IP9 renal 2

Question 1

CS of FLUTD

Answer 1

Multi trips to litter box
Vocalizing/😭
Straining w/ nothing coming out
Hematuria
Pollakiuria
Agitation
Pain
Collapse, bradycardia, coma

Question 2

FLUTD Incidence/ Signalment

Answer 2

Disease onset: 🚹 = 🚺
Males obstruct much more easily
1st onset: 1-5 yo
Any breed

Question 3

Causes of FLUTD (Syndrome)

Answer 3

~ 50% - no cause ID
Other 50% - CAB 🚕
calculi, urethral plug (debris+crystals from bladder), bladder anomaly (diverticulum)

Stress contributes

Question 4

FLUTD Predisposing diets

Answer 4

High Mg diets

Alk Urine pH > 7

Question 5

FLUTD Dx: 🚫blocked

Answer 5

UA – ✅USG is conc
+/- serum biochem profile
Symptomatic tx

Question 6

FLUTD Dx: Blocked

Answer 6

Unblock (Emergency)

UA – ✅ USG
Chem – Wait 18-24h to resolve post-renal azotemia
Rads or u/s? Definitely if >1st presentation

Question 7

FLUTD Treatment

Answer 7

Manage hyperkalemia (IV insulin + dextrose, NaHCO3, Ca-gluconate),
IV catheter and fl,
unblock.

Question 8

What is “Post-obstructive diuresis”?

Answer 8

Following mod-sev urinary obst, 2-5d period ⏩ massive PU can occur ➡️dehydration + electrolyte wasting.

Back-P➡️renal tubular damage
impt to monitor urine output and make sure replacement fluids are adequate.

Question 9

Other in-hospital management:

Answer 9

Analgesics
[K+] supplementation
Fl. therapy
alpha blocker (prazosin) to relax int urethral sphincter (not sure if it helps)

🚫Abx – while urinary catheter is in place.
Urinary catheters can block!!!

Question 10

Complications?

Answer 10

Bladder rupture
Urethral rupture
Repeat obstruction

Question 11

FLUTD Prevention strategies?

Answer 11

Diet: Acidifying, low Mg
❇️water intake

Anti-inflamm?
?? Amitryptilline (human antidepressant – increases substance P in mucosa)
?? Glycosaminoglycans (restore GAG layer in mucosa)
Surgery: Perineal urethrostomy?

Question 12

Canine prostatic disease predisposers

Answer 12

Intact 🚹🐶: Testosterone ➡️benign prostatic hypertrophy (BPH) in all male dogs – ⬆️w/age.
BPH ⏩ prostatitis (infx), abscess.
Paraprostatic cyst: Dev anomaly
Prostatic neoplasia: 🚫hormone-assoc (unlike in Hu)

Castrated 🚹🐶: Prostatic neoplasia

Question 13

Prostatic disease CS

Answer 13

Similar to LUTI
Bloody preputial discharge indep of voiding
Pain, tenesmus, 
Gait change
Infertility

Question 14

Prostate Dx

Answer 14

Rectal exam: Size, shape, pain, mobility. (Know normals for intact and castrated male dogs)

Rads- Prostatomegaly, calcification, sublumbar masses, localized peritonitis.
U/S– Internal structure, abscess, cyst
Cytology – look for malignancy (Fine-needle aspirate can “seed” cancer cells - avoid here!)

Question 15

Treatment: Benign prostatic hyperplasia

Answer 15

Castration ⬇️CS = Prostatic involution takes ~4wk

If still enlarged, 🔎 another cause
Rx involute prostate: Finasteride ⛔️5-hydrotestosterone (only use if breeding value)

Question 16

Tx: Bacterial Prostatitis

Answer 16

Acute: sepsis and life-threatening – tx as a case of systemic illness

Chronic: Abx & castration
Abx must x-BPB – lipid soluble, weak base, poorly protein-bound (Fluoroquinolones, TMS, chloramphenicol)
FTC

Question 17

Tx: Prostatic abscess

Answer 17

In addition to bacterial prostatitis tx, may need Sx drainage

Acute: tx sepsis
Chronic: Abx (FTC) & castration

Question 18

Tx: Prostatic neoplasia

Answer 18

2 MC:
Prostatic adenocarcinoma
TCC

Tx options: Poor
Can’t remove Sx – complications
Bad location for radiation
🚫chemotherapy-responsive
Palliate with castration 
Piroxicam (NSAID with anti-tumor properties)

Question 19

Tx: Paraprostatic cyst

Answer 19

Sx repair

Question 20

Hallmark Signs of Lower Urinary Tract Dis

Answer 20

Stranguria (straining)
Pollakiuria (Multiple, small volume voids)
Hematuria (Blood in urine – typically macroscopic but maybe🔬)

Question 21

Other LUTD dx clues

Answer 21

PE: Painful palpation➡️ voids/urinates, or has an exceedingly large or small bladder. +/- feel Cystic calculi.

UA: WBC, RBC, or bacteria in urine sediment
Imaging: See calculi

Question 22

Lower urinary tract infectious agents

Answer 22

Bacteria: 1° G(-) ➡️ MC E. coli

Yeast/🍄 infx possible

Question 23

Signalment for LUTI?

