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Flashcards in SA Urogenital Deck (228)
1

What is the definition of feline idiopathic cystitis?

Abnormal voiding behaviour after exclusion of other disorders
No obvious cause
May be a one-off, or may be chronic/recurrent

2

What are the 2 divisions of feline lower urinary tract disease?

Obstructive and non-obstructive

3

Give some causes of non-obstructive feline lower urinary tract disease

Idiopathic cystitis (most common)
Uroliths
Anatomical defects/cancer
Behavioural problems
Bacterial infection (common in dogs, rare in cats)

4

Give some causes of obstructive feline lower urinary tract disease

Idiopathic cystitis
Uroliths
Urethral plus
Bladder stones and bacterial infections

5

What is feline lower urinary tract disease?

Collective term for signs of lower urinary tract disease and abnormal voiding behaviour

6

What age of cats is more commonly affected by lower urinary tract disease?

Young to middle-aged neutered cats, 2-6 yrs old

7

Give some predisposing factors for feline lower urinary tract disease

Obesity
Indoor/sedentary cats
Dry diet
Multi-cat household

8

Give some clinical signs of feline lower urinary tract disease

Dysuria (difficulty urinating)
Pollakiuria (increased frequency)
Haematuria
Inability to urinate (urethral obstruction)
Behavioural changes
Periuria (urinating in inappropriate places)

9

How could you gauge whether a cat has obstructive or non-obstructive feline lower urinary tract disease?

Palpate the abdomen-large, often painful bladder if obstructed

10

Why should you check the penis of a cat with suspected feline lower urinary tract disease?

Can check for signs of self-trauma/crystals/sludge
Penis often blocks at the tip

11

Describe the pathophysiology of feline idiopathic/interstitial cystitis

Alterations in neurotransmission to and from the bladder -> triggers inflammation
Reduced glycosaminoglycan layer (protects bladder lining)

12

What is the main trigger of idiopathic/interstitial cystitis?

Stress
Cat respond badly to stressful events anyway, certain stressful events will trigger cystitis, can look at their history for other stress-induced signs eg over-groooming, GI changes etc

13

Urethral plugs in cats are more common in which sex?

Males
Most common cause of obstruction

14

What does a urethral plug consist of?

Mucus/glycoprotein matrix, often with other substances trapped in the matrix

15

What types of uroliths are there?

Struvite (magnesium ammonium phosphate) (normally sterile in cats, not in dogs)
Calcium oxalate
Calcium phosphate
Urates (may see with liver disease)
Silica
Mixed composition stones

16

Is bacterial infection a common or rare cause of feline lower urinary tract disease?

Rare

17

How may infection occur (which can lead to feline lower urinary tract disease)?

Usually iatrogenic (eg catheterisation)
Secondary to urolithiasis, anatomical defects or neoplasia

18

Which kind of cats are more prone to bacterial infection of the urogenital tract?

Older cats with CKD and poorly concentrated urine
Diabetics

19

Which neoplasia is more common in the bladder of dogs and cats?

Transitional cell carcinoma
More rare in cats than dogs

20

Give some inherited and acquired anatomical defects of the urogenital tract

Inherited:
-Vesico-urachal diverticulae
-Bladder hypoplasia
-Urethral strictures
-Phimosis (inability of the prepuce to be retracted behind the glans penis)
Acquired:
-Strictures due to trauma
-Inflammation
-Iatrogenic damage

21

What biochem results may you see on a blood sample of a cat with feline lower urinary tract disease?

Hyperkalaemia (potassium is normally exreted out in urine)
Hyperphosphataemia (phosphate is normally exreted out in urine)
Metabolic acidosis
Azotaemia

22

How should you examine the urine of a cat with suspected feline lower urinary tract disease?

Dipstick for haematuria, proteinuria, pH
Sediment analysis (RBC are common +/- WBC, epithelial cells)
Crystals are a normal finding
Specific gravity (highly concentrated predisposes to urolith formation, diluted predisposes to bacterial infection)
Culture and sensitivity (recurrent/persistent cases)

23

What should you make sure you include when radiographing the urinary tract?

