Upper Urinary Flashcards
1
Q
What USG tells you the patient is not PU/PD
A
> 1.030 (dog)
1.025 (cat
2
Q
What should you do if you dont know a patient is PU/PD
A
Confirm with a first-morning sample if history unclear
3
Q
What are non-kidney causes of PU/PD
A
1) Osmotic diuresis: diabetes mellitus + post-obstructive diuresis
2) Secondary nephrogenic diabetes insipidus: Cushing’s, Addisons, Hyperthyroidism, liver disease, hypercalcemia
4
Q
Your patient has USG <1.030 (dog) or <1.035 (cat). What do you do
A
They might be PU/PD
test USG on first morning sample
if still lower than 1.030 or 1.035 then they cannot concentrate their urine
5
Q
Rule out PU/PD if first morning USG is
A
concentrated
6
Q
What should you never do in patients with PU/PD
A
Never restrict water
7
Q
What are the causes of pre-renal azotemia
A
1) Lack of intake (dehydration)
2) Loss: GI loss, skin, vessels, 3rd spacing
3) Cardiac disease
4) Shock: hypotension
8
Q
Pre-Renal aoztemia has what USG
A
Concentrated urine - except if concurrent disease or fluids
9
Q
Renal azotemia has what USG
A
Ososthenuria or minimally concentrated
uses history and PE and labwork and imaging to differentiating
10
Q
What causes renal azotemia
A
all causes of AKI and CKD
11
Q
Post-Renal azotemia occurs where
A
anywhere from renal pelvis, ureter, bladder, urethra
12
Q
How do you confirm post-renal azotemia
A
history, PE, confirm with ultrasound
13
Q
T/F: a patient might have pre, renal, and post-renal azotemia at the same time
A
True
14
Q
T/F: you can distinguish post-renal azotemia with radiographs
A
False
15
Q
You should determine USG before
A
before you give fluids - then hard to tell if you have pre-renal or renal component
16
Q
T/F: Post-renal azotemia can have any USG
A
true
17
Q
Renal azotemia means
A
the kidney itself is damaged
18
Q
T/F: dehydration and a non-renal cause of PU/PD is renal azotemia
A
False
19
Q
Renal proteinuria means
A
problem with
1) Glomerulus
2) Tubules
3) Interstitium
20
Q
How does post-renal azotemia differ from post-renal proteinuria on the location cause
A
both can have issues with renal pelvis, ureters, bladder, or urethra
however
a post-renal proteinuria can also be caused by the genitals (free-catch)
21
Q
T/F: proteinuria can be asymptomatic
A
True
22
Q
T/F: proteinuria always occurs with azotemia
A
False- it can occur without azotemia
23
Q
T/F: proteinuria can occur without isosthenuria
A
True
24
Q
T/F: proteinuria always occurs with hypoalbuminemia
A
False
25
What are the characteristics of proteinuria
Asymptomatic and can occur without
1) Azotemia
2) Isosthenuria
3) Hypoalbuminemia
26
Why is urinalysis always part of the minumum database
Proteinuria can be asymptomatic and occur without
1) Azotemia
2) Isosthenuria
3) Hypoalbuminemia
27
We are concerned with proteinuria that is
1) Persistent
2) Renal origin
3) Significant origin
treat these
28
Dont run a UP:C ratio on proteinuria that is
1) Pre-renal: myoglobin, hemoglobin, light chain globulins
2) Post-Renal: Stones, neoplasia, infection, inflammation
only run when renal in origin
29
What might cause a pre-renal proteinuria
myoglobin, hemoglobin, light chain globulins
30
What might cause a post-renal proteinuria
Stones, neoplasia, infection, inflammation
31
In order to run a UP:C ratio what needs to be achieved
1) Renal origin
2) Persistent (2-3 occasions, 2-3 weeks apart)
3) Quiet urine sediment
32
What causes a persistent renal proteinuria
1) Glomerular: primary autoimmune, secondary antigen complex, hypertension, cushings
2) Tubular: nephrotoxins
3) Interstitial: Nephritis, infection
33
