Hypertension/renal failure CR

Question 1

What is this cases history and signalment?

Answer 1

Jess Hill is a 14 year old female domestic shorthair

She is a completely indoor cat and lives with one other cat (her brother)

She has been in the cattery for 2 weeks and the owners of the cattery suggested a visit to the vet as Jess seems to be drinking a lot.

Mrs Hill had noticed this at home too and also thinks Jess has lost some weight, so she has come to the surgery straight away.

Question 2

What did Jess’s clinical exam show?

Answer 2

CLINCIAL EXAM

Jess weighs 2.58kg. According to the records she weighed 3.25kg last time she was weighed 6 months ago

Jess has a body condition score of 2/5

Clinical examination is otherwise unremarkable

Mrs Hill does not want to leave Jess at the surgery as she has only just come out of the cattery.

Question 3

Do a SOAP analysis of this case?

Answer 3

SUBJECTIVE

• Drinking a lot

OBJECTIVE

• Weight loss (initially 3.25kg now 2.58kg)
• BCS = 2/5

ASSESSMENT

Degenerative – CKD,

Anomaly – polycystic kidney disease (PKD), liver disease

Metabolic – hyperthyroidism, psychogenic polydipsia, Diabetes mellitus, hypercalcaemia

Nutritional/neoplastic – lymphoma, transitional cell carcinoma of the bladder, malnourished, hypervitaminosis D. urolithiosis

Inflammatory/ idiopathic/ iatrogenic – UTI, cystitis, FeLV and FIV

Toxic/ trauma – ethylene glycol toxicity,

Vasculature – kidney infarction, glomerular disease

PLAN –

Investigation

Urinalysis – dipstick, sediment, USG. Ideally collect the sample by cystocentesis

Check for kidney function by USG, infection and crystals by sediment, glucose and protein using a dipstick.

Blood sample – CBC (look at WBC levels for infection/inflammatory) and PCV for anaemia and hydration) and

Biochemistry

check total protein, creatinine and electrolytes – kidney function

glucose – diabetes

azotaemia

liver enzymes

Question 4

What were the next steps with Jess?

Answer 4

THE NEXT STEP

Jess has not eaten so you collect a blood sample and carry out cystocentesis for a urine sample. Creatinine could be high due to not eating.

Mrs Hill takes Jess home and awaits a phone call from you

Question 5

What did the in house haematology show?

Answer 5

MCHC – slightly raised. Could be an artefact

Question 6

What did the in house biochemistry show?

Answer 6

Creatinine – high

Phosphate – high

BUN – high

Potassium is low

Question 7

What did the in house urinalysis show?

Answer 7

Isosthenuric and protein present. Also some blood in the urine – due to use performing cystocentesis.

Question 8

What further tests would you like?

Answer 8

Before evening surgery you call Mrs Hill to discuss Jess’ results.

She gives you permission to send the urine off for a urine protein:creatinine ratio and urine culture

She doesn’t want Jess to have anymore blood tests

You arrange for Jess to come back after morning surgery tomorrow to have her blood pressure measured and an ocular examination

Question 9

What were the results of the Urine protein:creatinine ratio?

Answer 9

RESULTS

Urine protein:creatinine ratio = 0.1 – this is fine. Reference <0.5 is normal

Urine culture negative

Systolic blood pressure is 230mmHg after repeated measurements – this high.

No abnormalities were detected on ocular examination

Question 10

Outline an immediate treatment (including dosages/quantities required) and management plan for Jess?

Answer 10

Plan

Phosphate restricted diet and phosphate binders

Kaminox – potassium supplement

Anti-hypertensive agents = Benazepril (this is licensed for cats but risk of hyperkalaemia) or amlodipine (Ca channel blocker and causes vasodilation and reduces afterload). Also Telmisartan is licensed for cats with CKD and has proteinuria – doesn’t lead to hyperkalaemia. This tends to be well tolerated by cats. We discussed this and decided we would start with amlodipine as IRIS guidelines.

Question 11

What are the IRIS guidelines on this case?

Answer 11

Guidelines on Iris =

• Phosphate restriction diets
• Start amlodipine
• Increase the dose of amlodipine
• Then add other drugs in

Dosage -

Amlodipine dose – initially 0.125-0.25mg/kg/day – given once daily.

Telmisartan – 0.25ml/kg/day.

Question 12

What is the prognosis for Jess?

Answer 12

Prognosis – if well managed can live for years. Cat has hypertension which we will manage. Needs regular monitoring for blood pressure and electrolyte monitoring.

Question 13

What was the CASE OUTCOME for Jess?

Answer 13

Jess was prescribed:

Amlodopine

Royal canin renal diet (sachets)

Kaminox