Exam 5 Flashcards

Question

Describe calcitriol can provide reno protection in CKD

Answer 1

Pathogenesis -Decreased calcitriol = Increased phosphorus -Decreased ionized calcium = parathyroid gland hyperplasia -High PTH is toxic = increased phosphorus retention -High cellular calcium is BAD = Kidney damage Calcitriol -PTH suppression -Blocks synthesis of the PTH molecule in gland by preventing transcription of the PTH gene -Immune system, anti-proliferative, anti-tumor and other effects Daily dosing -2.5 ng/kg/day -When phosphorus <6mg/dl and Ca x P <70 -Renal secondary hyperparathyroidism can develop prior to azotemia in cats even in the absence of hyperphosphatemia and hypocalcemia -HPTH & hyperphosphotemia occur frequently in digs with naturally occurring CKD, even at early stages. Monitor this parameter Management -Dietary phosphate restriction -Intestinal Phosphate binders -Vitamin D sterols: CALCITRIOL effective in prolonging survival

Answer 2

-Decreased erythropoiesis -Decreased RBC survival and increased RBC loss -Non-regenerative -Normocytic, normochromic -Hypoproliferative Tx -Transfusion -Darbepoetin

Answer 3

-Abrupt renal function decline -Recent onset of azotemia -Inability to regulate solute/water -Decreased renal synthetic and metabolic functions **Potentially reversible** -Important to consider: pre-renal, intrinsic (primary) renal, post-renal -Injury not a specific diagnosis Causes of Nephritis/Nephrosis -Lepto -Ischemia -Nephrotoxicity Post Renal -Obstruction: penile urethra most common in cats -Unilateral -Bilateral -Uroperitoneum

Answer 4

ALL need it -Nephroliths -Ureteroliths -Big kidney little kidney syndrome

Answer 5

Pre-Renal Volume Responsive AKI = Stage I IRIS Grading same as for CKD Staging **Increased S-creat = prediction of outcome** Hemodymanic AKI -Volume responsive -Transient Azotemia -Pre-renal AKI: low volume, low pressure -Usually rapidly reversal -Can progress to intrinsic AKI Azotemia Acute Pre-renal -Decreased perfusion of the kidney -Retention of Nitrogenous waste -It can be on top of primary renal, post renal. C/S -Dehydration -Hypotension -Anesthesia, ACE-I; NSAIDs history -Shock -Decreased CO Dx -Highly concentrated urine -USG >1.030, often >1.040 -Urinalysis normal -Hayline casts possible -Rapidly resolves if corrected volume issues ECFV -Increased urine volume -Improved Renal function **If oliguria or poor renal function persists, suspect primary renal failure** Pathophysiology AIRF -Nephrotoxins: Ethylene glycol (cytotoxic metabolites), antimicrobials (Aminoglycosides: Amphotericin, cephaloridine, sulfonamides, tetracyclines, Amikacin, Gentemacin). Cancer chemotherapeutics, Cholecalciferol rodenticide, heavy metals, radio contrast agents IV, fluorinated inhalant anesthesia **Lilly - cats** **Raisins/grape - dogs**, melamine + cyanotic acidic tainted food (crystal-associated nephropathy) -Acute tubular necrosis or injury -Acute Ischemic Renal failure: can take a long time in maintenance before resolution 1-3 weeks. Removal of inciting cause will not right away result in return of normal renal function -Recovery phase: Normal BUN/Creatinine. Complete recovery may not be possible with great injury -Partial improvement: can lead to CKD. Some nephron drop-out = inevitable NSAIDs -Any impairs renal auto regulation: Banamine, Ibuprofen, naproxicin, aspirin, carprofen, meloxicam, robenacoxib -Do not directly damage the kidney -Block renal vasodilatory response -AIRF -Renal injury occur if mediators of vasoconstriction activated by perception of volume depletion

Answer 6

Diagnosis of Azotemic AKI History -Uremia in general -Not specific for AIRF -Anorexia -Depression -Lethargy -Vomiting/diarrhea -Recent onset -Recent PU/PD PE -Dehydration -Overhydration: post fluid Rx -Bradycardia, arrhythmia, hyperkalemia -Normal to large kidneys -No evidence of LUT obstruction -Renal pain Urinalysis & Lab findings -USG 1.007-1.017 -Glucosuria, normoglycemia -Proteinuria, hematuria -Sediment: calcium oxalate or "hyppurate-like" crystals, ethylene glycol poisoning -Rapid increase BUN, serum creatinine, and serum phosphorus -Serum Potassium: sometimes >5.5 mEq/L -Severe decreased renal excretory function +/- Oliguria -Metabolic acidosis -Azotemia