What might cause a pre-renal proteinuria with elevated light-chain globulins
Benz-Jones proteins (Multiple myeloma, lymphoma)
34
UP:C greater or equal to 0.5. what should you do
Intervene with Aceinhibitor
35
UP:C greater or equal to 1.0 is likely
This is likely tubulointerstitial or glomerular
36
UP:C greater or equal to 2.0 is from what origin
GLomerular
Primary: diagnosis of exclusion, renal biopsy
Secondary: go on an antigen hunt
37
What do you do if proteinuria is glomerular (UP:C >2)
Primary: diagnosis of exclusion, renal biopsy
Secondary: go on an antigen hunt
38
What drugs are used to treat UP:C >0.5
ACE inhibitors
-Enalapril
-Benazepril
39
How do ACE inhibitors and ARBs decrease proteinura
Dilates the efferent arteriole which decreases intraglomerular pressure and decreases proteinuria
40
What are the angiotensin receptor blockers that dilate the efferent arteriole to decrease intraglomerular pressure and proteinuria
Telmisartan
Losartan
41
T/F: you should only run a UP:C if the urine sediment is quiet
True
42
What are the causes of AKI
1) Nephrotoxins: NSAIDS, aminoglycosides, ACE inhibitors, ethylene glycol, Amphotericin B, raisins and grapes (dogs), lilies (cats)
2) Infectious: bacterial pyelonephritis, lepto (dog), lyme (dog), FIP (cat)
3) Dehydration
4) Fever
5) Heat stroke
6) Shock
7) Sepsis
8) Acidosis
9) Hypercoagulation
10) Cardiac disease
11) Pancreatitis
12) Hypotension
43
What nephrotoxins can cause AKI
1) NSAIDS
2) aminoglycosides
3) ACE inhibitors
4) ethylene glycol
5) Amphotericin B
6) raisins and grapes (dogs)
7) lilies (cats)
44
What are infectious causes of AKI
1) bacterial pyelonephritis
2) lepto (dog)
3) lyme (dog)
4) FIP (cat)
45
What conditions can cause AKI
1) Dehydration
2) Fever
3) Heat stroke
4) Shock
5) Sepsis
6) Acidosis
7) Hypercoagulation
8) Cardiac disease
9) Pancreatitis
10) Hypotension
46
What is the typical history of AKI
previously healthy, exposure to drug/toxin/infectious disease/ condition
history of urolithiasis
47
What are PE findings of AKI
good BCS
painful abdomen (paralumbar)
48
What is typical CBC findings of AKI
unremarkable unless infectious
49
What will you see on biochemistry of animals with AKI
Azotemia
hypercalcemia
hyperPO4
hyperkalemia
50
What will you see on urinalysis of animals with AKI
-isothenuria/minimally concentrate
-proteinuria
-glucosuria
-casts
51
What might you see on radiographs of animals with AKI
uroliths (if strubite or calcium oxalate)
52
What might you see on ultrasound of animals with AKI
Radiolucent stones
Bright cortial rim
hydronephrosis/hydroureter
ascites (uroabdomen)
53
What do you do for AKI
CRUDD
1) Culture
2) Relieve obstructions
3) Treat underlying cause
4) Discontinue drugs
5) Deconaminate toxins
fluids: maintenance + deficit + ongoing losses
54
What is maintenance equation
70 x weight (kg) ^0.75
30 x weight (kg) +70
55
How do you determine the fluid deficit
kg x % dehydration
56
An animal is not azotemic until
they have lost 75% of nephrons
57
Loss of concentrating ability occurs when
67% of nephrons are lost
58
What occurs at 100% nephron lost
uremia and death
59
With CKD, why do cats typically lose concentrating ability first
because they get a tubulointerstitial nephritis
1) Lower USG
then
2) Azotemia
then
3) Proteinuria
60
With CKD, why do you dogs typically lose protein first
because they get glomerulonephropathies
1) Proteinuria
then
2) Azotemia
then
3) Loss of concentration
61
CKD
glomerulonephropathies typically occur in ________
tubulointerstitial nephritis typically occur in ________
glomerulonephropathies typically occur in dogs
tubulointerstitial nephritis typically occur in cats
