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URI 2 > Evaluation of urinary tract disease > Flashcards

Evaluation of urinary tract disease Flashcards

1
Q

Describe what SOAP stands for?

A

•Subjective: Signalment, history, things you cannot measure

•Objective: Things you can measure

•Assessment: What are your thoughts?- interpreting your S and O. Differential diagnoses

•Plan: What are you going to do? What would you like to do?

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2
Q

What tests can you use to evaluate Urinary Tract Disease?

A
  • Imaging (Radiography, Ultrasound, CT)
  • Clinical pathology (Haematology and Biochemistry tests)
  • Urinalysis
  • Surgical – biopsy, visualisation
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3
Q

Discuss plain radiography and its uses in urinary tract disease?

A
  • Lateral (right lateral to minimise superimposition of the kidneys) and dorsoventral abdominal views
  • Plain radiography good for bone and solid organs. Can comment in here the size and position of organs. With Urinary tract disease plain radiography is less useful.
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4
Q

Discuss Contrast Radiography and urinary tract disease?

A
  • Sodium salts of iodine compounds normally used (eg iohexol=Omnipaque®)
  • Contrast material infused via the urethra (cystograms). Pneumo-, positive, negative and double contrast
  • Contrast radiography much more useful for urinary tract disease. Plain does not allow us to see mucosal detail.
  • +positive = white on radiograph
  • – contrast= air black on radiograph
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5
Q

Discuss Intravenous urography (IVU)?

A
  • Contrast agent injected intravenously and excreted though the kidneys (time series of radiographs)
  • Left pic defines renal pelvis all the way down to bladder on the right which is radiograph taken later.
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6
Q

Discuss Ultrasound of the urinary tract?

A

Will see more detail of the soft tissue structure

Can identify calculi that are not radio-opaque

Middle top pic: can see lining of bladder is irregular.

Bottom right: relatively normal kidney with clear definition between medulla and cortex pic on left it is less pronounced.

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7
Q

Discuss CT and MRI for imaging urinary tract?

A
  • Can get very good resolution of soft tissue structures through multiple planes
  • MRI limited by movement caused by breathing
  • Expensive equipment
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8
Q

Discuss 3D CT imaging?

A

•Requires IVU (only possible with the injection of contrast material)

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9
Q

How do you Choose the Imaging Technique?

A
  • Cost and availability (most practices don’t have ready access to CT and it may cost £300-400)
  • Time (an IVU may take you several hours to set up and interpret)
  • Toxicity – iodinated compounds can precipitate/make worse renal failure – you may not want to perform an IVU in an animal that has renal failure. (take blood and renal sample to assess renal capacity first before doing this otherwise we may push it from compensated renal failure to decompensated renal failure)
  • What you want to see – some stones are not radio-opaque (ultrasound may be more appropriate), you cannot see ureters on plain radiographs
  • Your expertise – how comfortable are you in interpreting the image (referral to radiographer?)
  • Do you need to anaesthetise the animal?
  • Don’t forget the prostate!
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10
Q

Discuss Haematology and investigating urinary disease?

A
  • Usually non-specific which will prompt further investigation
  • Urinary tract infections may cause elevated white blood cell counts
  • Chronic kidney disease will cause non-regenerative anaemia
  • The above are not pathognomic for anything but form part of your further investigations

•Assessment of PCV and total protein is necessary in any clinical pathology study of renal function. You must compare the patient’s hydration status with their biochemistry and urinalysis results!

•PCV and TP to assess hydration status

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11
Q

What are the Biochemistry Parameters Commonly Altered in Renal disease?

A
  • Creatinine (increased)
  • Blood Urea Nitrogen (BUN) (increased)
  • Phosphorus (often increased)
  • Calcium (may be high or low)
  • Potassium (may be high or low)
  • Albumin (low – if there is protein loss)
  • Metabolic acidosis (in most situations)
  • SDMA (symmetric dimethyl arginine) New and idex say it is able to detect chronic kidney disease 8-9months earlier than creatinine can. When you’ve lost 40% of functional volume of kidney get changes compared to only 20% left when creatinine shows an increase and indicates renal disease. So SDMA is more sensitive.

Don’t look at any parameter in isolation!

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12
Q

Discuss Secondary renal hyperparathyroidism?

A

Failing kidney does not convert vit D to active form so get failure of excretion of phosphate so phosphate increases. Secondary hyperparathyroidism. Calcium binds the phosphate and drops and this increase the PTH.