ALL of the urinary tract, including penile urethra

24

What does US allow you to see when investigating feline lower urinary tract disease?

Thickened bladder walls
Bladder masses
Uroliths and acoustic shadowing
Hyperechoic sediment

25

When would a cystotomy be indicated in a cat with lower urinary tract disease?

Removal of uroliths that can't be dissolved medically
Biopsy of the bladder wall

26

How should you approach treatment of feline lower urinary tract disease?

Treat specific/underlying cause
If no obvious underlying cause, treat as idiopathic cystitis

27

How would you treat urethral plugs?

Emergency situation
Sedate and use catheter to flush plug back in, then flush bladder 4-5 times with warm saline

28

What could happen if you don't treat a urethral plug?

Could develop post-renal azotaemia within 24hrs
Bladder may rupture

29

How could you investigate whether or not fluid in the abdomen was urine from a ruptured bladder?

Take some fluid and measure creatinine (not urea as this travels quickly across perioneum)

30

How would you treat struvite uroliths?

Dissolve with medical dissolution diet

31

How would you treat calcium oxalate uroliths?

Surgical removal

32

How would you treat other uroliths?

Encourage water intake
Use diet to prevemt recurrence

33

How would you treat feline interstitial/idiopathic cystitis?

Most cases resolve spontaneously within 5-10 days
Corsticosteroids and antibiotics have no positive effects!
Reduce stress (eg feliway)
Encourage water intake to create dilute urine (wet diet, water fountain etc)
Could give GAG supplements (decrease bladder permeability) but no significant difference
Analgesia and anti-inflammatories (eg butorphanol)
Tricyclic antidepressants (amitriptyline), chronic cases

34

Give some causes of stress for a cat

Changes in diet
Weather
Overcrowding
Environment
Owner stress

35

Which tricyclic antidepressant may be used in cases of feline interstitial/idiopathic cystitis?

Amitriptyline 2.5-20mg/cat q 24hrs (evenings)
Reserve for long-term treatment
Anticholinergic (increases bladder capacity)

36

Give some side effects of amitriptyline (tricyclic antidepressant used to treat feline idiopathic cystitis)

May cause drowsiness or urinary retention
Raised liver enzymes, neutropenia and thrombocytopenia

37

How would you treat a urethral spasm?
Give a negative side effect

Smooth muscle antispasmodics
eg acepromazine
May help reduce severity of signs and prevent urethra re-blocking
May cause hypotension

38

When does azotaemia occur?

When 75% of nephrons are damaged and not working

39

Can you have end-stage glomerulopathy without azotaemia?

Yes, as nephrons can function with a damaged glomerulus

40

Define acute kidney injury

Any damage to the kidney present for less than 3 months

41

Give some clinical signs of acute kidney injury

Nausea/vomiting
Normuria/oliguria/anuria
Hyperkalaemia
Hypertension
Azotaemia/uraemia

42

Give some causes of acute kidney injury

Toxins
Infectious
Vascular
Post-renal obstructuve
Secondary to systemic disease

43

Define chronic kidney disease

Any structural or functional change that is present and stable for over 3 months

44

In which 5 ways can CKD become apparent?

Slow deterioration of renal function over time
Previously healthy kidney -> episode of AKI -> progresses to CKD
A congenital condition becomes a problem
Acute or chronic episode -> accelerating decline
A neoplastic process expands/invades

45

Give some causes of renal damage that would be staged as Stage 1 CKD

Reduced renal concentrating ability
Early neoplastic change
Structural change (eg renal cyst)
Tubular problems
Presence of renal proteinuria

46

Define glomerular filtration rate

Amount of ultrafiltrate that passes through the glomerulus
Measured in ml/kg/hr

47

What is the most accurate way to assess glomerular filtration rate?

Measure the renal clearance of an exogenous substance eg insulin, iohexhol, or injected/exogenous creatinine clearance
However, these are all affected by pre-renal factors eg dehydration, hypotension

48

What 3 things must an animal be before you assess glomerular filtration rate?

