Lecture 1 - Hypoproteinemia (Cooke) Flashcards
least likely to result in moderate to severe hypoproteinemia in an adult dog:
anorexia
hepatic dysfunction
PLE
anorexia!!
an adult dog with a functional liver can be starved for a long time and liver will maintain glucose, albumin, cholesterol, etc
in puppies this is different bc they don’t have the reserves of an adult
albumin is a __ protein that decreases with inflammation
negative acute phase
__ by itself is highly unllikely to cause hypoalbuminemia
malnutrition (maldigestion/malabsorption or starvation)
3 mechanisms of decreased protein production
hepatic failure
inflammatory dz
malnutrition (maldig/malabs, starvation)
4 mechanisms of increased protein loss
renal*
intestinal*
third space
burns/wounds
*first 2 are most common
example of how protein lost via the third space
protein entering the third space alone will not cause significant drop, however multiple taps of these spaces can result in hypoalbuminemia (ie. abd taps removing all the fluid)
CS of a patient with hypoproteinemia
none, can be incidental finding peripheral limb swelling ventral pitting edema abdominal distension (ascities) cough/dypsnea decreased appetite (incr pressure on viscera) vomiting/diarrhea (GI dz, gut edema)
is ascities or pleural effusion more common with hypoproteinemia
ascities
the lymphatics in the chest are good at taking excess fluid away
young dog with low protein is likely due to
congenital (hepatic shunt, failure of passive transfer)
infectious (parvo, hooks)
older dog with low protein is likely due to
inflammation (IBD, lymphangiectasia)
neoplasia
metabolic (EPI, hepatic dz, PLN)
infectious (parasite, fungal)
__ diarrhea more commonly causes protein loss
small bowel
large bowel (except HGE) will not cause significant protein loss
Retinal hemorrhage or detachemnt and tortuous retinal vessels indicate
hypertension
2 main mechanisms that result in hypooproteinemia
decreased production
increased loss
- NOT anorexia
oral ulcers and PLN indicates
uremia/kidney dz
a murmur with hypoproteinemia can indicate
endocarditis
more severe muscle wasting indicates __ timeline
several weeks, chronic
hypoalbuminemia from decreased production
hepatic failure
inflam dz
hypoalbuminemia from increased loss
PLN
PLE
Hypoglobulinemia ddx
PLE,
blood loss
failure of passive transfer
__ tell you nothing about liver function!
liver enzymes
5 liver function values on chemistry
glucose cholesterol BUN t. bilirubin albumin
always do a __, easy way to r/o PLN
urinalysis
don’t do a __ on an active urine sediment
UP:C
If hypoalbuminemia is causing ascities what do you expect the fluid to look like
transudate (or modified transudate if more chronic)
radiographs are beneficial in hypoproteinemia cases if
no ascities
want to measure liver*
assessing bones for infection or neoplasia*
assess kidneys
*can’t do with AUS
what does a normal AUS with bloodwork indicating hepatic damage tell you?
know the patient is NOT normal, must pursue other dx
r/o kidneys/PLN but not sure if it’s liver, gut, other. What next?
bile acids
if bile acids are abnormal then evaluate for PSS
+/- biopsies of liver and intestines
if albumin is less than 2 and giving IVF what is a risk
fluid overload
try using colloid support:
hetastarch/synthetics can help draw fluid from third spaces
plasma to replace albumin/clotting factors
if albumin less than 1 worry about gut edema
colloid therapy in hypoproteinemic patient is used to
buy time, it is not fixing the problem!
how does low albumin affect anesthesia
lots of protein bound agents! animal will be more sensitive to effects of protein bound drugs (more free form, need to decrease dose)
how does low protein affect wound healing
wound dehiscence is a concern if albumin is less than 1.5
in all protein losing dz there is loss of antithrombin, making patient prone to __
thromboemboli (most common with PLE)
Patient you are concerned has heaptic failure, low protein, and see petechiae. What test should be run before poking anything?
PT/PTT
7yo Yorkie presents with a chronic reoccuring swollen abdomen and balloted fluid wave (rDVM taps periodically). most likely ddx
fluid is most likely edema (not blood or pus due to hx duration)
ddx: RHF portal hypertension PSS hypoproteinemia neoplasia
panhypoproteinemia w/o azotemia would also expect what other lab abnormality
hypocholesterolemia
abdominal fluid with SG 1010, TP 1mg/dL and 100 cells/mcl, what kind of fluid is this?
pure transudate (low cell count, low protein count) ie. hypoalbuminemia
fluid with high protein and cell count
exudate
fluid with intracellular bacteria observed
septic
low cell count and higher protein count
modified transudate (portal hypertension)
liver makes globulins, why is it not usually a differential for panhypoproteinemia?
liver makes alpha and beta globulins
we measure gamma globulins on serum chm (made by plasma cells, doesn’t rely on liver function)
lymphangectasia tx
low fat diet
+/- steroids
lymphangectasia causes
IBD
Neoplasia
congenital
causes of hypoalbuminemia
PLN
PLE
Inflammation (neg APP)
liver dysfunction
causes of hyperglobulinemia
chronic inflammation
neoplasia
causes of proteinuria
PLN
Infection
neoplasia
hypertension
provides oncotic support, clotting factors, fibrin
plasma
provides oncotic support but no clotting factors or fibrin
synthetic colloids (hetastarch)
approach to hypoproteinemia; is there proteinuria? yes vs no
if yes, is the sediment active or inactive?
if no, run a bile acids
if urine sediment is active and proteinuria is present what is the next step
urine culture and sensitivity; treat and reassess
if urine sediment is inactive with proteinuria what is next step
UP:C
if this is normal then look for other sources of low protein
if high the check BP, HW, tick-borne dz
if bile acids are abnormal with hypoproteinemic patient? normal?
liver bx
if normal then do a fecal, deworm, diet trial, intestinal bx
