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Renal - Evaluation of Renal Disease Flashcards

1
Q

What are some historical indications for renal assessment?

A

Polyuria, polydipsia, known or suspected exposure to nephrotoxins, familial history of kidney disease
Other: history of hypoalbuminemia or vascular thrombus

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2
Q

What are some PE indications for renal assessment?

A

Abnormal renal size/shape, mucosal ulceration, +/- anemia

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3
Q

What are some preventative indications for renal assessment?

A

Pre-anesthetic bloodwork, pre-nephrectomy, and to help choose medications (aminoglycosides, amphotericin B, and NSAIDs)

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4
Q

When we talk about renal function, what are we really talking about?

A

Glomerular filtration rate (GFR)

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5
Q

GFR determines the rate of what?

A

Urine production, electrolyte excretion, and elimination of metabolic waste products

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6
Q

What is azotemia?

A

Abnormal (excess) accumulation of nitrogen waste products

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7
Q

When does azotemia occur?

A

With >75% decrease of GFR

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8
Q

What is uremia?

A

Clinical manifestations associated with azotemia

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9
Q

What are some clinical manifestations associated with azotemia?

A

GI ulcers, nausea, and anorexia

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10
Q

True or False: All uremic patients are azotemic, all azotemic patients are not uremic.

A

TRUE

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11
Q

What is pre-renal azotemia?

A

hypoperfusion of the kidneys due to dehydration, acute blood loss, and/or congestive heart failure

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12
Q

What is renal azotemia?

A

intrinsic disease of the nephrons due to CKD, nephrotoxic drugsm renal infecitons, renal neoplasia, congenital malformations, and/or glomerulonephritis

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13
Q

What is post-renal azotemia?

A

Obstruction of urine flow distal to the kidney due to urolithiasis, neoplasia, and/or trauma

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14
Q

How is GFR evaluated?

A

Serum markers, clearance tests, and renal scintigraphy

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15
Q

What are the serum markers of GFR?

A

Blood urea nitrogen (BUN), creatinine, and symmetric dimethylarginine (SDMA)

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16
Q

Serum markers of GFR are ideal characteristics of markers because they are normally what?

A

Freely filtered by the glomerulus, undergo no tubular reabsorption, and no tubular secretion

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17
Q

What is urea a product of? Where is it made? Where is it filtered? Where is it partially reabsorbed?

A

Urea is a product of protein metabolism in the liver. It is filtered through the glomeruli and partially reabsorbed in the renal tubules

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18
Q

What extra-renal influences can increase urea concentrations?

A

High protein diet, GI bleeding, and dehydration

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19
Q

What extra-renal influences can decrease urea concentration?

A

malnutrition, low protein diet, severe burns, and hepatic dysfunction

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20
Q

What is creatinine a product of?

A

creatine metabolism

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21
Q

Where is creatinine filtered? Reabsorbed?

A

It is freely filtered by the glomeruli and negligible tubular reabsorption/secretion

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22
Q

Is BUN or creatinine a more accurate GFR marker?

A

creatinine

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23
Q

What extra-renal influence can cause a decrease in creatinine?

A

muscle loss

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24
Q

What type of diet can increase creatinine?