Hydrated
Normovolaemic
Normotensive

49

How do urine and serum creatinine levels change with renal and pre-renal damage?

Pre-renal: high urine excretion of creatinine
Renal: low urine excretion of creatinine and high serum creatinine

50

What is the definition of a glomerulopathy?

Any damage to the glomeruli of the nephrons

51

What is the classical clinical sign of a glomerulopathy?

Proteinuria (used a method of diagnosis; >2.0)

52

Which dog breeds are prediposed to glomerulopathies?

Golden retrievers
Labradors

53

Give the pathophysiology of glomerulopathies

Deposition of immune complexes in the glomeruli (Type III hypersensitivity reaction) or
Antibody production against the glomerulus (Type II hypersensitivity reaction)
-> complement
-> local damage to the glomerulus by inflammation
-> leakage of proteins through glomerulus into urine
Can also get amyloid plaque deposition- high levels of proteinuria

54

Which breeds are more prone to amyloid plaque deposition in their glomeruli (renal amyloidosis)?

Shar pei
Siamese
Burmese cat

55

Give some causes of glomerulopathies

Familial (eg shar pei, beagle)
Acquired
Infectious (eg Lepto, sepsis, pyometra, pyelonephritis)
Inflammatory (eg severe pancreatitis)

56

When would you suspect a glomerulopathy?

Sick animal with proteinuria that does not resolve with treatment (eg has pancreatitis/sepsis)
Animal with newly diagnosed azotaemia and/or high urine protein
Hypertension of unknown origin
Thromboembolic event
At risk breeds

57

What is the gold standard method for diagnosing glomerulopathies?
Give some problems with this method

Biopsy, but is expensive, high risk of bleeding, doesn't change tx options

58

What should you do after getting a positive dipstick result for proteinuria?

Quantify this result using the urine protein:creatinine ratio
Most easily confirmed by taking a cystocentesis sample and analysing haem and biochem
Should also confirm persistence of proteinuria by having proteinuria in 3 samples, 2 weeks apart

59

You should only start treatment for a glomerulopathy after proteinuria is confirmed to be which 3 things?

Persistent (3 measurements, 2 weeks apart)
Renal
Quantified (do UP:C)

60

Which values for proteinuria suggest glomerulopathy and which suggest tubulointerstitial lesions?

>2.0 suggests glomerulopathy
<2.0 suggests tubulointerstitial lesions

61

For which values of proteinuria for dogs and cats would you start treatment?

Dogs: >0.5
Cats: >0.4

62

How do you treat proteinuria?
How does it work?
What may happen as a result?

Ace inhibitors (benazapril)
Reduces efferent arteriole pressure -> reduced GFR -> reduced pressure in glomerulus
Mild effect on BP
Reduced GFR may cause an increase in azotaemia, phosphate, potassium, serum creatinine (monitor?)

63

Why does hypercoagulability occur with glomerulopathies?

Due to loss of anti-thrombin III

64

Give some treatment options for hypercoagulability associated with glomerulopathies

Low-dose aspirin (diluted)
Clopidogrel (inhibits platelets)
Dalteparin (inhibits factor X)

65

Give a problem with hypertension

Can cause end-organ damage (eyes, heart, kidneys, liver, CNS)

66

What is the standard treatment for hypertension?
What is the target value?

Amlodipine
Target: 150mmHg systolic

67

How can you alter diet when treating glomerulopathies?

Restrict protein (reduces proteinuria and azotaemia)
Omega-3 supplementation (reduces glomerular inflammation)
Renal diet if azotaemic (stage 3 in dogs, stage 2 in cats)

68

Why is it important that an animal eats when it has azotaemia?

Starvation results in catabolism of body proteins -> increased protein through kidneys

69

Summarise how you'd treat a glomerulopathy

Ace-inhibitors or angiotensin receptor blockers (eg benazepril, to reduce proteinuria)
Anti-hypertensive medication (amlodipine)
Anti-thrombotic medication (loss of anti-thrombin III)
Diet (restrict protein, omega 3 supplementation)

70

What is the general prognosis time for dogs with a glomerulopathy and no azomtaemia?