62
How do you stage renal disease
Stage 1-4
Proteinuria substage: non-proteinuric, borderline proteinuric, proteinuric
Hypertension substage: normotensive, prehypertensive, hypertensive, severely hypertensive
63
What species is more likely to have glomerulonephropathies
dogs
64
What species is more likely to have tubulointerstitial disease
cats
65
What is important when managing CKD patients
keep them eating
keep them ydrated
slow on-going damage
avoid additional damage ie AKI
66
What might cause protein-losing nephropathy (PLN)
1) Immune-complex disease (glomerulonephritis)
-infectious, immune, inflammation, neoplasia
2) Non-Immune complex disease
-Glomerulosclerosis
-Glomerular basement membrane defects
-Podocyte abnormalities
-Mesangial abnormalities
3) Amyloidosis - sharpei, abyssinians, other
67
What breeds typically get amyloidosis
Sharpei
Abyssinians
68
What might cause glomerulonephritis
Immune complex disease
-chronic inflammation
infectious, immune, inflammation, neoplasia
this on-going glomerular damage causes proteinuria
69
What is your approach to PLN cases
Focus on ICGN (immune complex glomerulonephritis)
1) Neoplasia
2) Infectious
3) Immune
4) Inflammatory
70
What should you do to evaluate neoplasia as a cause of ICGN
-Lymph node aspirates
-Thoracic radiographs
-Abdominal radiographs
-Abdominal ultrasound
-Bone marrow aspirates
71
What infectious diseases might cause ICGN
Vector-borne (common)
1) Ehrlichiosis
2) Lyme disease (Borrelia burgdorferi)
3) Bartonella
4) Rocky Mtn Spotted Fever (Rickettsia rickettsia)
5) Heartworm
Viral/Bacterial
1) Leptospirosis
2) FeLV, FIV, FIP
3) Chronic bacterial infections e.g endocarditis
4) Other: Leishmaniasis, brucellosis
72
What vector borne diseases might cause ICGN
1) Ehrlichiosis
2) Lyme disease (Borrelia burgdorferi)
3) Bartonella
4) Rocky Mtn Spotted Fever (Rickettsia rickettsia)
5) Heartworm
73
What are viral causes of ICGN in cats
FeLV
FIV
FIP
74
What bacteria might cause ICGN
1) Ehrlichiosis
2) Borrelia biurgdorferi
3) Bartonella spp
4) Rickettsia rickettsia
5) Leptospirosis
6) Chronic bacteria infections e.g endocarditis
7) Other: leishmaniasis, brucellosis
75
T/F: rickettsia rickettsia is a chronic disease
false
76
What are immune mediated causes of ICGN
1) IM hemolytic anemia
2) IM thrombocytopenia
3) IM polyarthritis
4) Systemic lupus erythematosus
77
What diagnostics can you do to determine immune mediated cause of ICGN
CBC
joint taps
bone marrow aspirates
ANA titers
78
What are inflammatory causes of ICGN (although less likely to cause proteinuria
Chronic hepatitis
Pancreatitis
IBD
Prostatitis
dx: minimum database, imaging
79
What diagnostics can you use for infectious causes of ICGN
Minimum database
4DX snap test
Urine culture
Lepto 5MAT
80
What does 4DX test for
Heartworm
Ehrlichia canis
Lyme
Anaplasma phagocytophilum
81
Steroids can cause proteinuria, what might you do to see if this is the cause
ACTH stimulation for Cushing's
82
Do SDS-PAGE (sodium dodecyl sulfate- polyacrylamide gel electophoresis) if
everything is negative on your ICGN work up
can help tell ICGN or non-immune complex disease
83
What is a renal biopsy helpful for?
ICGN
Non-immune complex disease
Amyloidosis
84
Where do you send SDS-PAGE and renal biopsies
Vet nephrologist (Texas A&M)
85
Separates urinary proteins based on size
tells glomerular vs tubular
SDS-Page
86
How do you do renal biopsy
-control hypertension first
-must obtain special samples
-must use nephropathologist
-take wedge biopst
87
What should you do if owner cannot afford special test (SDS-Page) and renal biopsy is too risky?