Answer 23

🚺>🚹
Young or geriatric (lower natural defense)
Uncommon in healthy, middle-aged animals
Intact males (Source? Prostate)

🐱: Isosthenuria predisposes (therefore, older cats)

Question 24

Common risk factors for LUTI:

Answer 24

PU/PD (bacteria like isosthenuric urine)
Endocrine: DM, Hyperadrenocorticism, 1° hyperPTH)
Urinary catheterization
Urine retention (2° to micturition disorders, bladder atony)

Question 25

Dx LUTI

Answer 25

UA: Hallmark test for LUD (pH typically >7, sediment blood cells or bacteria, but sedi + culture findings not always 100% correlated) Urine culture: Always desirable, but sometimes there are $$ limitations or the bladder is empty)

Question 26

What is normal bladder residual volume?

Answer 26

Less than 1/4 mL/kg Failure to completely void attracts asc bact to attach & grow

Question 27

What Dx should I do in different situations?

Answer 27

Healthy first-time offender: UA, urine culture (desired) Repeat offender: UA and urine culture even more important! Also bloodwork, imaging studies Sick: UA + u.culture and 🔎 underlying disease

Question 28

Empirical treatment options?

Answer 28

First-time offender? FTC Abx with G- spectrum and wide safety margin for an appropriate dose and duration. (Augmented penicillins, higher-generation cephalosporins, fluoroquinolones, TMS) Signs should improve in 2-3 days.

Question 29

Recurrent UTI or UTI with concurrent illness?

Answer 29

Culture is imperative, and Abx based on C+S. 🔎 underlying predis cause – if you can correct that, you will have a better chance to cure the UTI Avoid the trap of “The first antibiotic must not have worked so I will try another one…”

Question 30

Long term follow up for recurrent UTI?

Answer 30

Negative C+S after tx, and then 2 more negatives over next 2 months. If urine pH still Alk >7 after resolving infx, consider urine acidification.

Question 31

Why do bladder stones form?

Answer 31

1. Nidus of infx a. Bacteria b. Debris c. Crystalline nidus 2. Bladder mucosal damage a. Loss of GAG 3. Unusual accumulation of crystals

Question 32

Clinical signs of cystic calculi?

Answer 32

Similar to LUTI Urinary obst LUTI that does not respond to conservative tx Predisposed breed or signalment?

Question 33

4 MC calculi types

Answer 33

Mg ammonium phosphate (a.k.a. “struvite”) Calcium oxalate Urate Cystine

Question 34

Which calculi are radiodense? Radiolucent? Echodense?

Answer 34

Radiodense: Mg ammonium phosphate, Ca oxalate Radiolucent: Urate, Cystine Echodense: All of them!

Question 35

Which urine crystals are always abnormal?

Answer 35

Ammonium biurate | Cystine

Question 36

Why is urinary obstruction a medical emergency?

Answer 36

Bladder rupture Bladder (detrusor) atony Hyperkalemia ARF

Question 37

Facts about Mg Ammonium Phosphate (“Struvite”)

Answer 37

``` *** Bact infx predisposes!*** 🚺>>> M Urine pH >7.0 (alk) High protein diet (a.k.a. table food) predisposes Intact 🚹 bact prostatitis ➡️ 2° struvite ```

Question 38

Mg ammonium phosphate: therapy

Answer 38

``` Sx removal = immediate fix Medical dissolution possible • Hill’s S/D diet = low protein, low phosphorous, high salt (for diuresis causing hyposthenuria) • 95% response rate in 1-2 months • DO NOT USE > 4 months! • Concurrent Abx ```

Question 39

Mg ammonium phosphate: prevention

Answer 39

Monitor for, and educate client about ⛔️infx Dx + tx infx early and completely Good quality diet if on table food Consider prevention diet (e.g. Hill’s C.D., Royal canin Stone diet…)

Question 40

Facts about Calcium Oxalate

Answer 40

M = F Radiodense Urine pH

Question 41

Calcium Oxalate management

Answer 41

Dissolution impossible – must resolve with surgery Prevention: ~50% will recur within 3 years Diet: Moderate calcium restriction? High salt diet to increase diuresis? Manage hyperadrenocorticism Alk urine (Potassium citrate)

Question 42

Facts about Urate

Answer 42

2 subsets: | Dalmatian dogs: Inborn error of metabolism. 🚹 more clinical, but all affected. Urine pH

Question 43

Urate Tx

Answer 43

Dalmatians: Low-protein, non-purine diet (Hill’s U/D) lifelong Surgery or dietary dissolution Manage obstruction Alk urine Tx infx if present Xanthine oxidase inhibitor (Allopurinol) to ⬇️full urate metabolism Non-Dalmatians: Dx and tx liver disease.

Question 44

Facts about Cystine

Answer 44

PT defect – AA Cystiene not reabs in PT, form Cystine which is insoluble Inborn defect – English breeds and Dachshunds Urine pH

Question 45

Cystine management

Answer 45

Sx removal Management similar to urate – low protein U/D diet, urine alkalinization 💊 complex with cystiene ➡️more solu compound: D-penicillamine or 4-MPG