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)
2
Q
What is a drug for urethral spasm treatment?
A
skeletal muscle relaxer: diazepam, methocarbamol, or baclofen
+
Alpha antagonist;
Phenoxybenzamine (or prazosin)
3
Q
What drugs can you use for bladder atony treatment?
A
Parasympathomimetic like bethanochol or cisapride
4
Q
What is a drug for bladder spasms treatment?
A
Parasympatholytic like
-Oxybutynin *
-Propantheline
5
Q
What is the toxicity of testosterone used to treat sphincter incompetence in dogs
A
Agrression
Prostatic hyperplasia
Up-regulate alpha receptos- hypertension?
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
7
Q
What is the toxicity of parasympatholytics like oxybutynin used to treat detrusor hyperactivity
A
Ileus at higher doses
8
Q
What is the toxicity of phenoxybenzamine or prazosin
A
hypotension
9
Q
What are causes of urinary incontinence?
A
1) Weak urethra
2) Hyperactive urethra
3) Atonic bladder
4) Hyperactive bladder
10
Q
What is the most common cause of urinary incontinence
A
weak urethra *Most common
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
12
Q
urinating small volumes frequently
commonly from an infection
A
pollakiuria
13
Q
If you are urinary continent then
A
your bladder tone is greater than your bladder pressure
14
Q
What is the first thing you should do when presented with urinary incontinence?
A
Determine if it is neurologic or non-neurologic
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)
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
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
17
Q
What estrogen is FDA approved
A
Estriol (Incurin)
(Diethylstilbestrol is not FDA approved)
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
19
Q
Why are injectable estrogens contraindicated
A
it will kill the bone marrow
20
Q
T/F: oral estrogens not associated with bone marrow suppression but rarely squamous metaplasia of prostate
A
True
21
Q
Reasons to use estrogens
A
1) Hormonal responsive
2) Congenital weak sphincter
3) Recurrent UTI
4) Recurrent vaginitis
22
Q
What are some toxicities of testosterone cypionate
A
aggression
prostatic hyperplasia
23
Q
Testosterone cypionate may upregulate
A
alpha receptors
24
How should you treat refractory incontinence
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
25
urethra not relaxing during detrusor reflex
sphincter hypertonicity
26
How do you treat sphincter hypertonicity
1) Skeletal muscle: Diazepam, Methocarbamol, Baclofen
+
2) Alpha-antagonist: Phenoxybenzamine (or prazosin) for smooth muscle
27
What is a consequence of using alpha-antagonists to relax urethral smooth muscle
hypotension
28
What are the effects of using diazepam for treating sphincter hypertonicity
sedation
hepatotoxicity (cats)
29
What skeletal muscle relaxer is hepatotoxic to cats
diazepam
30
What skeletal muscle relaxers can you use to treat sphincter hypertonicity
1) Diazepam
2) Methocarbamol
3) Baclofen
+ an alpha antagonist for smooth muscle relaxation
31
What might cause sphincter hypertonicity
inflammation
post-obstruction
neurological
idiopathic
*Urethra not relaxing during detrusor reflex
32
T/F: urodynamics are needed to diagnose detrusor atony
false
33
What might cause detrusor atony
Bladder wall cannot contract with normal parasympathetic tone
1) post obstruction
2) PU/PD
34
Bladder wall cannot contract with normal parasympathetic tone
bladder atony
35
What are the toxic affects of bethanochol
toxicity- salivation, vomiting, diarrhea, bradycardia, miosis
*Parasympathomimetic
36
What are the two things you can use Cisapride for
1) Megacolon in cats
2) Detrusor atony
37
T/F: Cisapride doesnt have very much toxicity
true
38
What should you use to treat detrusor atony
a parasympathomimetic
like bethanochol or cisapride
39
How do you treat detrusor hyperactivity
A parasympatholytic
1) Oxybutynin
or
2) Propantheline
40
What are some uses of Oxybutynin
1) Detrusor hyperactivity
2) FLUTDS
3) Bladder neoplasia
4) Cyclophosphamide cystitis
41
What toxicity might oxybutynin cause
ileus
42
What test do all pollakiuria cases need
1) Urinalysis
2) Radiographs
3) Urethrogram
4) Urethroscopy
Urinalysis
43
a prominent vulva fold (hooded) leads to
1) Recurrent vulvitis
2) Recurrent vaginitis- flora overgrowth
3) Recurrent cystitis- ascending infections
44
Why does urinary incontinence and hooded vulva happen together
both are from the same embryolical origin
surgical will not correct it, also need estrogen bc they have a concurrent weak sphincter
45
Routine UTI only needs _____ culture and ________
aerobic culture and anti-microbial sensitivity
46
What is likely occuring if you perform a vulvoplasty and urinary incontience persists
they likely have a concurrent weak urinary sphincter
will need medical management
47
What are causes of pollakiuria/dysuria
Urinary diseases- infectious, neoplasia, calculi, sterile (cats)
Prostatic diseases
48
What might cause vaginitis/vulvitis
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
49
What is a toxic effect of propantheline
ileus
50
How do you treat detrusor hyperactivity
A parasympatholytic like oxybutynin or propantheline
51
What is the alpha agonist you might use to treat sphincter incompetence
Phenylpropanolamine (PPA)
52
What are the side effects of Phenylpropanolamine
inappetence
arterial hypertension
lethargy
hyperactivity
53
Phenoxybenzamine is a ______ used to ______
alpha antagonist used to treat sphincter hypertonicity by relaxing smooth muscle
54
What are the side effects of estrogens
oral products not associated with bone marrow suppression but rarely squamous metaplasia of the prostate
55
Baclofen is a
skeletal muscle relaxer used to treat sphincter hypertonicity
56
In what breed should you avoid using sulfa drugs in? *
Dobermans
57
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
pollakiuria
58
Causes of pollakiruria/dysuria that you need to rule out
Urinary diseases
1) Infectious
2) Neoplasia
3)Calculi
4) Sterile (cats)
Prostate diseases
59
What test do all pollakiurua cases need
urinalysis
60
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?
