Urinary Flashcards
Why do urinary GGT and ALP increase with AKI?
Too big to filter through glomerulus. Tubular injury –> leaking GGT and ALP.
JVIM 2021, Nivy
What are heat shock proteins? Which family is reno-protective, and which HSP in particular?
HSPs: ubiquitous cytoprotective cellular proteins
HSP70 = reno-protective, esp HSP72
JVIM 2021, Nivy
These novel urinary biomarkers are most predictive of AKI when used together, but which single marker performs best? Which two were worst?
GGT, ALP, HSP70, IL-6, IL-18
Best = IL-6. Worst = HSP70, not predictive at all = IL-18.
JVIM 2021, Nivy
How do these novel urinary biomarkers (GGT, ALP, HSP70, IL-6, IL-18) compare with SDMA in predicting AKI?
Similar
JVIM 2021, Nivy
For serum and urine L-FABP and NGAL, which was most sensitive/specific for CKD? Did presence of hyperthyroidism affect these?
uL-FABP/Cr is high with CKD. Better sens/spec than sL-FABP. High in ~1/3 of hyperthyroid cats but no correlation with T4. NGAL was useless.
JVIM 2021, Kongtasai
Using an AI algorithm, which variable was the best predictor of short and medium term survival?
Clinical severity score
Age
Body weight
Creat at 48hrs
Appetite at 48hrs
Creat at 48hrs
JFMS 2021, Renard
What are Bracchi Italiani dogs predisposed to?
A) Cysteine urolithiasis
B) Urate urolithiasis
C) Primary renal hematuria
D) Familial proteinuric kidney disease
E) Minimal change disease
D) Familial proteinuric kidney disease
JAVMA 2021, Inman
What portion of the kidney is most commonly affected by incidental renal infarcts, and what is one possible explanation?
Caudal pole (55%) – no collateral blood supply
JVIM 2021, Sutthigran
What is the primary diagnosis in most dogs with incidental renal infarcts: infection, inflammation, or cancer
Cancer
JVIM 2021, Sutthigran
Most of the following factors had roughly half and half distribution in dogs with incidental renal infarcts. Which THREE were overrepresented?
Male vs female
R vs L kidney
Cranial vs caudal pole
1 lesion vs multiple
Grade 1 infarct vs > grade 1
Uni- vs bilateral
Caudal pole 55%
Unilateral 56%
Grade 1 84%
JVIM 2021, Sutthigran
What do the different grades of renal infarct (1, 2, 3) mean?
1: <25% of the kidney; likely blockage of small branch of the renal artery
2: 25-50%, blockage of a major branch
3: >50%
JVIM 2021, Sutthigran
True or False:
Contrast induced nephropathy carries a very guarded prognosis.
False. In a study of 3 animals with CIN, all had improvement or resolution of AKI within 2 weeks.
JAVMA 2021, Griffin
What is the cutoff in difference between kidney size to diagnose big kidney-little kidney syndrome?
0.7cm
JVIM 2021, Wu
Name at least 3 factors that could suggest ureteral obstruction as a cause for big kidney-little kidney syndrome vs other causes.
–Larger difference in kidney length
–Elevated creat
–Hyperkalemia
–Lower urine pH (since most ureteral stones are CaOx)
JVIM 2021, Wu
What is an early marker of CKD-mineral and bone disorder (MBD)?
High FGF-23
JVIM 2021, Miyakawa
Describe the normal physiology of fibroblast growth factor 23 (FGF-23).
–What stimulates its release? What makes it?
–What is the co-receptor called and what does it do?
–Where does FGF-23 bind and what does it do there? (2 different organs)
–What is the net effect of FGF-23?
–High phos OR high calcitriol stimulates FGF-23 release by osteoclasts
–FGF-23 binds to receptors on kidney and parathyroid gland.
–Klotho is a co-receptor that incr binding affinity of FGF-23.
–FGF-23 binding in kidney –> downregulate Na-Phos cotransporter in renal tubule, decr calcitriol synthesis
–FGF-23 binding in parathyroid gland –> decr PTH
–Net effect: incr urinary phos excretion, decr intestinal phos absorption
JVIM 2021, Miyakawa
FGF-23 and CKD:
–Is it high or low? Name 3 mechanisms that influence this.
–Does it occur before or after PTH and phos are increased?
–Does it affect prognosis?
–FGF-23 is high due to decr renal clearance, response to hyperphosphatemia, and decr klotho
–Occurs before high PTH, phos
–Negative prognostic indicator (unclear if simply a marker or if promotes progression of CKD)
JVIM 2021, Miyakawa
What are two potential consequences of hypercalcemia in CKD cats?
Decr GFR, nephrocalcinosis/stones
JVIM 2021, Geddes
What effect does a renal diet with strict phosphorus restriction and high Ca:P have on PTH, FGF-23, Ca, phos?
Low-normal PTH
High-normal FGF-23
High Ca
Normal phos
JVIM 2021, Schauf
How does the Ca:P and fiber content in a diet affect Ca absorption?
Ca:P: The closer to 1:1, the less of each will be absorbed b/c they’ll be bound to each other. High ratio (ie, more Ca) –> more Ca absorption. Low ratio (ie, more phos) –> more Phos absorption.
Fiber slows intestinal transit times, resulting in more bound Ca and decr absorption.
JVIM 2021, Geddes
In a group of cats with experimentally induced CKD fed a severely phos and protein restricted diet, most had improved azotemia, high-normal FGF-23, low-normal PTH, and hypercalcemia. What was the effect of switching to a moderate protein and phos diet with a lower Ca:P ratio? What does this imply about diet in CKD cats?
Stable azotemia, decr FGF-23, resolved hypercalcemia –> might be better to restrict protein and phos less in CKD diets.
JVIM 2021, Schauf
In a study of cats with naturally occurring CKD and hypercalcemia that developed while on a renal diet with very restricted phos and higher Ca:P ratio (RC Renal), what happened when they were switched to a moderate phos diet (RC senior)? (Ca, phos, FGF-23, PTH, CKD stage)
What happened with the cats that were hypercalcemic prior to renal diet? (Ca, phos, PTH, CKD stage)
–CKD + hypercalcemia when on renal diet: resolved hypercalcemia, no change phos and FGF-23 (ie, higher dietary phos did not make things worse), incr PTH but still WNL (probably b/c no longer suppressed by hypercalcemia)
–CKD + hypercalcemia prior to renal diet: no change in Ca or PTH, lower phos
–Neither group had progression in CKD
JVIM 2021, Geddes
What is the effect of omeprazole (SID x 14d) on appetite and body weight in CKD cats?
