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CLIN SCI: Urogenital System > Small Animal Urinary System > Flashcards

Small Animal Urinary System Flashcards

1
Q

What is a drug for urethral weakness treatment

A

Use estrogens for hormonal responsive, congenital weak sphincter, recurrent UTI, recurrent vaginitis
1) Estrogen-for dogs and bitches: Diethylstilbesterol or Estriol (Incurin)
2) Testosterone cypionate- Males
3) Phenylpropanolamine (dog and bitches)

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2
Q

What is a drug for urethral spasm treatment?

A

skeletal muscle relaxer: diazepam, methocarbamol, or baclofen
+
Alpha antagonist;
Phenoxybenzamine (or prazosin)

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3
Q

What drugs can you use for bladder atony treatment?

A

Parasympathomimetic like bethanochol or cisapride

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4
Q

What is a drug for bladder spasms treatment?

A

Parasympatholytic like
-Oxybutynin *
-Propantheline

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5
Q

What is the toxicity of testosterone used to treat sphincter incompetence in dogs

A

Agrression
Prostatic hyperplasia
Up-regulate alpha receptos- hypertension?

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6
Q

What is the toxicity of parasympathomimetics used to treat bladder atony

A

Cisapride has minimal toxicity but bethanochol can cause salivation, vomiting, diarrhea, bradycardia, miosis

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7
Q

What is the toxicity of parasympatholytics like oxybutynin used to treat detrusor hyperactivity

A

Ileus at higher doses

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8
Q

What is the toxicity of phenoxybenzamine or prazosin

A

hypotension

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9
Q

What are causes of urinary incontinence?

A

1) Weak urethra
2) Hyperactive urethra
3) Atonic bladder
4) Hyperactive bladder

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10
Q

What is the most common cause of urinary incontinence

A

weak urethra *Most common

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11
Q

What might cause a dog/cat to pee in the house

A

1) Urinary incontience (weak urethra, hyperactive urethra, atonic bladder, hyperactive bladder)

2) Pollakiuria (small volumes, frequently)

3) PU/PD

4) Inappropriate urination- behavioral

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12
Q

urinating small volumes frequently
commonly from an infection

A

pollakiuria

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13
Q

If you are urinary continent then

A

your bladder tone is greater than your bladder pressure

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14
Q

What is the first thing you should do when presented with urinary incontinence?

A

Determine if it is neurologic or non-neurologic

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14
Q

What might cause a bladder to have a large residual volume after urination

A

1) Bladder atony- common secondary to blocked tom

2) Obstruction- physical (stones, neoplasia, prostate) or functional/hyperactive (inflammation or idiopathic)

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15
Q

What might cause intermittent urinary incontinence

A

1) Detrusor instability (squirts of urine)

2) Urethral weakness (wet spots)- infection, hormonal, or partial obstruction

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16
Q

What should you do for your urinary incontinence disease work out

A

1) Rule out infection (culture and antibiotic trial)

2) Rule out stones/masses via radiographs +/- US, studies, scopes

3) Rule out PU/PD

4) Rule out prostate diseases (Radiographs +/- ultrasound)

5) Rule out ectopic ureters (continuous)- ultrasound, contrast studies, scopes

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17
Q

What estrogen is FDA approved

A

Estriol (Incurin)

(Diethylstilbestrol is not FDA approved)

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18
Q

Why is Incurin (Estriol) and Diethylstilbesterol good at treating sphincter incompetence

A

-Cheap
-Easy for the client
-Minimal toxicity with oral
-Hormonal responsive
-Congenital weak sphincter
-recurrent UTI
-Recurrent vaginitis

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19
Q

Why are injectable estrogens contraindicated

A

it will kill the bone marrow

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20
Q

T/F: oral estrogens not associated with bone marrow suppression but rarely squamous metaplasia of prostate

A

True

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21
Q

Reasons to use estrogens

A

1) Hormonal responsive
2) Congenital weak sphincter
3) Recurrent UTI
4) Recurrent vaginitis

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22
Q

What are some toxicities of testosterone cypionate

A

aggression
prostatic hyperplasia

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23
Q

Testosterone cypionate may upregulate

A

alpha receptors

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24
Q

How should you treat refractory incontinence

A

1) Combination estrogen/PPA (Incurin daily, PPA three times a day)

2) Urethral injection- collagen deposits

3) Surgical techniques- cystopexy, urethropexy, colposuspension, prostatopexy, cystourethroplasty, occluder

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25
Q

urethra not relaxing during detrusor reflex

A

sphincter hypertonicity

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26
Q

How do you treat sphincter hypertonicity

A

1) Skeletal muscle: Diazepam, Methocarbamol, Baclofen
+
2) Alpha-antagonist: Phenoxybenzamine (or prazosin) for smooth muscle

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27
Q

What is a consequence of using alpha-antagonists to relax urethral smooth muscle

A

hypotension

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28
Q

What are the effects of using diazepam for treating sphincter hypertonicity

A

sedation
hepatotoxicity (cats)

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29
Q

What skeletal muscle relaxer is hepatotoxic to cats

A

diazepam

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30
Q

What skeletal muscle relaxers can you use to treat sphincter hypertonicity

A

1) Diazepam
2) Methocarbamol
3) Baclofen
+ an alpha antagonist for smooth muscle relaxation

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31
Q

What might cause sphincter hypertonicity

A

inflammation
post-obstruction
neurological
idiopathic

*Urethra not relaxing during detrusor reflex

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32
Q

T/F: urodynamics are needed to diagnose detrusor atony

A

false

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33
Q

What might cause detrusor atony

A

Bladder wall cannot contract with normal parasympathetic tone
1) post obstruction
2) PU/PD

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34
Q

Bladder wall cannot contract with normal parasympathetic tone

A

bladder atony

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35
Q

What are the toxic affects of bethanochol

A

toxicity- salivation, vomiting, diarrhea, bradycardia, miosis

*Parasympathomimetic

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36
Q

What are the two things you can use Cisapride for

A

1) Megacolon in cats
2) Detrusor atony

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37
Q

T/F: Cisapride doesnt have very much toxicity

A

true

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38
Q

What should you use to treat detrusor atony

A

a parasympathomimetic
like bethanochol or cisapride

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39
Q

How do you treat detrusor hyperactivity

A

A parasympatholytic
1) Oxybutynin
or
2) Propantheline

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40
Q

What are some uses of Oxybutynin

A

1) Detrusor hyperactivity
2) FLUTDS
3) Bladder neoplasia
4) Cyclophosphamide cystitis

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41
Q

What toxicity might oxybutynin cause

A

ileus

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42
Q

What test do all pollakiuria cases need
1) Urinalysis
2) Radiographs
3) Urethrogram
4) Urethroscopy

A

Urinalysis

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43
Q

a prominent vulva fold (hooded) leads to

A

1) Recurrent vulvitis
2) Recurrent vaginitis- flora overgrowth
3) Recurrent cystitis- ascending infections

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44
Q

Why does urinary incontinence and hooded vulva happen together

A

both are from the same embryolical origin
surgical will not correct it, also need estrogen bc they have a concurrent weak sphincter

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45
Q

Routine UTI only needs _____ culture and ________

A

aerobic culture and anti-microbial sensitivity

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46
Q

What is likely occuring if you perform a vulvoplasty and urinary incontience persists

A

they likely have a concurrent weak urinary sphincter
will need medical management

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47
Q

What are causes of pollakiuria/dysuria

A

Urinary diseases- infectious, neoplasia, calculi, sterile (cats)

Prostatic diseases

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48
Q

What might cause vaginitis/vulvitis

A

1) Conformational- external (epivulvar fold) or internal (vaginal strictures) which is usually not a problem

2) Foreign bodies

3) Tumors

4) Incontinence

5) UTI primary

6) Primary infections- Mycoplasma, herpesvirus

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49
Q

What is a toxic effect of propantheline

A

ileus

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50
Q

How do you treat detrusor hyperactivity

A

A parasympatholytic like oxybutynin or propantheline

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51
Q

What is the alpha agonist you might use to treat sphincter incompetence

A

Phenylpropanolamine (PPA)

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52
Q

What are the side effects of Phenylpropanolamine

A

inappetence
arterial hypertension
lethargy
hyperactivity

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53
Q

Phenoxybenzamine is a ______ used to ______

A

alpha antagonist used to treat sphincter hypertonicity by relaxing smooth muscle

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54
Q

What are the side effects of estrogens

A

oral products not associated with bone marrow suppression but rarely squamous metaplasia of the prostate

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55
Q

Baclofen is a

A

skeletal muscle relaxer used to treat sphincter hypertonicity

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56
Q

In what breed should you avoid using sulfa drugs in? *

A

Dobermans

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57
Q

You have an 8yo FS lab that is urinating a small volume of urine at the backdoor around 5 times a day. What is the likely problem

A

pollakiuria

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58
Q

Causes of pollakiruria/dysuria that you need to rule out

A

Urinary diseases
1) Infectious
2) Neoplasia
3)Calculi
4) Sterile (cats)

Prostate diseases

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59
Q

What test do all pollakiurua cases need

A

urinalysis

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60
Q

You have a dog with a small bladder and upon rectal palpation toy feel a mild diffusely thick urethra
Dog is licking at vulva
What is the likely disease?