Answer 7

While on IVF Anuria <0.05 ml/kg/hr Oliguria <1ml/kg/hr Polyuria relative 1-2 ml/kg/hr Normal - No IVF 5-10 ml/kg/day = 0.2-0.4 ml/kg/hr

Answer 8

Treatment 1. Remove underlying cause 2. Fluids 3. Drugs 4. Dialysis 5. Prevention Ethylene Glycol -Fomepizole 4-mythylpyrazole -Less CNS depression than Ethyl alcohol -Ethyl alcohol diluted to 20% Prognosis Dogs <3 hrs excellent 5-8 hrs good to grave >24 hours Grave Prognosis Cats >3hrs grave Leptospirosis -Doxycycline -Penicillins K AIRF Maintenance phase 1-3 weeks therapy -IV fluids -Calculate ins and outs **Too many fluids = kidneys die, interstitial edema, new paradigm** -Too many fluids: acute pulmonary edema 1. Rapidly correct dehydration 2. Replace urine loss (20 ml/kg/day) 3. No weight gain after 1st 12 hours: consider curtail volume prescription. Avoid visceral edema Systemic Hypertension -Caused in part by fluid administration -Amlodipine: Ca channel blocker, fast, effective AKI Drug Rx: none proven beneficial. Prevention is key Oliguric Phase Tx -Furosemide: loop diuretics -Dopamine: renal vasodilation when <5ug/kg/min. If >5ug/kg/min = vasoconstriction (adrenergic receptors) -Mannitol: osmotic diuretic, contraindicated in volume overload -Diltiazem: Ca channel blocker, reversal of renal vasoconstriction, pre-glomerular vasodilation, natriuresis independent of GFR. Prevent intracellular calcium accumulation. **Used in Lepto AIRF** 1.76x faster decrease in creatinine Hyperkalemia -Severe >8.0 mEq/L = death soon -Tx: Calcium gluconate, Sodium bicarbonate, Dextrose injection, insulin. -Dx: ECG Atrial Standstill, Sino-ventricular rhythm. Calcium Gluconate protective Metabolic Acidosis -Variable -Tx: Sodium bicarbonate IV for most Phosphorus Control -Phosphate binders in gut, added to enteral feeding GI signs -Maropitant -Omeprazole -Famotidine Nutrition -Appetite stimulants -Esophageal tube -

Answer 9

Ethylene Glycol -Fomepizole 4-mythylpyrazole -Less CNS depression than Ethyl alcohol -Ethyl alcohol diluted to 20% Prognosis Dogs <3 hrs excellent 5-8 hrs good to grave >24 hours Grave Prognosis Cats >3hrs grave Hyperkalemia -Severe >8.0 mEq/L = death soon Dialysis -Peritoneal and hemodialysis -Not a last ditch therapy -Refer early and before over hydrated -Becoming more available $$$ Prognosis -Magnitude of azotemia -Oliguria or anuria -Electrolytes: hyperkalemia -Acidosis -Anemia Most likely cause of death during maintenance phase -Hyperkalemia -Metabolic acidosis -Severe Azotemia **Overhydration and pulmonary edema** **PREVENTION**

Answer 10

Lower UTI -Associated C/S not specific to any particular Lower urinary tract disease LUTD C/S -Hematuria -Stranguria/Dysuria -Inappropriate urination -Decreased volume of urine: obstruction to urethra -Most asymptomatic bacteriuria. Lower irritative voiding, upper may have fever, renal pain, PU/PD, uremia Cystitis -Inflammation of the bladder Urethritis -May coexist with cystitis UTI -Bacterial colonization -Superficial luminal surfaces -Deeper within the parenchyma or both -Gram negative E. coli most common -25% gram positive, 75% gram negative Uncomplicated UTI -1 isolate (bacteria) -2 isolates (bacteria) -Ascending infection most commonly, bowel flora, females >males, distance to anus shorter in females, short wide urethra -Normal host defenses in urine: High osmolality, highly acidic, ammonia content, all inhibit bacterial growth -Hydrokinetic Wash out when voiding, protective mechanism for bladder, also some antibacterial secretions -Host defenses abrogation = often UTI establish Urinalysis UTI -Most important screening -Increased leukocytes -Pyuria and bacteria -Hematuria and proteinuria suggestive but non specific -pH increase due to urease production bacteria -Gram stain urine sediment Urine Culture -Cystocentesis highly preferred **Gold standard** -Quantitative culture = colonies forming units per ml - cfu/ml Most UTI >100,000 cfu/ml some labs 30,000 cfu/ml -Convention >1,000 cfu/ml = UTI some skin contamination possible Key Points -Catheterized female can result >100,000 cfu/ml making diagnosis impossible -Midstream voided urine samples not satisfactory due to contamination Imaging -No visible lesions for uncomplicated UTI Tx General principles -Eradication of infection -Avoiding development of resistance **Clinical UTI should be treated with antibiotics, Asymptomatic depends**