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13
Q

Define Azotaemia:

A

increased concentrations of non-protein nitrogenous compounds in the blood

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14
Q

Define Uraemia:

A

The clinical syndrome associated with renal failure

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15
Q

Define Pre-renal:

A

Inadequate renal blood perfusion (dehydration, haemorrhage, shock)

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16
Q

Define renal:

A

Intrinsic kidney dysfunction

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17
Q

Define Post renal:

A

Obstruction or rupture of the ureters, bladder or urethra

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18
Q

Define renal insufficiency:

A

loss of renal reserve, reduced capacity to compensate for stresses such as dehydration

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19
Q

Define renal failure:

A

persistent abnormalities present (azotaemia and inability to concentrate urine), clinical signs

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20
Q

Discuss Urea?

A
  • Major nitrogenous waste of mammals
  • Mostly comes from breakdown of dietary protein
  • Synthesized in the liver via the Urea Cycle
  • Freely filtered at the glomerulus
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21
Q

Discuss things that change urea?

A
  • Dietary protein, protein catabolism
  • ⬆ fever, starvation, sepsis, burns
  • ⬇ severe hepatic dysfunction, protein restricted diets
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22
Q

Discuss limitations of urea?

A
  • Limitations an animal on high protein diet or animal which has just eaten may have a raised urea on that blood screen in ideal world wait 12hours to sample urea to negate that effect
  • Animal with gastrointestinal haemhorrhage can put urea up on your screen (another example when to refer to PCV. Animal with low PCV and high urea indicative of animal with chronic GI bleed)
23
Q

Discuss urea limitations further?

A
  • Reflects gut microbe activity more than kidney clearance in ruminants and horses
  • A lot of birds and reptiles excrete nitrogen compounds as uric acid rather than urea

•Remember that you must measure Urea and Creatinine in relation to Hydration status (PCV and TP) and urine output (volume and USG)

•There must be >70% loss of kidney function before you get sustained changes in levels of urea and creatinine

24
Q

Where does creatinine come from?

A
  • Majority from skeletal muscle breakdown which happens at constant rate and is irreversible so creatinine in blood usually represents breakdown of muscle. Daily production is dependent on total volume of creatinine. Relevant as diff ref ranges for diff breeds of dogs.
  • (small quantities from diet)
  • Freely filtered at the glomerulus
  • No reabsorption (cf urea)
  • Some (clinically insignificant) secretion by proximal tubules
25
Q

What is creatinine used for?

A

•Used in the international renal society staging of chronic kidney disease. Used by them as their benchmark for classifying renal disease.

http://www.iris-kidney.com/pdf/IRIS%20A4%20Poster.pdf

  • Creatinine is much less sensitive than Urea to changes in plasma concentrations due to non-renal causes (liver function, gut microbial activity)
  • Creatinine is used to diagnose and stage kidney disease
26
Q

What are normal creatinine values?

A
27
Q

Discuss limitations of Urinalysis -Dipstick?

A

Limitations need to consider:

  • Collection method (free catch get some washout of bacteria from lower urinary tract)
  • False negative if store urine in fridge
  • Left 12 hours on side may get crystals
  • Ph pad next to protein pad so if spill urine across may get false result (operating error)
28
Q

Discuss Urinalysis – Sediment Exam?

A
  • Blood
  • WBC
  • Other cells
  • Casts (formed muco protein in proximal tubule which can trap all sorts of other things which can give you and idea of what is going on e.g blood, hyaline etc)
  • Micro-organisms
  • Crystals
  • Can use in context of other diagnostic tests
29
Q

Define Hyposthenuria:

A

Diluted urine (active kidney process)

30
Q

Define Isosthenuria:

A

Urine that is neither diluted or concentrated (problem as urine is not being modified)

31
Q

Define Hypersthenuria:

A

Concentrated urine (active kidney process)

32
Q

Define polyuria:

A

Polyuria: increased volume of urine

33
Q

Define oliguriua:

A

Oliguria: decreased volume of urine

34
Q

Define Anuria:

A

Anuria: absence of urine

35
Q

What does urinanalysis do?

A

Measure density of urine relative to pure water think about in conjunction with hydration status of animal.

Normal response of dehydrated animal is to increas USG. Animal with renal disease kidneys loose ability to change the USG.

36
Q

Discuss Urinalysis USG?

A
  • MUST BE CONSIDERED IN THE LIGHT OF HYDRATION STATUS AND URINE OUTPUT
  • REMEMBER IN RENAL FAILURE THE KIDNEY LOSES THE ABILITY TO MODIFY THE URINE (it will probably be an inappropriate concentration and volume for the animals hydration status)
  • It is vital that you interpret this correctly!
37
Q

Discuss Proteinuria?

