，在提供的网页内容中没有明确说明。

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摘要

这篇文章是美国兽医内科学院(ACVIM)心脏病专科共识小组关于犬只慢性瓣膜心脏病(CVHD)的诊断和治疗指南。CVHD是北美地区犬只心脏病中最常见的类型，约占75%的病例。该病主要影响二尖瓣，约30%的病例同时影响三尖瓣，在小型犬(＜20kg)中更为普遍，雄性犬发病率高于雌性犬约1.5倍。文章介绍了一个新的心脏病分类系统，将CVHD分为四个阶段：A阶段(高风险但无结构异常)、B阶段(有结构异常但无临床症状，进一步分为B1和B2)、C阶段(有或曾有心力衰竭临床症状)和D阶段(终末期疾病，对标准治疗无反应)。文章详细讨论了每个阶段的诊断和治疗建议，包括药物治疗、饮食管理和监测方案，特别强调了基于证据的决策过程，并区分了共识建议和非共识观点。

与C阶段和D阶段心脏病犬只的钠摄入限制相关信息

文章中关于C阶段和D阶段心脏病犬只的钠摄入限制的信息主要集中在饮食管理部分。对于C阶段(已有心力衰竭临床症状)的犬只，专家组提出了饮食治疗的共识建议，但文章中截取的部分并未完整显示这些具体建议。文章提到在B2阶段(有血流动力学显著的二尖瓣反流伴心脏重塑但无症状)时，大多数专家已建议进行轻度饮食钠限制并提供足够蛋白质和热量的高适口性饮食，以维持最佳体况。

对于D阶段(对标准治疗无反应的终末期疾病)的犬只，文章截取部分也未完整显示相关饮食建议。但可以推断，由于D阶段是C阶段的进展，钠限制可能会更加严格。

文章强调了饮食管理在心脏病犬只治疗中的重要性，但在所提供的文本中，没有详细说明C阶段和D阶段心脏病犬只的具体钠摄入限制数值或详细的饮食方案。文章似乎在后续部分(未包含在提供的文本中)可能会有更详细的饮食管理指南。

相关网页链接

无与问题相关的网页链接。提供的文本中没有包含可点击的网页链接，只有文献引用标记(如1、2等)，这些是文献引用而非可访问的网页链接。

相关图片

无与问题相关的图片。提供的文本中没有包含任何图片或图片链接。

摘要

本文是ACVIM心脏病学专科共识小组发布的关于犬只黏液瘤性二尖瓣疾病(MMVD)诊断和治疗指南的更新版，原版发布于2009年。文章详细介绍了MMVD的发病率、病理学和发病机制，指出MMVD是北美犬只心脏疾病中最常见的类型，约占75%。文章采用了四阶段分类系统(A-D阶段)来描述心脏疾病和心力衰竭的进展，并根据建议强度和证据水平(LOE)对治疗方案进行了分级。与2009年指南相比，最显著的变化是在心力衰竭临床症状出现前(特别是B2阶段)的管理策略，以及对晚期心力衰竭和肺动脉高压的诊断和治疗方法。文章详细阐述了各阶段的诊断标准和治疗建议，包括药物治疗、手术治疗和饮食管理，为兽医临床实践提供了循证医学指导。

与钠摄入限制相关的信息

在提供的网页内容中，没有具体提到关于C阶段和D阶段心脏病犬只的钠摄入限制的具体建议。文章主要介绍了MMVD的分类系统、诊断标准和总体治疗方法，但在可见的部分中没有详细讨论饮食管理中的钠限制问题。

虽然文章提到了"dietary treatment"(饮食治疗)作为管理方法的一部分，但在可见的内容中仅提到A阶段不推荐任何饮食治疗("No dietary treatment recommended for any patient")，而没有具体说明C阶段和D阶段的饮食管理或钠摄入限制建议。