Statistically, but not clinically, significant incr in food intake (2.7%). No change in body weight.
JVIM 2021, Spencer
Other than ID/tx of underlying cause, what are four other medication groups to consider for renal proteinuria?
Immunosuppressants (if indicated)
Omega-3 FAs
Antithrombotics
Angiotensin II inhibitors (ACEi, ARB, spironolactone)
JVIM 2021, Lecavalier
What is ACE escape? Name one drug class that is affected by this, and one that isn’t.
Tx with ACEi –> alternate pathway for ATII generation. Does not affect ARBs.
JVIM 2021, Lecavalier
What receptors do ARBs selectively act on? What receptor is left alone, and what does it do?
ARBs block Angiotensin II type 1 (AT1) receptors. ATII can still bind AT2 –> renoprotective (vasodilation, natriuresis, inhibit inappropriate cell growth).
JVIM 2021, Lecavalier
Why is telmisartan used over losartan in dogs?
Dogs cant metabolize losartan to the active drug.
JVIM 2021, Lecavalier
In proteinuric dogs treated with telmisartan:
–What proportion (few, some, most) achieved the goal of UPC <0.5 or >50% decr from baseline?
–When did most dogs have at least a partial response?
–When did most dogs plateau?
–Most had good response to telmisartan
–Start improving at 1mo
–Plateau at 6mo – stable therafter
JVIM 2021, Lecavalier
Telmisartan adverse effects:
–Proportion with incr creat by >30% after starting?
–Proportion with GI signs?
–Effect on K+?
–Did either result in discontinuation of telmisartan?
–4% had incr creat – d/c drug
–11% mild, transient GI signs – able to continue
–K+ normal for all dogs (telmisartan probably affects aldosterone less than ACEi)
JVIM 2021, Lecavalier
What is the most common cause of ureteral obstruction in cats?
Ureteroliths (esp CaOx)
JVIM 2021, Testault
How does plain CT compare with AUS in terms of ureterolith identification and localization?
CT better for identification and localization, esp proximal and distal ureters (probably harder to see on AUS) and bilateral ureteroliths (ultrasonographer may have stopped looking after finding one).
Few cases where AUS found stones missed on CT – but for all of those, CT found at least some stones.
JVIM 2021, Testault
What are the renal pelvis dilation (mm) cutoffs associated with ureteral obstruction with AUS and CT, respectively, based on one study?
AUS >5mm, CT >3mm –> always ureteral obstruction (calculi)
JVIM 2021, Testault
True or False:
Urotomy for ureteral obstruction is important in additional to SUB placement, as this preserves another pathway if SUB obstructs and removes a site of potential persistent infection.
False. Increases procedure duration and complexity but no short or long term benefit – don’t do it!
JVIM 2021, Butty
True or false:
Severe azotemia, and particularly preexisting CKD, negatively impact prognosis in cats with ureteral obstruction and this should be considered prior to pursuing SUB placement.
False!! Most have a good outcome regardless!
JVIM 2021, Butty
True or False:
Pyuria and bacteriuria should be treated with antibiotics in cats with SUBs. If persists despite abx, consider SUB removal +/- replacement (if ureter not patent) out of concern for biofilm formation.
False!! Don’t treat unless LUT signs present or azotemia is progressive. Can have pyuria and bacteriuria for years and doesn’t necessarily cause problems.
JVIM 2021, Butty
True or False:
AUS guidance (rather than fluoroscopy) is highly successful for SUB placement, even if there is minimal (<4mm) renal pelvis dilation.
True
JVIM 2021, Butty
What proportion of cats with ureteral obstruction will improve with medical management?
13%
JVIM 2021, Wuillemin
True or False:
Bilateral ureteral obstruction is rare.
False – up to 44% depending on the study
JVIM 2021, Wuillemin
Are ureteral obstruction via stones or stricture associated with a longer hospital stay +/- worse outcome?
Stricture – may cause a more chronic obstruction
JVIM 2021, Wuillemin
What is the range of survival to discharge with SUBs, depending on the study?
80-100% – most are 90+ %
JAVMA 2018 Berent
JVIM 2021, Wuillemin
JFMS 2021 Vrijsen
In cats with ureteral obstruction treated with SUB placement:
–When does renal pelvis dilation improve?
–When does azotemia stabilize (and can IRIS stage them)?
–What effect does SUB placement have on CKD progression?
–Immediately
–1mo
–No effect – similar survival to cats with that stage CKD that don’t have UO/SUB placement
JVIM 2021, Wuillemin
What proportion of cats with SUB placement have long term recurrent LUT signs? What has been changed about the procedure to decrease the incidence of this?
14%. Might be due to straight bladder catheter. Now we use short straight catheters or locking loop catheters.
JVIM 2021, Wuillemin
When SUBs obstruct:
–Proportion of cats?
–Median time frame?
–Typical cause?
–Need for intervention?
–17%
–7mo
–Mineral debris suspected
–Half had no renal pelvis dilation – presumed ureter was patent so no intervention needed
JVIM 2021, Wuillemin
What is the overall MST for cats with SUB placement?
1.9-4.2 years, depending on the study and preexisting CKD
JVIM 2021, Butty
JVIM 2021, Wuillemin
For a study of 31 dogs with intramural ectopic ureters:
–What proportion were female?
–Proportion with normal AUS?
–Proportion with concurrent vestibulovaginal abnormalities?
–What proportion were continent with cystoscopic laser ablation alone?
–With meds added?
–All female
–22% normal AUS
–90% concurrent vestibulovaginal abnormalities
–45% continent with CLA only
–68% with meds added
JVIM 2021, Hooi
What is the relative frequency and degree of LUT signs post cystoscopic laser ablation for dogs with ectopic ureters?