Bacterial infection
Calculi
Neoplasia
get urine culture
61
What should you do for routine urinalysis
aerobic culture and anti-microbial sensitivity
*Culture first time cases because if UTI recurs, I base the workup on the 2 bugs identified
62
What is the antibiotic duration of dog with a simple urinary infection
3-5 days
63
What is the antibiotic duration of dog with recurrent cystitis (3 or more per 12 months)
Do a work up for primary diseases
10-14 days of therapy usually adequate
64
What is the antibiotic duration of dog with pyelonephritis
10-14 days initially but may require long term
65
How do recurrent urinary tract infections differ if they are with the same organism vs different organism
Same organism: incomplete therapy, nidus, immunodeficiency
Different organism: repeat ascending infection, immunodeficiency
66
How should you treat leptospirosis
Doxycycline for clearance phase
if acute disease and vomiting, recommend using IV penicillin if injectable doxy is not available
+/- IV quinolone if septic
67
What drug should you use for leptospirosis that has become septic
IV quinolone
68
What should you use for a dog with leptospirosis and vomiting is not present
Doxycycline
69
Do they recommend prophalyxically treating dogs that have had contact with leptospirosis dogs?
Yes- doxycycline
70
What are the clinical signs of Brucellosis
Abortion
Stillbirth
Failure to conceive
Bacteremia
Genital tract inflammation
Uveitis
Discospondylitis
71
Why is brucellosis hard to treat
because it is an intracellular organism
72
What CBC/CHEM/Urinalysis changes would you see with brucellosis
Neutrophilic leukocytosis
Monocytosis
Hyperglobulinemia
Polyclonal gammopathy
Proteinuria
73
How do you diagnose Brucellosis
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
74
How do you confirm serum antibody positive dogs for Brucella
if they are positive then confirm with AGID or tube agglutination or culture or PCR on blood
75
Brucella serum antibody testing can be falsely negative if
acute case
76
When should you trust a negative brucella serum antibody test
if it is negative and chronic signs
77
Does brucella canis positive dogs pose a zoonotic risk
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
78
How should you treat brucellosis?
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
79
You have a radiodense stone and bacterial UTI, what is most likely stone
Struvite
80
Why are struvite calculi commonly associated with infection
because infections commonly increase the pH and struvite precipitate in alkaline pH
81
Can Struvite calculi be dissolved?
Yes
82
How can struvite calculi be prevented
with diet
83
T/F: Struvite calculi are radiodense
True
84
You have a 4yo FS schnauzer with pollakiuria, hematuria, and bladder stones felt on abdominal palpation. What is the likely calculi?
Calcium oxalate calculi
85
a radiodense calculi that precipiatates in alkaline pH, commonly associated with infection and can be dissolved with acidifying diets
Struvite calculi
86
What breeds are commonly associated with calcium oxalate crystals
Schnauzers
87
What are the predispositions of calcium oxalate crystals
1) schnauzers
2) chronic acidification
3) hypercalcemia
88
T/F: Calcium oxalate crystals are radiodense
true
89
T/F: calcium oxalate calculi can be dissolved
False- they need to be surgically removed
90
How do you treat calcium oxalate calculi
Surgical excision
prevention:
diet- aiming for alkaline
potassium citrate
Vitamin B6
Thiazide diuretics
91
How do you prevent calcium oxalate crystals from forming
diet- aiming for alkaline
potassium citrate
Vitamin B6
Thiazide diuretics
92
You have a 3yo FS yorkie with a BCS 3/9 with a low BUN and Low Albumin. What is the likely calculi
Urate Calculi - likely from portosystemic shunt
93
What breed commonly gets urate crystals
Dalmations
94
How might an animal get urate calculi
1) Dalmation - metabolism
2) Liver insufficiency including PS shunt
95
T/F: urate calculi are radiodense
False- need an ultrasound
96
T/F: cystine calculi are radiodense
False- need an ultrasound
97
You can only acidify the urine of the _________
struvites
98
T/F: silicate calculi are radiodense
True
99
What calculi are radiolucent
Urate
Cystine
need an ultrasound
100
What calculi are radiodense
Calcium Oxalate
Struvite
Silicate
101
What stones can be dissolved
Struvite
Urate
Cystine
102
What stones should you prevent with an alkalinizing diet
Urate and Cystine
103
How do you treat urate calculi
correct underlying disease
medical dissolution
104
T/F: you can dissolve urate calculi
True- alkalinizing diet
105
What drug should you add on for Dalmations with urate calculi
Allopurinol
106
Allopurinol
a drug used to help treat urate calculi in dalmations in addition to medical dissolution and alkalinizing diet
107
What breeds do you see silicate calculi in but are really rare
GSD and retrievers
108
How do you treat silicate calculi
surgical excision
alkalinizing diet
109
What shape do silicate calculi have
jack shaped
110
T/F: silicate calculi are radiodense
True- jack shaped
111
Cystine calculi
seen in male dachshund, english bulldogs, bassett hounds, and others
medical dissolution: alkalinizing diet and D-penecillamine
Potassium citrate
112
What breeds do you commonly see cystine calculi in
seen in male dachshund, english bulldogs, bassett hounds, and others
113
How do you treat cystine calculi in?