6m-1yr

71

What would you suspect in a dog with a 24hr history of severe vomiting, collapse, intense abdominal pain and mild diarrhoea?

Acute pancreatitis

72

Why should you sometimes be skeptical when measuring urine P:C ratio in the vets?

UP:C will increase in the vets due to stress

73

What would you give to a dog with CKD with increased phosphate?

Phosphate binder

74

Renal amyloidosis in Shar peis can result in what?

High levels of proteinuria
Commonly preceded by episodes of 'Shar pei fever'-self-limiting swollen hocks/pyrexia
Rapidly progressive
Commonly leads to nephrotic syndrome

75

How would you treat renal amyloidosis (Shar peis)?

Typical treatment for a glomerulopathy plus colchicine +/- DMSO

76

What is the method of inheritance of polycystic kidney disease?

Depends on breed (persian, ragdoll, british short hair, WHWT)
Is autosomal dominant

77

How is polycystic kidney disease characterised?

Cysts in the kidney and also liver (slowly progressive)

78

What is nephrotic syndrome?
When is it seen?

Severe loss of protein from the glomerulus
Often seen in severe/end-stage glomerulopathies and common in amyloidosis

79

How is nephrotic syndrome characterised?

Hypoalbuminaemia
Peripheral oedema
Hypercholesterolaemia
+/- azotaemia

80

What is the prognosis like for nephrotic syndrome?

Very poor-12.5 days (due to low oncotic pressure)

81

Which fluids should you avoid in dogs with nephrotic syndrome?

Colloids

82

Give some pre-renal causes of acute kidney injury

Decreased renal blood flow caused by:
-Dehydration
-Hypovolaemia
-Hypotension
(Causes decreaed GFR and mild azotaemia)

83

Is pre-renal acute kidney injury reversible?

Yes if corrected in time

84

Give some causes of renal parenchymal disease

Ischaemia
Toxins
Intrinsic renal parenchymal disease
Systemic diseases targeting kidney

85

Give some causes of ischaemia which can then lead to renal parenchymal disease

Hypovolaemia
Hypotension
Renal vasoconstriction (prostaglandin inhibitors)
Thrombi, DIC
Pancreatitis, peritonitis, vasculitis

86

Give some toxins which can cause renal parenchymal disease

Antibacterials (aminoglycosides)
Chemotherapy drugs (cisplatin)
Radiographic contrast media
NSAIDs (eg ibuprofen)
Organic compounds (ethylene glycol)
Easter lily
Paracetamol

87

Give some intrinsic conditions that cause acute kidney injury

Infectious (leptospirosis, FIP, leishmaniasis)
Pyelonephritis, septic emboli
Glomerulonephritis
Trauma

88

Give some systemic diseases that cause acute kidney injury

Multiple organ failure
Polycythaemia
Lymphoma
Hypercalcaemia

89

Describe the 4 stages of acute kidney injury

Initiation phase: damage starts
Extension phase: ischaemia, hypoxia, inflammatory response, ongoing cellular injury, cell death
Maintenance phase: GFR stabilises, azotaemia, uraemia, variable urine production
Recovery phase: azotaemia improves, tubules undergo repair, can have marked polyuria

90

How do you diagnose acute kidney injury?

History (recent anorexia, PD, vomiting, diarrhoea, toxin exposure? Signs of infection?)
Physical exam (dehydration, uraemic breath, hypothermia, tongue/buccal ulceration, +/- kidney pain/enlargement, occasional neuro signs)
Bloods (azotaemia, hyperkalaemia, metabolic acidosis, increased PCV, TP)
Urine (isosthenuria, can see glucosuria and haematuria, look at sediment for casts, WBCs, bacteria, crystals)
Imaging (radiography: kidney size, shape, opacity, ureter, bladder, urethra. US: renal size, parenchyma, echogenicity)

91

How big should the kidney be in dogs?
What about cats?

Dogs: 2.5-3.5 x L2
Cats: 2-3xL2

92

How can you differentiate between acute and chronic kidney injury?

