Lecture 1 - Hypoproteinemia (Cooke)

Question 1

least likely to result in moderate to severe hypoproteinemia in an adult dog:
anorexia
hepatic dysfunction
PLE

Answer 1

anorexia!!

an adult dog with a functional liver can be starved for a long time and liver will maintain glucose, albumin, cholesterol, etc

in puppies this is different bc they don’t have the reserves of an adult

Question 2

albumin is a __ protein that decreases with inflammation

Answer 2

negative acute phase

Question 3

__ by itself is highly unllikely to cause hypoalbuminemia

Answer 3

malnutrition (maldigestion/malabsorption or starvation)

Question 4

3 mechanisms of decreased protein production

Answer 4

hepatic failure
inflammatory dz
malnutrition (maldig/malabs, starvation)

Question 5

4 mechanisms of increased protein loss

Answer 5

renal*
intestinal*
third space
burns/wounds

*first 2 are most common

Question 6

example of how protein lost via the third space

Answer 6

protein entering the third space alone will not cause significant drop, however multiple taps of these spaces can result in hypoalbuminemia (ie. abd taps removing all the fluid)

Question 7

CS of a patient with hypoproteinemia

Answer 7

none, can be incidental finding
peripheral limb swelling 
ventral pitting edema 
abdominal distension (ascities) 
cough/dypsnea
decreased appetite (incr pressure on viscera) 
vomiting/diarrhea (GI dz, gut edema)

Question 8

is ascities or pleural effusion more common with hypoproteinemia

Answer 8

ascities

the lymphatics in the chest are good at taking excess fluid away

Question 9

young dog with low protein is likely due to

Answer 9

congenital (hepatic shunt, failure of passive transfer)

infectious (parvo, hooks)

Question 10

older dog with low protein is likely due to

Answer 10

inflammation (IBD, lymphangiectasia)
neoplasia
metabolic (EPI, hepatic dz, PLN)
infectious (parasite, fungal)

Question 11

__ diarrhea more commonly causes protein loss

Answer 11

small bowel

large bowel (except HGE) will not cause significant protein loss

Question 12

Retinal hemorrhage or detachemnt and tortuous retinal vessels indicate

Answer 12

hypertension

Question 13

2 main mechanisms that result in hypooproteinemia

Answer 13

decreased production
increased loss

• NOT anorexia

Question 14

oral ulcers and PLN indicates

Answer 14

uremia/kidney dz

Question 15

a murmur with hypoproteinemia can indicate

Answer 15

endocarditis

Question 16

more severe muscle wasting indicates __ timeline

Answer 16

several weeks, chronic

Question 17

hypoalbuminemia from decreased production

Answer 17

hepatic failure

inflam dz

Question 18

hypoalbuminemia from increased loss

Answer 18

PLN

PLE

Question 19

Hypoglobulinemia ddx

Answer 19

PLE,
blood loss
failure of passive transfer

Question 20

__ tell you nothing about liver function!

Answer 20

liver enzymes

Question 21

5 liver function values on chemistry

Answer 21

glucose
cholesterol
BUN 
t. bilirubin 
albumin

Question 22

always do a __, easy way to r/o PLN

Answer 22

urinalysis

Question 23

don’t do a __ on an active urine sediment

Answer 23

UP:C

Question 24

If hypoalbuminemia is causing ascities what do you expect the fluid to look like

Answer 24

transudate (or modified transudate if more chronic)

Question 25

radiographs are beneficial in hypoproteinemia cases if

Answer 25

no ascities want to measure liver* assessing bones for infection or neoplasia* assess kidneys *can't do with AUS

Question 26

what does a normal AUS with bloodwork indicating hepatic damage tell you?

Answer 26

know the patient is NOT normal, must pursue other dx

Question 27

r/o kidneys/PLN but not sure if it's liver, gut, other. What next?

Answer 27

bile acids if bile acids are abnormal then evaluate for PSS +/- biopsies of liver and intestines

Question 28

if albumin is less than 2 and giving IVF what is a risk

Answer 28

fluid overload try using colloid support: hetastarch/synthetics can help draw fluid from third spaces plasma to replace albumin/clotting factors if albumin less than 1 worry about gut edema

Question 29

colloid therapy in hypoproteinemic patient is used to

Answer 29

buy time, it is not fixing the problem!

Question 30

how does low albumin affect anesthesia

Answer 30

lots of protein bound agents! animal will be more sensitive to effects of protein bound drugs (more free form, need to decrease dose)

Question 31

how does low protein affect wound healing

Answer 31

wound dehiscence is a concern if albumin is less than 1.5

Question 32

in all protein losing dz there is loss of antithrombin, making patient prone to __

Answer 32

thromboemboli (most common with PLE)

Question 33

Patient you are concerned has heaptic failure, low protein, and see petechiae. What test should be run before poking anything?

Answer 33

PT/PTT

Question 34

7yo Yorkie presents with a chronic reoccuring swollen abdomen and balloted fluid wave (rDVM taps periodically). most likely ddx

Answer 34

fluid is most likely edema (not blood or pus due to hx duration) ``` ddx: RHF portal hypertension PSS hypoproteinemia neoplasia ```

Question 35

panhypoproteinemia w/o azotemia would also expect what other lab abnormality

Answer 35

hypocholesterolemia

Question 36

abdominal fluid with SG 1010, TP 1mg/dL and 100 cells/mcl, what kind of fluid is this?

Answer 36

``` pure transudate (low cell count, low protein count) ie. hypoalbuminemia ```

Question 37

fluid with high protein and cell count

Answer 37

exudate

Question 38

fluid with intracellular bacteria observed

Answer 38

septic

Question 39

low cell count and higher protein count

Answer 39

modified transudate (portal hypertension)

Question 40

liver makes globulins, why is it not usually a differential for panhypoproteinemia?

Answer 40

liver makes alpha and beta globulins | we measure gamma globulins on serum chm (made by plasma cells, doesn't rely on liver function)

Question 41

lymphangectasia tx

Answer 41

low fat diet | +/- steroids

Question 42

lymphangectasia causes

Answer 42

IBD Neoplasia congenital

Question 43

causes of hypoalbuminemia

Answer 43

PLN PLE Inflammation (neg APP) liver dysfunction

Question 44

causes of hyperglobulinemia

Answer 44

chronic inflammation | neoplasia

Question 45

causes of proteinuria

Answer 45

PLN Infection neoplasia hypertension

Question 46

provides oncotic support, clotting factors, fibrin

Answer 46

plasma

Question 47

provides oncotic support but no clotting factors or fibrin

Answer 47

synthetic colloids (hetastarch)

Question 48

approach to hypoproteinemia; is there proteinuria? yes vs no

Answer 48

if yes, is the sediment active or inactive? | if no, run a bile acids

Question 49

if urine sediment is active and proteinuria is present what is the next step

Answer 49

urine culture and sensitivity; treat and reassess

Question 50

if urine sediment is inactive with proteinuria what is next step

Answer 50

UP:C if this is normal then look for other sources of low protein if high the check BP, HW, tick-borne dz

Question 51

if bile acids are abnormal with hypoproteinemic patient? normal?

Answer 51

liver bx if normal then do a fecal, deworm, diet trial, intestinal bx