medical dissolution: alkalinizing diet and D-penecillamine
Potassium citrate
114
What calculi are shown under radiographs
Calcium oxalate
Struvite
Silicate
115
What calculi are unable to be seen under radiographs
Urate
Cystine
116
What calculi need to be surgically removed because they cannot be dissolved
Calcium oxalate
Silicate
117
What diet for Struvite
acidify
118
What diet for preventing calcium oxalate
alkalinize
119
What diet for preventing silicate
alkalinize
120
What diet for urate
Alkalinize
121
What diet for cystine
alkalinize
122
You have a 3yo MC DSH with recurrent pollakiuria through his life. What is most common
Bacterial
Fungal
Stones
Neoplasia
Sterile (idiopathic cystitis)
Sterile (idiopathic cystitis)
123
What are the causes of feline lower urinary tract disease syndrome (FLUTD)
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
124
Cats with Sterile (idiopathic cystitis) likely have struvite crystals because
it is secondary to stress (which increases urine pH)
125
What likely is causing Sterile (idiopathic cystitis) in cats
Stress
126
What might be a viral cause of Sterile (idiopathic cystitis) in cats
Calicivirus
Herpesvirus
127
What diagnostics should you do for feline lower urinary tract disease syndrome (FLUTD)
-Abdominal palpation for obstruction or calculi
-UA
-Abdominal radiographs
other options: aerobic urine, abdominal ultrasound or cystourethrogram
128
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
Canned food
Stress relief
129
How should you treat all idiopathic feline lower urinary tract disease syndrome (FLUTD)
Canned food- enforces H20 consumption, dilutes crystals, dilutes matrix
Stress relief- ensure cats needs, indoorpet.osu.edu, agents to add to diet, pheromone defuser
130
What are the 7 most common prostatic diseases
1) Benign prostatic hyperplasia
2) Acute bacterial prostatitis
3) Chronic bacterial prostatitis
4) Prostatic abscess
5) Prostatic neoplasia
6) Squamous neoplasia
7) Periprostatic cyst
131
prostate that is bilaterally enlarged
132
6yo male intact bulldog with blood in semen likely has
benign prostatic hyperplasia
smoothyl marginated, bilaterally symmetrical, non-painful, hemorrhage is most common sign
Diagnosis: radiograph, urinalysis, ejaculate cytology, biopsy definitive
133
What is the most common sign of benign prostatic hyperplasia
hemorrhage
134
How do you treat benign prostatic hyperplasia
Castration
Low dose estrogen treatment
Anti-androgens to lessen some of size
135
Acute bacterial prostatitis
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
136
Why is aspiration, biopsy, and massage of acute bacterial prostatitis contraindicated?
because you can cause bacteremia if hemorrhage
137
Chronic Bacterial prostatitis
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
138
What antibiotics should you use for prostatitis
Gram Negative:
Potentiated sulfas
Quinolones
Chloramphenicol
Gram positive:
Erythromycin
Clindamycin
Azithromycin
*No Beta-lactams
139
What antibiotics should you not use for prostatitis
No Beta-Lactams
most other ones penetrate into prostate when it is chronic
140
Prostatic abscess
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!!
141
T/F: you should drain prostatic abscesses with ultrasound
False- dangerous
142
What is the one prostatic disease that neutering does not help
Prostatic neoplasia
-Adenocarcinoma
Treat with some NSAIDs, surgery, radiation, chemotherapy
143
Periprostatic cyst
Clinical findings: dysuria, dyschezia
Prostatic palpation: often intraabdominal, mass
Diagnosis: radiographs, ultrasound, aspirate
Treatment: surgery
144
What causes squamous metaplasia of the prostate
secondary to estrogen
1) Sertoli cell tumor
2) Exogenous estrogen for incontinence
145
How do you diagnose squamous metaplasia of the prostate
Cytology of the prepuce
-cornified squamous epithelial cells
146
How do you treat squamous metaplasia of the prostate
remove the estrogen source
1) remove sertoli cell tumor/ neuter
2) Exogenous estrogen for incontinence
147
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
Benign prostatic hyperplasia
Treat by neutering or anti-androgens
148
You have a male intact dog with an intraabdominal mass and dysuria and dyschezia and a normal UA. What is the diagnosis and treatment?
