Renal Treatment Flashcards
Chronic renal failure (companion animal)
- 1). DIET - dec phosphate + protein intake (dec uraemia)
- 2). PHOSPHATE BINDERS e.g. Pronefra - >1.6 mmol/L
- 3). HYPERTENSION - Amlodipine (Amodip): Ca^2+ channel blocker, SID, 0.625 mg - 1.25 mg); Telmisartan (Semintra) (Angrotensin receptor blocker (ARB) (1.5 mg/kg BID then 2 mg/kg SID)
- 4). PROTEINURIA - Telmisartan (ARB); Benazepril (Fortekor) (angiotensin-converting enzyme inhibitor (ACEI))
- 5). POTASSIUM SUPPLEMENTATION - Kaminox
- GI SIGNS: antiemetics: Maropitant, Metoclopramide; appetite stimulants: Miratazapine; H2 blockers: Famotidine; proton pump inhibitor: Omeprazole
- ANAEMIA - blood transfusions, EPO injection
- HYDRATION support - stage III/IV
Chronic renal failure stage 1 (companion animal)
- Use nephrotoxic drugs w/ caution
- Correct pre-renal + post-renal abnormalities
- Fresh water available at all times
- Monitor trends in creatinine + SDMA to document stability or progression
- Investigate for + treat underlying disease/complications
- Treat hypertension if systolic blood pressure > 160 mmHg/evidence of end-organ damage
- Treat persistent proteinuria w/ renal therapeutic diet + medication (UPC >0.5 dogs; UPC > 0.4 cats)
- Keep phosphorus < 4.6 mg/dL (<1.5 mml/L)
- Renal therapeutic diet + phosphate binder if required
Chronic renal failure stage 2 (companion animals)
- Stage 1 Tx
- Renal therapeutic diet
- Treat hypokalaemia in cats
Chronic renal failure stage 3 (companion animal)
- Stage 2 Tx
- Keep phosphorus <5.0 mg/dL (<1.6 mmol/L)
- Treat metabolic acidosis
- Consider anaemia Tx
- Treat V+, inappetence, nausea
- Inc enteral or subcut fluids to maintain hydration
- Consider calcitriol therapy in dogs
Chronic renal failure stage 4 (companion animals)
- Stage 3 Tx
- Keep phosphorus <6.0 mg/dL (<1.9 mmol/L)
- Consider feeding tube for nutritional + hydration support + ease of medicating
Acute kidney injury (AKI) (companion animal)
- 1). Prevent absorption toxins - induce emesis (apometic); activated charcoal (prevents systemic absorption)
- 2). Cessation nephrotoxic substances
- 3). Treat underlying cause
- 4). IV fluids - electrolyte imbalances, high rate if hypovolaemic (work out deficit); monitor w/ urine output/BW/PCV + TS
- 5). Assessment urine output - indwelling urinary catheter
Acute kidney injury - management of oliguric/anuric renal failure (companion animal)
- IVFT - tailored to hydration status, caution of fluid overload
- Furosemide (alleviate vol overload) - 0.5 - 1 mg/kg IV/CRI
- Hyperkalaemia - calcium gluconate (heart protection); insulin (co-transporter of K^+); glucose; sodium bicarbonate
Acute kidney injury - management in recovery phase (companion animal)
- Matching ‘in’ + ‘out’ - weight to see if urinating
- Hydration status assessment
- Taper fluids once eating, drinking + azotaemia resolved
- Hypertension Tx
- GI complications
- Nutritional support
Acute kidney injury (horse)
- Manage underlying cause
- Discontinue nephrotoxic drugs
- Fluid therapy
- Supportive Tx - nutrition, managing concurrent disease
- Diuretics if horse not producing urine after 12 - 24 h: furosemide (1 - 3 mg/kg q2h IV); dobutamine infusion
If ineffective: dialysis
- Haemodialysis
- Peritoneal dialysis - intermittent
Acute kidney injury - acute tubular necrosis (cow)
- Removal/binding of ingeted toxin if within first 24 h: rumenotomy; admin activated charcoal
- IVFT - renal perfusion + urine production restoration
Chronic kidney disease (horse)
- Maintain hydration
- Address any existing underlying causes
- Palatable diet - adequate protein intake <10%; supplement diet w/ CHO + fat
- Reduce calcium intake, avoid alfalfa
- May require NaCO3 supplementation
Chronic kidney disease - renal amyloidosis (cow)
- No Tx, poor Px = euthanasia
UTI (companion animal)
- AB therapy: Ampicillin/TMPS
- NSAIDs
- Glycosaminoglycans (GAGs) (esp feline idiopathic cystitis)
‘Sludgy Bladder’ (rabbit)
- IVFT
- Analgesia - meloxicam (cascade, 6 x dose)