要获取关于C阶段和D阶段心脏病犬只钠摄入限制的具体建议，需要查看文章的后续部分或其他相关文献。

相关网页链接

由于提供的网页内容中没有包含任何可点击的链接，因此无法识别与问题相关的网页链接。

相关图片

在提供的网页内容中没有包含任何图片链接或图片描述。

由于您没有提供任何网页内容，我无法对特定内容进行分析。如果您能提供关于犬只慢性肾病(CKD)的钠摄入限制的网页内容，我将很乐意为您分析并回答您的问题。

1. 摘要：无内容可摘要

2. 与犬只慢性肾病(CKD)的钠摄入限制相关的信息：无与问题有关的内容

3. 相关网页链接：无内容可分析

4. 相关图片：无内容可分析

如果您希望了解关于犬只慢性肾病(CKD)的钠摄入限制建议，建议您提供相关网页内容，或者我可以基于现有知识为您提供一些一般性信息。

Title: 4a. IRIS-DOG-Treatment_Recommendations_2023_approved_V3

URL Source: https://static1.squarespace.com/static/666b9ecb4064a156963b4162/t/66a6dc0145e3de78f7b830f1/1722211329976/IRIS-DOG-Treatment_Recommendations_2023.pdf

Markdown Content:
All treatments for chronic kidney disease (CKD) need to be tailored to the individual patient. The following recommendations are useful starting points for the majority of dogs at each stage. Serial monitoring of these patients is ideal and treatment should be modified according to the response to treatment. Note that staging of disease is undertaken following diagnosis of CKD – an increased blood creatinine or symmetric dimethylarginine (SDMA) concentration alone is not diagnostic of CKD. Treatment recommendations fall into two broad categories, namely: 1. Those that slow progression of CKD and thereby preserve remaining kidney function for longer 2. Those that seek to improve the quality of life of the dog, reducing signs of CKD In general, there are few clinical extra-renal signs at the early stages of CKD (Stages 1 and 2) and the therapeutic emphasis is on slowing progression. From Stage 3 onwards, extra-renal signs become more common and more severe. By Stage 4, treatments that are symptomatic and improve quality of life assume greater importance, and become more relevant than those designed to slow progression of CKD. Some of the treatment recommendations are not authorized for use in all geographical regions and some may not be authorized for use in dogs. Such recommended dose rates are therefore empirical. It is the treating veterinarian’s duty to make a risk:benefit assessment for each dog prior to administering any treatment.
1

© 2019 International Renal Interest Society (IRIS) Ltd. IRIS Ltd. is an independent non-profit organization limited by guarantee in the UK (Registered Number 10213173).

(2023) 2023 Treatment Recommendations for CKD in Dogs (2019)
2

© 2019 International Renal Interest Society (IRIS) Ltd. IRIS Ltd. is an independent non-profit organization limited by guarantee in the UK (Registered Number 10213173)..

Treatment recommendations for Dogs with CKD

Stage 1 Canine patients:

1. Discontinue all potentially nephrotoxic drugs if possible. 2. Identify and treat any pre-renal or post-renal abnormalities. 3. Rule out any treatable conditions like pyelonephritis and renal urolithiasis with radiographs and/or ultrasonography. 4. Measure blood pressure and urine protein to creatinine ratio (UP/C).
   Management of dehydration:
   In these patients, urine concentrating ability may be somewhat impaired and therefore ensure:
   • They have fresh water available at all times for drinking
   • If become ill for any reason that leads to fluid losses, correct clinical dehydration with
   isotonic polyioinic replacement fluid solutions (e.g. lactated Ringer’s) IV or SQ, promptly
   as needed
   Systemic hypertension:
   The blood pressure above which progressive renal injury may be induced is unknown. Our goal is to reduce systolic blood pressure to <160 mm Hg and minimize the risk of extra-renal target organ damage (CNS, retinal, cardiac problems/damage). If there is no evidence of such damage but systolic blood pressure persistently exceeds 160 mm Hg, treatment should be instituted.
   ‘Persistence’ of increase in systolic blood pressure should be judged on multiple measurements made over the following time-scales in these blood pressure substages:
   • Hypertensive (moderate risk of future target organ damage) – systolic blood pressure 160 to 179 mm Hg, persistence demonstrated over 1 to 2 weeks
   • Severely hypertensive (high risk of future target organ damage) – systolic blood pressure 180 mm Hg persistence demonstrated over 1 to 2 weeks If evidence of target organ damage exists, dogs should be treated without the need to demonstrate persistently increased systolic blood pressure. Reducing blood pressure is a long term aim when managing the patient with CKD and a gradual and sustained reduction should be the goal, avoiding any sudden or severe decreases leading to hypotension. It is recognized that some breeds (such as sight hounds) tend to have higher blood pressure (see Appendix 1) and that this may influence interpretation. A logical stepwise approach to managing hypertension is as follows: 1. Dietary sodium (Na) reduction – there is no evidence that lowering dietary Na will reduce blood pressure. If dietary Na reduction is attempted, it should be accomplished gradually and in combination with pharmacological therapy. 2. Angiotensin converting enzyme inhibitor (ACEI, such as benazepril) therapy at standard dose rate.

1

2023

ureteral obstruction with
(2023) Treatment Recommendations for CKD in Dogs (2019)
3

© 2019 International Renal Interest Society (IRIS) Ltd. IRIS Ltd. is an independent non-profit organization limited by guarantee in the UK (Registered Number 10213173)..

3. Double the dose of ACEI (in some dogs, increasing the dose may improve the antihypertensive effect). 4. Combine ACEI and calcium channel blocker (CCB, such as amlodipine) treatment, especially if severely hypertensive. 5. Combine ACEI and CCB with angiotensin receptor blocker (ARB, such as telmisartan) and/or hydralazine if additional treatment is required. Note: Take care not to introduce ACEI/CCB with or without ARB to unstable dehydrated dogs as glomerular filtration rate may drop precipitously if these drugs are introduced before the patient is adequately hydrated. The risk benefit analysis of combining ACEI with ARBs needs to be made on an individual dog basis and careful monitoring is required to ensure any deterioration in kidney function is detected.
   Monitoring response to antihypertensive treatment:
   Hypertensive dogs normally require lifelong therapy and frequently require adjustments in treatment. Serial monitoring is essential. After stabilization, monitoring should occur at least every 3 months. Systolic blood pressure <120 mm Hg and/or clinical signs such as weakness or tachycardia indicate hypotension, which is to be avoided. Blood creatinine concentration – reducing blood pressure may lead to small and persistent increases in creatinine concentration (<45 μmol/l or 0.5 mg/dl increase) and/or SDMA (< 2 μg/dl), but a marked increase suggests an adverse drug effect. Progressively increasing concentrations indicate progressive kidney damage/disease.
   Proteinuria:
   Dogs in Stage 1 with UP/C >0.5 should be investigated for disease processes leading to proteinuria (see 1 and 2 below) and treated with antiproteinuric measures (see 3, 4, 5 and 6 below). Those with borderline proteinuria (UP/C 0.2 to 0.5) require close monitoring (see 1 and 6 below). 1. Look for any concurrent associated disease process that may be treated/corrected. 2. Consider kidney biopsy as a means of identifying underlying disease (see Appendix 2 and/or consult experts if unsure of indications for kidney biopsy). 3. Administer an ACEI and feed a clinical renal diet. 4. Combine ACEI and diet with an angiotensin receptor blocker (ARB) if proteinuria is not controlled. 5. Administer low-dose acetylsalicylic acid (1 to 5 mg/kg once daily) or clopidogrel (1.1-3 mg/kg orally every 24 hours) if serum albumin is <20 g/l (2.0 g/dl). 6. Monitor response to treatment / progression of disease:
   – stable blood creatinine concentration and decreasing UP/C = good response.
   – serially increasing blood creatinine concentration and/or increasing UP/C = disease is progressing. Ordinarily therapy will be maintained lifelong unless the underlying disease has been resolved in which case dose reduction whilst monitoring UP/C might be considered.