Periprostatic cyst
-Surgically excise and neuter
149
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?
Prostate squamous metaplasia
Neuter
150
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?
Prostatic neoplasia
treat with piroxicam
151
How do you treat prostatic neoplasia
Piroxicam
Surgery
Radiation
Chemotherapy
(Neutering does not help)
152
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?
Prostatic abscess
treat by draining, neutering, and antibiotic (No beta-lactams)
gram negative: potentiated sulfas, quinolones, chloramphenicol
gram postive: erythromycin, clindamycin, azithromycin
153
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?
Chronic bacterial prostatis
Neuter and antibitioics (No beta-lactams)
gram negative: potentiated sulfas, quinolones, chloramphenicol
gram postive: erythromycin, clindamycin, azithromycin
154
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?
Acute bacterial prostatitis
neuter and antibiotics (No beta-lactams)
gram negative: potentiated sulfas, quinolones, chloramphenicol
gram postive: erythromycin, clindamycin, azithromycin
155
Which prostate diseases have a UA with hematuria, pyuria, and bacteriuria
Acute bacterial prostatits
Chronic bacterial prostitis
Prostatic abscess
156
When do you put PU/PD on your problem list
1) Owner reports increased drinking or urination
2) Inappropriate isothenuria/hyposthenuria
3) First morning urine is inappropriately concentrated (dont withhold water)
157
How do you rule out PU/PD
Do a urine specific gravity
Is the patient is Hypersthenuric
> 1.030 / 1.035
158
What USG might make you suspicious of PU/PD
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
What are your ruleouts for PU/PD
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
Causes of primary polydipsia
psychogenic, liver, hyperthyroidism
161
If a patient is PU/PD, you should only check bile acids if
if total bilrubin is not already elevated
162
You can rule out PU/PD if the first morning urine specific gravity is
concrentated
163
What should you never do in a patient with PU/PD
never restrict water
164
Increase BUN and/or Increased Creatinine
Azotemia
165
What is uremia
a clinical syndrome associated with azotemia
common signs: vomiting, diarrhea, weight loss, anorexia
more severe: uremic breath, uremic ulcers
severe: pneumonitis, encephalopathy, osteodystrophy
166
Can a patient have pre-renal, renal, and post-renal azotemia at the same time?
Yes:
"Fluffy has renal azotemia due to CKD and a pre-renal azotemia due to dehydration"
167
What might result in pre-renal azotemia
The kidneys are not being perfused appropriately
-Lack of intake
-Cardiac disease
-Loss: GI loss, skin, vessels, 3rd spacing
-Shock: hypotension
168
Why do you see azotemia with decreased perfusion to the kidney (pre-renal)
With decreased perfusion, there is water conservation
-decreased excretion
-increased urine specific gravity
-increased BUN/Creatinine
169
Azotemia with USG >1.030 is almost always
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
How might there be an azotemia with a USG > 1.030 that is not pre-renal
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
What might be a pre-renal cause for USG being really low
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
Post-renal azotemia might occur when
there is an obstruction to renal pelvis, ureter, bladder, or urethra
172
What might be occuring if your patient cannot pee and they have lower urinary tract signs with a firm bladder
urethral obstruction
173
What might be reasons for a patient not urinating, having no lower urinary signs, and a flaccid bladder
dehydrated
AKI
174
How might a patient have a post-renal azotemia that can still urinate
Ureteral obstruction
-confirm with ultrasound
175
T/F: radiographs can confirm ureteral obstruction
False- you must use ultrasound
176
How do you confirm a urinary tract rupture
a patient that can pee with history of trauma, ascites, fluid sample Cr (fluid) > Cr (serum) Azostix
confirm with ultrasound
177
What is a way to test abdominal fluid for a urinary tract rupture
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
How does the Azostix test for urinary tract rupture work
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
You should determine the USG before
giving fluids
180
You should use histroy and physical exam to identify pre-renal azotemia but what is used to identify post-renal
history, PE, and ultrasound
181
Does being able to urinate rule out post-renal azotemia?