Uncommon, mild
JVIM 2021, Hooi
How does age impact outcome of dogs with ectopic ureters treated with cystoscopic laser ablation?
No impact
JVIM 2021, Hooi
What factors contribute to ongoing incontinence in dogs with corrected ectopic ureters?
Unknown – probably other concurrent congenital problems
JVIM 2021, Hooi
What are the diagnostic criteria for obesity-related metabolic dysfunction (ORMD)? What is the similar syndrome in people called?
BCS >7/9 PLUS two of the following:
–High TG, Chol, BP, BG
–DM
Similar to metabolic syndrome in people – but dogs don’t experience many of the complications people do (ex: atherosclerosis)
JVIM 2021, Paulin
What proportion of obese dogs have obesity-related metabolic dysfunction (ORMD)?
20%
JVIM 2021, Paulin
Which are risk factors for uroliths based on one study? Which may have been confounded due to the design of the study?
High TG, Chol, BG; obesity, USG, pH
Risk factors: high TG, BG, low USG** (but were on urinary diet and encouraged incr H2O), obesity** (but controls = healthy staff pets)
No difference between stone and control groups: chol, urine pH** (but many were on urinary diet)
** = confounded by study design
JVIM 2021, Paulin
Which urolith stone type is most common in each sex category and why?
–Male
–Female
–Intact male
–Male: CaOx (females probably pass them easier)
–Female: struvite (urease UTI)
–Intact male: cystine – androgen dependent (type III cystinuria)
JVIM 2021, Kopecny
What are the three basic causes for cystine uroliths?
–High methionine diet (cystine precursor) – animal meat, tofu, nuts, wheat
–Genetics (type I and type II cystinuria) – mastiff, pitbull, bulldog, rotties
–Androgen dependent (type III cystinuria) – intact males
JVIM 2021, Kopecny
What is the genetic mutation associated with urate uroliths? Name three predisposed breeds.
SLC2A9 –> hperuricosuria
Dalmation, bulldogs, English bulldogs
JVIM 2021, Kopecny
Which two breeds are prone to xanthine stones?
Dalmation (probably due to allopurinol for urates)
CKCS (genetic)
JVIM 2021, Kopecny
_________ uroliths usually form a composite with _________ uroliths.
Apatite, struvite
JVIM 2021, Kopecny
Which cat breeds are overrepresented for urate uroliths?
Ocicat, siamese
JVIM 2021, Kopecny
True or False:
Urate urolithiasis in a cat is uncommonly due to portosystemic shunt.
True
JVIM 2021, Kopecny
Does urine Mg increase or decrease formation of CaOx stones?
Decrease
JVIM 2021, Kopecny
What is the prevalence of UTI with struvite stones in cats? Are abx indicated even if no LUT signs and stones are removed?
11%, no
JVIM 2021, Kopecny
Which dog breed is prone to sterile struvite uroliths?
Pugs
JVIM 2021, Wingert
In one study of 50 dogs with uroliths:
–What proportion had successful dissolution with diet?
–Median time to decr stone burden? (How does this affect whether to continue or d/c diet trial?)
–Median time to complete resolution?
–How did number and size of stones affect outcome?
–68%
–Improvement at median 29d. So, if no improvement by 1-2mo, probably not struvite – consider other tx.
–Complete resolution median 35d (but as long as 5.5mo).
–No effect
JVIM 2021, Wingert
What is the most common bacteria found in UTIs with struvite uroliths? What is the average duration of abx use in these dogs while also undergoing diet therapy for dissolution?
Staph, 4wks (some d/c’d prior to documenting resolution of stones)
JVIM 2021, Wingert
What risk factors are vets concerned for when considering dietary dissolution of uroliths (unknown composition)? What is the actual prevalence of these? (Name three.)
–Urethral obstruction 8% – usually in dogs who originally presented obstructed (so don’t do diet only for these dogs)
–Pancreatitis 4%
–Persistent LUT signs 2%
JVIM 2021, Wingert
True or False:
Risk factors for possible struvites (breed, alkaline urine, urease UTI, stone number and size) are not highly predictive – reasonable to try dietary dissolution even if risk factors not present.
True – risk factors are hit and miss. Give diet a shot before more invasive stuff.
JVIM 2021, Wingert
In a study of 21 dogs with LUT signs and voided urine sample:
–What was the sens/spec and PPV/NPV of point of care RIA dipstick compared with UCS?
–Is this overall more or less accurate than urine microscopy?
–Any caveats about these results?
–POC RIA: Sens 89, Spec 100, PPV 100, NPV 92.
–Urine microscopy is still more accurate (sens 93, spec 99, PPV 94, NPV 99)
–Caveats: this study was small so the confidence values were wide; hard to compare with other studies since they often used cystos, didn’t require LUT signs to be present
JVIM 2021, Grant
In a study of 50 healthy dogs with no LUT signs, how many had a positive UCS? How many had positive next generation DNA sequencing (NGS)?
No positive UCS, all had lots of bacteria and fungi on NGS
JVIM 2021, Melgarejo
What is the most common bacterial cause of pyelonephritis? What is the best first line abx for this? Which two common empiric abx aren’t good for this and why?
E. coli. Best = fluoroquinolone. Bad = beta lactams, convenia (don’t reach adequate tissue concentration).
JVIM 2021, Weese
What is a very effective minimum duration of abx for uncomplicated UTI?
3-5d
JVIM 2021, Weese
In hospitalized dogs, how common is incomplete urine voiding? When does this peak?
Common (88%), peaks at 3d. But, unclear whether it’s a clinically relevant problem.
JVIM 2021, Vasquez
How does SediView compare with traditional reference lab UA for detection of casts (agreement, sens, spec)? What is one major drawback to the automated images SediView obtains compared with manual UA?
Moderate agreement.
–Low sensitivity (52%) but UA not perfect either. Sediview caught 36% of cases UA missed.
–Spec pretty good (90%) but higher false positives than UA – Dr should review images.
SediView automatically takes images at 40x. Hard to determine length, size, and type of cast (should be using low power).
JVIM 2021, Vasilatis
How long do LUT signs take to resolve post cystoscopy?
1 week
JVIM 2021, Rayhel
How did epidural affect cystoscopy dogs in terms of post procedure pain control, urine retention, and presence of neuro deficits?
