Proteinuria & Hypertension (Marin) Flashcards
ANY level of proteinuria should NOT be ignored, especially if…
the sediment is INACTIVE=np WBCs, no blood, no bacteria
true or false: proteinuria means there is a problem with the kidney
false! it’s sometimes the kidney, but not always!!!!
if protein does get filtered thru the glomerulus (which is shouldnt), how do the tubules react?
lysosomes come along and try to clean it up, and they become little bombs that explode and do lots of damage due to all the enzymes!!!!!
proteinuria usually happens for 5 reasons which are:
- too many small proteins sent to the kidney (example is hemoglobinemia)
- glomerulus is injured and lets protein through (example is PLN)
- tubular injury (aminoglycosides, lilies, grapes)
- CKD
- result of the lower urinary tract and has no effect on the kidneys
remember SGTCL: single girls take cheese loot
small proteins sent to kidneys
glomerlulus damaged
tubular injury
CKD
lower urinary tract issue
proteins going through the glomerulus and into the tubulues is kinda like…
pin ball machine!
one thing you can see under the microscope in the urine that can indicate kidney damage from proteinuria is
hyaline casts
proteinuria is usually split into 3 categories, prerenal, renal, and post renal. list some examples of causes for each category
pre renal: fever, infectious disease, endocrine disease, auto-immune disease like IMHA, pancreatitis, IBD
renal: CKD, glomerular disease, tubular damage
post renal: UTIs, stones, neoplasia, FLUTD, prostatitis (remember the protein is after the kidneys so it doesn’t hurt them)
if pre renal causes of proteinuria are transient and usually resolve, why do we care?
because some persist or cause severe proteinuria and can hurt the kidney
renal causes of proteinuria affect both dogs and cats. Dogs tend to get ____ and cats tend to get____
dogs: glomerulonephritis, amlyoidosis (they lose a LOT of protein)
cats: CKD
can pre-renal proteinuria lead to renal proteinuria? what is an example?
YES
example: cushings dog with 2+ protein before given trilostane, but the proteinuria was never rechecked, and the dog died :(
what are the 2 kinds of protein losing nephropathy aka glomerulonephritis?
primary/idiopathic
secondary: things that cause pre renal but go unchecked and result in renal
which tends to cause more of a severe proteinuria, PLN/GN or CKD?
PLN/GN
what is the clinical presentation of proteinuria?
it depends….proteinuria itself is silent, but pre-renal and renal can lead to irreversible damage!!!!
GN dogs often have_______ when diagnosed compared to dogs/cats with CKD who have _____
no clinical signs
signs of kidney disease
true or false: there is no such thing as benign proteinuria
true
Baron Wigglesworth Barkington III the 5 yo cocker spaniel comes to you for an annual health exam and you run a CBC/chem UA and find 3+ proteinuria. what are your next steps?
rule out pre renal by doing: CBC/chem, UA, urine culture, UPC
then rule out post renal by doing medical imaging
can consider infectious disease testing/immune testing
what are important things to consider when using a urine dipstick?
1-2+ protein in concentrated urine can be normal
false positives are also very possible: alkaline urine, hemoglobin, myoglobin, fever, stress, etc
they…kinda suck
what is UPC test?
urine protein creatinine ratio: a quantatative measure of protein excreted over 24 hrs. this is the preferred test for proteinuria.
most renal GN causes will have a UPC of ___
most CKD causes will have a UPC of _____
more than 2
less than 2
true or false: you need a cyto urine sample to submit a UPC
false, free catch is fine!
