Urinary system and theraputics Flashcards
1
Q
azotemia definition
A
build up of nitrogenous waste in the body
2
Q
pyelonephritis definition
A
inflammation of kidneys
3
Q
renal insufficiency
A
poor function of kidneys
4
Q
hypersthenuric definition
A
well concentrated urine
- >1.030 for dogs
- > 1.035 for cats
5
Q
hyposthenuria definition
A
active dilution of urine
<1.008
6
Q
isothenuria definition
A
no modification of urine concentration
- same osmolarity as plasma
- 1.008-1.012
7
Q
types of urine collection
A
- free catch
- non-absorbable cat litter
- catheterisation
- cystocentesis (blind/ultrasound)
8
Q
urinalysis
A
- USG
- dipstix analysis
- microscopy (crystals/casts)
- some types crystals are normal
- cytology
- bacterial culture
9
Q
blood testing
A
- urea and creatinine
- recent protein meal will give false increased urea (use fasted sample)
- azotemia= increased urea and creatinine
- indicates reduced glomerular filtration
- anaemia
- electrolytes- decreased K+ (contributes to inappetence)
- hyperphosphataemia (reflects reduced renal excretion)
10
Q
pre-renal azotemia cause
A
- inadequate renal perfusion
- not filtering enough blood
- hypovolaemia
11
Q
renal azotemia cause
A
- reduced functional mass of kidney due to underlying kidney disease
12
Q
post-renal azotemia cause
A
- kidneys functional but waste products not excreted
- obstruction of urinary tract (ureter/urethra)
- rupture of urinary tract
13
Q
differentiating origin of azotemia
A
pre-renal- concentrated urine (trying to preserve as much water to compensate for hypovolaemia)
- renal- dilute urine (kidney not functioning well enough for water reabsorption)
14
Q
radiography
A
- size and shape of kidneys
- radiopaque stones
- radiolucent stones with double contrast
- evaluating ureteric course/insertion
- evaluating urethral morphology
15
Q
ultrasonography
A
- for parenchymal detail (cellular)
- bladder wall morphology
- evaluating some causes of post-renal azotemia
- uroabdomen/obstruction
16
Q
cytology/biopsy
A
- uncommonly used for kidneys
- commonly used for prostate
17
Q
acute kidney injury
A
- acute nephron damage/dysfunction
- kidneys highly susceptible to toxic/ischaemic injury
- severe AKI presents with anuria/oliguria
18
Q
intrinsic AKI
A
- toxins (grapes, raisins)
- ischaemic
- infectious (leptospirosis- dogs, pyelonephritis)
- cutaneous and renal glomerular vasculopathy (alabama rot)
19
Q
clinical findings of AKI
A
- azotemia, uraemia
- an/oliguria -> failure of K+ excretion
- arrhythmias/arrest
- +/- hyper/hypoperfusion- care with fluids if an/oliguria
20
Q
diagnosis of AKI
A
- acute azotemia (increased urea, creatinine, phosphate)
- increased K+ if anuric, decreased if polyuric
- with dilute urine= excludes pre-renal
- and no evidence of obstruction/rupture= excludes post-renal
21
Q
AKI diagnosis- urinalysis
A
- often isosthenuric (dilute)
- casts- indicate tubular injury
- crystals- Ca oxalate monohydrate= ethylene glycol toxicity
- inflammatory cells or positive culture= pyelonephritis
22
Q
crystals that are normal in dogs and cats
A
calcium oxalate dihydrate
23
Q
AKI management
A
- remove underlying cause
- known nephrotoxic drugs, gastric decontamination/adsorption
- supportive- fluid balance, electrolytes, nutrition, nausea, analgesia
- treat hyperkalaemia
- calcium gluconate- stabilises heart for 20 mins
- glucose- stimulates insulin release
- insulin- stimulates uptake of glucose and K+
24
Q
fluid therapy for AKI
A
- crystalloids (hartmanns)
- correct any hypovolaemia
- 10ml/kg -dog, 5ml/kg cat over 10-15 mins
- once euvolaemic- correct dehydration over 6hrs
25
hyperkalaemia as complication of AKI
- kidneys= major route of K+ excretion
- hyperkalaemia= >6.5-7mmol/l
- leads to arrhythmias/ arrest
- ECG quicker than bloods to detect changes
- wide QRS, spiked T, flat P wave
- bradycardia, V-fib
26
nursing care for AKI patient