A

Bacterial infection
Calculi
Neoplasia

get urine culture

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61
Q

What should you do for routine urinalysis

A

aerobic culture and anti-microbial sensitivity

*Culture first time cases because if UTI recurs, I base the workup on the 2 bugs identified

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62
Q

What is the antibiotic duration of dog with a simple urinary infection

A

3-5 days

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63
Q

What is the antibiotic duration of dog with recurrent cystitis (3 or more per 12 months)

A

Do a work up for primary diseases
10-14 days of therapy usually adequate

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64
Q

What is the antibiotic duration of dog with pyelonephritis

A

10-14 days initially but may require long term

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65
Q

How do recurrent urinary tract infections differ if they are with the same organism vs different organism

A

Same organism: incomplete therapy, nidus, immunodeficiency

Different organism: repeat ascending infection, immunodeficiency

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66
Q

How should you treat leptospirosis

A

Doxycycline for clearance phase

if acute disease and vomiting, recommend using IV penicillin if injectable doxy is not available

+/- IV quinolone if septic

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67
Q

What drug should you use for leptospirosis that has become septic

A

IV quinolone

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68
Q

What should you use for a dog with leptospirosis and vomiting is not present

A

Doxycycline

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69
Q

Do they recommend prophalyxically treating dogs that have had contact with leptospirosis dogs?

A

Yes- doxycycline

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70
Q

What are the clinical signs of Brucellosis

A

Abortion
Stillbirth
Failure to conceive
Bacteremia
Genital tract inflammation

Uveitis
Discospondylitis

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71
Q

Why is brucellosis hard to treat

A

because it is an intracellular organism

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72
Q

What CBC/CHEM/Urinalysis changes would you see with brucellosis

A

Neutrophilic leukocytosis
Monocytosis
Hyperglobulinemia
Polyclonal gammopathy
Proteinuria

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73
Q

How do you diagnose Brucellosis

A

Serum antibody testing: trust a negative if chronic signs, falsely negative in acute cases, confirm a positive

Confirmation: AGID or tube agglutination, culture or PCR on blood

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74
Q

How do you confirm serum antibody positive dogs for Brucella

A

if they are positive then confirm with AGID or tube agglutination or culture or PCR on blood

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75
Q

Brucella serum antibody testing can be falsely negative if

A

acute case

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76
Q

When should you trust a negative brucella serum antibody test

A

if it is negative and chronic signs

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77
Q

Does brucella canis positive dogs pose a zoonotic risk

A

Yes- there is a zoonotic risk
Let state public health vet know
get animal spayed or neutered

mild undulant fever (less severe than B. abortus

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78
Q

How should you treat brucellosis?

A

1) Carefully spay or neuter if intact
2) Quinolone, PO, daily for 14 days
3) Doxycycline (or minocycycline) PO, daily for 14 days
4) Repeat the cycle until seronegative

Discuss the zoonotic risk with family, their MD and report to state

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79
Q

You have a radiodense stone and bacterial UTI, what is most likely stone

A

Struvite

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80
Q

Why are struvite calculi commonly associated with infection

A

because infections commonly increase the pH and struvite precipitate in alkaline pH

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81
Q

Can Struvite calculi be dissolved?

A

Yes

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82
Q

How can struvite calculi be prevented

A

with diet

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83
Q

T/F: Struvite calculi are radiodense

A

True

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84
Q

You have a 4yo FS schnauzer with pollakiuria, hematuria, and bladder stones felt on abdominal palpation. What is the likely calculi?

A

Calcium oxalate calculi

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85
Q

a radiodense calculi that precipiatates in alkaline pH, commonly associated with infection and can be dissolved with acidifying diets

A

Struvite calculi

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86
Q

What breeds are commonly associated with calcium oxalate crystals

A

Schnauzers

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87
Q

What are the predispositions of calcium oxalate crystals

A

1) schnauzers
2) chronic acidification
3) hypercalcemia

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88
Q

T/F: Calcium oxalate crystals are radiodense

A

true

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89
Q

T/F: calcium oxalate calculi can be dissolved

A

False- they need to be surgically removed

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90
Q

How do you treat calcium oxalate calculi

A

Surgical excision

prevention:
diet- aiming for alkaline
potassium citrate
Vitamin B6
Thiazide diuretics

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91
Q

How do you prevent calcium oxalate crystals from forming

A

diet- aiming for alkaline
potassium citrate
Vitamin B6
Thiazide diuretics

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92
Q

You have a 3yo FS yorkie with a BCS 3/9 with a low BUN and Low Albumin. What is the likely calculi

A

Urate Calculi - likely from portosystemic shunt

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93
Q

What breed commonly gets urate crystals

A

Dalmations

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94
Q

How might an animal get urate calculi

A

1) Dalmation - metabolism
2) Liver insufficiency including PS shunt

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95
Q

T/F: urate calculi are radiodense

A

False- need an ultrasound

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96
Q

T/F: cystine calculi are radiodense

A

False- need an ultrasound

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97
Q

You can only acidify the urine of the _________

A

struvites

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98
Q

T/F: silicate calculi are radiodense

A

True

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99
Q

What calculi are radiolucent

A

Urate
Cystine

need an ultrasound

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100
Q

What calculi are radiodense

A

Calcium Oxalate
Struvite
Silicate

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101
Q

What stones can be dissolved

A

Struvite
Urate
Cystine

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102
Q

What stones should you prevent with an alkalinizing diet

A

Urate and Cystine

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103
Q

How do you treat urate calculi

A

correct underlying disease
medical dissolution

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104
Q

T/F: you can dissolve urate calculi

A

True- alkalinizing diet

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105
Q

What drug should you add on for Dalmations with urate calculi

A

Allopurinol

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106
Q

Allopurinol

A

a drug used to help treat urate calculi in dalmations in addition to medical dissolution and alkalinizing diet

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107
Q

What breeds do you see silicate calculi in but are really rare

A

GSD and retrievers

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108
Q

How do you treat silicate calculi

A

surgical excision
alkalinizing diet

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109
Q

What shape do silicate calculi have

A

jack shaped

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110
Q

T/F: silicate calculi are radiodense

A

True- jack shaped

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111
Q

Cystine calculi

A

seen in male dachshund, english bulldogs, bassett hounds, and others

medical dissolution: alkalinizing diet and D-penecillamine

Potassium citrate

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112
Q

What breeds do you commonly see cystine calculi in

A

seen in male dachshund, english bulldogs, bassett hounds, and others

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113
Q

How do you treat cystine calculi in?

A

medical dissolution: alkalinizing diet and D-penecillamine

Potassium citrate

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114
Q

What calculi are shown under radiographs

A

Calcium oxalate
Struvite
Silicate

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115
Q

What calculi are unable to be seen under radiographs

A

Urate
Cystine

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116
Q

What calculi need to be surgically removed because they cannot be dissolved

A

Calcium oxalate
Silicate

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117
Q

What diet for Struvite

A

acidify

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118
Q

What diet for preventing calcium oxalate

A

alkalinize

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119
Q

What diet for preventing silicate

A

alkalinize

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120
Q

What diet for urate

A

Alkalinize

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121
Q

What diet for cystine

A

alkalinize

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122
Q

You have a 3yo MC DSH with recurrent pollakiuria through his life. What is most common
Bacterial
Fungal
Stones
Neoplasia
Sterile (idiopathic cystitis)

A

Sterile (idiopathic cystitis)

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123
Q

What are the causes of feline lower urinary tract disease syndrome (FLUTD)

A

1) Sterile (feline interstitial cystitis)
2) Bacterial- unlikely if <4yr, up to 15% if >4yr, more common in males after PU
3) Calculi
4) Neoplasia
5) Sterile- unknown cause, could be viral (calcivirus or herpesvirus) or struvite crystals/calculi secondary to increased pH (unrelated) or stress

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124
Q

Cats with Sterile (idiopathic cystitis) likely have struvite crystals because

A

it is secondary to stress (which increases urine pH)

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125
Q

What likely is causing Sterile (idiopathic cystitis) in cats

A

Stress

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126
Q

What might be a viral cause of Sterile (idiopathic cystitis) in cats

A

Calicivirus
Herpesvirus

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127
Q

What diagnostics should you do for feline lower urinary tract disease syndrome (FLUTD)