50-85% of renal proteinuric animals, whether its GN or CKD, are
hypertensive
when you find an animal with proteinuria, why should you get a BP too?
many proteinuric animals are hypertensive and sustained hypertension makes an animal more likely to die. we arent exactly sure why this happens
Baron Wigglesworth Barkington III has no clinical signs and is NOT azotemic, but has 3+ proteinuria. You tell the owner this needs to be addressed and they think you’re making it up. To convince them, you tell them about prognosis if you do nothing which is…
the dog will die in 1 year if you dont treat
with CKD in either dogs or cats, you should investigate a UPC higher than ______
in cats, treat if UPC is ___
in dogs, treat if UPC is ___
0.2
more than 0.4
more than 0.5
what are our GOALS for treating renal proteinuria in CKD cats? What treatments help us acheive this goal?
goal is to have UPC lower than 0.4
renal diets, ace inhibitors, angiotensin receptor blockers, watch for UTIs
what are our GOALS for treating renal proteinuria in dogs with GN? What treatments help us acheive this goal?
goal is a 50% UPC reduction
renal diet, omega 3s, angiotensin receptor blockers, clopidogrel +/- mycophenolate
why are renal diets helpful for manageing proteinuria?
high protein diets can make protienuria worse, and renal diets restrict protein and also better quality protein. they also restrict phosphorus and controls potassium too
why are omega 3s helpful for treating dogs with GN?
it decreases renal inflammation
compare and contrast ACE inhibitors and ARBs for treating proteinuria
ACE inhibitors: enalapril, benazepril
- used to be the only class of drug we could use for this
ARBs: Telmisartan (Semintra for cats)
- newer and likely the better drug for GN and CKD proteinuria
true or false: ACE inhibitors and ARBs can work well even if the patient is severely azotemic
false! one the patient is severely azotemic and likely clinically ill, treating wont do much at this stage and prognosis is usually poor. usually wont live more than a few weeks :(
once you start a patient on ACE inhibitors or ARBs, what is one thing you HAVE TO DO
recheck them in 1 week!!!!!!!
recheck BUN/creatinine: these drugs can increase these slightly
recheck potassium: drugs can also increase potassium (inhibits aldosterone)
recheck blood pressure: these drugs can decrease this
you sent Baron Wigglesworth Barkington III home with Telmisartan and 1 week later he comes in to recheck his UPC. If the UPC has not reduced by 50%, what will you do? What if the UPC HAS been reduced by 50%?
goal not met: increase the dosage of the drug and recheck in 1 week
goal met: recheck in 1 month and then Q 3 months
ACEi and ARBs can cause a slight increase in BUN and creatinine. explain why
they inhibit RAAS and lead to vasodilation of the efferent arteriole and therefore decrease GFR a little bit. Aka, it’s now super easy for the blood to leave the glomerulus, and there’s less pressure and not as many proteins from the blood can leak out of the glomerulus
Baron Wigglesworth Barkington III ‘s owners want to know the risks if they decide to not treat him. You have explained that he will die in 1 year without treatment, but the owner asks what he could die from specifically and doesn’t understand. You say…
severe GN can cause thromboembolism, likely due to the loss of antithrombin (its a protein so the dog is peeing it out), and this protein normally helps the body to avoid clots, so without it, Baron Wigglesworth Barkington III is prone to forming clots that can travel thru the body and into places like his lungs and his brain and kill him.
what is one way to prevent thromboembolism in dogs with GN?
Plavix or aspirin (limited evidence for treatment)
which responds better to treatment regarding the reduction of proteinuria, CKD or GN?
CKD! often target is met with initial dose of ACEi or ARB
GN proteinuria is very difficult to treat and usually needs multiple dosage increases +/- an immune suppressant to reduce immune complexes
blood pressure is a function of
cardiac output and systemic vascular resistance
CO is HRxSV
what is more common in cats and dogs, primary or secondary hypertension?
secondary! humans get primary
list some of the most common causes of secondary hypertension
cushings, CKD, acute renal failure, GN/PLN, hyperthyroidism, pheochromocytoma, hyperaldosteronism
what are some clinical signs of hypertension?
hypersensitive retinopathy, cardiac murmur, gallop, or arrhythmia (increased afterload), hypertensive encephalopathy
what are the conseuences of hypertension?
organ damage, cardiac remodelling and potential failure, renal damage, cerebral damage, retinal damage, death.
vasoconstriction–>fibrosis–>ischemia
if systolic BP is more than 160mmHg,….
you need to treat!!!
best way to treat hypertension in dogs and cats?
cats: calcium channel blockers (Amlodipine), ARBs
dogs: ACE inhibitors (enalapril, benazepril), calcium channel blockers
low sodium diets and weight loss for both