A
  • Typically indicates glomerular damage but may be found in other cases (e.g inflammation, infection)
  • If there is haematuria (blood in the urine) this will produce a positive results for protein as well (this doesn’t mean the animal is losing protein).
  • Microalbuminuria tests: good marker for early renal failure in people – seems to occur secondarily to other diseases in dogs
38
Q

Discuss Urine protein:creatinine ratio?

A
  • Can get this test done in most commercial pathology labs (follow up persistent proteinuria on dipstick)
  • Tells you how severe the proteinuria is
  • UPC should be <0.5 for Dogs and <0.4 for cats (IRIS guidelines)
  • Animals in renal failure that are proteinuric have a poorer prognosis and survival time than those that are not proteinuric.
39
Q

Discuss Cystoscopy?

A
  • Visualisation and biopsy of the bladder and urethra via an endoscope passed up the urethra
  • Requires general anaesthesia
  • Should be considered for recurrent or persistent lower urinary tract disease
  • Scope passed up urethra to visualise bladder.
  • Pictured can see polyp.
40
Q

Discuss Cystoscopy - Uses?

A
  • Masses or polyps (visualisation, biopsy and removal)
  • Evaluation of recurrent urinary tract infection (mucosal biopsy)
  • Diagnosis of Ectopic Ureters
  • Localisation of haematuria
  • Aid in the removal of uroliths
  • Dilating urethral strictures
41
Q

Discuss Renal Biopsy?

A
  • May be necessary to diagnose the cause of renal insufficiency, haematuria or proteinuria
  • Particularly useful in the diagnosis of glomerular disease and acute renal failure.
  • Not useful in stage IV chronic kidney failure (low chance of finding initiating cause)
  • You are collecting a sample for histological analysis
  • Not done very often
  • Risky procedure. Pick cases appropriately e.g end stage renal disease cat is a pointless risky waste of time.
42
Q

Discuss Renal Biopsy risks and contraindications?

A

•Not a common procedure – risk of haemorrhage/blood clots in the kidney, may further compromise renal function. Renal artery is a direct branch of the aorta!

•Contraindications: hydronephrosis, renal cysts or pyeloneprhitis/abcessation (leakage of fluid into abdomen)

43
Q

What are the methods or renal biopsy?

A

•Percutaneous methods: Ultrasound guided, blind (not recommended) usually a needle biopsy (Tru cut or spring biopsy needle)

•Surgical methods: laparoscopy, laparotomy – wedge section

  • Either way you should take care to collect the sample from the cortex (less risk of fluid leak)
  • The animal will need a general anaesthetic (obvs!)
44
Q

You will not know it has renal failure…..

A
  • It will be one of your differentials.
  • Some clinical signs are suggestive but not pathognomonic
  • Hydration status – normal to severely dehydrated
  • History history history
45
Q

At some point you will take blood in renal investigation remember?

A
  • Remember many things can affect urea, creatinine, PO4 and potassium!
  • Why are you doing the bloods? (do not over interpret them!)
  • What else might be going on?
46
Q

As a clinician what do you need to consider?

A
  • Not concerned about individual nephrons or glomeruli
  • Enough of them have to go wrong at the same time
  • Acutely or chronically
47
Q

What is bad news?

A
  • Homeostasis goes wrong
  • Fluid imbalances
  • Electrolyte imbalances
  • Acid-based imbalances

All the other functions of the kidney are affected

48
Q

Discuss the functional reserve of the kidney?

A

Remember functional reserve. We’re born with more kidney than we need. It is a cumulative problem that leads to renal disease.

49
Q

Discuss Azotaemia?

A
  • Urea and Creatinine can increase for many reasons
  • Is it a renal problem or not?

Can only establish this with a urine specific gravity

50
Q

How can Classification of azotaemia be done?

A

You need urine!

Never interpret raised creatinine and/or urea without urinalysis

51
Q

How is azotaemia classified?

A

Have vague idea of normal ranges but interpret with examination of animal and hydration status

52
Q

Look at this for Classification of renal azotaemia?

A
53
Q

Discuss renal Failure vs renal disease?

A
  • Not all animals with renal disease will have renal failure
  • Renal failure can be due to renal disease (chronic or acute) or other things (acute)
  • All animals with renal failure will be azotaemic
  • Animals with conditions other than renal failure can also be azotaemic
54
Q

3 presentations - All azotaemic?

A

URI 2 (44 decks)

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