No- the patient can still urinate with urinary tract rupture and ureteral obstruction
182
Renal azotemia means the
kidney itself is damaged
183
How might azotemia with a low USG not equal kidney disease?
there might be diabetes mellitus, cushings, addisons, fluid admin, nephrogenic diabetes inspidus
184
T/F: dehydration and a non-renal cause of PU/PD is renal azotemia
False
185
The _______ stops proteins due to the size and charge while the ________ sops up anything that passs through via receptor mediated processes
glomerulus
proximal tubules
186
Pathologic proteinuria can occur without
without:
-PU/PD
-low USG
-Azotemia
-hypoalbuminemia
187
Why we care if there is excessive protein in the urine
shorter survival times regardless of azotemia
hypercoagulation as anti-thrombin 3 is lost
188
What is seen early in dogs with glomerular disease
proteinuria
189
Cats with interstitial disease, does proteinuria show up early or late
late
190
How do you assess proteinuria
with a basic urine dipstick
191
We are primarily concerned about proteinuria that is
Renal
Persistent- take 2-3 measurements, 2-3 weeks apart
Magnitude - measure urine protein:creatinine ratio
192
If proteinuria is pre-renal or post-renal what do you do?
treat the cause but do not treat the proteinuria and do not run a UP:C
193
What are causes of pre-renal proteinuria
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
What might cause pre-renal proteinuria that is light chain
-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
What might cause post-renal proteinuria?
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
What should you do to rule in urinary tract infection/inflammation
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
You can rule in renal proteinuria once
pre-renal and post-renal proteinuria are ruled out
198
How do you establish persistent proteinuria
Take 2-3 measurements, 2-3 weeks apart
if it goes away it is transient
if it persist then it is pathologic
199
You should not run a UP:C if
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
You can only run a UP:C if
1) Sediment is inactive
2) You suspect renal in origin
201
UP:C <0.2
non-proteinuric
do nothing
202
UP:C of
0.2-0.5 (dogs)
0.2-0.4 (cats)
borderline proteinuria
recheck in 2-4 weeks
203
UP:C of
0.5-2.0 (dogs)
0.4-2.0 (cats)
significant proteinuria, this could be interstitial, tubular, or early glomerular
actions:
1) measure blood pressure
2) other tubulointerstitial
3) other systemic disease
204
What do you do if a dog has a UP:C of 0.3
recheck in 2-4 weeks due to borderline proteinuria
205
What should you do if a dog has a high UP:C and you suspect interstitial proteinuria
Urine culture for pyelonephritis
206
What might cause significant proteinuria (indicated by a high UP:C) of tubular origin
Leptospirosis
Acute Kidney Injury (AKI)
Chronic Kidney Disease (CKD)
Fanconi syndrome (uncommon)
Action: Lepto titers +/- PCR, check for toxin exposure
207
What miht cause significant proteinuria (indicated by a high UP:C of >2
severe, significant proteinuria
glomerular disease - Immune complex glomerulonephritis (ICGN), glomerulosclerosis, congenital, amyloidosis
go on an antigen hunt for an immune complex disease
208
What are the 4 causes of glomerulonephritis (ICGN)
Neoplasia
Infectious
Immune
Inflammatory
209
How might chronic heartwork antigen lead to glomerulonephritis
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
What should you do if there is a persistent proteinuria that is renal and glomerular and no antigen found
Treat proteinuria - ACE inhibitors and ARBs
Monitor UP:C and sequelae
*Renal biopsy is very expensive and dangerous
211
How do you treat glomerulonephritis
Treat proteinuria - with ACE inhibotrs (Enalapril and Benazepril) and ARBs (Losartan and Temisartan)
Monitor UP:C and sequelae
212
T/F: you treat pre-renal azotemia with ACE inhibitors
False - never
only for renal azotemia
213
ACE inhibitors (Enalapril and Benazepril) and ARBs (Losartan and Temisartan) function to
Dilate the efferent arteriole
1) Decrease intraglomerular hydrostatic pressure
2) Decreases proteinuria
214
How do you treat proteinuria of renal glomerular origin
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
ACE inhibitor and ARBs dilate the
efferent arteriole
216
Enalapril and Benazepril are
ACE inhibitors
Dilate the efferent arteriole
1) Decrease intraglomerular hydrostatic pressure
2) Decreases proteinuria
217
Name two ACE inhibitors
Enalapril
Benazepril
218
Name two angiotensin II receptor blockers (ARBs)
Losartan
Telmisartan
219
Losartan and Temisartan are
Angiotensin II receptor blocker
Dilate the efferent arteriole
1) Decrease intraglomerular hydrostatic pressure
2) Decreases proteinuria
220
How might you sympomatically treat hypertension
ACE inhibitors (Enalapril or Benazepril) or Amlodipine (calcium channel blocker)
221
What anticoagulant drugs might be helpful with a patient with proteinuria
aspirin (low dose) or clopidogrel
222
T/F: protein can occur in a concentrated urine
True
223
SDS-PAGE
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
you should only perform a renal biopsy if
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
What two things do you need to run a UP:C
1) Persistence
2) Renal origin
226
What is the history of animals with AKI
-Healthy prior
-Recent onset
-May have a risk factor (Toxins, NSAIDs, anesthesia, etc)
227
What might you see on your physical exam in an animal with AKI
Good BCS
Painful kidneys that are normal or increased in size
228
What do you see diagnostically with AKI
-Glucosuria with normal serum glucose
-Casts (+/-)
-Proteinuria (+/-)
-Bright kidneys on US
229
What are common nephrotoxins specific to dogs that can lead to AKI
raisins and grapes
230
What are common nephrotoxins specific to cats that can lead to AKI
Lilies
231
What are common nephrotoxins, causing AKI in small animals
-NSAIDs
-Aminoglycosides
-Ace inhibitors
-Ethylene glycol
-Amphotericin B
-Raisins/Grapes (Dogs)
-Lilies (cats)
232
What can lead to AKI
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
What infectious agents might cause AKI in dogs
Bacterial (pyelonephritis)
Leptospirosis
Lyme
234
What infectious agents might cause AKI in cats
Bacterial (pyelonephritis)
FIP
235
What conditions might cause AKI in small animals?