Immunosuppression
-Steroids can worsen proteinuria
-Cyclosproine or mycopenolate
if no response - still ICGN but no response
or non-ICGN
88
How do you treat proteinuria
1) Maintain nutrition
2) Reduce protein loss
3) Avoid systemic hypertension
4) Prevent thrombosis
89
What nutrition should you use for proteinuria
1) Low protein but high quality
2) Polyunsaturated fatty acids (PUFAs)
3) Renal support diets
options: Royal canin renal support, Hills Diet k/d, purina NF, homecooked diets by vet nutritionist
90
How do you decrease intra-glomerular pressure to reduce protein loss
ACE inhibitors
-Benazepril
-Enalapril
Angiotensin receptor blocker (ARBs)
-telmisartan **
-Losartan
caution in stage 4 CKD
91
you should be cautious using ACE inhibitors and ARBs in what patients
Stage 4 CKD and dont start during AKI
92
How do you prevent thrombosis in proteinuria cases
Prevent Anti-thrombin III loss (ATIII)
1) Low-dose aspirin (1-5mg/kg/day)
2) Clopidogrel
1-2mg/kg/day (dogs)
18.75 mg per cat per day
93
How do you avoid systemic hypertension in cases of proteinuria
Amlodipine
-decreases intra-glomerular pressure
-decreases proteinuria
-Prevents target organ damage
*caution in stage 4 CKD *
94
You should cautiously use amlodipine in proteinuria cases that are
stage 4 CKD
95
What should you monitor when treating proteinura
1) Progressive azotemia: adjust ACE-I or ARB therapy
2) Progressive proteinuria: adjust ACE-I or ARB therapy
3) Hypertension: add amlodipine
4) Hyperkalemia: adjust ACE-I or ARB therapy
96
What should you do if you suspect immune complex GN
go on an antigen hunt
with neoplasia, infectious, immune, inflammatory based on clinical signs and region-specific infectious diseases
97
What are your treatment targets for glomerulonephritis
underlying cause
nutrition
proteinuria
thrombosis
hypertension
98
What are the main species of lepto that infect dogs
Leptospira interrogans (Icterhaemorrhagiae, Canicola, Pomona) and kirschneri (Gripptyphosa)
99
gold standard for leptospira
MAT serology
-6-8 serovars
100
What diagnostic is good for acute illness of leptospirosis, prior to antibiotics
first 10 days
PCR - highest in blood (first 10 days) and then become highest in the urine during the bacteruric phase
you should send both blood and urine PCR
101
point of care lepto test that detects IgM antibodies as early as 4-6 days post-infection
Witness LeptoRapid Test
102
How do you treat acute phase of leptospirosis
Ampicillin IV - does not clear carrier phase
Doxycycline for 2 weeks after resolution of GI signs
manage with fluids and urinary catheter
103
When a dog is diagnosed with leptospirosis, what should you do for other dogs in the household
They need to be treated with doxycycline for 2 weeks. Ideally they should be tested for acute and convalescent titers as well
104
What tick transmits Ehrlichia canis
Rhipicephalus sanguineous (brown dog tick)
105
What tick transmits Ehrlichia ewingii
Ambylomma americanum (Lone star tick)
106
What are the clinical signs of Ehrlichiosis in dogs
Acute phase: lethargy, depression, anorexia, bleeding tendacies (epistaxis), fever, lymphadenopathy, splenomegaly, petechiae/echhymoses
Subclinical: no overt clinical signs
Chronic phase: similar to acute but more severe: significant weight loss, pale mucous membranes, weakness, ophthalmic abormaltiies (anterior uveitis, retinal hemorrhage, retinal detachment), meningitis/hemorrhage, PU/PD, joint pain
107
How might you test for Ehrlichiosis
1) Indirect immunofluorescence antibody test (IFA)
2) Point of care SNAp 4dx by ELISA
3) PCR
108
In regards to Ehrlichiosis, what does the SNAP 4dx test detect
Antibodies to E.canis and E. ewingii
109
What is gold standard for diagnosing ehrlichiosis
Indirect immunofluorescence antibody testing
-detect anti-E.canis IgG antibodies
-Acute infections: two IGA tests 7-14 days apart and 4 fold increase is suggestive of active infection
-IgG antibodies typically become negative within 6-9 months but can persist for year after treatment and elimination of rickettsial organism