Answer 11

7-14 days for uncomplicated, 7 days per ISCAID 30-60 days for Upper UTI 30 days for sexually intact males

Answer 12

Uncomplicated UIT -Healthy, normal anatomy and function -First time bladder infection Dx -Presumptive -Urine sediment +/- Gram stain +/- Culture and susceptibility Tx -Correct predisposing factors -Treat with antibacterials **Urine concentration of antimicrobials = most important factor for UTI eradication** Complicated UTI >2 episodes/year -Immunosuppression -Recent antibacterial treatment -Anatomical abnormality, metabolic, or functional abnormality Managing complicated UTI -Correct underlying issue -Anatomic/structural, metabolic, functional

Answer 13

First line -TMP-sulfa -Amoxicillin Avoid: fluroquinolones, save for more difficult cases -Urine culture recommended post Rx Treatment Uncomplicated -Amoxicillin -Trimethroprim sulfadiazine -7 day duration

Answer 14

Minimum Inhibitory Concentration (mg/ml) In vitro -Amoxicillin 59% -Cephalexin 66% -Enrofloxacin 74% -Trimethorpim sulfamethoxazole 86 % **Higher in uncomplicated vs. complicated** -Uncomplicated susceptibility <90% for PO administration Getting the drug to the bug -Urine concentration antibiotics: aim to achieve 4-7 times MIC at site of infection -Can = 10-100 times that of blood -Time: above MIC dependent -Maximal concentration: above MIC dependent Amoxicillin with Clavulanate -Poor prostate penetration, not for intact dogs -Good against E. coli -Alternative to Sulfa-TMP 1st Generation Cephalosporins -Not a good choice -E. colu resistance Trimethoprim/Ormetoprim Sulfa -Side effects: IMHA, ITP, keratosis conjunctivitis sick Fluoroquinolones -Kidney friendly -Chose when other agents fail -Concentration dependent above MIC -High tissue concentration -Excellent GI absorption -Ciprofloxacin, enrofloxacin, Cefovecin not USA Aminoglycosides -Reserve for highly resistant bacteria -Nephrotoxic -Gentamicin

Answer 15

Enrofloxacin - First Line 20mg/kg PO SID x 3 days Amoxicillin - Second line choice 13-25 mg/kg BID x 14 days

Answer 16

Successful therapy UTI -Sterile urine during and after medication -Resolution of c/s does not mean cure -Culture 5-7 days, 1 and 3 months after stop medication to ensure sterility of urinary tract Recurrent UTI -Therapeutic failure -Relapsing, same bug, new bug -Need multiple cultures and time line -Imaging important: contrast urography, ultrasonography, cystoscopy -5-10 days after Rx rule out relapse Hidden Vulva Syndrome - Reinfection UTI -Sunken vulva, wooden vulva, peek-a-boo vulva, turtle neck vulva -Tx: Episoplasty surgery

Answer 17

When -Lower UT symptoms: pollakuria, stranguria, hematuria, dysuria -Active urinary sediment: bacteriuria, pyuria -Unclassified proteinuria: occult bacterial cystitis -Alkauria: pH urase producing bacteria -PU/PD isosthenuria -Structural/anatomical conditions UTI predisposition

Answer 18

Urolith types -Infection related: Struvite & Calcium phosphate -Metabolic: Struvite, calcium phosphate, oxalate, urate, xanthine, cystine, silicate -Both Stone Growth -Crystalloid supersaturation/precipitation -Absence of critical inhibitor: crystal poison lacking -Nidus for precipitation -Growth on another lattice: epitaxy Formation -pH -Time -Temperature -Promoters -Inhibitors Most frequent type of stone **Struvite, Oxolate** **60% small breed dogs** History - Kidney -Flank pain -No pain -Painless hematuria -Signs of infection -Signs of renal failure History - Ureter -No signs, especially cats -Flank pain (acute urethral obstruction) -Signs of post-renal azotemia (bilateral obstruction) History - Bladder -No signs -Dysuria -Increased frequency -Hematuria -Sensitivity varies by individual History - Urethra -Signs of obstruction -Signs of post-renal azotemia -Dysuria -Increased frequency -Hematuria PE findings -Thickened bladder wall -Palpable stones in bladder **Do not rely on palpation to determine if stones are present** -Rectal exam stone palpable if urethra obstruction -Large distended bladder

