CKD Treatment Protocol in Dogs (Based on IRIS Guidelines)

1. Staging first (IRIS system)

2. Core drug protocol by problem

A. Renoprotection - proteinuria and hypertension

• Benazepril (ACE inhibitor, first-line in dogs): 0.25-0.5 mg/kg PO q12-24h
• Enalapril: 0.5 mg/kg PO q12-24h
• Telmisartan (ARB, alternative/adjunct for proteinuria and hypertension): 1 mg/kg PO q24h; can titrate up to 2 mg/kg/day for hypertension
• Amlodipine (if hypertension persists despite ACEi/ARB, systolic BP >160 mmHg): 0.1-0.2 mg/kg PO q24h, adjusted to blood pressure target (<160 mmHg)

B. Phosphorus control (Stage 2 and beyond)

• Renal diet first-line (phosphorus-restricted, e.g. Hill's k/d, Royal Canin Renal, Purina NF)
• Aluminum hydroxide: 30-100 mg/kg/day PO divided with meals, titrated to serum phosphorus target
• Calcium carbonate + chitosan (Epakitin): dosed per product label by body weight, given with meals
• Lanthanum carbonate: 30-100 mg/kg/day PO with food

C. Calcitriol (renoprotective, Stage 2-4; start only once phosphorus is controlled, ≤6 mg/dL)

• Low daily dose: 2.5-3.5 ng/kg/day PO (some protocols start as low as 0.5-1 ng/kg/day and titrate)
• Alternative pulse dosing: 20 ng/kg PO twice weekly
• Monitor ionized calcium and PTH weekly initially; maximum dose generally capped around 5 ng/kg/day; stop or reduce if hypercalcemia develops

D. Metabolic acidosis

• Sodium bicarbonate or potassium citrate/bicarbonate: 8-12 mg/kg PO q8-12h, titrated to keep serum bicarbonate (total CO2) in the 18-24 mmol/L range

E. Anemia (non-regenerative, common in Stage 3-4)

• Darbepoetin alfa: 0.5-1 mcg/kg SC once weekly initially, then taper frequency (e.g. every 2-3 weeks) once target hematocrit (~30-40%) is reached
• Supplement iron dextran or ferrous sulfate concurrently since ESAs increase iron demand
• IRIS 2026 revision: consider starting anemia treatment at HCT <30%, or if persistent 30-35% with clinical signs

F. GI signs - nausea, vomiting, uremic gastritis (common Stage 3-4)

• Maropitant (Cerenia): 1-2 mg/kg PO or SC q24h
• Ondansetron: 0.5-1 mg/kg PO/IV q12-24h
• Metoclopramide: 0.2-0.5 mg/kg PO/SC q8h, or as CRI 1-2 mg/kg/day IV
• Famotidine: 0.5-1 mg/kg PO/IV/SC q12-24h
• Omeprazole (preferred over famotidine for uremic gastritis, evidence grade higher): 0.5-1 mg/kg PO q24h
• Sucralfate (if GI ulceration suspected): 0.5-1 g PO q8-12h, given apart from other oral meds by 2 hours

G. Appetite/nutrition support

• Mirtazapine: ~1.1-1.4 mg/kg PO q24h (transdermal or oral)
• Capromorelin (Entyce): 3 mg/kg PO q24h

H. Fluid therapy (Stage 3-4 or during uremic crisis)

• IV isotonic crystalloids (e.g. 0.9% NaCl or balanced solution) for rehydration, then subcutaneous fluids at home (typically 75-100 mL/kg every 24-72 hours SC) for maintenance in azotemic/dehydrated dogs
• Discontinue all nephrotoxic drugs (NSAIDs, aminoglycosides) immediately

I. Potassium supplementation (if hypokalemic, more common in cats but can occur in dogs)

• Potassium gluconate: 2-6 mEq/day added to food, titrated to serum potassium

3. Monitoring

• Recheck serum creatinine/SDMA, phosphorus, calcium, potassium, bicarbonate, PCV/HCT, blood pressure, and UPC every 2-4 weeks when adjusting therapy, then every 3-6 months once stable.