1

2023

(2023)
Those with confirmed and persistent renal proteinuria should be treated with antiproteinuric measures (see 3, 4, 5 and 6 below). Those with borderline proteinuria (UP/C 0.2 to 0.5) require close monitoring (see 1 and 6 below). The goal of treatment is nuanced. Treatment should be aimed to have the reduction in proteinuria to the lowest UPC possible without doing harm (see point 6). 1. Look for any concurrent associated disease process that may be treated/corrected. 2. Consider kidney biopsy (for dogs in stages 1 to 3, not stage 4) as a means of identifying underlying disease (see Appendix 2 and/or consult experts if unsure of indications for kidney biopsy). 3. Administer an angiotensin receptor blocker (ARB) and feed a clinical renal diet. 4. Combination of an ACEI and diet with an angiotensin receptor blocker (ARB) if proteinuria is not controlled should be done judiciously and cautiously, ideally under consultation with a veterinary nephrologist (see note 1 below). 5. Administer clopidogrel (1.1-3 mg/kg orally every 24 hours) if serum albumin is <20 g/l (2.0 g/dl). If clopidogrel is not available, low-dose acetylsalicylic acid (2 to 5 mg/kg once daily) is an acceptable alternative (see note 2 below). Treatment Recommendations for CKD in Dogs (2019)
4

© 2019 International Renal Interest Society (IRIS) Ltd. IRIS Ltd. is an independent non-profit organization limited by guarantee in the UK (Registered Number 10213173)..

Note: ACEI or ARB use is contraindicated in any dog that is clinically dehydrated and/or is showing signs of hypovolemia. Correct dehydration before using these drugs otherwise glomerular filtration rate may drop precipitously. The risk benefit analysis of combining ACEI with ARBs needs to be made on an individual dog basis and careful monitoring is required to ensure any deterioration in kidney function is detected. Further detailed recommendations for diagnosis and management of glomerular disease in dogs can be found in the IRIS Consensus Statements published in Journal of Veterinary Internal Medicine in 2013 (supplement to volume 27).

1

2023

(2023)
Note 1: 6. Monitor response to treatment / progression of disease: – stable blood creatinine concentration, decreasing UP/C and/or increasing serum albumin (if previously low) = good response. – a UPC of < 0.5 is not achievable for many dogs with primary glomerular disease. For these dogs the goal should be a 50% reduction in UPC from baseline – serially increasing blood creatinine concentration and/or increasing UP/C = disease is progressing. Ordinarily therapy will be maintained lifelong unless the underlying disease has been resolved in which case dose reduction whilst monitoring UP/C might be considered.
Note 1:
ACEI or ARB use is contraindicated in any dog that is clinically dehydrated and/or is showing signs of hypovolemia. Correct dehydration before using these drugs otherwise glomerular filtration rate may drop precipitously. The risk benefit analysis of combining ACEI with ARBs needs to be made on an individual dog basis and careful monitoring is required to ensure any deterioration in kidney function is detected. Further detailed recommendations for diagnosis and management of glomerular disease in dogs can be found in the IRIS Consensus Statements published in Journal of Veterinary Internal Medicine in 2013 (supplement to volume 27).
Note 2:
Dogs with PLN are at risk of thrombosis however it is not possible to predict the risk for thrombosis in the individual patient as serum albumin, antithrombin and degree of proteinuria are poorly associated with thrombotic risk. Tests such as thromboelastography, thrombin generation and markers of activated clotting can be used to document hypercoagulability, however, identification of a hypercoagulable state has not been shown to correlate to risk of developing thrombosis. Prothrombin and partiel thrombloplastin times (PT, PTT) also cannot be used to predict thrombotic risk. Antithrombotic therapy is indicated in dogs with PLN (CURATIVE Guidelines DOI: 10.1111/vec.12801). Clopidogrel (1-4mg/kg orally once daily) administration may be more effective than low dose acetylsalicylic acid (1-5mg/kg orally once daily) for thromboprophylaxis Treatment Recommendations for CKD in Dogs (2019)
5

© 2019 International Renal Interest Society (IRIS) Ltd. IRIS Ltd. is an independent non-profit organization limited by guarantee in the UK (Registered Number 10213173)..