- ensure euhydrated
- ensure renal perfusion (systolic BP)
- manage inappetence, nausea, pain
- nutrition (oral, assisted)
- liquid food needs calculating into fluid 'ins'
27
prognosis of AKI
- persistent anuria with vol overload and unmanageable hyperkalaemia= consider dialysis or euthanasia
- 50% have CKD
- survival 34-59% dogs, 27-42% cats
- better prognosis if polyuric
28
CKD overview
- most common in older cats
- functional and/or structural disease of > 3 month duration
- irreversible and progressive damage and dysfunction
management:
- protect remaining nephrons, supportive treatment to protect quality of life
29
aetiology of CKD (causes)
- chronic interstitial nephritis (CIN)
- end stage of many pathological processes
- glomerulonephropathy
- untreated infections (pyelonephritis, leptospirosis)
- chronic obstructive disease (uroliths)
- congenital (polycystic kidneys (cats) renal dysplasia (dogs))
- neoplastic
30
historical findings of CKD
- signs may be subtle, tolerable due to slow onset of disease
- PUPD
- dehydrated due to polyuria
- weight loss
- lethargy, weakness
- inappetence
- vomiting +/- diarrhoea +/- heamatemesis/melaena
- hypertension signs (blindness)
31
clinical exam findings of CKD patient
- catabolic state, reduced body condition
- dehydrated
- hypokalaemic, neck ventroflexion
- mouth ulcers, halitosis (bad breath)
- hypertensive retinopathy
- small, irregular kidneys on palpation
- rubber jaw
32
consequence of systemic hypertension
target organ damage
- ocular (hypertensive retinopathy)
- retinal oedema, haemorrhage
- can cause acute blindness
- renal
- cardiac
- neurological
epistaxis may also be complication
33
normal BP
120-140mmHg
- sight hounds 10-20mmHg higher in hospital
34
pre-hypertension range
140-159mmHg
35
severe hypertension range
>180mmHg
- high risk of future target organ damage
36
diagnosis of CKD
- dilute urine (not until 67% GFR loss)
- with azotemia (increased urea, creatinine) not until 75% GFR loss
- anaemia
- increased phosphate, decreased K+
- hypertension
- imaging
- symmetric dimethylarginine SDMA test- approximates glomerular filtration rate
37
management of CKD
initially:
- stop any nephrotoxic drugs
- find and treat any underlying cause
- hypertension, UTI, ureteroliths
- correct and maintain fluid balance
ongoing:
- encourage oral water intake
- different water sources, wet food
38
delaying progression of CKD
- renal diet
- control:
- hypertension
- proteinuria
- hyperphosphataemia
- hypokalaemia
39
nutritional guidelines for renal patients
- calculate and feed RER
- weigh food in and out
- monitor bodyweight/condition
- avoid protein calorie malnutrition (ensure getting enough calories)
- avoid aversions- introduce new diet at home
40
renal diet
- restricted protein, phosphorus, sodium
- supplemented antioxidants, K+, soluble fibre
41
additional management of CKD
- phosphate binders to decrease levels of phosphate
- potassium supplementation if hypokalaemic
- amlodipine to reduce hypertension
42
nephrotic syndrome
- complication of glomerular disease
- renal albumin loss
- leads to hypoalbuminaemia
- decreases oncotic pressure leading to effusions, oedema
management:
- reduce levels of protein within blood
- omega 3 supplementation (protects kidneys
- antiplatelet drugs due to increased risk of blood clots
43
lower urinary tract disease
disease of bladder and urethra
+ prostate in males
44
pollakiuria definition
increased frequency of urination
45
periuria definition
voiding inappropriate places
- cats not voiding in litter tray due to association with pain
46
cystitis definition
inflammation of bladder
47
causes of cystitis
- feline idiopathic cystitis
- bacterial urinary tract infection (female dogs)
- urolithiasis
- neoplasia
- drug induced
- implants/indwelling catheters
48
phone triage of LUT disease
- clinical signs of LUT disease
- are they still able to pass urine?