A

-Abdominal palpation for obstruction or calculi

-UA

-Abdominal radiographs

other options: aerobic urine, abdominal ultrasound or cystourethrogram

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128
Q

Which of the following should you use to treat all idiopathic feline lower urinary tract disease syndrome (FLUTD) cats?
Canned food
acidying diet
Amitryptyline
Stress relief
Hydroxazine
Glycosaminoglycans
Piroxicam/meloxicam

A

Canned food
Stress relief

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129
Q

How should you treat all idiopathic feline lower urinary tract disease syndrome (FLUTD)

A

Canned food- enforces H20 consumption, dilutes crystals, dilutes matrix

Stress relief- ensure cats needs, indoorpet.osu.edu, agents to add to diet, pheromone defuser

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130
Q

What are the 7 most common prostatic diseases

A

1) Benign prostatic hyperplasia
2) Acute bacterial prostatitis
3) Chronic bacterial prostatitis
4) Prostatic abscess
5) Prostatic neoplasia
6) Squamous neoplasia
7) Periprostatic cyst

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131
Q

prostate that is bilaterally enlarged

A
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132
Q

6yo male intact bulldog with blood in semen likely has

A

benign prostatic hyperplasia

smoothyl marginated, bilaterally symmetrical, non-painful, hemorrhage is most common sign

Diagnosis: radiograph, urinalysis, ejaculate cytology, biopsy definitive

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133
Q

What is the most common sign of benign prostatic hyperplasia

A

hemorrhage

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134
Q

How do you treat benign prostatic hyperplasia

A

Castration
Low dose estrogen treatment
Anti-androgens to lessen some of size

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135
Q

Acute bacterial prostatitis

A

Signs: acutely ill, fever, stiff gait, hematuria/pollackiuria

Palpation: normal size unless secondary, extremely painful, normal median groove and margination

Diagnosis: Hematuria, pyuria +/- bacteriuria, normal imaging, aspirate, biopsy and massage is contraindicated,

treatment: antibiotics and castration

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136
Q

Why is aspiration, biopsy, and massage of acute bacterial prostatitis contraindicated?

A

because you can cause bacteremia if hemorrhage

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137
Q

Chronic Bacterial prostatitis

A

Clinical signs; subclinical, hematuria, pollackiuria, straining to defectate

Prostate palpation: enlarged +/- asymmetry, irregular margination, firm, non-painful, normal median groove

Diagnosis: ejaculate, massage, biopsy definitive

Treatment: Antibiotics and castration

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138
Q

What antibiotics should you use for prostatitis

A

Gram Negative:
Potentiated sulfas
Quinolones
Chloramphenicol

Gram positive:
Erythromycin
Clindamycin
Azithromycin

*No Beta-lactams

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139
Q

What antibiotics should you not use for prostatitis

A

No Beta-Lactams

most other ones penetrate into prostate when it is chronic

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140
Q

Prostatic abscess

A

Clinical signs: acutelly ill, fever, stiff gait, hematuria/pollackiuria, dyschezia

Prostatic palpation: asymmetrical +/- fluctuant areas, extremely painful, normal median groove

Diagnosis: Hematuria, pyuria +/- bacterirua, imaging asymmetrical and fluid filled areas, aspirate, biopsy and massage is contraindicated

Treatment: Antibiotics, surgical drainage, castration,
Ultrasound drainage is dangerous!!

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141
Q

T/F: you should drain prostatic abscesses with ultrasound

A

False- dangerous

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142
Q

What is the one prostatic disease that neutering does not help

A

Prostatic neoplasia
-Adenocarcinoma

Treat with some NSAIDs, surgery, radiation, chemotherapy

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143
Q

Periprostatic cyst

A

Clinical findings: dysuria, dyschezia

Prostatic palpation: often intraabdominal, mass

Diagnosis: radiographs, ultrasound, aspirate

Treatment: surgery

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144
Q

What causes squamous metaplasia of the prostate

A

secondary to estrogen
1) Sertoli cell tumor
2) Exogenous estrogen for incontinence

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145
Q

How do you diagnose squamous metaplasia of the prostate

A

Cytology of the prepuce
-cornified squamous epithelial cells

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146
Q

How do you treat squamous metaplasia of the prostate

A

remove the estrogen source
1) remove sertoli cell tumor/ neuter
2) Exogenous estrogen for incontinence

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147
Q

You have a male intact dog with a prostate exam that feels bilaterally enlarged, smooth and nonpainful

UA reveals hematuria without pyria or normal

What is the diagnosis? How do you treat

A

Benign prostatic hyperplasia

Treat by neutering or anti-androgens

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148
Q

You have a male intact dog with an intraabdominal mass and dysuria and dyschezia and a normal UA. What is the diagnosis and treatment?

A

Periprostatic cyst

-Surgically excise and neuter

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149
Q

You have a male intact dog that rectal exam, prostate feels bilaterally enlarged, smooth, and non-painful. UA shows hematuria without pyuria. He also has a testicular mass. What is the diagnosis? What do you do?

A

Prostate squamous metaplasia

Neuter

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150
Q

You have a MC dog with a prostate that feels unilaterally or bilaterally enlarged, very firm, loss of septum, fixed and stranguria. What is the diagnosis? How do you treat?

A

Prostatic neoplasia

treat with piroxicam

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151
Q

How do you treat prostatic neoplasia

A

Piroxicam
Surgery
Radiation
Chemotherapy
(Neutering does not help)

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152
Q

You have a male intact dog with unilateral enlarged, fluid fluid, painful prostate. He is critically ill

UA shows hematuria, pyuria, and bacteriuria.

What is the diagnosis and treatment?

A

Prostatic abscess

treat by draining, neutering, and antibiotic (No beta-lactams)

gram negative: potentiated sulfas, quinolones, chloramphenicol

gram postive: erythromycin, clindamycin, azithromycin

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153
Q

You have a male intact dog with a prostate that feels bilaterally enlarged, irregular, and nonpainful

UA shows hematuria, pyruria, and bacteriuria

What is diagnosis? How do you treat?

A

Chronic bacterial prostatis

Neuter and antibitioics (No beta-lactams)

gram negative: potentiated sulfas, quinolones, chloramphenicol

gram postive: erythromycin, clindamycin, azithromycin

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154
Q

You have a male intact dog with a prostate that feels normal size but is in extreme pain upon palpation and clinically ill

UA shows hematuria, pyuria, bacteriuria

What is diagnosis? How do you treat?

A

Acute bacterial prostatitis

neuter and antibiotics (No beta-lactams)

gram negative: potentiated sulfas, quinolones, chloramphenicol

gram postive: erythromycin, clindamycin, azithromycin

155
Q

Which prostate diseases have a UA with hematuria, pyuria, and bacteriuria

A

Acute bacterial prostatits
Chronic bacterial prostitis
Prostatic abscess

156
Q

When do you put PU/PD on your problem list

A

1) Owner reports increased drinking or urination
2) Inappropriate isothenuria/hyposthenuria
3) First morning urine is inappropriately concentrated (dont withhold water)

157
Q

How do you rule out PU/PD

A

Do a urine specific gravity
Is the patient is Hypersthenuric
> 1.030 / 1.035

158
Q

What USG might make you suspicious of PU/PD

A

If the USG <1.030 / 1.035

Follow up and test USG on first morning sample
if still <1.030 / 1.035 the ask why they cannot concentrate

159
Q

What are your ruleouts for PU/PD

A

Primary polydipsia: psychogenic, liver, hyperthyroidism

Primary polyuria:
1) Central diabetes insipidus (CDI): decreased or absent ADH
2) Lack of renal response to ADH:
primary nephrogenic diabetes inspidius rare and secondary nephrogenic diabetes inspidus: lots
3) Medullary washout: often a consequence of diseases above
4) Osmotic diuresis: osmole prevents gradient

160
Q

Causes of primary polydipsia

A

psychogenic, liver, hyperthyroidism

161
Q

If a patient is PU/PD, you should only check bile acids if

A

if total bilrubin is not already elevated

162
Q

You can rule out PU/PD if the first morning urine specific gravity is

A

concrentated

163
Q

What should you never do in a patient with PU/PD

A

never restrict water

164
Q

Increase BUN and/or Increased Creatinine

A

Azotemia

165
Q

What is uremia

A

a clinical syndrome associated with azotemia

common signs: vomiting, diarrhea, weight loss, anorexia

more severe: uremic breath, uremic ulcers

severe: pneumonitis, encephalopathy, osteodystrophy

166
Q

Can a patient have pre-renal, renal, and post-renal azotemia at the same time?