Somewhat better pain control, but possible bias (more control dogs had cystsoscopic laser ablation). No effect on urine retention. Epidural dogs did not have neuro deficits the next day.
JVIM 2021, Rayhel
What is the effect of prazosin on recurrent urethral obstruction within 30 days?
Higher occurrence in prazosin vs placebo, but study may have been underpowered. At best, it didn’t reduce the risk any.
JVIM 2021, Hanson
True or False:
The prevalence of current or prior vector borne diseases is higher among dogs with proteinuria than the general population.
True – PLN 34%
JVIM 2020, Purswell
What two values on biochemistry are associated with a higher likelihood of vector borne disease in proteinuric dogs?
Lower alb, higher creat
JVIM 2020, Purswell
–Vit D tends to be (lower, higher) in PLN dogs.
–At least two possible basic mechanisms?
–Does this correlate with albumin and/or azotemia, or neither one?
–Lower in PLN
–Possible mechanisms: decr vit D intake, decr vit D synth, decr vit D binding protein (VDBP – loss through PLN?)
–Correlates with albumin. Independent of presence/severity of azotemia.
JVIM 2020, Miller
Which were NOT associated with positive urine culture in dogs with UPC >0.5?
–Pyuria
–Microscopic hematuria
–Bacteriuria
–LUT signs
–Endocrinopathies (HAC, DM)
–CKD
Hematuria, endocrinopathies, CKD
JVIM 2020, Grimes
What are the first and second most common glomerular diseases in dogs?
What are some general differences between the two?
1 - ICGN
2 - focal segmental glomerular sclerosis (FSGS)
General differences:
–ICGN tends to have higher UPCs (esp >12.5), hypoalbuminemia, ascites
–FSFS tends to have more moderate UPCs (median 5.9), normal to slightly low albumin, non-azotemic
JVIM 2020, Lorbach
What is the basic pathophysiology of focal segmental glomerular sclerosis (FSGS) at the level of the glomerulus?
Insult –> compensatory podocyte hypertrophy –> alteration of podocyte foot process and slit diaphragm (connects podocytes – important part of the glomerular filter)
If insult persists, podocyte detachment –> naked basement membrane –> Bowman’s capsule adhesions –> matrix deposition (sclerosis) in that capillary segment which eventually obliterates the lumen –> global glomerular sclerosis
JVIM 2020, Lorbach
Regarding causes of focal segmental glomerular sclerosis (FSGS):
–Possible causes (generally speaking) for secondary acquired FSGS? Treatment?
–Treatment for primary acquired? If so, treatment?
–Treatment for congenital?
In humans, which tends to have the slowest progression?
–Secondary acquired: Infectious, drugs, adaptive, maladaptive, etc. Remove underlying cause, give antiproteinuric drugs.
–Primary acquired: immunosuppression
–Congenital: antiproteinuric drugs, slowest progression
JVIM 2020, Lorbach
What is the MST post renal bx for focal segmental glomerular sclerosis (FSGS)? Which of the following negatively affect prognosis?
–Azotemia
–Hypoalbuminemia
–Ascites/edema
–UPC
–Higher urinary IgM, IgG
MST 8.5mo (range 1mo - 2.7yrs)
All but UPC – thus, not the best marker for extent of glomerular scarring. Ig’s were more prognostically important.
JVIM 2020, Lorbach
Regarding treatment of proteinuria with telmisartan and enalapril:
–What proportions of dogs have UPC reduction >50% within the first month for each drug as monotherapy? (more than half vs less than half)
–Which monotherapy was more efficacious overall?
–Are adverse events more common with one or the other?
–What is the most common adverse effect of dual therapy (max dose of one, starting dose of the other)?
–Telmisartan 80%, enalapril 35%
–Telmisartan – greater UPC reduction, bigger returns with dose escalation
–Similar rate for both (15%), usually an incr in creat >30% from baseline. Hyperkalemia was uncommon.
–Incr creat, often within a week. Don’t do dual therapy even though it’s more effective.
JVIM 2020, Laurenco
True or false:
Clopidogrel adequately inhibits ADP mediated platelet aggregation in most PLN dogs.
True. But, Plt can still aggregate with other stimulators such as arachidonic acid).
JVIM 2020, Shropshire
Serum phos is ___% of total body phos.
1%
JVIM 2020, Laflamme
In general, how do the following affect dietary phos availability:
–Source – rank bioavailability from low to high. Grains, protein, supplements
–Ca:P ratio
–Dietary Mg
–Grains proteins, supplements
–low Ca:P –> more P available to absorb
–High dietary Mg –> decr Phos absorption
JVIM 2020, Laflamme
What is the primary route of phos absorption in the intestines? Name at least 4 hormones that affect this.
Na dependent active absorption
PTH, vit D, FGF23, glucocorticoids, thyroid hormone
JVIM 2020, Laflamme
Regarding renal handling of phos:
–What proportion is filtered out by the glomerulus vs excreted by the tubules?
–Method of reabsorption?
–How does urinary phos contribute to acid/base balance?
–List at least three things that DECREASE reabsorption and two that INCREASE it.
–100%, 0%
–Na/Phos cotransport – usually reabsorb 80-90%
–Urinary phos removes excess acids in a buffered form (H2PO4-)
–DECR reabsorption: PTH, FGF23, metabolic acidosis
–INCR reabsorption: vit D, dietary Mg
JVIM 2020, Laflamme
True or False:
High phosphorus intake can cause kidney damage, even if they were normal to start with.
True
JVIM 2020, Laflamme
Regarding FGF23:
–What makes it?
–At least 2 stimuli for synthesis?
–Where does Klotho act and what makes it?
–Effect on:
–Phos and Ca reabsorption in the kidneys?
–PTH secretion?
–Calcitriol production?
–Osteoclasts and -blasts
–Incr Phos, calcitriol, possibly incr Ca
–Cofactor for action on kidneys, made by kidneys
–Effects:
–Kidneys reabsorption: decr phos, incr Ca
–Decr PTH and calcitriol (thus decr intestinal phos absorption)
JVIM 2020, Tang
What are the three basic mechanisms for increased calcium? Which does NOT appear to be a mechanism in CKD cats with high Ca?