Stage 2 Canine patients:

All of the above listed for Stage 1 (listed here again for convenience), plus any additional steps indicated below. 1. Discontinue all potentially nephrotoxic drugs if possible. 2. Identify and treat any pre-renal or post-renal abnormalities. 3. Rule out any treatable conditions like pyelonephritis and renal urolithiasis with radiographs and/or ultrasonography. 4. Measure blood pressure and urine protein to creatinine ratio (UP/C). 5. Consider feeding a clinical renal diet: this may be accomplished more easily early in the course of CKD, before inappetence develops.
Management of dehydration:
These canine patients have decreased urine concentrating ability and therefore ensure:
• They have fresh water available at all times for drinking.
• If they become ill for any reason leading to fluid losses, correct clinical dehydration/hypovolemia with isotonic, polyionic replacement fluid solutions (e.g., lactated Ringer’s) IV or SQ promptly as needed
Systemic hypertension:
The blood pressure above which progressive renal injury may be induced is unknown. Our goal is to reduce systolic blood pressure to <160 mm Hg and minimize the risk of extra-renal target organ damage (CNS, retinal, cardiac problems/damage). If there is no evidence of this but systolic blood pressure persistently exceeds 160 mm Hg, increasing the risk of such damage, treatment should be instituted.
‘Persistence’ of increase in systolic blood pressure should be judged on multiple measurements made over the following time-scales in these blood pressure substages:
• Hypertensive (moderate risk of future target organ damage) – systolic blood pressure 160 to 179 mm Hg – persistence demonstrated over 1 to 2 weeks
• Severely hypertensive (high risk of future target organ damage) – systolic blood pressure 180 mm Hg persistence demonstrated over 1 to 2 weeks If evidence of target organ damage exists, dogs should be treated without the need to demonstrate persistently increased systolic blood pressure. Reducing blood pressure is a long term aim in a patient with CKD and a gradual and sustained reduction should be the goal, avoiding any sudden decreases or hypotension.
2

2023

(2023)
ureteral obstruction with Treatment Recommendations for CKD in Dogs (2019)
6

© 2019 International Renal Interest Society (IRIS) Ltd. IRIS Ltd. is an independent non-profit organization limited by guarantee in the UK (Registered Number 10213173)..