- AB - enrofloxacin/TMPS
- Sx - remove calculi; flush bladder
- Hygiene - chlorhexidine; fusidic acid; zinc oxide; rearguard (cyromazine)
- Diet - avoid calcium rich diet; change to Timothy hay
- If suspected encephalitozooanosis - albendazole/fenbendazole for 30 d
Lower urinary tract trauma (companion animal)
Stabilisation:
- IV - manage azotaemia, correct electrolyte imbalance (prevent bradycardia due to hyperkalaemia)
- Urine drainage - catheter placement; intermittent cystocentesis; peritoneal catheter (can also be used for lavage to treat hypothermia)
LUT trauma - bladder rupture (companion animal)
- Conservative - indwelling urinary catheter
- Surgical debridement + repair
LUT trauma - urethral rupture (companion animal)
- Urinary diversion to favour wound healing
- Conservative management - indwelling urinary catheter
- Surgical - surgical repair of wound; perineal urethrostomy
Bladder tumour - transitional cell carcinoma (dog)
- Chemotherapy
- Piroxicam (NSAID)
Feline idiopathic cystitis (FIC) (cat)
(No cure)
- Litter tray management
- Stress management - Feliway; tricyclic antidepressants e.g. amitriptyline
- Enhance water intake, wet diet, reduction in urine SG
- Analgesia - metacam, butorphanol, buprenorphine, NSAIDs
- Environmental enrichment
- Glycosaminoglycans (GAGs)
Urolithiasis (companion animal)
- 1). Medical - treat UTI; dietary modification
- 2). Surgical removal - invasive
- 3). Catheter retrieval
- 4). Voiding urohydropulsion - GA; agitation + gravity
- 5). Retrograde urohydropulsion (pushing uroliths back into bladder) - catheter + lubricant/saline mixture, finger to occlude pelvic urethra + create high pressure around urolith, flush back into bladder
- 6). Lithotripsy - breaking up uroliths into smaller fragments by laser to pass through urethra
Ureteric obstruction (companion animal)
- Subcutaneous ureteric bypass (SUB)
Urethral obstruction (companion animal)
Emergency stabilisation:
- IV catheter
- IVFT - Hartmann’s 5 - 10 mL/kg bolus over 10 - 15 min
- Protect heart from hyperkalaemia - calcium gluconate/dextrose + insulin
- Analgesia - opioids, burprenorphine; NSAIDs (once eating, urinating + adequate renal perfusion)
- Urinary catheter - GA/sedate - Vygon Kat Kath (can flush + left in situ, softens w/ body temp in urethral lumen) - assess closed collection system, calculate urine vol produced (1 - 2 ml/kg/hr)
- Antispasmodics - prazosin (0.25 - 1 mg, BID/TID), smooth muscle relaxant; dantrolene (0.5 - 2 mg/kg BID)
- Monitor azotaemia + electrolytes
- Discharge when normal consistent voiding behaviour + correction of biochemical parameters
Urinary incontinence, improving storage (companion animal)
- IUS (intra urethral sphincter) stimulant - sympathomimetics: phenylpropanolamine (or ephedrine, pseudoephedrine; sensitisation of adrenergic receptors: oestriol (oestrogen)
- Bladder relaxant (detrusor muscle relaxant) - antimuscarinic: propantheline; tricyclic antidepressants/anxiolytics: imipramine, amitriptyline
Improving bladder voidance (companion animal)
- Bladder contraction (detrusor muscle stimulant) - paraysympathomimetic: bethanechol (+ cispride, gastric prokinetic, inderict PS stimulation)
- IUS (intra urethral sphincter) relaxant - phenoxybenzamine, non-selective alpha-adrenergic receptor antagonist; prazosin, selective alpha-adrenergic antagonist
- EUS (external) relaxant - smooth muscle relaxants: diazepam, dantrolene
Urethral sphincter mechanism incompetence (USMI) (companion animal)
- Weight loss
- Alpha-sympathomimetics: phenylpropanolamine (PPA) (propalin), 1.5 mg/kg q8 - 12 hrs PO
- Ephedrine - converts to PPA in liver, enurace + caniphedrin
- Oestriol (incurin) - 0.5 - 1.0 mg/dog q24 hrs PO for 5 -7 d then q2 - 3 d as needed
Surgery:
- Artificial urethral sphincter (AUS)/collagen implant
- Move bladder neck into abdo - colposuspension; urethral sling; cystourethropexy
Restricted bladder filling - detrusor overactivity e.g. bladder hypoplasia, bladder neoplasia, transitional cell carcinoma (companion animal)