Answer 19

Urolithiasis data base -Urinalysis -Urine culture -Imaging: radiographs, ultrasound, contrast -Stone analysis quantitative Urinalysis -Inflammatory sediment: pyuria, hematuria, proteinuria, bacteriuria -pH variable -Struvite pH: alkaline if urase positive UTI -Cystine: acidic pH -Oxalate, urate, silicate: variable **Crystalluria = many problems** -Crystals can be present despite stones or vice versa Radiographic findings Most to least radiopaque - most radiolucent -Calcium phosphate -Calcium oxalate -Silicate -Struvite -Cystine -Urate Most common urolith: Struvite + Calcium oxalate + Urates

Answer 20

-Don't submit in formalin -Quantitative at UM, UC Davis, etc.

Answer 21

Struvite Urolithiasis -Most common type in dogs -Cats: slightly less common than oxalates -Bladder is the most common site -High recurrence in young animals -Alkaline urine -UTI bacterial in dogs Staph or Proteus Urase positive, mycoplasma rare Cats -90% sterile, metabolic -10% infectious Dogs -90-95% infectious, Staph Urase positive **H2PO4 - HPO4 - PO4** progression of alkalinity -Miniature Schnauzer, Cocker Spaniel -Females >> males -50% 3-8 years old -Tx: Calculolytic diet + UTI treatment. **AVOID SULFAS** decrease calculolysis.

Answer 22

Medical Dissolution calculolytic Diets DOG -Highly acidifying -Severe decrease in protein -Decrease urea generation -Decrease precursor minerals: Mg, Pi, Ca -Promote diuresis, increase Na, Cl -Diet 1-3 months, then maintain for 1 month Medical Dissolution calculolytic Diets CAT -Can not protein restrict -Mean 13 days for S/D, 27 days for C/D multicore diet -Struvite Stones should be gone within 4 weeks -No antibiotic needed in most cases Diet Modifications Struvite Prophylaxis -Urinary acidification (pH 6.0-6.5) -Magnesium restriction -Increase water intake -Decrease urine SG -Monitor dogs for UTI -Prevention diets

Answer 23

Increasing frequency in dogs and cats Dogs -Second most common type -Acid or neutral pH urine -Hypercalcemia can predispose -Older male dogs >> females 8-9 years old -Small/miniature breeds: Min Schnauzer, Min poodle, Yorkshire terrier, etc. -Risk factors: chronic hypercalcemia -Hyperadrnocorticism Cats -Least likely breeds: Siamese, Abyssinian, Mixed breed, Birman -Diets helpful for Struvite = Increased risk for Calcium oxalate in a sensitive animal Hypercalciuria -Resorptive bone -Hyperabsorptive - intestine -Renal leak Treatment -Medical calculolytic protocols DO NOT WORK -Prophylactic NOT EFFECTIVE -Avoid vitamin C -Diet change -Chlorothiazine: Increases renal tubular calcium reabsorption. Recurrent cases only -Potassium Citrate = more soluble than calcium oxalate -Promote water intake, canned diets -Urine pH >6.5 -Add Citrate if needed -Mild alkalinizing diet, veterinary diets for renal failure patients "O" neutral pH Goals -Reduce calcium excretion -Reduce calcium urinary concentration -Reduce urinary calcium availability Recurrence Rates -25-48% -Slow growing -3-4 months -6 months until large enough to obstruct **Miniature Schauzers 3x at risk**

Answer 24

Dogs = ammonium urate -Dalmatians: Mutation in SLC2A9, decreased urate transport in kidney and liver = increased secretion in kidney. Acidic urine, serum acid -English Bulldogs **Secondary Calcium oxalate, Struvite (increased in PSS dogs)** -Males >> females -UTI 2nd -High recurrence rate 30-50% Tx -Decrease protein and organ meat -Decrease nucleated cell density desired -Modify urine pH to <5.7 (6.3 pH = ammonium urate precipitation in Dalmatians) -Alkalinization - mild **Allopurinol** Competitive inhibitor Xanthine Oxidase -Low protein, low purine diet to reduce risk xanthine stone formation Feline - Urate -Rare in cats -Look for hepatic dysfunction -Medical dissolution NOT useful in cats -Increase water intake, low protein diet -Allopurinol??