Chronic:
Weight loss
Previous history of PUPD/poor appetite/GI signs
Non-regenerative anaemia
Kidneys typically small, firm, irregular
Often not ill
Normal or low potassium
Poor hair coat

Acute:
Good BCS
Acute onset of signs +/- history of toxin exposure
Kidneys may be enlarged/painful
May be ill +/- hyperkalaemia
May be casts in urine
Good hair coat

93

What is the antidote for ethylene glycol poisoning in cats?

4-methylpyrazole (fomepizole)
Ethanol (needs to be given within 8 hours)
Prognosis poor if already azotaemic/oliguric

94

Which crystals can you see in the urine of a cat with ethylene glycol poisoning?

Calcium oxalate monohydrate

95

Which supportive treatment can you give animals with acute kidney injury?

Correct hydration status, acid-base status, electrolytes
Monitor hydration, MM, PCV, CRT, HR, RR, BP, biochemistry
IVFT

96

What treatment can you give to increase urine output?

Furosemide (increases urine output but does not inprove GFR or outcome)
Mannitol

97

How can you correct hyperkalaemia?

Fluid therapy (0.9% NaCl or Hartmanns)
Calcium gluconate 10% (doesn't lower K but is an antagonist of the cardiac effects of hyperkalaemia)
Dextrose (stimulates insulin secretion)
Insulin (facilitates the uptake of glucose into the cell, which brings potassium with it)
Sodium bicarbonate (K+ moves into cells in exchange for H+)

98

Which drugs could you give to reduce vomiting?

H2 antagonists (eg ranitidine), proton pump inhibitors (eg omeprazole)
Maropitant, metoclopramide, ondansetron

99

Which drugs could you give to reduce hypertension?

Exacerbated by overhydration; reduce IVFT and give diuretics
If persistent, can give antihypertensives (most are oral)
-Nitroprusside
-Hydralazine
-Amlodipine

100

What should you consider if you can't induce diuresis in a pet with acute kidney injury?

Euthanasia
Dialysis (referral; haemodialysis or peritneal dialysis)

101

Whar is the prognosis for acute kidney injury in cats and dogs?

Dogs: 53-60% mortality
Cats: 50% mortality

102

What is the definition of pyuria?

WBCs in urine

103

What is the definition of a UTI?

The adherence, multiplication and persistence of an infectious agent in the urogenital system

104

Give some routes of infection of a UTI

Ascending infection
Upper urinary tract infections are most commonly infected by:
-Pyelonephritis
-Nephritis

105

Give some clinical signs of an upper UTI

Abdominal pain
Renal failure
Septicaemia

106

Give some clinical signs of a lower UTI

Dysuria
Pollakiuria
Haematuria
Urinary incontinence

107

How may blood results differ between upper and lower UTIs?

Lower UTIs: unremarkable
Upper UTIs: bloods may be consistent with septicaemia or renal failure

108

How do you diagnose a UTI?

Urine culture=gold standard (bacteria)
Urinalysis
Urine sedament exam (WBC >5 per hpf, microburia, pyuria)

109

How do we choose an appropriate antibiotic for a UTI?

Agar disk diffusion
Antimicrobial dilution technique (MIC)

110

An antimicrobial agent must be able to attain a urinary concentration that exceeds the MIC of the uropathogen by how much?

At least four times

111

How do we treat UTIs?

Eradication of underlying causes if possible (eg diabetes mellitus, CKD, hyperadrenocorticism)
Antimicrobials

112

Which antimicrobials are a first-line treatment for UTIs?

Amoxicillin
Cephalexin
Trimethoprim

113

How can we prevent UTIs?

Avoid indiscriminate use of urinary catheters (use a closed collection system, avoid indwelling catheters in immunocompromised patients)
Risk of UTI infection increases with duration of catheterisation

114

What is the difference between complicated and uncomplicated UTIs?

Uncomplicated=no underlying structural, neurological or functional abnormalities

115

How would you treat an uncomplicated UTI?

10-14 days course of antibiotics
If possible, a urine culture should be performed 5-7 days after therapy ends

116

How would you treat a complicated UTI?