- Inc bladder capacity/dec spasticity (voidance)
- Antimuscarinic (anticholinergic) agents - propantheline
- Relaxants - imipramine
Ectopic ureter (companion animal)
Surgery:
- Intramural - transurethral cystoscopic ablation of intramural ectopic ureters - ureteral orifice relocated to urinary bladder
- Extramural - surgical re-implantation of ureteral orifices to urinary bladder
- Nephrectomy/ureterectomy if unilateral
- Supportive Tx - PPA/oestrogen
Bladder distension - detrusor atony (companion animal)
- Address underlying cause
- Relieve any obstruction, catheterise if necessary
- Parasympathomimetics e.g bethanechol (only effective on smooth muscle cells)
Reflex dyssynergia - failure of coordination of sphincter relaxation + detrusor contraction (companion animal)
- Prevent bladder distension + restore normal detrusor contraction
- Catheterisation - prevents inc bladder filling
- Parasympathomimetic (bethanechol) - restores detrusor contraction
- Sypatholytic agent (prazosin) - allows sphincter relaxation (dec outflow resistance)
- Monitor for UTIs
Urinary tract infections (UTIs) (equine)
- AB that concentrate within urine - trimethoprim sulphonamide (TMPS) = first line, broad spectrum (or penicillin, cephalopsorins), 7 - 10 d
Urolithiasis (equine)
- AB for concurrent bacterial infection
Surgical resection where possible:
- Cystotomy - laparoscopy + techniques to manipulate +/- break down calculus
- Urethrostomy (perineal)
- Nephrectomy (nephrolithiasis) - viable option for unilateral disease if ruptured
- Manual crushing/fragmentation (mallet + osteotome) - lithotripsy: extracorporeal shock wave therapy; trans-endoscopic lithotripsy: electrohydraulic shockwave/laser; Holmium YAG
Sabulous urolithiasis/sabulous cystitis (large animal)
- Promote bladder emptying e.g. bethanechol
- AB to control cystitis
- Anti-inflammatories
Patent urachus (foal)
- May resolve w/ supportive care - urachus may close spontaneously
- Care with umbilical disinfection - may prematurely remove stump -> acquired patent urachus
- Systemic AB therapy
- Surgical resection of umbilical remnants if obviously septic structures and/not responding to medical Tx
Uroperitoneum (foal)
Initial medical support to address metabolic disturbances:
- Peritoneal drainage
- IVFT - address azotaemia
- Address hyperkalaemia - IV glucose/dextrose solution; sodium bicarbonate solution?
- Broad spectrum AB
Once stabilised:
- (K^+ < 5.5 mEq/L)
- Surgical repair of bladder - two layers, second layer inverting, monofilament suture, pos laparoscopy assisted
- Resection of umbilical remnants if indicated
UTIs - corynebacterium renale (ruminant)
- Prolonged + aggressive antimicriobial therapy - penicillin (first line due to C. renale): propenicillin (22 - 44 mg/kg IM BID), ampicillin (11 mg/kg IM BID)
- Urine acidifiers e.g. ammonium salts to reduce adherence of C. renale (not palatable on food)
- Unilateral nephrectomy may be indicated in chronic/refractory cases
Urolithiasis (ruminant)
Surgical intervention - clear/bypass obstruction + regain urine output
- Amputation of urethral process
- Urethrostomy - perineal/pre-pubic
- Cystomy
- Tube cystomy
- Bladder marsupilsation (draining)
Acute renal tubular necrosis/AKI from lily toxicity (cat)
- Decontamination if ingestion of lilies in last 6 h: activated charcoal, emetic, gastric lavage, wiped down/wash coat
- Anti-emetics - maropitant if continued V+ to relieve nausea (visceral pain relief); metoclopramide; pot oesophagostomy tube for additional nutrition
- Gastric protectants - omeprazole – proton pump inhibitor (PPI) to reduce gastro-oesophageal reflux; famotidine – histamine (H2) receptor antagonist
- Others: mirtazapine – appetite stimulant. Only if nausea and vomiting controlled (watch); IV antimicrobials – have to justify
- Treatment of hyperkalaemia – indicated if significant ECG changes/arrhythmias - loss of p waves, peaked t waves + eventual bradycardia; IVFT, calcium gluconate, insulin + glucose