Answer 25

1. Catheter Aspiration 2. Voiding Urohydropropulsion General Principles -Relieve urinary tract obstruction -Correct fluid, electrolyte, and acid-base imbalances -Non-surgical retrieval -Surgical retrieval if necessary -Lithotripsy -Medical dissolution -Struvite, urate, cystine -Preventative therapy -Increase water intake -Add water to dry food, change to canned food -Induce polyuria, decrease USG -Increase voiding opportunities -Treat UTI Stone Prevention COCO C: clear O: odorless C: colorless O: Often

Answer 26

63% Idiopathic

Answer 27

Rule Out -Urolithiasis -Behavioral -UTI -Neoplasia Pandora Syndrome: it is more than just the bladder -Bladder is the target organ -Clinical signs in other organs present -Hear disease, arrhythmia, gallop rhythm. -GI vomiting, diarrhea, dyschezia. -Lung asthma C/S -Intermittent hematuria -Stranguria -Pollakiuria -Urinating outside the box Urinalysis, PE findings, Histopathology -Idiopathic Cystitis -Thick bladder palpable -Increased bladder vascularity

Answer 28

-Increased activation of sympathetic system -Dysregulation of SRS -Unrestrained outflow of CATECHOLAMINES -Chronic "wear and tear" -Upregulation of pro inflammatory genes

Answer 29

See previous card -The brain is the central organ of stress response -Physiological and behavioral response to what is potentially or actually harmful -Loud stimuli response -Acoustic startle reflex in cats

Answer 30

Spontaneously resolve (85%) -5-7 days or earlier >50% recurrence within 12 months Acute Episode -Analgesics: BUPRENORPHINE 5-7 days -NSAIDs? renal risk -Antispasmodics: Acepromazine 3-5 days -Tranquilizer **Water increase intake** -Diet: canned food = decreased osmolality USG 1.030 vs. 1.050, increased voiding pattern -Food puzzle trays good MEMO -Detailed questionnaire, environmental, behavioral -Drugs -Pheromones -TCA- Amitryptyline -Clomipramine -GAG: Glucosaminoglycans -Improve husbandry -Enriched environment -Decrease magnitude of stress -Behavioral Cat and human -Environmental **The client is the treatment** Litter Box **Litterbox hygiene/husbandry PIVOTAL** Rule 1+1 -Size: bigger is better -No scented -Litter texture -Depth of liter -No hoods -Location -Access Environment -Cats are not pack animals -They are not antisocial -They are independent -Resting areas -Toys Antibiotics: NO NSAIDs: NO Outside: preferably NO GAG (glycosaminoglycans): YES, sometimes, no proof it works Pheromones: YES

Answer 31

Involuntary Passage of Urine -Results from high bladder pressure, low urethral pressure or combinations -Or anatomical defects, urethral or sphincter mechanism

Answer 32

-Observations -PE -History, where, when, urinary habits -Rectal/vaginal PE -Anal tone: tells you if Sacral reflex are is intact or not -Bulbocavernosus reflex -Bladder size at time of episode -Caudal neurologic exam **History is key** **Urinary bladder residual volume is Key** -Urinary incontinence: when resting or sleeping, unaware of leakage? -Pollakiuria: small, frequent volumes -PU/PD large volumes -Inappropriate: in your shoes Bladder Residual Volume 1. Storage disorders **Small residual volume** -Primary sphincter mechanism incontinence -Ectopic ureters -Detrusor hyper contractility -PU/PD resulting from inability to hold urine -Inflammation/infectious: weakening sphincter -Both exacerbate problem 2. Emptying disorders **Large residual volumes** Functional -Detrusor-urethral dyssynergia -Urethrospasm -Detrusor atony -Neurogenic upper motor neuron bladder Obstructive/Mechanical -Neoplasia -Calculi -Stricture Minimum Data Base -CBC/Chem -Urine culture -Neurologic exam -Imaging to exclude calculi, stricture, pelvic bladder, ectopic ureters

Answer 33

Primary Sphincter Mechanism Incompetence -Spay incontinence 12-18 months post op -Urethral pressure continues to decrease with advancing age -Hormone responsive incontinence, estrogen, testosterone -Seen in some castrated males **The most common and important acquired cause of incontinence in dogs** Pathophysiology -Failure of urethral sphincter to function adequately -Dogs >20kg more at risk -Breeds: Boxer, doberman, Gian schnauzer, Old English sheepdog Urethral Smooth Muscle -Alpha adrenergic stimulation provides 60% urethral tone -Receptors may have decreased in number or responsiveness to stimulation Spayed Females -Decreased estrogen = increased FSH = Increased LH -Estrogen: sensitizes smooth muscle of proximal urethra to the effects of catecholamines, increasing urethral tone -Aging: may affect collagenous support tissue -Abnormal positioning of the bladder and/or urethra can contribute to functional failure -Obesity exacerbates -Vestibulo-vaginal structural abnormalities are associated C/S -Sleeping incontinence -Recumbent, no urgency -May dribble before OHE and then it increases after OHE Breeds -Dobermans -Soft coated wheaten terrier -Greater swiss mountain dog Dx -Exclusion -History of leaking when recumbent or sleeping -Minimum database -Rule our other causes, calculi, masses, pelvic bladder, bacterial infection, ectopic ureters -Neurologic exam -Imaging