Antimicrobial therapy for 4-6 weeks
Intact male dogs with UTI should be assumed to have prostatic infection, consider blood-prostate barrier

117

Which type of animals are more likely to have a complicated UTI?

Sexually intact dogs
Most cats
Animals with predisposing factors for UTIs
Animals with upper respiratory tract infections

118

Give some possible complications of bacterial urinary tract infections

Polypoid cystitis
Emphysematous cystitis
MAP crystals
Pyelonephritis

119

Is bacterial cystitis common or rare in cats?

Rare

120

How does the bladder receive sympathetic innervation during the filling stage?

Hypogastric nerve

121

How does the bladder receive somatic (voluntary) innervation during the filling stage?

Pudendal nerve

122

How is relaxation of the bladder achieved?

Sympathetic action on beta-adrenoceptors in detrusor muscle

123

How is contraction of the bladder achieved?

Sympathetic action on alpha-adrenoceptors in urethral smooth muscle and trigone
Also somatic innervation of urethral striated muscle and inhibition of detrusor reflex

124

What innervation does the bladder receive during the emptying phase?

Parasympathetic nervous system predominates via the pelvic nerve (contraction of detrusor, relaxation of urethral muscle: detrusor reflex)

125

How is urinary continence achieved?

Brainstem micturition centre integrates urethral and detrusor function
Cerebral cortex gives voluntary control by over-riding the detrusor reflex

126

How can you investigate urinary incontinence?

Detailed history
Clinical exam
Biochem and haematology
FeLV test (cats)
Urinalysis
Urine culture and sensitivity
Observe patient urinating
Further tests:
-Plain abdominal radiographs
-Intravenous urogram (opacification of kidneys and ureters)
-Retrograde (vagino) urethrogram
-US of urinary tract
-Cytoscopy

127

Give some typical findings of abnormalities of the filling phase of the bladder

Patient can urinate normally but dribble urine between urinations
Often have reduced bladder capacity

128

Give some differential diagnoses for abnormalities of the filling phase

Ectopic ureter
Reduced pressure at bladder neck
Urge incontinence (can't hold it in when they need the toilet)

129

Why may an animal have reduced pressure at the bladder neck?

Congenital USMI (urethral sphincter mechanism incompetence)
Acquired USMI
Intrapelvic/caudal bladder
Bladder neck mass (polyp/neoplasia/cystic calculus)
Hypoplastic bladder

130

Give some causes of urge incontinence (patient knows it needs the toilet and can't hold it in)

Bacterial infection
Cystic calculus
Drug-induced
FeLv+ cats
Neoplasia of bladder neck

131

Give some typical findings of abnormalities of the emptying phase of the bladder

Distended bladder
Constant dribbling of urine ?
No normal urination
(Overflow incontinence as bladder is full)

132

Give some differential diagnoses for abnormalities of the emptying phase

Partial/complete urethral obstruction
Chronic distension of bladder (urethral obstruction, pelvic trauma, intervertebral disc protrusion, feline dysautonomia)
Dyssynergia

133

What is a non-neurogenic incontinence?

Urethral sphincter mechanism incontinence
Commonest cause of incontinence in bitch
Intermittent involuntary passage of urine, usually while dog is relaxed
Do not constantly dribble urine

134

Give the aetiology of a USMI

Low urethral tone
? Hormonal influence
? Intrapelvic bladder
Obesity

135

Acquired USMI usually affect which dogs?

Medium/large breeds (Dobermans, boxers, irish setters)
Usually neutered females

136

Congenital USMI usually affects which dogs?

Juvenile bitches (prior to first season)
50% resolve after first season

137

How do you medically treat a USMI? (urethral sphincter mechanism incontinence)

Increase muscle tone (phenylpropanolamine, estriol)
Reduce contributing factors (weight loss, treat secondary UTI)

138

How do you surgically treat a USMI? (urethral sphincter mechanism incontinence)

Colposuspension
Urethropexy
Hydraulic occluder

139

How is a colposuspension carried out?

Caudal midline coeliotomy
Pull bladder cranially
Reposition bladder neck in abdomen
Suture vagina to prepubic tendon
Increases pressure in urethra as it is now sandwiched between vagina and pubic brim

140

What is the prognosis like for a colposuspension?