A

Yes:

“Fluffy has renal azotemia due to CKD and a pre-renal azotemia due to dehydration”

167
Q

What might result in pre-renal azotemia

A

The kidneys are not being perfused appropriately
-Lack of intake
-Cardiac disease
-Loss: GI loss, skin, vessels, 3rd spacing
-Shock: hypotension

168
Q

Why do you see azotemia with decreased perfusion to the kidney (pre-renal)

A

With decreased perfusion, there is water conservation
-decreased excretion
-increased urine specific gravity
-increased BUN/Creatinine

169
Q

Azotemia with USG >1.030 is almost always

A

pre-renal

exception:
-Urethral obstruction occurs acutely so urine often concentrate
-Significant glucosuria leading to a false elevation of refractometer
-AKI: USG > 1.030 is rare; most are not concentrated
-Glomerular disease: dog may develop azotemia but have intact tubular function

170
Q

How might there be an azotemia with a USG > 1.030 that is not pre-renal

A

1) Urethral obstruction occurs acutely so urine often concentrate
2) Significant glucosuria leading to a false elevation of refractometer
3) AKI: USG > 1.030 is rare; most are not concentrated
4) Glomerular disease: dog may develop azotemia but have intact tubular function

171
Q

What might be a pre-renal cause for USG being really low

A

Nephrogenic Diabetes Insipidus or others like cushings, diabetes mellitus, addisions, prior admin of fluids

*Not renal azotemia if a secondary disease is preventing the kidney from concentrating

172
Q

Post-renal azotemia might occur when

A

there is an obstruction to renal pelvis, ureter, bladder, or urethra

172
Q

What might be occuring if your patient cannot pee and they have lower urinary tract signs with a firm bladder

A

urethral obstruction

173
Q

What might be reasons for a patient not urinating, having no lower urinary signs, and a flaccid bladder

A

dehydrated
AKI

174
Q

How might a patient have a post-renal azotemia that can still urinate

A

Ureteral obstruction
-confirm with ultrasound

175
Q

T/F: radiographs can confirm ureteral obstruction

A

False- you must use ultrasound

176
Q

How do you confirm a urinary tract rupture

A

a patient that can pee with history of trauma, ascites, fluid sample Cr (fluid) > Cr (serum) Azostix
confirm with ultrasound

177
Q

What is a way to test abdominal fluid for a urinary tract rupture

A

Azostix (BUN) is a quick test for abdominal fluid

Creatinine and potassium take longer to diffuse back into the bloodstream than BUN

Creatinine and potassium will be higher in abdominal fluid than in serum

178
Q

How does the Azostix test for urinary tract rupture work

A

Azostix (BUN) is a quick test for abdominal fluid

Creatinine and potassium take longer to diffuse back into the bloodstream than BUN

Creatinine and potassium will be higher in abdominal fluid than in serum

179
Q

You should determine the USG before

A

giving fluids

180
Q

You should use histroy and physical exam to identify pre-renal azotemia but what is used to identify post-renal

A

history, PE, and ultrasound

181
Q

Does being able to urinate rule out post-renal azotemia?

A

No- the patient can still urinate with urinary tract rupture and ureteral obstruction

182
Q

Renal azotemia means the

A

kidney itself is damaged

183
Q

How might azotemia with a low USG not equal kidney disease?

A

there might be diabetes mellitus, cushings, addisons, fluid admin, nephrogenic diabetes inspidus

184
Q

T/F: dehydration and a non-renal cause of PU/PD is renal azotemia

A

False

185
Q

The _______ stops proteins due to the size and charge while the ________ sops up anything that passs through via receptor mediated processes

A

glomerulus

proximal tubules

186
Q

Pathologic proteinuria can occur without

A

without:
-PU/PD
-low USG
-Azotemia
-hypoalbuminemia

187
Q

Why we care if there is excessive protein in the urine

A

shorter survival times regardless of azotemia

hypercoagulation as anti-thrombin 3 is lost

188
Q

What is seen early in dogs with glomerular disease

A

proteinuria

189
Q

Cats with interstitial disease, does proteinuria show up early or late

A

late

190
Q

How do you assess proteinuria

A

with a basic urine dipstick

191
Q

We are primarily concerned about proteinuria that is

A

Renal
Persistent- take 2-3 measurements, 2-3 weeks apart
Magnitude - measure urine protein:creatinine ratio

192
Q

If proteinuria is pre-renal or post-renal what do you do?

A

treat the cause but do not treat the proteinuria and do not run a UP:C

193
Q

What are causes of pre-renal proteinuria

A

1) Excess normal proteins: Myoglobin and hemoglobin - check urine dipstick for blood and if there is little to no RBC
Myoglobin: chem for AST and CK
Hemoglobin: CBC for hemolysis

2) Abnormal proteins: Light chain proteins (multiple myeloma or ehrlichia) . if elevated perform protein electrophoresis and monoclonal gammopathy and look for lytic lesions along the vertebral bodies

194
Q

What might cause pre-renal proteinuria that is light chain

A

-Multiple myeloma
check serum globulins
if elevated perform protein electrophoresis and confirm monoclonal gammopathy

or check for lytic lesions along the vertebral bodies

Ehrlichia can also have this

195
Q

What might cause post-renal proteinuria?

A

1) Urinary tract infection/ inflammation
check urine sediment for gross hematuria: RBC >250/hpf, puria (Increased WBCs), bacteriuria
Culture urine
Perform radiographs/ ultrasound

2) Genital tract (free catch sample)along skin, prepuce, vagina
check the urine sediment for bacteria or obtain cystocentesis

196
Q

What should you do to rule in urinary tract infection/inflammation

A

Elevated urine protein then proceed to

1) Check urine sediment
-Gross hematuria: RBCs >250/hpf
-Pyuria: Increased WBCs or WBCs proportional to RBCs
-Bacteriruia
2) Culture urine
3) Perform radiographs/ ultrasound

197
Q

You can rule in renal proteinuria once

A

pre-renal and post-renal proteinuria are ruled out

198
Q

How do you establish persistent proteinuria

A

Take 2-3 measurements, 2-3 weeks apart

if it goes away it is transient
if it persist then it is pathologic

199
Q

You should not run a UP:C if

A

1) Active sediment:
-Hemoglobin or myoglobin is present OR
-Gross hematuria OR
-RBC> 250/hpf
-WBCs >10-20/hpf
-Bacteria is present

2) Location is pre-renal or post-renal

200
Q

You can only run a UP:C if

A

1) Sediment is inactive
2) You suspect renal in origin

201
Q

UP:C <0.2

A

non-proteinuric

do nothing

202
Q

UP:C of
0.2-0.5 (dogs)
0.2-0.4 (cats)

A

borderline proteinuria

recheck in 2-4 weeks

203
Q

UP:C of
0.5-2.0 (dogs)
0.4-2.0 (cats)

A

significant proteinuria, this could be interstitial, tubular, or early glomerular

actions:
1) measure blood pressure
2) other tubulointerstitial
3) other systemic disease

204
Q

What do you do if a dog has a UP:C of 0.3

A

recheck in 2-4 weeks due to borderline proteinuria

205
Q

What should you do if a dog has a high UP:C and you suspect interstitial proteinuria

A

Urine culture for pyelonephritis

206
Q

What might cause significant proteinuria (indicated by a high UP:C) of tubular origin

A

Leptospirosis
Acute Kidney Injury (AKI)
Chronic Kidney Disease (CKD)
Fanconi syndrome (uncommon)

Action: Lepto titers +/- PCR, check for toxin exposure

207
Q

What miht cause significant proteinuria (indicated by a high UP:C of >2

A

severe, significant proteinuria

glomerular disease - Immune complex glomerulonephritis (ICGN), glomerulosclerosis, congenital, amyloidosis

go on an antigen hunt for an immune complex disease

208
Q

What are the 4 causes of glomerulonephritis (ICGN)

A

Neoplasia
Infectious
Immune
Inflammatory

209
Q

How might chronic heartwork antigen lead to glomerulonephritis

A

1) body fights by producing antibodies
2) Form antigen-antibody complelxes
3) Stick in glomerulus and destroys it
4) No longer filters protein
5) Proteinuria (severe UP:C >2)

210
Q

What should you do if there is a persistent proteinuria that is renal and glomerular and no antigen found

A

Treat proteinuria - ACE inhibitors and ARBs
Monitor UP:C and sequelae

*Renal biopsy is very expensive and dangerous

211
Q

How do you treat glomerulonephritis

A

Treat proteinuria - with ACE inhibotrs (Enalapril and Benazepril) and ARBs (Losartan and Temisartan)

Monitor UP:C and sequelae

212
Q

T/F: you treat pre-renal azotemia with ACE inhibitors

A

False - never
only for renal azotemia

213
Q

ACE inhibitors (Enalapril and Benazepril) and ARBs (Losartan and Temisartan) function to

A

Dilate the efferent arteriole
1) Decrease intraglomerular hydrostatic pressure
2) Decreases proteinuria

214
Q

How do you treat proteinuria of renal glomerular origin

A

ACE inhibitors (Enalapril and Benazepril) and ARBs (Losartan and Temisartan) function to
Dilate the efferent arteriole
1) Decrease intraglomerular hydrostatic pressure
2) Decreases proteinuria