Answer 34

Goal: tighten urethra, increase pressure, cause smooth muscle cells to contract Medical management -Alpha agonist (PPA) in both males and females -Estrogen in females -Testosterone only in males -Combination hormone and alpha agonist synergistic Alpha adrenergic agonists -Phenylpropanolamine -Stimulate proximal urethra alpha receptor and cause norepinephrine release = increase urethral closure function -70-90% effective, TID most effective -Monitor systemic blood pressure 0, 1, 3, 6 months, Twice yearly Epinephrine -Adverse effects: restlessness, anorexia, tachycardia, hyper excitability, aggression, tremors, GI upset. -Hypertension -Caution with cardiac or renal disease Estrogen (DES, diethylstilbestrol) -Enhance the number and responsiveness of the alpha adrenergic receptors in proximal urethra -65% response fully, 20-25% partially -Dose per dog, not body weight -Maintins normal urethral submucosal blood flow, maturation and collagen synthesis -Low dose protocols to avoid anemia, thrombocytopenia. -Adverse effects: vulvar or mammary swelling, attractiveness to males, lethargy, vomiting, diarrhea. Bone marrow suppression with overdose **should not be used in intact females, males, cats** **Estradiol cycloproprionate should not be used**

Answer 35

Urethral Bulking -Candidates: when failed medical therapy or can not tolerate side effects or oral medication -3 submucosal urethral protrusions to touch in center of lumen Artificial urethral sphincter: Hydraulic occluder -Used for PSMI unresponsive to medical therapy or failed ectopic ureter repair -Occluders medical grade silicone -90% effective and safe -Potential complications: obstruction due to fibrosis, lack of efficacy Surgical Management Colposuspension Cytosurethropexy Urethropexy Prostatopexy

Answer 36

Tx Testosterone -Methyltestosterone. Should not be used in patients with prostatic carcinoma, caution with renal, cardiac or hepatic disease. May decrease insulin needs in diabetic patients -Testosterone cypionate effective and safe option

Answer 37

Ectopic Ureters -Most common congenital cause for incontinence -Female >> male -Breeds: Golden retriever, Labrador, Siberian Husky, Poodle -Intermitent incontinence -Bilateral 90% of cases -Silent UTI common Dx -Urethrocytoscopy: imaging method of choice for female dogs -Helical CT +/- contrast as effective and better in males Tx -Traditional surgical techniques -Laser Ablation Ectopic Ureter YAG laser -Urethral pressure profile (UPP) testing can help predict post-surgical continence -Medical therapy: Phenylpropanolamine (PPA) or surgical therapy

Answer 38

-Incontinence due to detrusor contraction during storage of urine or low compliance of detrusor muscle -Urge incontinence causes: detrusor compliance, inflammatory conditions, infection, urolithiasis, UTI -Often concurrent pollakiuria, stranguria and or dysuria **No identifiable cause for detrusor compliance** Tx -Anticholinergic medications -Decrease detrusor contraction during urine storage -Oxybutynin : antimuscarinic effects -Propantheline: antimuscarinic agent

Answer 39

Detrusor-urethral dyssynergia -Functional urethral obstruction -"Reflex dyssynergia" -Urethral sphincter relaxes during onset of detrusor contraction and urination -Normal neurologic exam -Unclear pathophysiology -Middle aged, large giant breeds, males >> females **Large residual volume after conscious void** Dx -Ruling out mechanical obstruction -Easy passage of urinary catheter -Large residual volume -Interrupted urination pattern -Ultrasound -Contrast urethrography and or urethroscopy Tx -Reduce smooth muscle sphincter tone -Reduce skeletal muscle sphincter tone -Address anxiety if present -Prevent bladder over-distension -Teach owner to catheterize dog Meds -Alpha adrenergic blockage -Phenoxybenzamine -Prazosin -Tamsulosin: side effect hypotension Striated muscle involvement -Benzodiazepine: diazepam -Acepromazine -Methocarbamol -Dantrolene and baclofen Associated Bladder Atony -Bethanechol (parasympathomimetic) -Cisapride or Metoclopramide (dopaminergic) **Monitor for bacterial cystitis** Prognosis: usually good -May need anxiolytic -Life long therapy Urethrospasm -Functional urethral obstruction -Address similar to Detrusor-Urethral dyssynergy -Alpha adrenergic blockage -Skeletal muscle relaxation Detrusor atony -Results from neurogenic or myogenic causes Tx -Goal: detrusor muscle contraction -Bethanechol (parasympathomimetic) -Metoclopramide or Cisapride (dopaminergic) -Keep bladder empty: catheter, manual expression Neurogenic upper motor neuron bladder -Suprasacral spinal cord lesions -Brain stem lesions -Cerebellar lesions