Dehydration
Fever
Heat stroke
Shock
Sepsis
Acidosis
Hypercoagulation
236
What other organ systems can lead to AKI
Cardiac disease
pancreatitis
hypotension
237
AKI can potentially be reversible but eventually
it becomes irreversible damage, doesnt matter if you eliminate inciting injury
238
Should you condemn a patient based on the magnitude of azotemia?
No never-
ex: urolith, once eliminated azotemia will decrease
238
How do you know if an animal with an increased azotemia has responded to therapy
Azotemia plateaus- see how the patient responds to therapy and where you can get them in their stable state
239
What are the treatment principles of AKI
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
How do you treat pyelonephritis in dogs and cats
IV fluoroquinolones after aerobic urine culture
240
What culture in mandatory in AKI patients?
aerobic culture to rule in/out pyelonephritis
however it is not a common cause
241
What are risk factors for AKI that are additives?
Pyelonephritis
Post-renal causes
underlying cause
nephrotoxic drugs
nephrotoxic toxins
242
Are lower urinary tract infections or upper urinary tract infections systemic illness
upper urinary tract infection- systemically ill and will have a fever
243
Post renal causes occur anywhere between the
Urethra and the renal pelvis
Levels: urethra, bladder, ureter, and renal pelvis)
243
What is a really good question to ask clients to see if there is a post-renal cause
Can you pet urinate?
Do they strain when urinating?
244
Does being able to pee rule out a post-renal cause
No- there could be an obstruction in the ureter or renal pelvis associated with one kidney
245
If there is a bladder rupture, can patients still urinate
yes- often times just a tear
246
What will you do when you suspect a post-renal azotemia
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
What are sources of leptospirosis
stagnant water, urine
248
If you suspect leptospirosis, what should you ask
-Is your pet vaccinated?
-What other animals do you have
-Is there PU/PD?
249
How many serovars are in the leptospirosis vaccination
4 serovars (out of 200)
250
How should you manage a patient with leptospirosis for zoonotic risk
use barrier nursing to control PU/PD and spread
251
When can lepto be detected in blood vs the urine PCR
Blood: Day 1-10 days
Urine: 11-14 days
252
Why might you need to run both urine and blood PCR in animals you suspect leptospirosis
Leptospirosis is detected in
Blood: Day 1-10 days
Urine: 11-14 days
253
What is the gold standard for leptospirosis testing
MAT (IgM and IgG)
not as sensitive early on. best after 12 days
254
When can IgM antibodies for leptospirosis be detected in Witness POC
IgM can be detected at 5 days
255
When can MAT detect leptospirosis antibodies
Earliest IgM: day 8-11 (insensitive)
Earliest IgG: day 12-onwards
256
Witness POC detects ____ while MAT detects _____
POC: IgM
MAT: IgM and IgG
257
How do you treat leptospirosis in small animals
Ampicillin (IV) or Doxycycline (IV or PO)
no oral doxy if patient is vomiting
Eliminate the carrier state: Doxycycline (PO)
258
What are different drugs you need to discontinue in patients with AKI
NSAIDs
Aminoglycosides
ACE Inhibitors (ex: Enalapril)
Amphotericin B (antifungal)
259
What is the only drug for eliminating the leptospirosis carrier phase?
Doxycycline (PO)
260
Why do you need to discontinue ACE inhibitors in patients with AKI
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
What are the metabolites of ethylene glycol after metabolism by alcohol dehydrogenase
1) Glycoaldehyde: cause CNS signs
2) Glycolic acid: acidosis
3) Glycoxylic acid: converted to oxalic acid
262
What crystals in the urine is seen with ethylene glycol toxicity
calcium oxalate monohydrate
can also see casts, glucosuria, proteinura
263
What will you see on a blood gas in an animal with ethylene glycol toxicity
Severe acidosis (unknown origin as lactate is normal)
High base excess
Low pH with no explanation
Unmeasured is the ethylene glycol
264
What should you do for ethylene glycol
test kit: 30min-12 hours (less sensitive in cats)
decontaminate within 1-3 hours
265
What can you use to treat ethylene glycol toxicity
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
What is the mechanism of action of fomepizole
blocks alcohol dehydrogenase
267
What is the maintenance formula for fluids per dya
Cats: 80 x weight (kg) ^0.75
Dogs: 132 x weight (kg) ^0.75
Total / 24 hours = mls/hour
268
How do you calculate the deficit of fluids
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
Deficits are often replaced over
4-6 hours in some conditions
270
Ongoing urinary losses are determined by
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
T/F: placing a urinary catheter in AKI cases is mandatory
True - mostly
need to measure the on-going urinary losses
272
Insensible losses
20mls/kg/day
273
How do you determine how much fluid is lost
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
How do you ensure perfusion to the kidneys in AKI cases
1) Lower systemic blood pressure- be careful and maintain adequate BP
2) Stop ACE-inhibitors: nephrotoxic drug that decreases GFR
275
In AKI cases, what can you do to treat nausea and vomiting
Ondansetron
Maropitant
Omeprazole
276
How do you remove waste products (BUN, creatinine, others) in AKI
adress uremia
-Peritoneal dialysis
-Intemittent hemodialysis
-Continuous hemodialysis
very expensive
277
if one kidney is destroyed, will you see azotemia and concentration?