215
Q

ACE inhibitor and ARBs dilate the

A

efferent arteriole

216
Q

Enalapril and Benazepril are

A

ACE inhibitors

Dilate the efferent arteriole
1) Decrease intraglomerular hydrostatic pressure
2) Decreases proteinuria

217
Q

Name two ACE inhibitors

A

Enalapril
Benazepril

218
Q

Name two angiotensin II receptor blockers (ARBs)

A

Losartan
Telmisartan

219
Q

Losartan and Temisartan are

A

Angiotensin II receptor blocker

Dilate the efferent arteriole
1) Decrease intraglomerular hydrostatic pressure
2) Decreases proteinuria

220
Q

How might you sympomatically treat hypertension

A

ACE inhibitors (Enalapril or Benazepril) or Amlodipine (calcium channel blocker)

221
Q

What anticoagulant drugs might be helpful with a patient with proteinuria

A

aspirin (low dose) or clopidogrel

222
Q

T/F: protein can occur in a concentrated urine

A

True

223
Q

SDS-PAGE

A

localizes source (glomeruli versis tubules) of urine protein based on molecular weight

(Sodium Dodecyl Sulfate-Poly Acrylamide Gel Electrophoresis)

alternative for renal biopsy, much cheaper and safer

224
Q

you should only perform a renal biopsy if

A

1) patient is stable and non-hypertensive

2) Do it correctly and send it to Texas A&M under serious instructions

3) Owners are aware of expensive

4) Owners know it may not change therapy

225
Q

What two things do you need to run a UP:C

A

1) Persistence
2) Renal origin

226
Q

What is the history of animals with AKI

A

-Healthy prior
-Recent onset
-May have a risk factor (Toxins, NSAIDs, anesthesia, etc)

227
Q

What might you see on your physical exam in an animal with AKI

A

Good BCS
Painful kidneys that are normal or increased in size

228
Q

What do you see diagnostically with AKI

A

-Glucosuria with normal serum glucose
-Casts (+/-)
-Proteinuria (+/-)
-Bright kidneys on US

229
Q

What are common nephrotoxins specific to dogs that can lead to AKI

A

raisins and grapes

230
Q

What are common nephrotoxins specific to cats that can lead to AKI

A

Lilies

231
Q

What are common nephrotoxins, causing AKI in small animals

A

-NSAIDs
-Aminoglycosides
-Ace inhibitors
-Ethylene glycol
-Amphotericin B
-Raisins/Grapes (Dogs)
-Lilies (cats)

232
Q

What can lead to AKI

A

1) Nephrotoxins: NSAIDs, Aminoglycosides, Ace inhibitors, Ethylene glycol, Amphotericin B, Raisins/Grapes (Dogs), Lilies (cats)

2) Infectious: pyelonephritis, leptospirosis and lyme (dogs), FIP (cats)

3) Conditions: dehydration, fever, heat stroke, sepsis, acidosis, hypercoagulation

4) Organ system: Cardiac disease, pancreatitis, hypotension

233
Q

What infectious agents might cause AKI in dogs

A

Bacterial (pyelonephritis)
Leptospirosis
Lyme

234
Q

What infectious agents might cause AKI in cats

A

Bacterial (pyelonephritis)
FIP

235
Q

What conditions might cause AKI in small animals?

A

Dehydration
Fever
Heat stroke
Shock
Sepsis
Acidosis
Hypercoagulation

236
Q

What other organ systems can lead to AKI

A

Cardiac disease
pancreatitis
hypotension

237
Q

AKI can potentially be reversible but eventually

A

it becomes irreversible damage, doesnt matter if you eliminate inciting injury

238
Q

Should you condemn a patient based on the magnitude of azotemia?

A

No never-

ex: urolith, once eliminated azotemia will decrease

238
Q

How do you know if an animal with an increased azotemia has responded to therapy

A

Azotemia plateaus- see how the patient responds to therapy and where you can get them in their stable state

239
Q

What are the treatment principles of AKI

A

Treat the treatable (culture urine, relieve post renal causes, underlying cause, discontinue nephrotoxic drugs, decontaminate toxins)

Save nephrons- fluid resuscitation, maintain perfusion

Address the uremia: anti-nausea, appetite stimulants, remove the waste

240
Q

How do you treat pyelonephritis in dogs and cats

A

IV fluoroquinolones after aerobic urine culture

240
Q

What culture in mandatory in AKI patients?

A

aerobic culture to rule in/out pyelonephritis

however it is not a common cause

241
Q

What are risk factors for AKI that are additives?

A

Pyelonephritis
Post-renal causes
underlying cause
nephrotoxic drugs
nephrotoxic toxins

242
Q

Are lower urinary tract infections or upper urinary tract infections systemic illness

A

upper urinary tract infection- systemically ill and will have a fever

243
Q

Post renal causes occur anywhere between the

A

Urethra and the renal pelvis

Levels: urethra, bladder, ureter, and renal pelvis)

243
Q

What is a really good question to ask clients to see if there is a post-renal cause

A

Can you pet urinate?

Do they strain when urinating?

244
Q

Does being able to pee rule out a post-renal cause

A

No- there could be an obstruction in the ureter or renal pelvis associated with one kidney

245
Q

If there is a bladder rupture, can patients still urinate

A

yes- often times just a tear

246
Q

What will you do when you suspect a post-renal azotemia

A

ultrasound - you might see a large bladder, free fluid, stones, kidney with hydronephrosis or hydroureter

Palpate: firm hard bladder if in urethra and/or painful kidneys

247
Q

What are sources of leptospirosis

A

stagnant water, urine

248
Q

If you suspect leptospirosis, what should you ask

A

-Is your pet vaccinated?
-What other animals do you have
-Is there PU/PD?

249
Q

How many serovars are in the leptospirosis vaccination

A

4 serovars (out of 200)

250
Q

How should you manage a patient with leptospirosis for zoonotic risk

A

use barrier nursing to control PU/PD and spread

251
Q

When can lepto be detected in blood vs the urine PCR

A

Blood: Day 1-10 days

Urine: 11-14 days

252
Q

Why might you need to run both urine and blood PCR in animals you suspect leptospirosis

A

Leptospirosis is detected in
Blood: Day 1-10 days
Urine: 11-14 days

253
Q

What is the gold standard for leptospirosis testing

A

MAT (IgM and IgG)

not as sensitive early on. best after 12 days

254
Q

When can IgM antibodies for leptospirosis be detected in Witness POC

A

IgM can be detected at 5 days

255
Q

When can MAT detect leptospirosis antibodies

A

Earliest IgM: day 8-11 (insensitive)

Earliest IgG: day 12-onwards

256
Q

Witness POC detects ____ while MAT detects _____

A

POC: IgM

MAT: IgM and IgG

257
Q

How do you treat leptospirosis in small animals

A

Ampicillin (IV) or Doxycycline (IV or PO)
no oral doxy if patient is vomiting

Eliminate the carrier state: Doxycycline (PO)

258
Q

What are different drugs you need to discontinue in patients with AKI

A

NSAIDs
Aminoglycosides
ACE Inhibitors (ex: Enalapril)
Amphotericin B (antifungal)

259
Q

What is the only drug for eliminating the leptospirosis carrier phase?

A

Doxycycline (PO)

260
Q

Why do you need to discontinue ACE inhibitors in patients with AKI

A

because ace inhibitors cause reduced blood flow to the kidneys and glomerular filtration (used to treat hypertension and proteinuria) this can precipitate an AKI

261
Q

What are the metabolites of ethylene glycol after metabolism by alcohol dehydrogenase

A

1) Glycoaldehyde: cause CNS signs

2) Glycolic acid: acidosis

3) Glycoxylic acid: converted to oxalic acid

262
Q

What crystals in the urine is seen with ethylene glycol toxicity

A

calcium oxalate monohydrate

can also see casts, glucosuria, proteinura

263
Q

What will you see on a blood gas in an animal with ethylene glycol toxicity

A

Severe acidosis (unknown origin as lactate is normal)
High base excess
Low pH with no explanation
Unmeasured is the ethylene glycol

264
Q

What should you do for ethylene glycol

A

test kit: 30min-12 hours (less sensitive in cats)

decontaminate within 1-3 hours

265
Q

What can you use to treat ethylene glycol toxicity

A

Fomepizole (dogs)
High dose fomepizole (cats)
this blocks alcohol dehydrogenase

fluid resuscutation based on patients ability to conserve or unload fluid (provide maintenance, replace defiti, replace ongoing losses)

266
Q

What is the mechanism of action of fomepizole

A

blocks alcohol dehydrogenase

267
Q

What is the maintenance formula for fluids per dya

A

Cats: 80 x weight (kg) ^0.75

Dogs: 132 x weight (kg) ^0.75

Total / 24 hours = mls/hour

268
Q

How do you calculate the deficit of fluids

A

dehydration (as decimal) x wt(kg) = deficit (L)

deficit (L) x 1000mls/L = deficit (mls)