110
PCR false negatives for Ehrlichia can occur if patient received
antibiotics effective against Ehrlichia spp
111
How do you treat Ehrlichiosis
1) Doxycycline for 28 days
2) CBC 2 weeks after to monitor resolution of thrombocytopenia (if present after therapy then failed therapy or re-infected or another vector borne disease)
3) Year round tick prevention
112
What should you monitor when treating Ehrlichiosis with Doxycycline
CBC 2 weeks after to monitor resolution of thrombocytopenia (if present after therapy then failed therapy or re-infected or another vector borne disease)
113
What causes Rocky Mountain Spotted fever
Rickettsia rickettsii
114
What vector spreads Rickettsia rickettsii
1) American dog tick (Dermacenter variabilis)
2) D. andersoni (Rocky mountain wood tick)
3) Amblyomma americanum (Lone star tick)
4) Rhipacelphalus sanguineus (Brown dog tick)
115
What are the clinical signs of RMSF
anorexia, lethargy, depression, abdominal pain, myalgia, respiratory signs, neurologic abnormalties, fever, petechiae, peripheral edema, anterior uveitis, hyphema, scleral petechiae/hemorrhages
116
What are labwork findings of RMSF
Hypoalbuminemia
Proteinuria
Thrombocytopenia
117
How do you test for RMSF
IFA - lot of cross-reactivity with non-pathogenic species
the patient must have clinical signs consistent with RMSF
PCR- available for R. rickettsii
118
How do you treat RMSF
Doxycycline -14 days
Enrofloxacin
Chloramphenicol
prevent with tick contorl
119
What tick spreads lyme
Ixodes
120
What are the two main clinical syndrome in dogs with Lyme (Borrelia)
1) Arthritis: acute onset fever, lameness, joint swelling, anorexia, mild lymphadenopathy
2) Lyme nephropathy: PU/PD, weight loss, anorexia, hypertension, proteinuria, thrombocytopenia, thrombosis
121
What do lyme tests need to measure
anti-C6 antibodies (only from natural infection and not in lyme vaccines)
antibodies against c6 peptide suggest exposure but cannot determine active infection
122
Lyme seropostivie patients should have what additional testing
assess cytopenias, proteinuria, renal disease
123
How do you test for lyme
Serology for anti-C6 antibodies (snap 4dx)
124
How do you treat lyme disease
Doxycycline is first choice for acute lyme arthritis
Convenia (cefovecin) for patients who dont tolerate tetracyclines
Doxycycline for PLN along with standard therapy for proteinuria
*year round tick prevention is important
125
Dont treat seropostivie lyme dogs if they are
asymptomatic and non-proteinuric
126
Why can you not rule out a pre-renal component just because the patient isnt concentrating their urine
Consider:
1) Secondary nephrogenic diabetes insipidus (Addisons, Cushings, hyperthyroidism, liver disease (PSS), hypercalcemia, CKD
2) Osmotic diuresis
3) Recent fluid therapy
127
What are signs of a urethral obstruction
posturing
stranguria
vocalization
unable to urinate
large firm bladder
128
What are signs of a urinary tract rupture
history of trauma
gross hematuria
small bladder
painful abdomen
ascites
129
what are signs of a ureteral obstruction
can still urinate
normal bladder
painful abdomen
may have hx of stones
hydropnephrosis/ureter
130
renal biomarker that detects renal damage when only 25% of total nephrons are compromised
ie before concentrating ability is lost (67%)
SDMA (symmetric dimethylarginine)
131
What are the consequences of CKD
1) Anemia (loss of erythropoietin)
2) Hypertension (systemic blood pressure)
3) Dehydration (loss of water conservation)
4) Proteinuria (loss of protein conservation)
5) Hyperphosphatemia (phosphorus excretion)
6) Hypocalemia-ionized (loss of Ca2+ retention)
7) Hypokalemia (K+ retention loss)
132
you can only give phosphate binders when
when the patient is eating
133
Consider Dabepoetin for anemia that is
HCT: <20%
134
Monocolonal gammopathy can be caused by what
Ehrlichia
Multiple myeloma
135
What is the primary purpose or mechanism of action of darbepoetin?