–Decr renal excretion – not a mechanism in CKD
–Incr intestinal absorption
–Incr bone reabsorption
JVIM 2020, Tang
An upward trend in calcium correlates with (faster, slower, no change) in progression of CKD in cats.
Faster
JVIM 2020, Tang
What are the steps to making active vit D? What are the names of each type of vit D?
(dietary vit D) –[organ]–> (metabolite) –[organ]–> (active vit D)
cholecalciferol –[liver]–> calcifediol –[kidney]–> calcitriol
JVIM 2020, Parker
Based on a recent study, what was the effect of calcifediol supplementation on the following markers of CKD-bone and mineral disease?
–PTH
–FGF23
–Phos
No change PTH (possibly a positive thing – lack of progression), phos
Incr FGF23 – but may be because vit D stimulates synthesis vs CKD progression
JVIM 2020, Parker
Cats:
How does the survival to discharge rate compare in hospitalized AKI vs AoCKD, and how does this possibly relate to underlying cause?
What is the overall long term prognosis for AoCKD, and one positive and negative prognostic indicator?
–Similar – 50-60%. Would have expected AoCKD cats to do worse. But, nephrotoxicity (irreversible) is more common in AKI vs AoCKD cats (usually have reversible acute insults, like ureteral obst, panc, pyelo, etc).
–Long term prognosis is guarded to poor (MST 66d)
–Better prognosis if ureteral obst (esp if surgically treated)
–Worse prognosis if higher creat at DISCHARGE (faster progression than would be expected for stable CKD at similar IRIS stage). In dogs, azotemia at admit is more important.
JVIM 2020, Chen
Dogs:
How does the survival to discharge rate compare in hospitalized AKI vs AoCKD, and how does this possibly relate to underlying cause?
What is the overall long term prognosis for AoCKD, and one negative prognostic indicator on labwork?
–AoCKD dogs do better (65%) than AKI (40-50%). Would have expected AoCKD dogs to do worse. But, nephrotoxicity (irreversible) is more common in AKI vs AoCKD cats (usually have reversible acute insults, like ureteral obst, panc, pyelo, etc).
–Long term prognosis is guarded (MST 105d)
–Worse prognosis with based on labs at ADMIT: azotemia (in cats, creat at discharge is more important), phos, HCT, CK, DGGR lipase
JVIM 2020, Dunaevich
Regarding systemic hypertension (SHT) in dogs with AKI:
–Prevalence at admit to hospital (uncommon, about half, almost all)? Does this increase or decrease during hospitalization?
–Any predictors for SHT on blood or urine?
–Any association with hypertensive retinopathy?
–True or False: SHT usually resolves at the time of follow up.
–About half at admit, 3/4 throughout hospitalization
–No – no correlation with azotemia, UPC
–No – some non-hypertensive dogs had it too (possible variable BP –> incr risk of TOD)
–False! Even if on antihypertensive meds. So, important to recheck BP.
JVIM 2020, Cole
How do the sens/spec of SDMA and creat compare for detection of decr GFR in cats? (Better, worse, equal)
Negligible differences in sens/spec – SDMA doesn’t add much over creat (but, not many CKD IRIS Stage I cats in the study)
JVIM 2020, Brans
Which renal measurement has the highest sens/spec for CKD on AUS:
–Kidney size (lateral view)
–Kidney size (sagittal view)
–Cortical thickness
–Renal pelvic dilation
Cortical thickness. Neg correlation with CKD disease severity.
JVIM 2020, Yan
Which is frequently a normal finding in kidneys on AUS in healthy cats:
–Thin medullary line
–Thick medullary band
–Neither
Thin medullary line = usually normal
Thick medullary band –> more common with kidney disease (but not completely sens/spec)
JVIM 2020, Cordella
Which are true about liver-type fatty acid binding protein (L-FABP) in cats?
A) Urinary L-FABP (uL-FABP) can be elevated due to renal hypoxia/oxidative stress
B) uL-FABP is elevated in CKD due to decr GFR
C) uL-FABP correlates with SDMA and creat
D) L-FABP is only made by the liver and pancreas
E) L-FABP is freely filtered by the glomerulus
True: A (L-FABP released from renal tubules), E (in normalcy, all is reabsorbed)
False: B, C, D
JVIM 2020, Katayama
Regarding hemojuvelin in cats:
–What nutrient homeostasis is it involved in?
–Does urine hemojuvelin creat ratio (UHCR) distinguish renal disease vs healthy cats?
–Does it distinguish AKI vs CKD?
–Does it correlate with severity of azotemia?
–Iron
–Yes
–No
–Yes – potential as early biomarker of renal disease (use in people)
JVIM 2020, Jing
Which are true based on a recent study:
A) Lab UMIC was more accurate than in house (IH) – fewer contaminants
B) IH UMIC was more accurate than lab (fresher plating)
C) Mid-stream free catch is a reasonable sampling technique for UMIC
D) Most subclinical bacteriuria dogs have <100K CFU
True: C – as long as using 100 CFU as cutoff for bacteriuria vs LUT contamination
False: A, B (lab vs IH UMIC performed similarly), D (most have >100K CFU)
JVIM 2020 Coffey
What group of conditions is more common in dogs with Enteroccus bacteriuria compared with E. coli bacteriuria? How might this relate to Enteroccus pathogenicity?
LUT abnormalities (anatomic, uroliths, neoplasia, etc). R/o disrupted urinary epithelium –> opportunistic infection.
JVIM 2020, Wood
True or False:
Hyperthyroidism is a risk factor for positive UMIC in cats.
False
JVIM 2020, Peterson
Which are true about CKD cats with positive UMIC:
A) Most are E. coli
B) Most are Enterococcus faecalis
C) Most are subclinical bacteriuria
D) Cats without pos UMIC have more slowly progressive CKD compared to those with pos UMIC
E) Cats with multiple pos UMIC have more rapidly progressive CKD than those with only one pos UMIC
F) Cats with true UTI have more rapidly progressive CKD than those with subclinical bacteriuria
True: A (77% E. coi, 18% E. faecalis), C
False: B, D, E, F – number and CS of bacteriuria don’t affect CKD progression
JVIM 2020, Hindar
What is one benefit and one disadvantage of procuring bladder bx before completing the full cystoscopic study?