Deficit (mls) / 24 hours = mls/hr

add this deficit to the maintenance rate

269
Q

Deficits are often replaced over

A

4-6 hours in some conditions

270
Q

Ongoing urinary losses are determined by

A

urine output

Polyuric AKI > 2mls/kg/hr
Relative Oliguric AKI= 1-2ml/kg/hr
Oliguric AKI <1ml/kg/hr
Anuric AKI= 0mls/kg/hr

this can be determined by placing a urinary cather, which is mandatory for AKI

271
Q

T/F: placing a urinary catheter in AKI cases is mandatory

A

True - mostly
need to measure the on-going urinary losses

272
Q

Insensible losses

A

20mls/kg/day

273
Q

How do you determine how much fluid is lost

A

1) Calculate insensible losses: 20mls/kg/day
2) Measure urine volume in the bag every 4 hours
3) Estimate other losses (e.g vomiting, diarrhea)

Total loss: insensible + urine volume +other

Fluid rate (mls/hr): total loss (mls) /24 hours
only put this amount into the IV line

274
Q

How do you ensure perfusion to the kidneys in AKI cases

A

1) Lower systemic blood pressure- be careful and maintain adequate BP
2) Stop ACE-inhibitors: nephrotoxic drug that decreases GFR

275
Q

In AKI cases, what can you do to treat nausea and vomiting

A

Ondansetron
Maropitant
Omeprazole

276
Q

How do you remove waste products (BUN, creatinine, others) in AKI

A

adress uremia
-Peritoneal dialysis
-Intemittent hemodialysis
-Continuous hemodialysis

very expensive

277
Q

if one kidney is destroyed, will you see azotemia and concentration?

A

not necessarily
50% reserve so no difference

278
Q

If a well hydrated (ie no prerenal azotemia) patient with a right urethral obstruction has azotemia. What conclusion do you draw

A

the left kidney is likely diseased as well
exception in acute ureteral obstruction

279
Q

The kidney can maintain normal homeostasis with

A

50% nephron lost

280
Q

At what percent of nephron lost is concentrating ability lost

A

67%

281
Q

At what percent of nephron lost do you see azotemia

A

75% nephron lost

282
Q

At what percent of nephron lost do you see uremia and death

A

100% nephron lost

283
Q

a renal biomarker that detects renal damage when only 25% of total nephrons are compromised
ie. before concentrating ability is lost

A

SDMA (symmetric dimethylarginine)

284
Q

Is SDMA or loss of concentrating ability able to detect renal damage sooner

A

SDMA- 25% total nephrons compromised

Loss of concentrating ability- 67%

285
Q

What are the clinical consequences of CKD

A

1) PU/PD (early sign in cats)
2) Weight loss
3) Inappetance/nausea
4) Vomiting / Diarrhea
5) Weakness
6) Constipation
7) Uremic ulcers

286
Q

What are the physiological consequences of CKD

A

1) Anemia (decreased erythropoietin) - later stage
2) Hypertension (Systemic blood pressure)
3) Dehydration (Decreased water conservation)
4) Proteinuria (protein conservation compromised)
5) Hyperphosphatemia (decreased P excretion)
6) Hypocalcemia (ionized) from decreased Ca retention
7) Hypokalemia (K+ retention decreased)
8) Acidemia
9) Decreased vitamin D (Vitamin D conversion decreased)

287
Q

Is proteinuria in CKD more common in dogs or cats

A

Dogs

288
Q

What electrolyte abnormalities is seen with CKD in dogs and cats ?

A

Hyperphosphatemia
Hypocalcemia (ionized)
Hypokalemia
Acidemia

289
Q

Is hypo or hyperkalemia seen in CKD in dogs and cats

A

hypokalemia

290
Q

Is hypo or hyperphosphatemia in CKD in dogs and cats seen

A

hyperphosphatemia

291
Q

Is calcium or ionized calcium low in CKD in dogs and cats

A

ionized calcium

292
Q

What are the species differences in CKD in dogs and cats

A

Cats: mostly tubulointerstitial nephritis
decreased USG first
Azotemia second
Proteinuria usually later

Dogs: often Glomerulonephritis
proteinuria first
USG is often normal (tubules normal)
Azotemia and low USG later

293
Q

What is seen in renal secondary hyperparathyroidism in dogs and cats

A

Hyperphosphatemia
Hypocalcemia (ionized)
Decreased Vitamin D

294
Q

What species typically has tubulointerstitial nephritis with CKD

A

Cats

295
Q

What species typically has glomerulonephropathies with CKD

A

Dogs

296
Q

Dogs with CKD- glomerulonephropathies, what is typically the first sign

A

Proteinuria first
USG often normal (nx tubules)
Azotemia and low USG later

297
Q

Cats with CKD- tubulointerstitial nephritis, what is typically the first sign

A

Decreased USG first (some exceptions)
Azotemia second
Proteinuria usually later

298
Q

With IRIS staging, what is used to put an animal in Stage 1-4

A

Creatinine or SDMA
then substage based on proteinuria and blood pressure

299
Q

How many creatinine measurements do you need to stage a CKD patient

A

YOu need two creatinine measurements in a stable patient

300
Q

At what creatinine would each IRIS stage be

A

Stage 1: <1.4
Stage 2: 1.4-2.8
Stage 3: 2.9-5.0
Stage 4: >5.0

301
Q

What are the different IRIS substages for proteinuria

A

Dog: Nonproteinuric <0.2, borderline proteinuria 0.2-0.5, proteinuric >0.5

Cat: Nonproteinuric <0.2, Borderline proteinuric 0.2-0.4, proteinuric >0.4

302
Q

What are the IRIS substages of systolic blood pressure

A

Normotensive <140
Prehypertensive 140-159
Hypertensive 160-179
Severely hypertensive >180

303
Q

Should you stage a sick patient based on a single creatinine *

A

NO- you need two creatinine measurements in a stable patient

304
Q

When should you recommend a renal therapeutic diet for CKD patients

A

When they are stage 2 (Creatinine 1.4-2.8)

305
Q

What are the overall goals of CKD

A

-Keep them eating
-Keep them hydrated
-Prevent on-going damage
-Avoid AKI or CKD
-Monitor

306
Q

In CKD, how do you address nausea

A

anti-nausea drugs: Ondansetron
Maropitant

307
Q

In CKD, how do you enhance appetite

A

mirtazapine (cats), capromorelin (dogs)
warm food, switch foods, add tasty treats

do not force feed- creates food aversions

308
Q

Why should you not force feed

A

it creates food aversions

309
Q

In CKD, how might you keep the GI tract moving

A

avoid hypokalemia

310
Q

In CKD, how do you prevent acidosis

A

Potassium citrate
Renal Diet

311
Q

In CKD, how do you prevent hyperphosphatemia

A

phosphate binders
1) aluminum hydroxide
2) lanthanum carbohydrate (Renalzin)
3) Sevelamer hydrochloride (Renagel)

312
Q

In CKD, how do you treat anemia <20%

A

Darbepoeitin

313
Q

In CKD, how do you prevent weakness

A

avoid hypokalemia

314
Q

In CKD, how do you treat hypertension in cats

A

Amlodipine

315
Q

In CKD, how do you treat hypertension in dogs

A

1) Ace Inhibitors (Enalaparil, Benazepril) - first
2) Angiotensin Receptor Blockers (ARBs): Losartan, telmisartan

316
Q

In CKD, how do you reduce proteinua

A

1) Ace Inhibitors (Enalaparil, Benazepril) - first
2) Angiotensin Receptor Blockers (ARBs): Losartan, telmisartan

317
Q

If proteinuric due to CKD, how do you prevent thrombi

A

Clopidogrel

318
Q

How might a patient with CKD have an acute AKI

A

Nephrotoxins
Infectious
Conditions
Organ System compromise

319
Q

T/F: you can differentiate CKD from AKI if PCV is normal

A

False

320
Q

T/F: you can differentiate CKD from AKI based on magnitude of azotemia

A

False

321
Q

T/F: you can differentiate CKD from AKI based on urine specific gravity

A

False

322
Q

How do you differentiate CKD from AKI

A

AKI: Recent onset, eg. PU/PD previously healthy. Sick relative to degree of azotemia, good BCS, normal or enlarged kidney size +/- painful kidneys
Normal or Increased PCV
Hyperkalemia
Proteinura
Glucosuria w normal serum glucose (tubular damage)

CKD: Chronic PU/PD +/- weight loss, may not be sick despite azotemia, may be poor BCS, small or irregular kidneys, non painful kidneys
Normal to decreased PCV
Normal to decreased K