50% cure
30% improved
20% no better or worse

141

Acquired USMIs in male dogs typically affect which kind of dogs?

Older, castrated, medium/large breeds
Usuallu overweight

142

How could you treat an acquired USMI in a male dog?

Phenylpropanolamine
Oestrogen-based drugs
Weight loss
Vas deferensopexy?
Prostatopexy?

143

Describe ectopic ureters

Congenital anomaly, ureter bypasses bladder to empty into urethra, vagina or rectum
Can be intramural (more common) or extramural
Dribble urine all the time
More common in females
Mostly unilateral

144

Which dog breeds are more prone to ectopic ureters?

Golden labradors/retrievers, skye terriers, siberian huskies

145

How do you treat an ectopic ureter?

Treat associated UTI
Early surgical management (before irreversible secondary changes)
Technique depends on whether uni/bilateral and intra/extramural

146

Which surgery options are available when treating an ectopic ureter?

Ureteronephrectomy (removal of kidney and ureter; used for unilateral ectopia, severe hydronephrosis)
Ureteral transection and re-implantation (extramural ectopia)
Intravesical repair (intramural ectopia)

147

How may an acquired ureteral ectopia occur?

Ureters may be ligated during ovariohysterectomy, usually by inclusion in the cervical ligature
Severe hydronephrosis may develop (reversible if ligature removed in 1 week)
May develop uretero-cervical fistula

148

What is the most common cause of urinary incontinence in cats?

Neurogenic (eg tail pull, sacral fracture, poor prognosis if no improvement after 6 weeks)

149

Give some other less common causes of feline urinary incontinence

Juvenile urinary incontinence (ectopic ureter, hypoplastic urethra/vaginal aplasia)
Iatrogenic (eg after perineal urethrostomy)

150

What are the 3 types of ureteric obstruction?

All rare
Intraluminal
Intramural
Extramural

151

Give some causes of intraluminal ureteric obstruction

Ureteric calculus
Pedunculated mass

152

Give some causes of intramural ureteric obstruction

Tumour (v. rare)
Fibrosis/stricture

153

Give some causes of extraluminal ureteric obstruction

Compression or invasion by abdominal tumour/mass
Ligation during spay
Uterine stump infection

154

What can happen if there is prolonged ureteric obstruction?

Hydronephrosis
Reversible if obstruction is relieved within 7 days

155

How would you diagnose ureteric trauma (avulsion)?

May see electrolyte abnormalities as urine accumulates in retroperitoneal space
Renal function tests may be unaffected if unilateral injury
Definitive diagnosis requires IV urography

156

How may ureteric trauma (avulsion) occur?

Blunt abdominal trauma, ballistic injuries

157

How do you treat ureteric trauma (avulsion)?

Correct electrolyte/metabolic abnormalities
Management depends on site and severity of injury:
-Ureteral avulsion at kidney (ureteronephrectomy)
-Mid-ureteral trauma (mild tears may spontaneously resolve, surgical repair)
-Avulsion at bladder (re-implantation)

158

Define chronic kidney disease

Structural or functional abnormalities of one or both kidneys that have been there for 3 months or longer
Adaptive changes have already occurred
Irreversible, slowly progressive

159

Define azotaemia

An abnormal concentration of urea, creatinine and other nitrogenous compounds in the blood
Can be pre-renal, renal or post-renal

160

Define uraemia

Clinical syndrome that results from loss of kidney function, involving multiple metabolic derangements

161

Give some congenital causes of CKD in dogs and cats

Renal dysplasia
Polycystic kidney disease
Amyloidosis
Fanconi-like syndrome

162

Give some acquired causes of CKD in dogs and cats

Idiopathic tubulointerstitial nephritis
Glomerular disease
Amyloidosis
Sequel to AKI
LUT obstruction
Pyelonephritis
Hypercalcaemia
Renal neoplasia
Nephrotoxic drugs
Hypokalaemia in cats
Hypertension

163

Give the pathology of CKD

Intraglomerular hypertension
Increased GFR
Systemic hypertension
Proteinuria
Precipitation of calcium phosphate in renal tubules

164

Of cats and dogs, which are more affected by glomerular disease and which by tubulointerstitial disease?