Answer 40

Transitional Cell Carcinoma or Urothelial Carcinoma -9 years -No sex predilection -Collies, Scottish terriers, Beagles, America Eskimo, Airedales -Lawns and gardens treated with herbicides and or insecticides -Consumption of yellow-orange vegetables association Staging Bladder TCC T1 Carcinoma in situ T2 Infiltration of sub epithelial T3 Invasion of muscular layers T4 Tumor fixed to adjacent History and C/S -Lower urinary tract signs -Urgency +/- Palpable mass -Incontinence -Stranguria -Hematuria -Pyuria +/- -Urine culture often positive -Malignant epithelial cell in 30% sediment Lab findings 25-50% positive culture at diagnosis -Avoid cystocentesis due to tumor seeding concerns Dx **Biopsy, urinary catheter aspiration/traumatic, Gold Standard** -Free catch UA 30% dogs ID tumor cells -Urine sediment wet mount - Rafts -Urine Cytoprep dry mount - cellular detail -Traumatic catheterization, blind or ULS guided. Chunk of TCC often retrieved into catheter -Biopsy through cystoscope at surgery **Do NOT FNA = tumor seeding** -Imaging: Bladder mass lesions -Radiographs metastasis: sublumbar LN, then lungs and bones TCC presumptive diagnosis -Rafts of epithelium -Cellular Atypia -Reactive epithelium = confusing

Answer 41

66% occur in Trigone region >50% metastasized at presentation Locally invasive, prone to transplantation - seeding Treatment -Surgery only if not in the trigone area -Chemotherapy -Photodynamic therapy -Radiation therapy -Immunotherapy -Tube cystotomy or permanent urethral scenting **Piroxicam or other NSAIDs great therapy** Surgery -Complete resection = 12 months survival -Incomplete resection = 4 months survival Bladder TCC Prognosis -Poor if hydronephrosis, hydrometer, Azotemia, Metastatic disease. -Survival poor: overall 16% alive 1 year after diagnosis -50% metastatic disease development to lung and bone

Answer 42

Piroxicam NSAID -Anti-TCC effect = not directly cytolytic -Unknown mechanism of action -0.3 mg/kg/day PO -Evaluate at 56 days 53% stable, 6% remission -Side effects: reduced renal function, vomiting, melena, anorexia, gastric ulcers. **Inhibits both Cox 1 and Cox 2, Cox 2 over expressed in TCC** Deracoxib -Cox 2 inhibitor -Sparing Cox 1 -Median survival 323 days -17% remission -No CR Chemotherapy -Cisplatin -Carboplatin -Mitoxantrone -Vinblastine -Gemcitabine **Most TCC very resistant to chemotherapy** Supportive care -Antibiotics -Temporary catheterization -"Debulking" -Urinary tract diversion

Answer 43

V-BTA test -Rapid test for the detection of bladder tumor analyses in canine urine -Yellow at top = positive -False positives due to not specific for TCC BRAF DNA mutation - Preferred -80% TCC and Prostatic CA -Very sensitive -Very specific

Answer 44

-Rare in dogs -Extremely rare in cats Females >> males Small breeds C/S -Bladder obstruction -Rectal exam = mass palpable Ddx -Urethral stricture -Proliferative urethritis

Answer 45

Primary Renal Neoplasia - German shepherd predisposed - Mean age 9 yo C/S -Abdominal mass -Weight loss -Hematuria -Classic triad -Often no c/s -Highly invasive -Poorly response to chemotherapy -Pareneoplastic syndromes Imaging Ultrasound -Nephroblastoma -Adenoma/Papilloma -Sarcoma -Fibroma -Lymphoma Lab findings -Polycythemia -Paraneoplastic Tx -Surgery -Median survival 8 months