323
Q

Do you see small or irregular kidneys with AKI or CKD

A

CKD

324
Q

Is hyperkalemia more likely to be seen with CKD or AKI

A

AKI

325
Q

Is hypokalemia more likely to be seen with CKD or AKI

A

CKD

326
Q

T/F: both AKI and CKD result in minimally concentrated or isosthenuric urine

A

True - cannot differentiate based on USG

327
Q

How often should you monitor patients with CKD

A

typically every 3-6 months but depends on severity, progression, number of medications, frequency of medication changes, and owner

Monitor:
BUN, creatinine, phosphorus, electrolytes
Blood pressure and fundic exam
PCV/ total solids
Urinalysis
Body and muscle condition score
Hydration Status

328
Q

In a patient with CKD, what should you monitor every 3-6 months

A

BUN, creatinine, phosphorus, electrolytes
Blood pressure and fundic exam
PCV/ total solids
Urinalysis
Body and muscle condition score
Hydration Status

329
Q

To increase appetite, capromorelin is typically used in _______ while mirtazapine is typically used in ________

A

Capromorelin: dogs
Mirtazapine: cats

330
Q

What drug is used to reduce gastric acid

A

omeprazole - controversial whether cats and dogs develop GI ulcers with CKD

331
Q

Renal secondary hyperparathyroidism

A

1) Loss of function nephrons
2) Decreased Vitamin D production
3) Decreased Ca and P from Gi tract
4) Increased PTH to increase bone resorption

Net: Increase P , Decrease calcium

332
Q

Gloria is CKD stage 2 (creatinine - 1.9), non-proteinuric (UP:C - 0.1, severely hypertensive (BP - 183 mmHg).

Please select the drug you would like to start for Gloria:

A

Amlodipine (calcium channel blocker)

333
Q

A 12-yr-old, MC, cat with CKD Stage II presents with constipation and inappetence. Which electrolyte would you want to check and then supplement?

A

Potassium

334
Q

What kind of drug is telmisartan?

A

Angiotensin receptor blocker

335
Q

Of the following drugs, which might you use as an appetite stimulant?
Group of answer choices

Cisapride

Ondansetron

Metoclopramide

Meloxicam

Mirtazapine

Maropitant

A

Mirtazapine

336
Q

We consider starting darbepoetin most often when the PCV is in what range?

A

<20%

337
Q

A dog presents with acute onset anorexia and vomiting for 3 days. Which drug would you use to treat leptospirosis when the patient is first hospitalized?

A

Ampicillin IV

338
Q

Which of the following drugs is used to treat ethylene glycol toxicity in both dogs and cats?

A

Fomepizole

339
Q

Select the drugs below which is used primarily to treat nausea.

A

Maropitant
Ondansetron

340
Q

What kind of drug is benazepril

A

ACE-inhibitor

341
Q

A 10 year old, MC, mixed breed dog presents with PU/PD. Select the top 3 diseases you would have on your list before knowing anything else about the patient?

A

CKD
Diabetes mellitus
Cushings

342
Q

A 10 year old, FS, domestic short hair cat presents with PU/PD. Select the top 3 diseases you would have on your list before knowing anything else about the patient?

A

CKD
Diabetes mellitus
Hyperthyroidism

343
Q

A 5 year old, MC, border collie presents with a complaint of PU/PD. A urinalysis reveals a urine specific gravity of 1.040 with no other abnormalities.

What is your next best diagnostic/therapeutic step?

A

Nothing. The dog is not PU/PD

this dog has an appropriate concentrating ability and can concentrate their urine even if the owner perceives PU/PD

344
Q

A 5 year old, MC, border collie presents with a complaint of PU/PD. A urinalysis reveals a urine specific gravity of 1.015 with no other abnormalities.

What is your next best diagnostic/therapeutic step?

A

Repeat urine specific gravity on a first morning sample

We must confirm that the patient can appropriately concentrate their urine overnight normally when dogs/cats dont drink water

remember do not withhold water during the night as this can result in AKI if the patient is polyuric and needs to drink to compensate for their fluid loss

345
Q

A urinalysis is performed in a patient with intravascular immune-mediated hemolytic anemia. The urinalysis shows:

USG: 1.030
Protein: neg
Glucose: neg
Ketones: neg
Blood 3+
Casts: none
Bacterial: none
RBCs: 0-5 / hpf
WBCs: 0-1 / hpf

This patient has:

A

Hemoglobinuria

3+ blood - but there is not any RBCs in the sediment so they must have pigmenturia (due to hemoglobin or myoglobinuria)

346
Q

Do you see hemoglobinuria with intra-vascular or extra-vascular hemolysis

A

Intra-vascular hemolysis

347
Q

What does extra-vascular hemolysis mean

A

it means that the RBCs are broken down in the reticuloendothelial system and thus proceeded into bilirubin. Hyerbilirubinemia and hyperbilirubinuria are considered pre-hepatic

348
Q

A 3 year-old, FS, mixed breed dog presents with a 3-day history of anorexia, lethargy and vomiting. The patient had been perfectly normal prior to a dental one week ago.

On bloodwork, the patient has a BUN of 63 (7-30) and creatinine of 3.8 (0.6 – 1.6). Her USG is 1.015.

Please indicate what processes are likely contributing to the azotemia, i.e., classify (cateorize) the azotemia.

For the purpose of the classification questions, use the following definitions:

YES/LIKELY: You are confident or fairly confident that the component in question is contributing to the patient’s overall azotemia.
NO/UNLIKELY: You are confident or fairly confident that the component in question is not contributing to the patient’s overall azotemia.
POSSIBLE: Given the circumstances, it is worth further diagnostics to explore whether or not the component in question is possibly contributing to the patient’s overall azotemia.

A

Pre-Renal Azotemia: Yes/Likely

Renal Azotemia: Yes/Likely

Post-Renal Azotemia : No/ Unlikely

3 days of vomiting and decreased intake lead to dehydration and pre-renal azotemia. If the azotemia is purely pre-renal then the kidneys should respond by trying to conserve water, but this patient’s urine is not concentrated

There isnt evidence that the patient is unable to urinate or that he has an obstructed ureter at this time. She is a young, healthy dog with no prior hx

Hypotension under anesthesia could be the cause of AKI- which would account for both a renal and pre-renal cause of azotemia

349
Q

A 12 year-old, MC, cat presents with a history of CKD (IRIS Stage 2) presents for 3-day history of anorexia, lethargy and vomiting. On his last recheck exam, his BUN was 34 (18-35), creatinine was 1.7 (0.8 - 2.4 mg/dL), and potassium was 3.3 (3.7 - 5.4 mEq/L).

On bloodwork today, the patient has a BUN of 63 (18-35) and creatinine of 2.8 (0.8 – 2.4). His USG is 1.015. You also note an elevated potassium at 5.8.

Please indicate what processes are likely contributing to the azotemia, i.e., classify/categorize the azotemia.

For the purpose of the classification questions, use the following definitions:

YES/LIKELY: You are confident or fairly confident that the component in question is contributing to the patient’s overall azotemia.
NO/UNLIKELY: You are confident or fairly confident that the component in question is not contributing to the patient’s overall azotemia.
POSSIBLE: Given the circumstances, it is worth further diagnostics to explore whether or not the component in question is possibly contributing to the patient’s overall azotemia.

A

Pre-Renal Azotemia: Yes/likely
3 day history of vomiting and lethargy

Renal Azotemia: Yes/Likely
Cat already has a known renal component because it has been previously diagnosed with CKD. We cannot tell if this is a new renal insult that is resulting in the AKI or CKF

Post Renal Azotemia: Yes/Likely

The finding of hyperkalemia is highlt suspicious for either an AKI or post-renal azotemia.

350
Q

After 24 hours of fluid therapy, the 12-yr-old cat from the previous question appears well-hydrated, but his BUN, creatinine and potassium have increased. The cat has been urinating.

What is your next best diagnostic or therapeutic step?

A

Abdominal Ultrasound- the only diagnostic to confirm whether or not there is a post-renal obstruction.

(Lepto is unlikely in cats)

351
Q

A 6 year-old, FS, mixed breed dog presents for having accidents in the house.

You perform a urinalysis:

USG=1.025
Protein: 1+
Glucose: neg
Ketones: neg
WBCs: 50/hpf
RBCs; 20/hpf
Bacteria: 2+ cocci.

Would you perform a urine protein:creatinine (UP:C) ratio to quantify the protein?

A

No - active sediment

equal or greater number of WBCs compared to RBCs which is not what you would expect if this were just blood contamination from cystocentesis

-Bacteria: this supports a post-renal proteinuria

This is not the type of proteinuria you would treat with ACE-inhibitors or ARBs therefore it is not necessary to quantify it. If you were, you would be quantifying bacteria from the infection and not from protein that is entering the glomerulus

352
Q

Where is rocky mountain spotted fever located

A

in the east and southeast- not on your list of differentials for dogs in CO with no history of travel

353
Q

You have an 8 year old, MC, dog with a persistent (proteinuria detected 2-3 times over a two week period) renal proteinuria (UP:C - 3.4). The dog is from Fort Collins and has never traveled outside the state.

