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Small Animal Medicine > Renal - Evaluation of Renal Disease > Flashcards

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
Q

What breeds have increased creatinine?

A

Greyhounds and Birmans

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26
Q

What is symmetric dimethylarginine (SDMA) a product of?

A

cytoplasmic proteolysis

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27
Q

How is SDMA filtered, reabsorbed, and secreted in the kidneys?

A

It is freely filtered by the kidneys with no tubular reabsorption/secretion

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28
Q

Why is SDMA a good serum marker of GFR function?

A

Because it allows for earlier detection of renal dysfunction than traditional markers - it is increased with as little as 25-40% loss of GFR

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29
Q

True or False: SDMA is influenced by muscle mass.

A

FALSE

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30
Q

What are some possible extra-renal influences of SDMA?

A

altered metabolic rates - hypo/hyperthyroidism, neoplasia, age, and breed

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31
Q

What are the potential uses of SDMA markers?

A

Monitoring of kidney function in patients with progressive muscle loss
Investigation of PU/PD cases that normal creatinine values (non-azotemic chronic kidney disease)

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32
Q

Loss of concentating ability occurs with what loss of GFR?

A

66% loss of GFR

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33
Q

Increases in creatinine or BUN occurs with what loss of GFR?

A

75% loss of GFR

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34
Q

When should we considere other measurements of renal function?

A

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

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35
Q

How do clearance assays work?

A

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

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36
Q

What clearance assays do we use in small animal medicine?

A

Inulin clearance, creatinine clearance, iohexol clearance

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37
Q

How does renal scintigraphy work?

A

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

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38
Q

What does renal scintigraphy allow for the measurement of?

A

Individual kidney GFR

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39
Q

What are the disadvantages of renal scintigraphy?

A

Expensive, specialized facilities, and limited availability

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40
Q

What are the strengths to doing a UA?

A

It is cheap and it allows for assessment of both renal and non-renal components of the urinary system

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41
Q

What parts of the urinary system can a UA assess?

A

Urine concentrating ability, urinary loss of metabolites, tubular injury, and upper/lower urinary tract infections

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42
Q

What are the weaknesses of UA?

A

Easily influinced by extra-urinary causes - fluid administration and delayed processing (bacterial overgrowth, dissolution of casts, formation of crystals)

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43
Q

What are the collection/storage variables of a UA?

A

method of collection, clean and clear container, temperature, and processing time

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44
Q

What are the 3 steps to success of a urinalysis?

A

Physical properties, chemical properties, and sediment exam

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45
Q

What is the typical color of urine?

A

yellow to amber

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46
Q

What are the abnormal colors of urine?

A

brown to dark red

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47
Q

What can cause brown to dark red urine?

A

Hematuria, hemoglobinuria, myglobinuria, and bilirubinuria

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48
Q

If you centrifuge brown to dark red urine and a pellet forms, what is likely the cause?

A

hematuria

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49
Q

If you centrifuge brown to dark red urine and it is still the same color, what can be the cause?

A

Bilirubinuria, hemoglobinuria, and myoglobinuria

50
Q

What is the USG?

A

The ratio of the weight of urine versus the weight of an equal amount of water (density ratio)

51
Q

How is USG measured?

A

refractometer

52
Q

At what USG is a patient considered hyposthenuric?

A

< 1.008

53
Q

At what USG is a patient considered isosthenuric?

A

1.008 to 1.012

54
Q

What mOsm is equal to 1.008-1.017?

A

300 mOsm

55
Q

What mOsm is equal to <1.008?

A

<300 mOsm

56
Q

What is specific gravity influenced by?

A

urine composition and fluid status

57
Q

What about urine composition can mildly increase gravity?

A

Glucose and protein

58
Q

How does dehydration affect the USG?

A

it causes it to be more concentrated

59
Q

How do IV fluids do to the USG?

A

they cause it to be less concentrated

60
Q

What physiologically affects the USG?

A

Adequate number of functional nephrons, robust renal medullary gradient, and anti-diuretic hormone

61
Q

At 66% renal function loss, the kidney loses the ability to concentrate urine. What will the USG be at this point?

A

isosthenuric

62
Q

What can effect the robust medullary gradient of the kidney?

A

Liver failure, hypoadrenocorticism, glucosuria, and medullary washout

63
Q

What disease process can cause decreased ADH production?

A

central diabetes insipidus

64
Q

What can cause central diabetes insipidus?

A

Pituitary/hypothalamic injury or hyperadrenocorticism

65
Q

What disease process can cause absence of response to ADH?

A

nephrogenic diabetes insipidus

66
Q

What can cause nephrogenic diabetes insipidus?

A

pyelonephritis/pyometra and hypercalcemia

67
Q

True or False: Changes in urine color can affect interpretation of urine dipsticks.

A

TRUE

68
Q

What does the glucose portion of the urine dipstick test for?

A

Presence of glucose in the urine

69
Q

If you get a positive response on the glucose portion of a urine test stripk what does that indicate?

A

There is renal tubular dysfunction or the renal tubular reabsorption threshold has been exceeded

70
Q

What is the renal threshold for glucose in cats?

A

Approximately 300 mg/dl

71
Q

What is the renal threshold for glucose in dogs?

A

Approximately 200 mg/dl

72
Q

What does the bilirubin portion of the urine dipstick detect?