- emergency
49
urolith definition
- urinary stone
- macroscopic (can be seen by naked eye)
50
crystal definition
- microscopic
- mineral precipitate
- needs to be analysed in fresh, room temp urine
51
crystalluria definition
crystals in urine
- crystals and uroliths can happen separately or together
52
common urinary crystals and stones
- struvite (normal as crystals)
- calcium oxalate (normal as crystals)
- urate
53
crystal and urolith formation
- urine is frequently saturated with compounds
- increased saturation causes increased risk of precipitation
- compound can no longer be held in solution (crystal formation)
- further supersaturation can cause urolith formation
54
treatment of urolithiasis
- crystalluria is frequently normal and asymptomatic
- uroliths are abnormal but may be asymptomatic
- symptomatic uroliths need treating
55
symptomatic upper urinary uroliths
- nephroliths
- cause abdominal pain leading to anorexia/inappetence + lethargy
- ureteroliths
- can cause ureteric obstruction
- leading to post-renal azotemia
56
symptomatic lower urinary uroliths
- urethroliths- can cause obstruction
- leads to stranguria
- cystoliths- cystitis signs
- pollakuria, stranguria, dysuria, haematuria
uroliths may predispose animal to UTIs
57
importance of urolith type
- can change management
- some can be dissolved through diet or medication
- some need surgical removal
- some are associated with infections
- radiolucency can be used to guess type
- crystals cannot predict stone type
58
urolith radiographs
- uroliths need to be >2-3mm to visualise
- contrast/double contrast can be used for radiolucent stones
59
general principles for urolith management
if urine is dilute, crystal/stone formation cannot occur
- encourage water intake (n+1 sources)
- wet diet preferably
- monitor USG (<1.030 (cats) <1.020 (dogs))
- encourage voiding
- avoid obesity
60
dietary dissolution of stones
- usually protein restricted
- unsuitable for long term use, lactating animals or growing animals
- some diets are suitable for more than one type of stone
61
nursing considerations for urolithiasis
- vigilance- monitor for unproductive urination (indicates obstruction)
- maintain hydration, urine dilution/output
- urinary catheter care and management
- analgesia requirements (pain scoring)
62
feline idiopathic cystitis- signalment
- young to middle aged (2-7yrs)
- overweight, inactive
- indoor, litter tray users
- multi-animal household
- nervous disposition
- dry diet
- stressors in life (seasons, other animals, house move)
63
cats susceptible to feline idiopathic cystitis
- neuroendocrine modulation
- adjusted sensory nerve function
- abnormalities of CNS stress response
- GAG layer of bladder hypofunction
- typically protects bladder
FIC affects susceptible cats in provocative environment
64
diagnosing FIC
rule out other causes
- urinalysis (excludes UTI)
- radiographs (uroliths, masses)
- ultrasonography (abnormalities of UT)
- nothing found= FIC
65
presentation of non-obstructed FIC
- signs of LUTD
- pollakiuria, stranguria, haematuria
- still able to void
- often self limiting (2-3 days)
- may experience recurrent episodes
66
presentation of obstructed FIC
- urethral spasm or plug
- unproductive attempts to urinate
- emergency
- more common in males (high recurrence rates)
- >40% experience recurrence within 6-12 months
67
urinary catheter care
- leave in place or remove?
- closed, clean system
- keep collecting bag off floor
- wear gloves for handling
- keep connections clean
- change bag daily
- tape tubing to tail to avoid pulling
- avoid antibiotics
68
post-catheterisation management
- monitor urine output
- monitor hydration/volaemic status
- monitor electrolytes
- post-obstruction diuresis will cause hypokalaemia
- examine urine sediment/cytology daily for evidence of infection
69
calculating UOP
1. weight of bag now- weight of bag 4hrs ago
2. UOP for last 4hrs/4= UOP for 1hr
3. UOP for 1hr/patient weight= UOP (ml/kg/hr)
70
medical management of FIC
- analgesia (opioids= buprenorphine, NSAIDs)
- avoid NSAIDs if azotemic
71
environmental modifications for FIC patient
- alleviate predisposing stressor
- address negative cat-cat interactions
- provide easy exit route from cat/places to hide
- resource availability (n+1 for water + litter trays + beds)
- use of feliway
72
antispasmodics for obstructive FIC
- used post-obstruction
prazosin- smooth muscle relaxant
- monitor BP due to risk of hypotension
73
urinary incontinence definition
- loss of normal, voluntary control of micturition
normal control of urination:
- sensory reflexes and conscious control
- relaxation of urethral sphincter and bladder contraction
74
neurogenic incontinence
- upper motor neurone lesion (CNS)
- spastic bladder, difficult to express
- lower motor neurone lesion (PNS)
- flaccid bladder, easy to express
75
non-neurogenic incontinence
- urethral sphincter mechanism incompetence
- typically leak during recumbency
- anatomical defects- ureter voids directly into urethra
- frequent dribbling, risk of ascending infection
- dyssynergia- failure of coordination of bladder contraction with urethral relaxation
76
urethral sphincter mechanism incompetence (USMI)
- common in larger breed, spayed bitches
- leak during recumbency
- multifactorial:
- intra-pelvic bladder, obesity, neutering: increased collagen
77
treatment of USMI
- tighten sphincter
- alpha agonists (trigger contraction of sphincter)
- oestrogens (enhance agonists)
- surgical repositioning of bladder
- urethral cuffs
78
management considerations of urinary incontinence
- neurogenic
- treat neurogenic disease, bladder expression
- anatomic
- repositioning of ureters