What infectious agents should you consider testing?

A

Leptospirosis
Heartworm

354
Q

A 5 year old, FS, Labrador retriever presents for a 3-day history of anorexia, lethargy and vomiting. The dog has been previously healthy with normal blood work on her wellness exam 6 months ago. Owners have no other complaints until 3 days ago.

On physical exam, her body condition score is 5 of 9. She is 5% dehydrated on physical exam. No other abnormalities were appreciated.

On bloodwork, you note the following:

PCV: 48% (32 - 52)
Total solids: 8
BUN: 71 (7 - 30)
Creatinine: 2.5 (0.6 - 1.6)
Phosphorus: 6.9 (2.6 - 6)
Urinalysis reveals:

USG=1.018
Protein: 1+
Glucose: 1+
Ketones: neg
WBCs: 1-2/hpf
RBCs; 3-5/hpf
Bacteria: neg

What attributes of this case suggest this is an acute kidney injury (AKI) rather than chronic kidney disease (CKD), i.e., what parameters or facts help you differentiate AKI from CKD?

A

Glucosuria
History

355
Q

What are the parameters that are highly suggestive of AKI

A

1) Glucosuria without serum hyperglycemia. This suggests tubular damage and often accompanies and AKI
2) Casts: suggests tubular damage
3) Acute onset in previously healthy patient
4) High potassium (sometimes): if the patient is acidotic, they may have a falsely elevated potassium so be careful assuming an AKI just because of an elevated potassium. If the patient is straining to urinate without producing urine, palpate the bladder to see if it is large / turgid

356
Q

What factors DO NOT help you differentiate between CKD and AKI

A

1) BUN/Creatinine: magnitude does not help you.
2) Hyperphosphatemia: elevated in both
3) Isothenuria or minimally concentrated urine: both can be low
4) Proteinuria: both CKD and AKI can result in proteinuria

357
Q

Low BCS is more likely to be consistent with (CKD or AKI)

A

CKD

358
Q

If a patient has a low PCV, they are more likely to have (CKD or AKI)

A

CKD

359
Q

T/F: PCV cant be used to differentiate CKD or AKI if it is normal

A

True

360
Q

Match the drug with its primary purpose or mechanism of action:
Darbepoetin

A

Increase hematocrit

361
Q

Match the drug with its primary purpose or mechanism of action:
Aluminum hydroxide

A

Phosphate binder

362
Q

Match the drug with its primary purpose or mechanism of action:
Tumil-K

A

Improve hypokalemia

363
Q

Aspirin is an

A

anti-thrombotic medication

364
Q

“Bobby”, a 2-yr old, MC, mixed breed dog, presents for a 2-day history of vomiting and diarrhea. You estimate him to be 7% dehydrated. He weighs 20 kg.

Calculate his fluid rate for the next 24 hours (in mls/hr):

A

110

365
Q

Which of the following conditions should result in pre-renal azotemia with a concentrated urine if the patient becomes dehydrated with the condition?

Hyperthyroidism

Cardiac failure

Addison’s disease

Central diabetes insidipus

A

*Cardiac failure - pre-renal cause of azotemia. The kidney senses decreased perfusion and hypotension due to reduced cardiac output, attempts to fluid retain and therefore concentrated urine

Addison’s causes Na+ wasting, which is osmole necessary to establish medullary gradient. There is no gradient to pull water across. Even when the patient is dehydrated, the kidney simply cant conserve water

Hyperthyroidism- causes loss of gradient since high GFR doesnt allow time for capture of osmoles such as Na+. That means that even in the face of dehydration, there is no gradient that allows recovery of water

With central diabetes inspidius, ADH is not present and so no water channels are inserted into the tubules to allow water to be retained, even when the patient is dehydrated

366
Q

How does dehydation affect hyperthyroidism

A

causes loss of gradient since high GFR doesnt allow time for capture of osmoles such as Na+. That means that even in the face of dehydration, there is no gradient that allows recovery of water

367
Q

How does dehydration affected diabetes insipidus

A

With central diabetes inspidius, ADH is not present and so no water channels are inserted into the tubules to allow water to be retained, even when the patient is dehydrated

368
Q

How does dehydration affect Addisons

A

Addison’s causes Na+ wasting, which is osmole necessary to establish medullary gradient. There is no gradient to pull water across. Even when the patient is dehydrated, the kidney simply cant conserve water

369
Q

You obtain a urine sample from a dog on which 1+ protein is reported. One additional abnormality is reported.

Of the following, which one would still count as a “quiet sediment”, meaning that you could submit a UP:C on the sample.

Group of answer choices

> 250 RBCs

Glucose

10-15 WBCs

2+ cocci

3+ blood with 1-2 RBCs

A

Glucose - not a protein

370
Q

Which antibiotic is necessary to eliminate the carrier state in leptospirosis?

A

Doxycycline

Ampicillin IV or doxycycline (IV if the patient is vomiting) can eliminate the leptospiremic phase. Only doxycycline can eliminate the carrier phase.

371
Q

A previously healthy dog presents after 3 days of vomiting. He is azotemic and severely acidotic on presentation. A UA shows a USG of 1.012, glucosuria, proteinuria, casts and many calcium oxalate crystal. Your top differential is ethylene glycol toxicity.

What do you recommend next?

A

Hemodialysis

Decontamination is only useful in the hours after ingestion. This patient as been sick for 3 days which means all of the ethylene glycol has been absorbed.

The ethylene glycol test is only helpful if administered within 12 hours of ingestion. The patient has been sick for 3 days.

Although this is an AKI, there is no need to culture the urine in this case because the clinical progression, the severe acidosis, and urinalysis with evidence of tubular damage calcium oxalate crystals, point to ethylene glycol.

Unfortunately, at this stage of the toxicity, the patient’s only shot at recovery is to institute hemodialysis to give the kidney time to repair. Owners should be aware that even with hemodialysis, the dog may not recover.

372
Q

You have a patient that has been ill for 1 month and has UP:C of 2.1. No other abnormalities are apparent in the urine except for the proteinuria.

Which of the following diagnostics would you do next?

A

Ehrlichia titers

A UP:C of 2.1 is in the range that suggest glomerular disease, as opposed to tubular or interstitial. Ethylene glycol toxicity causes tubular necrosis and is an acute illness, not a 1-month long disease. Protein electrophoresis would be performed if you suspected multiple myeloma, which is a pre-renal cause of proteinuria. A renal biopsy is considered after you have exhausted your antigen hunt. Rickettsial diseases, including Ehrlichia, are among those that can cause chronic antigen stimulation (and this dog has been ill for 1 month) which can lead to Immune Complex Glomerulonephritis.

373
Q

The ethylene glycol test is only helpful if

A

administered within 12 hours of ingestion.

374
Q

Your patient, a 10, FS, DLH, who has been staged as IRIS Stage 3, non-proteinuria, hypertensive, presents for not having had a bowel movement for 4 days. She has still been eating intermittently.

Assume that her BUN and creatinine are unchanged.

What would you be most interested in performing?

A

*Potassium

Hypokalemia can slow down the GI tract and result in ileus and/or constipation. The other thing to consider in your CKD patients with constipation is dehydration. Starting subq fluids might also be beneficial in those patients.

Proteinuria should not result in decrease GI contractility. Diarrhea, not constipation, is one possible consequence of hyperthyroidism. Cats do not get hypothyroidism, which can lead to mild (and usually clinically insignificant) hypomotility.

AST is a reflection of skeletal muscle, not smooth muscle, which is found in the GI tract.

375
Q

A 3-year old, MC, black lab weighing 65 lbs presents with an estimated 6% dehydration.

Calculate his total fluid deficit (mls).

A

1772

376
Q

A 10 yr old, FS, Dachshund, weighing 16 kg, presents with 7% dehydration. You decide to replace his deficit over 18 hours.

Calculate his fluid rate (mls/hour) for replacing the deficit only:

A

62

377
Q

Patient: 12 yr old, FS, DSH

Weight: 12 lbs

Calculate her total maintenance rate (mls/hr) over the next 24 hours:

A

12

378
Q

Patient: 7 year old, MC, mixed breed, weighing 36 kg, is estimated to be 8% dehydrated.

How much total fluids (mls) do you need to give him over the next 24 hours?

A

4820

379
Q

Calculate the fluid rate (mls/hr) over the next 24 hours for a 9 year old dog that weighs 27 lbs and is estimated to be 5% dehydrated.

A

62

380
Q
A

CLIN SCI: Urogenital System (6 decks)

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