not necessarily
50% reserve so no difference
278
If a well hydrated (ie no prerenal azotemia) patient with a right urethral obstruction has azotemia. What conclusion do you draw
the left kidney is likely diseased as well
exception in acute ureteral obstruction
279
The kidney can maintain normal homeostasis with
50% nephron lost
280
At what percent of nephron lost is concentrating ability lost
67%
281
At what percent of nephron lost do you see azotemia
75% nephron lost
282
At what percent of nephron lost do you see uremia and death
100% nephron lost
283
a renal biomarker that detects renal damage when only 25% of total nephrons are compromised
ie. before concentrating ability is lost
SDMA (symmetric dimethylarginine)
284
Is SDMA or loss of concentrating ability able to detect renal damage sooner
SDMA- 25% total nephrons compromised
Loss of concentrating ability- 67%
285
What are the clinical consequences of CKD
1) PU/PD (early sign in cats)
2) Weight loss
3) Inappetance/nausea
4) Vomiting / Diarrhea
5) Weakness
6) Constipation
7) Uremic ulcers
286
What are the physiological consequences of CKD
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
Is proteinuria in CKD more common in dogs or cats
Dogs
288
What electrolyte abnormalities is seen with CKD in dogs and cats ?
Hyperphosphatemia
Hypocalcemia (ionized)
Hypokalemia
Acidemia
289
Is hypo or hyperkalemia seen in CKD in dogs and cats
hypokalemia
290
Is hypo or hyperphosphatemia in CKD in dogs and cats seen
hyperphosphatemia
291
Is calcium or ionized calcium low in CKD in dogs and cats
ionized calcium
292
What are the species differences in CKD in dogs and cats
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
What is seen in renal secondary hyperparathyroidism in dogs and cats
Hyperphosphatemia
Hypocalcemia (ionized)
Decreased Vitamin D
294
What species typically has tubulointerstitial nephritis with CKD
Cats
295
What species typically has glomerulonephropathies with CKD
Dogs
296
Dogs with CKD- glomerulonephropathies, what is typically the first sign
Proteinuria first
USG often normal (nx tubules)
Azotemia and low USG later
297
Cats with CKD- tubulointerstitial nephritis, what is typically the first sign
Decreased USG first (some exceptions)
Azotemia second
Proteinuria usually later
298
With IRIS staging, what is used to put an animal in Stage 1-4
Creatinine or SDMA
then substage based on proteinuria and blood pressure
299
How many creatinine measurements do you need to stage a CKD patient
YOu need two creatinine measurements in a stable patient
300
At what creatinine would each IRIS stage be
Stage 1: <1.4
Stage 2: 1.4-2.8
Stage 3: 2.9-5.0
Stage 4: >5.0
301
What are the different IRIS substages for proteinuria
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
What are the IRIS substages of systolic blood pressure
Normotensive <140
Prehypertensive 140-159
Hypertensive 160-179
Severely hypertensive >180
303
Should you stage a sick patient based on a single creatinine *
NO- you need two creatinine measurements in a stable patient
304
When should you recommend a renal therapeutic diet for CKD patients
When they are stage 2 (Creatinine 1.4-2.8)
305
What are the overall goals of CKD
-Keep them eating
-Keep them hydrated
-Prevent on-going damage
-Avoid AKI or CKD
-Monitor
306
In CKD, how do you address nausea
anti-nausea drugs: Ondansetron
Maropitant
307
In CKD, how do you enhance appetite
mirtazapine (cats), capromorelin (dogs)
warm food, switch foods, add tasty treats
do not force feed- creates food aversions
308
Why should you not force feed
it creates food aversions
309
In CKD, how might you keep the GI tract moving
avoid hypokalemia
310
In CKD, how do you prevent acidosis
Potassium citrate
Renal Diet
311
In CKD, how do you prevent hyperphosphatemia
phosphate binders
1) aluminum hydroxide
2) lanthanum carbohydrate (Renalzin)
3) Sevelamer hydrochloride (Renagel)
312
In CKD, how do you treat anemia <20%
Darbepoeitin
313
In CKD, how do you prevent weakness
avoid hypokalemia
314
In CKD, how do you treat hypertension in cats
Amlodipine
315
In CKD, how do you treat hypertension in dogs
1) Ace Inhibitors (Enalaparil, Benazepril) - first
2) Angiotensin Receptor Blockers (ARBs): Losartan, telmisartan
316
In CKD, how do you reduce proteinua
1) Ace Inhibitors (Enalaparil, Benazepril) - first
2) Angiotensin Receptor Blockers (ARBs): Losartan, telmisartan
317
If proteinuric due to CKD, how do you prevent thrombi
Clopidogrel
318
How might a patient with CKD have an acute AKI
Nephrotoxins
Infectious
Conditions
Organ System compromise
319
T/F: you can differentiate CKD from AKI if PCV is normal
False
320
T/F: you can differentiate CKD from AKI based on magnitude of azotemia
False
321
T/F: you can differentiate CKD from AKI based on urine specific gravity
False
322
How do you differentiate CKD from AKI
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
Do you see small or irregular kidneys with AKI or CKD
CKD
324
Is hyperkalemia more likely to be seen with CKD or AKI
AKI
325
Is hypokalemia more likely to be seen with CKD or AKI
CKD
326
T/F: both AKI and CKD result in minimally concentrated or isosthenuric urine
True - cannot differentiate based on USG
327
How often should you monitor patients with CKD
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
In a patient with CKD, what should you monitor every 3-6 months
BUN, creatinine, phosphorus, electrolytes
Blood pressure and fundic exam
PCV/ total solids
Urinalysis