Increase hematocrit
136
What class of drug is telmisartan?
Angiotensin receptor blocker
137
Of the following drugs, which might you use as an appetite stimulant?
Maropitant
Ondansetron
Meloxicam
Mirtazapine
Cisapride
Metoclopramide
Mirtazapine
138
We consider starting darbepoetin most often when the PCV is in what range?
<20%
139
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
140
Which of the following drugs is used to treat ethylene glycol toxicity in both dogs and cats?
Fomepizole
141
Select the drugs below which is used primarily to treat nausea.
Capromorelin
Potassium citrate
Aluminum hydroxide
Ondansetron
Sucralfate
Maropitant
Mirtazapine
Omeprazole
Ondansetron
Maropitant
142
Which of the following drugs is an ACE-inhibitor?
Amlodipine
Losartan
Benazepril
Propranolol
Benazepril
143
What is the primary purpose or mechanism of action of Tumil-K?
Improve hypokalemia
144
What is the primary purpose or mechanism of action of losartan (within the context of renal disease)?
Reduce proteinuria
145
What is the primary purpose or mechanism of action of omeprazole?
Proton pump inhibitor
146
What is the primary purpose or mechanism of action of low-dose aspirin?
Anti-thrombotic agent
147
What is the primary purpose or mechanism of action of ondansetron?
Anti-nausea medication
148
What is the primary purpose or mechanism of action of aluminum hydroxide?
Phosphate binder
149
What is the primary purpose or mechanism of action of capromorelin?
Stimulate appetite
tradenames: Entyce and Elura
150
Clopidogrel mechanism of action
Clopidogrel (brand name: Plavix) selectively (and irreversibly) inhibits the binding of ADP to its platelet P2Y12 receptor, which normally activates the glycoprotein GPIIb/IIIa complex. By inhibiting that initial step, clopidogrel inhibits platelet aggregation.
151
Aspirin mechanism of action
Thromboxanes are responsible for the aggregation of platelets that form blood clots. Low-dose, long-term aspirin use irreversibly blocks the formation of thromboxane A2 in platelets, producing an inhibitory effect on platelet aggregation.
152
Do cats or dogs require higher dose of fomepizole
cats
153
Per the CKD guidelines, phosphorus should be maintained below .
4.6 mEq/dL
154
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?
HYPERTHYROIDISM
CKD
DIABETES MELLITUS
155
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.
You recognized that a dog that can concentrate its urine to 1.030 or higher has an appropriate concentrating ability and can concentrate their urine, even if the owner perceives PU/PD.
156
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.
You must confirm that a patient can appropriately concentrate their urine overnight when dogs/cats normally don't 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 fluid loss.
157
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:
Hemoglobinnuria
158
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.
Pre-Renal: Yes likely
Renal: Yes likely
PostRenal: No unlikely
159
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 creatinine was 1.7 (0.8 - 2.4 mg/dL), BUN was 34 (18-35), 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.
Pre-Renal: Yes likely
Renal: Yes likely
PostRenal: Possible
160
After 24 hours of fluid therapy, the cat 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?
Perform abdominal ultrasound
161
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
You recognized that the sediment is active because there is an equal or greater number of WBCs compared to RBCs, which is not what you would expect if this were just blood contamination from a cystocentesis. There are also bacteria which supports the assumption that this is a post-renal proteinuria, i.e., the protein is being added to the urine once it has been produced. This is not the kind of proteinuria you would treat with ACE-inhibitors or ARBs, therefore it's not necessary to quantify it. In fact, if you were to quantify it and the protein was abnormally high (because you were measuring the protein related to the infection rather than protein slipping through the glomeruli), you might inappropriately institute unnecessary -- and potentially dangerous -- therapy aimed at mitigating pathologic proteinuria.
Bottom line: you should NOT quantify protein using a UP:C if you suspect the proteinuria is post-renal.
162
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 parameters suggest this is an acute kidney injury (AKI) rather than chronic kidney disease (CKD), i.e., what parameters help you differentiate AKI from CKD?