A

high protein diet

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25
What breeds have increased creatinine?
Greyhounds and Birmans
26
What is symmetric dimethylarginine (SDMA) a product of?
cytoplasmic proteolysis
27
How is SDMA filtered, reabsorbed, and secreted in the kidneys?
It is freely filtered by the kidneys with no tubular reabsorption/secretion
28
Why is SDMA a good serum marker of GFR function?
Because it allows for earlier detection of renal dysfunction than traditional markers - it is increased with as little as 25-40% loss of GFR
29
True or False: SDMA is influenced by muscle mass.
FALSE
30
What are some possible extra-renal influences of SDMA?
altered metabolic rates - hypo/hyperthyroidism, neoplasia, age, and breed
31
What are the potential uses of SDMA markers?
Monitoring of kidney function in patients with progressive muscle loss Investigation of PU/PD cases that normal creatinine values (non-azotemic chronic kidney disease)
32
Loss of concentating ability occurs with what loss of GFR?
66% loss of GFR
33
Increases in creatinine or BUN occurs with what loss of GFR?
75% loss of GFR
34
When should we considere other measurements of renal function?
Assessing renal function in nonazotemic polyuric patients Identifying occult renal failure prior to starting (possibly) nephrotoxic therapies Optimizing dosage schedules for renal-excreted drugs Screening patients with familial history of kidney disease Investigating discrepancies in BUN/creatinine/SDMA
35
How do clearance assays work?
An injectable marker is administered intravenously - they are freely filtered through the glomeruli and ideally not secreted or reabsorbed by the tubules Serum or urine levels are measured over time
36
What clearance assays do we use in small animal medicine?
Inulin clearance, creatinine clearance, iohexol clearance
37
How does renal scintigraphy work?
The use of radiopharmaceutical that is filtered by the kidneys without secretion or reuptake. Emitted gamma-rays are detected and GFR is determined by rate of renal uptake
38
What does renal scintigraphy allow for the measurement of?
Individual kidney GFR
39
What are the disadvantages of renal scintigraphy?
Expensive, specialized facilities, and limited availability
40
What are the strengths to doing a UA?
It is cheap and it allows for assessment of both renal and non-renal components of the urinary system
41
What parts of the urinary system can a UA assess?
Urine concentrating ability, urinary loss of metabolites, tubular injury, and upper/lower urinary tract infections
42
What are the weaknesses of UA?
Easily influinced by extra-urinary causes - fluid administration and delayed processing (bacterial overgrowth, dissolution of casts, formation of crystals)
43
What are the collection/storage variables of a UA?
method of collection, clean and clear container, temperature, and processing time
44
What are the 3 steps to success of a urinalysis?
Physical properties, chemical properties, and sediment exam
45
What is the typical color of urine?
yellow to amber
46
What are the abnormal colors of urine?
brown to dark red
47
What can cause brown to dark red urine?
Hematuria, hemoglobinuria, myglobinuria, and bilirubinuria
48
If you centrifuge brown to dark red urine and a pellet forms, what is likely the cause?
hematuria
49
If you centrifuge brown to dark red urine and it is still the same color, what can be the cause?
Bilirubinuria, hemoglobinuria, and myoglobinuria
50
What is the USG?
The ratio of the weight of urine versus the weight of an equal amount of water (density ratio)
51
How is USG measured?
refractometer
52
At what USG is a patient considered hyposthenuric?
< 1.008
53
At what USG is a patient considered isosthenuric?
1.008 to 1.012
54
What mOsm is equal to 1.008-1.017?
300 mOsm
55
What mOsm is equal to <1.008?
<300 mOsm
56
What is specific gravity influenced by?
urine composition and fluid status
57
What about urine composition can mildly increase gravity?
Glucose and protein
58
How does dehydration affect the USG?
it causes it to be more concentrated
59
How do IV fluids do to the USG?
they cause it to be less concentrated
60
What physiologically affects the USG?
Adequate number of functional nephrons, robust renal medullary gradient, and anti-diuretic hormone
61
At 66% renal function loss, the kidney loses the ability to concentrate urine. What will the USG be at this point?
isosthenuric
62
What can effect the robust medullary gradient of the kidney?
Liver failure, hypoadrenocorticism, glucosuria, and medullary washout
63
What disease process can cause decreased ADH production?
central diabetes insipidus
64
What can cause central diabetes insipidus?
Pituitary/hypothalamic injury or hyperadrenocorticism
65
What disease process can cause absence of response to ADH?
nephrogenic diabetes insipidus
66
What can cause nephrogenic diabetes insipidus?
pyelonephritis/pyometra and hypercalcemia
67
True or False: Changes in urine color can affect interpretation of urine dipsticks.
TRUE
68
What does the glucose portion of the urine dipstick test for?
Presence of glucose in the urine
69
If you get a positive response on the glucose portion of a urine test stripk what does that indicate?
There is renal tubular dysfunction or the renal tubular reabsorption threshold has been exceeded