It is recognized that some breeds (such as sight hounds) tend to have higher blood pressure (see Appendix 1) and that this may influence interpretation. A logical stepwise approach to managing hypertension is as follows: 1. Dietary sodium (Na) reduction – there is no evidence that lowering dietary Na will reduce blood pressure. If dietary Na reduction is attempted, it should be accomplished gradually and in combination with pharmacological therapy. 2. Angiotensin converting enzyme inhibitor (ACEI, such as benazepril) therapy at standard dose rate. 3. Double the dose of ACEI (in some patients, increasing the dose may improve the antihypertensive effect). 4. Combine ACEI and calcium channel blocker (CCB, such as amlodipine) treatment, especially if severely hypertensive. 5. Combine ACEI and CCB with angiotensin blocker (ARB, such as telmisartan) and/or hydralazine if additional treatment is required. Note: Take care not to introduce ACEI/CCB with or without ARB treatment to unstable dehydrated dogs as glomerular filtration rate may drop precipitously if these drugs are introduced before the patient is adequately hydrated. The risk benefit analysis of combining ACEI with ARBs needs to be made on an individual dog basis and careful monitoring is required to ensure any deterioration in kidney function is detected.
Monitoring response to antihypertensive treatment:
Hypertensive dogs normally require lifelong therapy and frequently require adjustments in treatment dosages. Serial monitoring is essential. After stabilization, monitoring should occur at least every 3 months. Systolic blood pressure <120 mm Hg and/or clinical signs such as weakness or tachycardia indicate hypotension, which is to be avoided. Blood creatinine concentration – reducing blood pressure may lead to small and persistent increases in creatinine (<45 μmol/l or 0.5 mg/dl increase) and/or SDMA (< 2 μg/dl), but a marked increase suggests an adverse drug effect. Progressively increasing concentrations indicate progressive kidney damage/disease.
Proteinuria:
Dogs in Stage 2 with UP/C >0.5 should be investigated for the disease processes leading to proteinuria (see 1 and 2 below) and treated with anti-proteinuric measures (see 3, 4, 5 and 6 below). Those with borderline proteinuria (0.2 to 0.5) require close monitoring (see 1 and 6 below). 1. Look for any concurrent associated disease process that may be treated/corrected. 2. Consider kidney biopsy as a means of identifying underlying disease (see Appendix 2 and/or consult experts if unsure of indications for kidney biopsy). 3. Administer an ACEI and feed a clinical renal diet.
2

2023

(2023)
Dogs in Stage 2 with UP/C >0.5 should be investigated for the disease processes leading to proteinuria (see 1 and 2 below). Those with confirmed and persistent renal proteinuria should be treated with anti-proteinuric measures (see 3, 4, 5 and 6 below). The goal of treatment is nuanced. Treatment should be aimed to have the reduction in proteinuria to the lowest UPC possible without doing harm (see point 6). Those with borderline proteinuria (0.2 to 0.5) require close monitoring (see 1 and 6 below). 1. Look for any concurrent associated disease process that may be treated/corrected. 2. Consider kidney biopsy (for dogs in stages 1 to 3, not stage 4) as a means of identifying underlying disease (see Appendix 2 and/or consult experts if unsure of indications for kidney biopsy). 3. Administer an angiotensin receptor blocker (ARB) and feed a clinical renal diet. Treatment Recommendations for CKD in Dogs (2019)

©2019 International Renal Interest Society (IRIS) Ltd. IRIS Ltd. is an independent non -profit organization limited by guarantee in the UK (Registered Number 10213173)

4. Combine ACEI and diet with an angiotensin receptor blocker (ARB) if proteinuria is not controlled. 5. Low-dose acetylsalicylic acid (1 to 5 mg/kg once daily) or clopidogrel (1.1-3 mg/kg orally every 24 hours) if serum albumin is <20 g/l (2.0 g/dl). 6. Monitor response to treatment / progression of disease:
   – stable blood creatinine concentration and decreasing UP/C = good response.
   – serially increasing blood creatinine concentrations and/or increasing UP/C = disease is progressing. Ordinarily therapy will be maintained lifelong unless the underlying disease has been resolved in which case dose reduction whilst monitoring UP/C might be considered. Note: ACEI or ARB use is contraindicated in any animal that is clinically dehydrated and/or showing signs of hypovolemia. Correct dehydration before using these drugs otherwise glomerular filtration rate may drop precipitously. The risk benefit analysis of combining ACEI with ARBs needs to be made on an individual dog basis and careful monitoring is required to ensure any deterioration in kidney function is detected. Further detailed recommendations for diagnosis and management of glomerular disease in dogs can be found in the IRIS Consensus Statements published in Journal of Veterinary Internal Medicine in 2013 (supplement to volume 27).
   Reduction of phosphate intake:
   Evidence suggests that chronic reduction of phosphate intake to maintain plasma phosphate concentration below 1.5 mmol/l (but not less than 0.9 mmol/l; <4.6 mg/ dl but >2.7 mg/dl) is benefici ...