1) High potassium
2) Glucosuria without serum hyperglycemia
3) Casts- tubular damage
4) Acute onset (history)
163
Is a patient with a low PCV more likely to have AKI or CKD
CKD
164
What factors help you distinguish AKI from CKD
1) High potassium
2) Glucosuria without serum hyperglycemia
3) Casts- tubular damage
4) Acute onset (history)
165
Is a low body score more consistent with AKI or CKD
CKD
166
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?
ultrasound the urinary system
167
A 12-yr-old, MC, cat with CKD Stage II presents with constipation and inappetence. Which electrolyte would you want to check?
potassium can cause decreased GI motility and lead to constipation and inappetence. iCa could also be low, so this could would likely receive credit, but potassium is the big focus in cats.
168
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?
Heartworm
Lepto
169
A 5 year old, MC, border collie presents for a wellness exam. A urinalysis reveals a urine specific gravity of 1.030 with a 2+ proteinuria and no other abnormalities. CBC and biochemistry panel are within normal limits.
What is your next best diagnostic/therapeutic step?
Repeat a urinalysis in 2 weeks
170
A sediment is active if
1) Hemoglobin or myoglobin present
2) Gross hematuria
3) RBCs >250/hpf
4) WBCs >10-20.hpf suggesting infection
5) Bacteria is present
171
Which of the following statements is TRUE regarding testing and monitoring of infectious causes of proteinuria in dogs?
Group of answer choices
A Lyme PCR is indicated in a proteinuric patient with a travel history to California.
Leptospirosis PCR should be performed on both blood and urine in acute disease.
A SNAP 4Dx is indicated in a patient with chronic Rocky Mountain spotted fever.
Antibody titers are an accurate measure of successful treatment for ehrlichiosis.
Leptospirosis PCR should be performed on both blood and urine in acute disease.
172
Which of the following statements is TRUE regarding possible clinical signs in infectious causes of proteinuria?
Dogs with Leptospirosis can present acutely ill or may only have profound PU/PD.
Dogs with Rocky Mountain spotted fever often have immune-mediated hemolytic anemia.
Cats with leptospirosis are more likely to have azotemia and proteinuria than dogs.
Dogs with acute ehrlichiosis frequently present with spinal pain and neurologic signs.
Dogs with Leptospirosis can present acutely ill or may only have profound PU/PD.
173
Which of the following is TRUE regarding the distribution of the following infectious causes of proteinuria in dogs?
Leptospirosis is most common in the high desert areas of California and Arizona.
Rocky Mountain spotted fever is found primarily in Idaho, Montana, and Wyoming.
The Lyme disease organism has been documented in ticks in the Upper Midwest.
Ehrlichiosis is most common in Southeastern states, especially Florida and Georgia.
The Lyme disease organism has been documented in ticks in the Upper Midwest.
174
Which of the following is TRUE regarding the diagnostic approach to proteinuria?
A renal biopsy is indicated (and safer) in proteinuric patients with a borderline UP:C (0.2 and 0.5).
A UP:C is indicated in cats with ureteral obstruction, hypertension, and chronic kidney disease.
Elevations in UP:C, creatinine and BUN are necessary to confirm proteinuria is pathologic.
Protein electrophoresis is indicated in patients with an elevated UP:C and high globulins.
Protein electrophoresis is indicated in patients with an elevated UP:C and high globulins.
175
Which of the following is TRUE regarding therapy for proteinuria?
Telmisartan and losartan are third generation angiotensin converting enzyme inhibitors.
Amlodipine is the first line therapy in a cat with proteinuria and severe hypertension.
Angiotensin II receptor blockers result in dilation of the glomerular afferent arterioles.
Clopidogrel is used to increase the binding capacity of anti-thrombin III on platelets.
Amlodipine is the first line therapy in a cat with proteinuria and severe hypertension.
Proteinuria in cats with severe hypertension is likely secondary to the hypertension. Calcium channel blockers (amlodipine) are the first-line therapy for hypertension in cats.
Telmisartan and losartan are angiotensin-receptor blockers, not ACE inhibitors. ARBs result in dilation of the efferent -- not the afferent -- arterioles. Clopidogrel inhibits the aggregation of platelets.