70
What is the renal threshold for glucose in cats?
Approximately 300 mg/dl
71
What is the renal threshold for glucose in dogs?
Approximately 200 mg/dl
72
What does the bilirubin portion of the urine dipstick detect?
conjugated bulirubin in urine
73
Is bilirubin in urine normal in dogs?
yes - 1+/2+ can be normal in dogs
74
In what cases does bilirubinuria occur prior to onset of icterus?
In cases of hemolytic anemia or hepatobiliary disorders
75
How are ketones filtered in the kidney normally?
They are freely filtered in the glomeruli but reabsorbed to the maximum transport capacity in the tubules
76
What does ketonuria suggest?
excess ketogenesis
77
What ketones are detected by the urine dipstick?
Acetone and acteoacetate
78
Is the specific gravity on the urine dipstick reliable?
No - it is not recommended in animals and a refractometer should be used instead
79
What does the blood portion on the urine dipstick detect?
heme - NOT RBCs
80
In what scenarios does the blood portion on the urine dipstick become positive?
In cases of hematuria, hemoglobinuria, and myoglobinuria
81
What will you see on sediment in patients with hematuria?
RBCs
82
What will the serum be like in patients with hemoglobinuria?
hemolysed serum
83
What will you see on sediment and in a chemistry in patients with myoglobinuria?
No RBC on sediment and increased CK on chemistry
84
What can affect the pH on a urine dipstick?
Influenced by diet, post-prandial alkalinuria, and UTI by urease producing bacteria
85
How can a high protein diet affect urine pH?
it lowers the pH
86
Post-prandially, what will the urine pH be in a patient?
It will be alkaline
87
How does urease affect pH?
it raises it
88
What bacteria produce urease?
Proteus, Staphylococcus, and Klebsiella
89
What does the protein portion on the urine dipstick detect?
primarily albumin
90
What does is the detection threshold for protein?
30 mg/dl
91
Does the urine dipstick determine the source of proteinuria?
no
92
The severity of the protein response on the urine dipstick is influenced by urine ________.
concentration
93
True or False: Positive results should be confirmed with additional tests.
TRUE
94
What causes renal proteinuria?
Increased loss in the glomeruli and decreased reabsorption in tubules
95
What are some causes of renal protein loss?
Tubular/glomerular damage (nephron death), loss of anti-coagulant proteins (antithrombin), loss of albumin (low vascular oncotic pressure)
96
What are the consequences for renal protein loss?
Faster progression of chronic kidney disease, thromboembolic disease, cavitary effusions and edema
97
True or False: Proteinuria always implies a pathologic process.
False - it can be transient due to fever, seizures, and strenuous exercise
98
What could protein in the urine, that is not due to the kidney, be the cause of?
Inflammation elsewhere in the urinary tract, inflammation in neighboring structures (genital tract), and increased plasma protein load
99
What is the gold standard quantitave measurement of proteinuria?
Urine protein/creatinine ratio (UPC)
100
What is the normal UPC ratio in dogs?
Dog <0.5
101
What is the normal UPC ratio in cats?
Cat <0.4
102
What is urobilinogen a product of?
intestinal bilirubin
103
Is urobilinogen on the urine dipstick a commonly used detector in animal medicine?
no
104
Is the nitrate portion on the urine dipstick reliable?
No
105
What can reduce nitrate on the urine dipstick?
gram negative bacteria
106
What does the leukocyte portion on the urine dipstick detect?
leukocyte esterase
107
Is the leukocyte portion of the urine dypstick dependable?
Not in dogs and cats
108
What are you looking for in a sediment exam?
Cellular components (RBC, WBC, epithelial cells, bacteria/yeast), casts and crystals
109
Is it normal to find RBCs in urine sediment?
If it is <5/high power field
110
What do more than 5 RBCs/high power field suggest?
There is inflammation, trauma, and active bleeding
111
What can cause false positives of RBC in urine sediment?
collection meds especially cystocentesis
112
Is it normal to find WBCs in urine sediment?
Yes of it is <5/hpf with a cysto sample or 5-10/hpf if it is a free catch
113
What does an abnormal number of WBCs on urine sediment suggest?
inflammation, infection, or neoplasia
114
True or False: The evidence of epithelial cells are always an indication of something serious.
False - they are a common contaminant from the bladder/urethra
115
When can epithelial cells in urine sediment be increased?
With inflammation and certain cancers (TCC)
116
What can cause false positives of bacteria/yeast on urine sediment? How can they be confirmed?
Distal urinary tract contamination or stain particles. They can be confirmed via gram stain and bacterial culture
117
Where are casts formed?
In the renal tubules
118
When is the presence of casts normal?
If there are few granular/hyaline
119
When is the presence of casts abnormal?
IF there are is a presence of cellular or many other cats - may indicate renal tubular damage
120
True or False: Crystals are not a diagnostic for bladder stones.
True - it is a common finding
121
What can cause false positives of crystals in sediment?
refrigeration (calcium oxalate and struvites)

Small Animal Medicine (100 decks)

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