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1

Case 1

10 yo M-n PBGV

Presents for wellness, Cr = 2.5 mg/dL, USG 1.018

Is this kidney dz?

Other useful values?

Can we stage this?

Other recom DX?

  • Kidney dz: inappropriate USG for being azotemic
  • Other useful values
    • BUN
    • Phos
    • K, Na, Cl, Ca
    • TCO2
    • Alb
    • Hct
  • Can't stage b/c we only have 1 time point
  • Other recom DX
    • Recheck
    • Full U/A
    • urine culture, UPC
    • +/- imaging
    • +/- infectious dz testing

2

Case 1

Communication with client?

Management at this time?

Plan for high UPC?

  • communication with client
    • likely permanent, progressive, can be managed sometimes for years
    • best with regular monitoring and likely new treatments in future
  • Management strategy
    • +/- diet
    • +/- monitoring weights - fluids
  • Plan for high UPC:
    • further evaluate
      • localization: double check labs/PE/HX for pre/post renal factors
      • persistence: recheck 2-3 weeks
      • magnitute: see if avg is > 0.5
    • No Tx yet

3

Case 1

Managing UPC = 1.2

  • +/- infectious dz testing
  • +/- bx
  • likely use ACEi
    • +/- thrombophrophylaxis
  • No immunosuppression now
  • Monitor over time
    • goal: UPC , 0.5 or 50% reduction
    • side effects: watch for inc K+ and/or inc Cr

4

Case 2

1 yr F/S Golden retriever

PC: constant accidents in house esp when sleeping or left alone.

What HX questions to ask?

  • Duration of CS
    • since adopted 3 months ago, unkown prior hx
  • Characterize: dribbling, constant leakage, puddles when rising, etc...
    • mostly small puddles found, constant leaking not noted
  • Any odor, discoloration?
    • no
  • Does she ever urinate normally?
    • yes
  • Other clinical signs?
    • no

5

Case 2

What specific things will be evaluated related to this dogs signs on PE?

  • Observation of micturation
    • normal stream
  • Bladder palpation
    • small to normal, non painful, no obvious urine expression
  • External urogenital eval
    • wet hair around vulva, 'prepubertal' conformation w/dorsal skin fold
  • Rectal
    • no obvious urinary abnormalities

6

Case 2

DDX

  • USMI
  • Ectopic ureters

---------------------------------------

  • LMN condition
  • Other functional abn
  • Secondary UTI, other structural dz

7

Case 2

DX plan?

DX plan if limited funds?

  • DX plan
    • UA
    • Urine culture
    • Chem, CBC
      • for causes PU/PD or infection
    • Imaging: AXR +/- AUS +/- other (CT, endoscopy)
  • DX plan if limited $
    • UA, U culture
    • empiric tx: 80-90% success rate
      • PPA
      • estrogen

8

Case 2

Patient improves with PPA but not 100%, imaging susp for unilateral ectopic ureter.

Treatment options?

Prognosis?

Discussion with clients?

  • Tx options
    • laser sx: 50% success rate
    • may need meds as well: 75% success rate
    • hydraulic occluder: 90% success rate

9

Case 3

3 yr F-s Mix breed dog

Asking to go out a lot more often last couple days, has one accident in house of stinky pink urine, cried when picked up.

What HX questions should you ask?

  • Characterize: PU vs pollakiuria
    • havent noted PU, seems like mostly small amounts of urine
  • Any straining / discomfort
    • hard to tell, don't watch dog outside
  • Has anything like this happened in the past?
    • no
  • Other CS, tenesmus
    • no / not sure

10

Case 3

What specific things on PE will be evaluated related to this dog's signs?

  • Observation of micturation
    • normal stream, urine is red the whole time
  • Bladder palpation
    • small and uncomfortable
  • External urogenital eval
    • pre-pubertal conformation w/dorsal skin fold
  • Rectal
    • no obvious urinary abnormalities

11

Case 3

Can you localize the problem?