A

conjugated bulirubin in urine

73
Q

Is bilirubin in urine normal in dogs?

A

yes - 1+/2+ can be normal in dogs

74
Q

In what cases does bilirubinuria occur prior to onset of icterus?

A

In cases of hemolytic anemia or hepatobiliary disorders

75
Q

How are ketones filtered in the kidney normally?

A

They are freely filtered in the glomeruli but reabsorbed to the maximum transport capacity in the tubules

76
Q

What does ketonuria suggest?

A

excess ketogenesis

77
Q

What ketones are detected by the urine dipstick?

A

Acetone and acteoacetate

78
Q

Is the specific gravity on the urine dipstick reliable?

A

No - it is not recommended in animals and a refractometer should be used instead

79
Q

What does the blood portion on the urine dipstick detect?

A

heme - NOT RBCs

80
Q

In what scenarios does the blood portion on the urine dipstick become positive?

A

In cases of hematuria, hemoglobinuria, and myoglobinuria

81
Q

What will you see on sediment in patients with hematuria?

A

RBCs

82
Q

What will the serum be like in patients with hemoglobinuria?

A

hemolysed serum

83
Q

What will you see on sediment and in a chemistry in patients with myoglobinuria?

A

No RBC on sediment and increased CK on chemistry

84
Q

What can affect the pH on a urine dipstick?

A

Influenced by diet, post-prandial alkalinuria, and UTI by urease producing bacteria

85
Q

How can a high protein diet affect urine pH?

A

it lowers the pH

86
Q

Post-prandially, what will the urine pH be in a patient?

A

It will be alkaline

87
Q

How does urease affect pH?

A

it raises it

88
Q

What bacteria produce urease?

A

Proteus, Staphylococcus, and Klebsiella

89
Q

What does the protein portion on the urine dipstick detect?

A

primarily albumin

90
Q

What does is the detection threshold for protein?

A

30 mg/dl

91
Q

Does the urine dipstick determine the source of proteinuria?

A

no

92
Q

The severity of the protein response on the urine dipstick is influenced by urine ________.

A

concentration

93
Q

True or False: Positive results should be confirmed with additional tests.

A

TRUE

94
Q

What causes renal proteinuria?

A

Increased loss in the glomeruli and decreased reabsorption in tubules

95
Q

What are some causes of renal protein loss?

A

Tubular/glomerular damage (nephron death), loss of anti-coagulant proteins (antithrombin), loss of albumin (low vascular oncotic pressure)

96
Q

What are the consequences for renal protein loss?

A

Faster progression of chronic kidney disease, thromboembolic disease, cavitary effusions and edema

97
Q

True or False: Proteinuria always implies a pathologic process.

A

False - it can be transient due to fever, seizures, and strenuous exercise

98
Q

What could protein in the urine, that is not due to the kidney, be the cause of?

A

Inflammation elsewhere in the urinary tract, inflammation in neighboring structures (genital tract), and increased plasma protein load

99
Q

What is the gold standard quantitave measurement of proteinuria?

A

Urine protein/creatinine ratio (UPC)

100
Q

What is the normal UPC ratio in dogs?

A

Dog <0.5

101
Q

What is the normal UPC ratio in cats?

A

Cat <0.4

102
Q

What is urobilinogen a product of?

A

intestinal bilirubin

103
Q

Is urobilinogen on the urine dipstick a commonly used detector in animal medicine?

A

no

104
Q

Is the nitrate portion on the urine dipstick reliable?

A

No

105
Q

What can reduce nitrate on the urine dipstick?

A

gram negative bacteria

106
Q

What does the leukocyte portion on the urine dipstick detect?

A

leukocyte esterase

107
Q

Is the leukocyte portion of the urine dypstick dependable?

A

Not in dogs and cats

108
Q

What are you looking for in a sediment exam?

A

Cellular components (RBC, WBC, epithelial cells, bacteria/yeast), casts and crystals

109
Q

Is it normal to find RBCs in urine sediment?

A

If it is <5/high power field

110
Q

What do more than 5 RBCs/high power field suggest?

A

There is inflammation, trauma, and active bleeding

111
Q

What can cause false positives of RBC in urine sediment?

A

collection meds especially cystocentesis

112
Q

Is it normal to find WBCs in urine sediment?

A

Yes of it is <5/hpf with a cysto sample or 5-10/hpf if it is a free catch

113
Q

What does an abnormal number of WBCs on urine sediment suggest?

A

inflammation, infection, or neoplasia

114
Q

True or False: The evidence of epithelial cells are always an indication of something serious.

A

False - they are a common contaminant from the bladder/urethra

115
Q

When can epithelial cells in urine sediment be increased?

A

With inflammation and certain cancers (TCC)

116
Q

What can cause false positives of bacteria/yeast on urine sediment? How can they be confirmed?

A

Distal urinary tract contamination or stain particles. They can be confirmed via gram stain and bacterial culture

117
Q

Where are casts formed?

A

In the renal tubules

118
Q

When is the presence of casts normal?

A

If there are few granular/hyaline

119
Q

When is the presence of casts abnormal?

A

IF there are is a presence of cellular or many other cats - may indicate renal tubular damage

120
Q

True or False: Crystals are not a diagnostic for bladder stones.

A

True - it is a common finding

121
Q

What can cause false positives of crystals in sediment?

A

refrigeration (calcium oxalate and struvites)

Small Animal Medicine (100 decks)

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