Benefit – avoid iatrogenic mucosal edema from saline flush
Con – bleeding limits visibility
JVIM 2020, Llido
Dogs with ectopic ureters also commonly have what other anatomic abnormality?
Vestibulovaginal septal remnant
JVIM 2020, Llido
True or False:
Bladder mucosa culture has higher sensitivity than UMIC.
True – so culture them even if UMIC was negative
JVIM 2020, Llido
When is urine calcium:creat ratio most accurate to detect excessive calciuresis in dogs prone to CaOx formation?
–First AM
–Post prandial
–Any time
Any time
JVIM 2020, Carr
Regarding Vetfoam cross-linked gelatin as a urethral bulking agent:
–How does efficacy compare to bovine glutaraldehyde cross-linked collagen (GAX)?
–How does the adverse effect rate compare with GAX? What are is at least one clinical and one cystoscopic adverse effect?
–Average duration of efficacy?
–Proportion that require more than one procedure?
–Similar efficacy ~85% (some need meds added)
–Similar adverse effects ~15%; transient LUT signs, minor urethral mucosal defect
–Median 11mo but probably underestimated; a few dogs had >3mo
– ~1/3
JVIM 2020, Chen
Regarding proliferative urethritis:
–What are two risk factors?
–Most common presenting sign?
–Are gross lesions usually single, multifocal, circumferential? How common is stenosis?
–Medical management options?
–Minimally invasive options?
–What component of treatment offers the longest remission of signs?
–Female, hx UTI
–Partial or complete urethral obstruction
–Multifocal/diffuse and circumferential, stenosis is common. Diff from what would expect for TCC.
–Anti-inflamm, immunomodulatory, abx, drugs for urethral spasm
–Debulking, balloon dilation, stent (single best tx)
JVIM 2020, Emanuel
True or False: AKI can cause vWB Type II phenotype.
True
JVIM 2019 McBride
What is the association/relationship between Mg and FGF-23, BP, progressive CKD, and risk of death in CKD cats?
These go together:
Low Mg
High FGF-23
Higher BP – but slight/not clinically relevant
Low OR high MG –> Higher risk of death
No association:
Progressive CKD
Presence of nephroliths
Unclear if correlation or causation
JVIM 2018 Van den Broek
JFMS 019 Chacar
True or False: CKD is associated with higher carbonyl end products.
True
JFMS 2019 Valle
What are indoxyl sulfate and p-cresol sulfate?
What is their relationship to CKD in cats?
How does indoxyl sulfate relate to FGF-23 and what does this imply?
Colonic derived uremic toxins
CKD –> dysbiosis –> more indoxyl sulfate. Independently correlated to FGF-23 –> may play a role in mineral metabolism.
No difference in p-cresol sulfate in CKD vs healthy cats
JVIM 2019 Summers
JVIM 2019 Liao
What is the mathematical relationship between GFR and creat? How could this be used to monitor kidney function in nonazotemic vs azotemic cats?
Exponential relationship
Kidney damage:
–Non-azotemic cats –> GFR will dramatically change, small changes in creat
–Azotemic cats –> GFR has more within-individual variability –> suggests there is significant functional renal reserve, and creat is a more useful monitoring tool
JFMS 2018 Finch
Which is/are lipiduria associated with?
Sex
Renal cortical density on CT
Kidney values
Urinary tract disease
MN, decr renal cortical density
Not associated with azotemia or urinary/extra-urinary disease
JFMS 2021 Schwarz
True or False: A mineralized structure in the feline penis always indicates urethrolith or dystrophic mineralization.
False – can see os penis in some cats
VCNA 2019 Rademacher
What is a ureterocele? What are the two types?
What two ureteral abnormalities is it usually associated with?
What is the tx of choice?
Cystic dilation of the ureter
Orthotopic (intravesicular) – live in the bladder lumen
Ectopic – live in abnormal position at urinary bladder neck or urethra
Associated with stenotic ureteral opening, which is assoc with ectopic ureters
Cystoscopic laser ablation. Occ need to convert to sx if male dog.
VCNA 2019 Rademacher
JVIM 2019 Rogatko
True or False: Echogenic urine on AUS should raise concern for active urinary sediment.
False – low PPV. Anechoic urine is more reliable (higher NPV) but only if USG >1.015.
JSAP 2019 Valls Sanchez
Answer the following regarding pyelography in dogs and cats:
–% diagnostic yield?
–Major/minor complication rate?
–Reliability of UMIC via pyelocentesis vs cystocentsis?
94%
2% major, 23% minor
No advantage of pyelocentesis
JAVMA 2019 Etedali
What is the best test for polycystic kidney disease in Persians?
What is a reasonable alternative if unable to do that test?
Genetic test
AUS. Number of renal cysts needed to establish dx increases with age (ie, at least 1 cyst up to 15mo old; 2 1.5-2.5yr old; etc)
JFMS 2019 Guerra
What change to renal blood flow is seen on contrast enhanced AUS in AKI dogs?
Congested medulla
JSAP 2019 Mannucci
What is F2-isoprostane?
How do the following affect the levels?
–CKD IRIS stage
–Urine vs plasma
–Renal diet
Marker of oxidative stress
Highest in CKD IRIS stage I vs healthy or CKD IRIS stage II.
When transitioning to stage II, plasma F2-IsoP stays high but urinary level falls –> plasma and urinary values are not interchangeable.
Plasma F2-IsoP decr in stage I cats fed a renal diet, diminishing returns in stage Ii.
JFMS 2021 Granick
True or False: There is a positive correlation between ammonia, azotemia, and phos.
True
JFMS 2021 Carvalo
True or False: The proportion of CKD cats with positive fecal occult blood test correlates with IRIS stage.
True – higher stage –> higher proportion of cats with positive test
**Note – was NOT related to plt function
JFMS 2020 Benson
Which is the best marker of CKD in Birman cats and why?
SDMA
Creat
BUN
USG
SDMA. Healthy birmans tend to have higher BUN and creat vs other breeds –> false positive for azotemia (unless using breed specific RI).