Body and muscle condition score
Hydration Status
329
To increase appetite, capromorelin is typically used in _______ while mirtazapine is typically used in ________
Capromorelin: dogs
Mirtazapine: cats
330
What drug is used to reduce gastric acid
omeprazole - controversial whether cats and dogs develop GI ulcers with CKD
331
Renal secondary hyperparathyroidism
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
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:
Amlodipine (calcium channel blocker)
333
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?
Potassium
334
What kind of drug is telmisartan?
Angiotensin receptor blocker
335
Of the following drugs, which might you use as an appetite stimulant?
Group of answer choices
Cisapride
Ondansetron
Metoclopramide
Meloxicam
Mirtazapine
Maropitant
Mirtazapine
336
We consider starting darbepoetin most often when the PCV is in what range?
<20%
337
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?
Ampicillin IV
338
Which of the following drugs is used to treat ethylene glycol toxicity in both dogs and cats?
Fomepizole
339
Select the drugs below which is used primarily to treat nausea.
Maropitant
Ondansetron
340
What kind of drug is benazepril
ACE-inhibitor
341
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?
CKD
what is the best way to determine if post-renal azotemia is a component of a patient's azotemia assuming the animal is still urinating? mellitus
Cushings
342
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?
CKD
Diabetes mellitus
Hyperthyroidism
343
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?
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
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?
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
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:
Hemoglobinuria
3+ blood - but there is not any RBCs in the sediment so they must have pigmenturia (due to hemoglobin or myoglobinuria)
346
Do you see hemoglobinuria with intra-vascular or extra-vascular hemolysis
Intra-vascular hemolysis
347
What does extra-vascular hemolysis mean
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
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.
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
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.
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
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?
Abdominal Ultrasound- the only diagnostic to confirm whether or not there is a post-renal obstruction.
(Lepto is unlikely in cats)
351
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?
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
Where is rocky mountain spotted fever located
in the east and southeast- not on your list of differentials for dogs in CO with no history of travel
353
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?
Leptospirosis
Heartworm
354
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?
Glucosuria
History
355
What are the parameters that are highly suggestive of AKI
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
What factors DO NOT help you differentiate between CKD and AKI
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
Low BCS is more likely to be consistent with (CKD or AKI)
CKD
358
If a patient has a low PCV, they are more likely to have (CKD or AKI)
CKD
359
T/F: PCV cant be used to differentiate CKD or AKI if it is normal
True
360
Match the drug with its primary purpose or mechanism of action:
Darbepoetin
Increase hematocrit
361
Match the drug with its primary purpose or mechanism of action:
Aluminum hydroxide
Phosphate binder
362
Match the drug with its primary purpose or mechanism of action:
Tumil-K
Improve hypokalemia
363
Aspirin is an
anti-thrombotic medication
364
"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):
110
365
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
*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
How does dehydation affect 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
367
How does dehydration affected diabetes insipidus
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
How does dehydration affect Addisons
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
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
Glucose - not a protein
370
Which antibiotic is necessary to eliminate the carrier state in leptospirosis?
Doxycycline
Ampicillin IV or doxycycline (IV if the patient is vomiting) can eliminate the leptospiremic phase. Only doxycycline can eliminate the carrier phase.
371
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?
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
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?
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
The ethylene glycol test is only helpful if
administered within 12 hours of ingestion.
374
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?
*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 pation, 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
A 3-year old, MC, black lab weighing 65 lbs presents with an estimated 6% dehydration.
Calculate his total fluid deficit (mls).
1772
376
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:
62
377
Patient: 12 yr old, FS, DSH
Weight: 12 lbs
Calculate her total maintenance rate (mls/hr) over the next 24 hours:
12
378
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?
4820
379
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.
62
380