Initial DDX?

 

  • Yes: LUT
    • can't rule out additional upper UT involvement
  • Initial DDX
    • UTI
    • Urolithiasis
    • Neoplasia
    • Renal hematuria - clots

12

Case 3

DX plan?

DX plan in limited money?

  • DX plan
    • UA
    • Urine culture
    • Imaging: AXR +/- AUS
      • ​+/- other endoscopy
    • chem, CBC
      • could give us info about risk factors
  • DX plan if limited money
    • UA, and U culture
    • empiric tx?

13

Case 3 results

  • UA (dipstick)
    • protein 3+
    • blood / heme = 3+
  • UA (sediment)
    • WBC = 8-12/hpf (inc)
    • RBC = TNTC
    • Many struvite crystals
  • AXR
    • 2 radiopaque stones
    • stones in both kidneys
  • Urine culture positive for proteus (urease prod bact)

Is it reasonable to suspect stones are struvite based on crystalluria? How certain?

Complicated or uncomplicated UTI?

  • Yes reasonable to guess struvites
    • can't be certain
  • Yes complicated b/c of stones

14

Case 3

Plan

When recheck?

  • Antibiotics
    • until stones resolved (6-8+ weeks)
  • Dissolution diet
  • Monitoring
    • Clinical signs
    • stone growth or dissolution
  • 1 month recheck
    • imp clinically w/in few days
    • culture neg
    • still some hematuria
    • rads show 3 stones

15

Case 3

Why are the stones bigger now?

Options for tx?

What about kidney stones?

 

  • Bigger because may have had oxalates first and gotten secondary infection
    • new stone type could be in response to diet
  • TX options
    • sx
    • lithotripsy
    • stones too big for catheter sampling
  • Kidney stones
    • leave in place for now
    • wait to see if necessary to remove later

16

Case 4

14 yr F DSH

vomited multiple times last couple days, seems to feel very sick, brough in to emergency clinic as walk in

Triage?

  • Need to get an idea of how sick the cat is
    • ask some questions
    • check some physical exam parameters
    • check some point-of-care test results

17

Case 4

specific questions to ask, tests to perform?

Emergency actions?

  • HR/pulse, RR/RE, Temp, Bladder palpation
    • azo stick off the charts high
  • obvious exposure to ethylene glycol?
  • Has the cat urinated recently?
  • Other primary clinical signs?
  • +/- Azo, BG, PCV/TS
  • No emergency actions

18

Case 4

specific things to evaluate on PE?

  • Drinking, urinating?
    • drinking less last couple of days
  • Bladder palpation
    • small
  • Kidney palpation
    • mildly enlarged, uncomfortable

19

Case 4

1st steps

  • Collect dx samples
    • UA (USG at a min)
    • Chem, CBC
    • Urine culture
    • imaging
    • EG testing
  • ID life-threatening disturbances
    • hyperkalemia
    • acidosis
  • ID pre and post-renal factors
  • Plan to assess urine output

20

Case 4

results

  • USG: 1.009, 2-3 granular casts, 2+ protein
  • Chem: Cr: 12.4, BUN: 268, Phos: 16.5, K: 5.5, TCO2: 15, alb: 3.6
  • AXR/AUS: bilaterally enlarged, smooth surface, hyperechoic kidneys

INITIAL TX an monitoring plan?

  • azotemia plus isosthenuria means there is a renal component
  • TXs
    • IVF (Maintenance + replacement + excess losses)
    • abx
    • anti-emetic / anti-nausea
  • monitoring
    • weights, urine output, BP
    • Serial bloodwork
      • esp K and TCO2/HCO3

21

Case 4

After 6 hours no urination, K now 6.0

What now?

Possibilities?

What do you do next?

  • Possibilities
    • still dehydrated
    • obstructed (bilateral ureteral)
    • Pathologic oliguria
  • What to do next
    • discuss prognosis
    • options: fluids, diuretics, other meds, dialysis