JFMS 2018 Paltrinieri
How does SDMA correlate with severity of disease in critically ill dogs and their prognosis?
It doesn’t
JVECCS 2019 Koster
Sort the following biomarkers into associated with glomerular damage vs renal tubular damage.
CRP
IgG
NGAL (Neutrophil gelatinase-associated lipocalin)
RBP (retinol binding protein)
Have any of these been evaluated as biomarkers of CKD?
Glomerular: high MW proteins (CRP, IgG)
Tubular: low MW proteins (NGAL, RPB)
urinary NGAL : creat ratio (UNCR) is higher in progressive vs stable CKD
JVIM 2018 Liu
JVIM 2019 Kim
What is cystatin C?
How does it perform in detection of reduced GFR compared with SDMA and creat?
low MW cysteine protease made at a stable rate by all nucleated cells, cleared by glomerular filtration
Inferior performance
JVIM 2019 Pelander
What is KIM-1 (kidney injury molecule 1)? What is its potential diagnostic utility?
Proximal tubular transmembrane glycoprotein involved in cell-cell and cell-matrix adhesion, phagocytosis/clearance of dead/dying cells
A preliminary study showed a marked (but transient) increase in cats with AKI due to sepsis and urethral obst
JFMS 2019 Bland
What is one potential histopathologic finding associated with use of hyperosmolar agents?
What are a few examples of hyperosm agents? Which was associated with severity of lesions?
What blood value at presentation was also associated with severity of lesions?
Osmotic nephrosis: vacuolization/swelling of renal proximal tubular cells
Hyper osm agents: IVIG, low MW dextran, glucose, HES (**associated with severity of lesions), iodine contrast
Creat
JVECC 2019 Schmid
Your FNA of a primary renal mass returned nondiagnostic. What tumor type moves up on your ddx list?
Renal sarcoma. Most other renal tumors exfoliate.
VCNA 2019 Wycislo
True or False: Combining USG and qualitative proteinuria (urine dipstick) has moderate correlation with UPC.
False – not a good substitute, need to do UPC
JSAP 2020 Perez-Accino
JVIM 2018 Mindl
What renal parameter should be closely monitored when treating with masitinib?
What should you do if an abnormality arises?
UPC. 18% of dogs become proteinuric and can be rapidly progressive. D/C drug –> UPC should improve.
JSAP 2020 Kuijlaars
True or False: Pre-existing proteinuria is a contraindication for masitinib.
False. Can cause proteinuria but study included a small number of dogs with pre-existing proteinuria, and these did not get worse.
JSAP 2020 Kuijlaars
True or False: Urine should be collected in a glass container for most accurate UPC results.
False – doesn’t make a clinical difference glass vs plastic
JVIM 2019 Moyle
True or False: PLN does not affect serum AA amounts or ratios.
False – PLN dogs have altered AA status
JVIM 2019 Parker
True or False: In vitro experimentation shows TGF-beta and AT II have fibrotic effects on renal epithelial cells.
True
JFMS 2019 Van Beusekom
In a study of dogs with bx confirmed ICGN, what treatment choice resulted in higher chance of survival?
Immunosuppression (mycophenolate)
JSAP 2019 Vessieres
What substrate is the rate limiting step in the RAAS system?
Renin production
JVIM2019 Ames
Which part of the kidney does AT II affect to increase reabsorption of Na and Cl?
Proximal tubule
JVIM2019 Ames
List at least four clinical findings that worsen prognosis for dogs undergoing dialysis.
Anuria
Respiratory complications
DIC
Higher grade AKI
Pancreatitis
SIRS
JVECC 2019 Perondi
Which correlates better with renal function in dogs with CKD IRIS Stage 4 treated with IVF and intermittent dialysis?
Creat
SDMA
SDMA (note – both SDMA and creat are dialyzable)
JVIM 2019 Le Sueur
What is the difference between multipotent vs pluripotent? Which group do mesenchymal stem cells (MSCs) belong to?
Pluri = can become anything. Multi = can become some but not all tissue types.
MSCs –> multipotent
VCNA 2019 Quimby
True or False: Mesenchymal stem cell therapy has shows significant benefit in reducing severity of AKI and partially reversing CKD, but is too prohibitively expensive for routine clinical use at this time.
False – most studies show no to minimal benefit in AKI and CKD
VCNA 2019 Quimby
Regarding positive UMIC in cats with SUB placement:
–Two risk factors?
–One factor that decr risk?
Are these usually, sometimes, or rarely symptomatic UTIs?
Growth of what organism increased risk of needing SUB removal or replacement?
Incr risk:
Pre-op pos UMIC
Periop hypothermia
Decr risk:
Abx post op
**Note: CKD and post op u-cath not associated with incr risk
Usually symptomatic
E. coli
JVIM 2019 Kopecny
JFMS 2021 Pennington
True or False: Lack of significant renal pelvis dilation on AUS makes ureteral obstruction very unlikely.
False – in one study 25% had minimal dilation (<4mm)
JFMS 2021 Lemieux
Which is the most common cause for ureteral obstruction?
Stone
Stricture
Clot
Inspissated debris
Stones 2/3 or more of cases (depending on study
JAVMA 2018 Berent
JSAP 2020 Milligan
JFMS 2021 Lemieux
List at least 4 potential complications of SUB placement (excluding general sx/anesth complications).
In what time frame do most complications occur?
Intra-op
Periop
Short term
Long term
UTI
Sterile cystitis
SUB obst (mineralization, blood clot, kink)
SUB leakage
Long term
JAVMA 2018 Berent
JFMS 2021 Vrijsen
You diagnosed a cat with ureteral obstruction. She has severe azotemia, hyperphosphatemia, hyperkalemia, and is oliguric.
If owner moves forward with SUB placement, how do these findings affect post op hospitalization and likelihood of survival?
Post obstructive diuresis (urine >2mL/kg/hr) duration and severity are correlated with these labwork findings and anuria.
Does not impact survival
JAVMA 2019 Balsa
What post op finding increases risk for SUB mineralization?
One small study of N = 8 mineralized SUBs found 100% efficacy with what therapy? What was the complication rate?