Answer 46

Dipstrip -Mostly Albumin -Nuance interpretation with USG -Lower limit 30 mg/dl -Over diagnosed and under diagnosed -False positives: alkaline urine, concentrated urine, prolonged contact with pad. -False negatives: dilute urine, acidic urine, Bence-Jones proteinuria Urine protein creatinine ratio (UPC) - Albumin + Globulins = mg/dl - mg/dl Creatinine - Urinary Creatinine = constant steady state -Proportional change urinary creatinine concentration or dilution **<0.2 = normal** >/= 0.5 abnormal in dogs >/= 0.4 abnormal in cats >0.2 <0.3 = primary glomerular disease, not always black and white Amyloid 22.5 (11-47) Glomerulonephritis 5.73 Glomerulosclerosis 2.89 Individual overlap -3 Pool urine samples preferable within 24-36 hours -Microscopic hematuria can interfere -WBC can interfere (urine culture before UPC) Microscopic hematuria -ELISA species specific measures albumin -Urine standardized to USG of 1.010 Value of Microalbuminuria -Negative = great, barrier is working well -Positive = worrisome, breakdown of barrier function, many possible causes -Normal 0 -1-2 Micro Albuminuria -30 macro Albuminuria, UPC >0.5

Answer 47

Titers -Borrelia (lyme) -Ehrlichia -Rocky mountain spotted fever -Anaplasma -Babesia -Heartworm -Brucella -Lepto

Answer 48

Proteinuria - Severe Hypoalbuminemia Hypercholesterolemia Edema/Ascites More guarded prognosis than general PLN

Answer 49

Pre-Renal -Causes: metabolic, neoplastic, hypertension, endocrine (cushing's), early primary renal disease. Systemic inflammatory/infectious -Hypertension -Hyperthermia -Hemoglobinemia --uria -Myoglobinemia --uria -Paraproteinemia -- Bence Jones Proteins **Glomerulus and Tubules are normal** Intra-Renal -Filtration - Glomerular -Glomerular barrier function impaired -Albuminuria (proteins from plasma "leaking") -Tubular reabsorption, degradation, necrosis, interstitial inflammation **Most common Glomerulonephritis** -Amyloidosis, glomerulosclerosis Post-Renal -Rule out: UTI, urolithiasis, neoplasia, trauma, iatrogenic, cells/plasma proteins

Answer 50

Glomerulonephritis -48% immune complex GN Glomerulosclerosis Amyloidosis -Breeds: Shar pei, Beagle, English foxhound, Abyssinian cat. Familial Glomerulopathy -Breeds: Soft-coated wheaten terrier, Doberman pinscher, Dalmatian, English cocker spaniel, Bernese mountain dog, Greyhound. -

Answer 51

Conmsequences of Renal Proteinuria -Epethilum into myofibroblast leading to fibrosis -Tubular interstitial damage and fibrosis -Damage to renal tubules by other molecules e.g., Free fatty acids Glomerular Disease = Hypertension -84% of dogs are hypertensive -Check BP -Treat Tx -ACE-I ~10mmHg reduction -Calcium channel blocker: Amlodipine more effective than ACE-I to lower BP ~40 mmHg reduction Protein Losing Nephrotic Syndrome Hypercoagulable State **Thromboembolic events may be the main reason for presentation** -Multifactorial -Low albumin -Loss of anti-thrombin -Thromboembolism -Pulmonary, others Tx -Aspirin -Clopidogrel Edema Control -Furosemide -Spironolactone -As needed, avoid dehydration

Answer 52

Infectious/Inflammatory -Lyme Nephritis -Borrelia may or not may be present -Most dogs with lyme are asymptomatic -Breeds: Labrador, Golden >0.5 UPC = follow closely 0.2-0.5 grey zone -Measure BP -Tx: Doxycycline, 30-45 days -Immunosuppression if renal biopsy supports immune mediated IFA + complexes EM deposits Immunosuppression -Mycophenolate - first choice -Cyclophosphamide -Chlorambucil -Steroids alone not advised Amylodosis -B-pleated sheets subunit protein form -Congo red Dx Tx -Colchicine administer prior to amyloidosis to prevent deposition. Share pei Fever -DMSO: anti inflammatory effect, solubilize deposits?? -Nothing to prevent or slow progression -Poor prognosis to grave Shar pei dogs -Recurrent acute self limiting fever and tibiotarsal joint swelling history -Severe liver involvement may cause icterus or hemoabdomen due to liver rupture

Answer 53

Yes, when Immunosuppression may be needed for Lyme/other if renal biopsy supports immune mediated IFA + complexes EM deposits

Exam 5 Flashcards

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