Let's look at a case study. So I'd like to tell you about a cat that I saw called Misty. She was an elderly 15-year-old cat who presented because her owners reported an increase in thirst over recent months, some weight loss, and some occasional vomiting.

On physical examination, she was in reduced body condition, 3 out of 9, with some muscle wastage, and her kidneys were slightly small and irregular on palpation. Her blood pressure was checked during the consultation and an average of 5 readings was 182 millimetres of mercury. We performed a fundic examination which was unremarkable.

I spoke to her owners at this point because I was concerned about chronic kidney disease and recommended performing a kidney panel and a urinalysis. And my suspicions were confirmed, she was azotemic with a creatinine concentration of 224 micromoles per litre and inappropriately dilute urine. Her specific gravity was 1017 and there was 1+ protein on dipstick.

Now the signalment and history here clearly gave me some indication of chronicity, together with the findings on kidney palpation. So it seemed highly likely that this was going to be chronic rather than acute disease. I chatted with the clients about CKD management and the importance of starting the gradual transition to a renal diet.

But what about her blood pressure? So Misty had had a bit of a wait in the waiting room before her blood pressure had been measured and without overt ocular target organ damage, I recommended that her SBP was rechecked in a week. The owners were on board with this.

It turned out that one of her owners was also on blood pressure medications. And so she came back for a nurse's appointment a week later. Her systolic blood pressure on recheck was still high at 176 millimetres of mercury.

So I felt that this was likely to be a genuine finding, and she was going to be classified as iris substage hypertensive warranting treatment. Misty was started on amlodipine besylate 0.625 milligrammes once a day by mouth, and we advised a recheck in a further week.

The good news was that at the next visit we had seen a good reduction in her blood pressure to about 150 millimetres of mercury, and we were really happy with this progress. To try and keep things simple, we'd advise that the next evaluation of her kidney function and calcium and phosphate balance should be in about 4 to 6 weeks after transitioning her to a renal diet. When we saw her back for this visit, things were going well.

She was eating about 75% renal diet, 25% senior cat food. Her kidney values were stable, and her blood pressure was still well controlled with readings between 146 and 155 millimetres of mercury. So at this point, we were able to confirm that she was Iris stage 2 and we decided to complete her substaging by performing a urine protein to creatinine ratio.

This showed that she was non-proteinuric, so that overall at this point, I was happy that we'd optimised her care and she could be transitioned to slightly longer intervals between monitoring. I suggested a recheck in 3 to 4 months or sooner if the clients had any concerns. This was definitely a scenario where we could have performed the assessment for proteinuria sooner.

So for example, at the first visit where we initially suspected CKD but it was most efficient for Misty and the owners to try and optimise management for CKD and hypertension before we made this assessment. Ultimately, it meant that Misty was only needing a single medication for her hypertension. The number of visits were minimised as much as possible, but we still optimised her monitoring and care.