High iCa
Infusion with tetrasodium ethylenediaminetetraacetic acid (tEDTA) –> dissolves Ca. 0% complications
JVIM 2019 Chik
11mo FI lab with lifelong urinary incontinence.
–What is your initial primary ddx?
–AUS shows bilateral, severe hydronephrosis. What additional ddx is now on the list?
–Do you expect kidney values to be normal, mildly elevated, or severely elevated?
–What treatment do you recommend?
–What do you tell the owner about the likelihood for CKD?
Ectopic ureter
Congenital distal ureteral orifice stenosis – rare but when it does occur, it’s almost always with ectopic ureters; labs overrepresented
Kidney values are usually normal despite AUS findings
Recc cystoscopic laser ablation
Severe hydronephrosis –> concern for chronicity –> CKD is likely. If caught within 4 days, damage is completely reversible; within 2 weeks, 50% reversible; after 5 weeks, not reversible.
JAVMA 2018 Meler
True or False: Artificial urethral sphincter placement is a salvage procedure with a significant complication rate and modest success rate.
False. Serious complications (ex: urinary obst from stricture) are rare and success is 90%.
VCNA 2019 Butty
True or False: In animals with urinary implants (SUB, cystostomy, etc), positive UMIC should only be treated if there are LUT signs.
True
2yr MN DSH with distal urethrolith causing urinary obstruction. Multiple unsuccessful attempts to place u-cath and a urethral tear is suspected.
What treatment do you recommend?
Percutaneous antegrade urethral catheterization
Requires GA and fluoro
VCNA 2019 Butty
True or False: Decreased conversion of 25(OH)D to less active metabolites may contribute to CaOx urolithiasis.
True
JVIM 2019 Growth
When should you start screening for uroliths in high risk but asymptomatic dog breeds? What is the purpose?
5-6yrs old – to have option of minimally invasive removal
JVIM 2019 Hunprasit
Which is better for dogs vs cats?
SUB
Ureteral stent
Cat - SUB (more complications with stents)
Dog - ureteral stent (SUBs have a high rate of mineralizatoin/occlusion)
VCNA 2019 Milligan
What are three indications for nephrolithectomy?
How successful is this procedure for addressing these issues?
Chronic UTI/pyelo
Growing stone –> loss of renal parenchyma
Obstructed ureteropelvic junction
Very successful
VCNA 2019 Milligan
JAVMA 2019 Petrovsky
How does decompressive cysto in UO impact the following:
Metabolic derangements
How much time it takes to place u-cath
Ease of placing u-cath
Risk of uroabdomen
It doesn’t – no major risk bot no benefit either
JAVMA 2021 Reineke
True or False: Half of FIC cats will have recurrence at some point after the first episode but this does not seem to affect survival and etiologies of each episode may be different (stress, stone, etc).
True
JFMS 2020 Kaul
JFMS 2021 Eggertsdottir
In a study of UO cats treated with phenoxybenzamine and alprazolam, what effect did the addition of meloxicam have on risk for reobstruction?
None
JVIM 2019 Nivy
Regarding UO cats:
What effect does urinary bladder flushing immediately after u-cath placement have on duration of u-cath retention and risk for in hospital reobstruction?
No effect – probably not worth doing
JAVMA 2019 Dorsey
What is the relative frequency of positive UMIC at the time of UO diagnosis and during hospitalization with u-cath? How does this affect abx administration?
Rare at diagnosis, 13% at 24hrs post u-cath, none beyond that time point
Don’t give prophylactic abx
JVECC 2019 Cooper
List at least 4 factors that increase risk for FIC.
Obese
Inactive
Nervous
Multicat household
No high vantage points
Non-clumping litter
VCNA 2019 Westropp
True or False: Overweight BCS is not a risk factor for subclinical bacteriuria in middle aged and older cats.
True
JFMS 2020 Moberg
True or False: Submitting urine in tryptic soy broth worsens the sensitivity for positive UMIC compared with submitting plain urine.
True
JAVMA 2019 Acierno
Regarding Corynebacterium urealyticum, a rare, opportunistic urinary pathogen:
– At least 3 risk factors?
–How can AUS increase suspicion?
–How to confirm dx?
–Usually susceptible to which antibiotic?
–One major (potentially fatal) complication of this UTI?
Risk factors:
U-cath
Urologic sx
Neurogenic urinary incontinence
LUT disease
AUS –> encrusted cystitis (urease –> alkaline pee –> struvite deposits)
Need prolonged (72+ hr) UMIC in enriched media
Tetracycline
Sepsis
JSAP 2019 Maurey
True or False: Subclinical bacteriuria can be accompanied by pyuria.
True
VCNA 2019 Byron
True or False: Abx are not indicated for subclinical bacteriuria, incl in patients with comorbidities such as CKD and DM.
True
VCNA 2019 Byron
True or False: Type of urethritis inflammation does not inform likelihood of occult deep infection (detected by FISH).
True
JVIM 2019 Borys
What can the ordering practitioner do to improve the accuracy of SediVue results?
Review the images to rule out false pos/negs
SediVue overall has moderate to high sens/spec depending on cell and crystal type
JVIM 2019 Hernandez
What are two ways to monitor for recurrence of glucosuria at home in cats in DM remission?
Urine dipstick
Purina Glucotest litter – accurate 30 min - 8hrs after exposure to urine
VCNA 2019 Piech
True or False: USG of first morning urine is consistent in clinically healthy dogs, but not clinically unhealthy dogs.
False – variable for everyone, to a degree that could affect decision making
JVIM 2019 Rudinsky
What are two risk factors for urinary incontinence in male dogs?
Breed (mastiff, Irish setter, fox terrier, bulldog, boxer)
Older
Note – no association with neuter or body weight, unlike in female dogs
JSAP 2019 Hall
What are three pharmacologic treatment options with good efficacy to decrease feline urinary spraying/marking?
Feliway
Fluoexetine
Clomipramine
VCNA 2019 Borns-Weil
In cats with uroabdomen:
–What part of the urinary tract is the most common source?
–Most common cause?
–% survival to discharge?
–One neg px indicator?
Urinary bladder
Trauma (external or iatrogenic)
76%
AKI
**Note – not associated with px = urine source, need for sx, UMIC results, age
JFMS 2021 Hornsey