Dogs: glomerular disease
Cats: tubulointerstitial disease

165

Briefly describe the 4 IRIS stages of CKD

Stage 1: Primary renal injury
Stage 2: Mild azotaemia, maladaptions
Stage 3: Uraemia, systemic complications
Stage 4: End-stage renal failure

166

Give the clinical signs of CKD

Weight loss
Poor appetite
Poor coat
Dullness, lethargy, sleeping more
PUPD
Dehydration
Vomiting
Constipation
Neuro signs
Signs related to hypertension
Oedema/ascites in severe protein-losing CKD

167

What may you see in a physical exam of an animal with CKD?

Dehydration
Poor body condition
Pale mm
Hypothermia
Oral ulceration
Uraemic breath
Retinal lesion-hypertension
Osteodystrophy ('rubber jaw')
Palpate kidneys
Ascites/subcutaneous oedema

168

What 3 criteria do you need for the staging of CKD?

Creatinine concentration (GFR estimate)
Proteinuria
Blood pressure

169

Give the plasma creatinine concentrations for the 4 stages of the IRIS staging system of CKD in dogs

Stage 1: 0-125umol/l
Stage 2: 125-180
Stage 3: 180-440
Stage 4: >440

170

Give the plasma creatinine concentrations for the 4 stages of the IRIS staging system of CKD in cats

Stage 1: 0-140umol/l
Stage 2: 140-250
Stage 3: 250-440
Stage 4: >440

171

Give the values of urine protein:creatinine ratio that represent non-proteinuria, borderline proteinuria and proteinuria

Non-proteinuria: 0-0.2
Borderline proteinuria: 0.2-0.5
Proteinuria: >0.5

172

Which dog breed is more prone to fanconi-like syndrome?

Basenji

173

Which cat breed is more prone to polycystic kidney disease?

Persian

174

Sub-stages of CKD are based on what 2 things?

Proteinuria
Blood pressure

175

Which criteria must we use when staging CKD?

Animal must be hydrated
Creatinine must be stable (ie take 2 samples 2 weeks apart)

176

What are the minimal things you must do when investigating CKD?

History
Physical exam (eyes, thyroid)
Haem and biochem
Urinalysis
Blood pressure
Abdominal radiographs
Abdominal US

177

What are the end-organs?

Eyes, brain, heart, kidneys

178

How does muscle mass affect creatinine?

Higher muscle mass -> higher creatinine

179

What may you see on a haematology of CKD?

Normocytic, normochromic non-regenerative anaemia

180

What may you see on a biochem of CKD?

Azotaemia (increased urea and creatinine)
Increased phosphate
Increased or decreased total calcium (usually increased total calcium with normal-low ionized calcium)
Decreased potassium (cats, not usually dogs)
Decreased albumin in protein-losing nephropathies

181

Give some differential diagnoses for high blood urea

CKD
High protein diet
GI bleeding
Dehydration

182

What does increased phosphate lead to?

Secondary hyperparathyroidism
Metastatic calcification
Linked to increased mortality and progression of CKD (calcium and phosphate interact and can cause tissue damage)

183

Give some clinical signs of low potassium in cats

Neuromuscular signs (ventral neck flexion)
Decreased renal function
Anorexia

184

What happens to blood potassium concentrations during end-stage CKD?

Increases

185

What value for urine specific gravity would you expect in a dog or cat with CKD?

Isosthenuria
1.008-1.012

186

Isosthenuria with azotaemia usually = renal azotaemia.
What are the 3 exceptions?

Hypercalcaemia
Addisons
Animal on diuretics

187

What would you look at on a radiograph when investigating CKD?

Kidney size, shape, opacity
Ureters
Bladder
Urethra

188

What should you asses on an US when investigating CKD?

Renal size, parenchyma, echogenicity

189

How should you take a BP measurement?

Cuff should be 30-40% circumference of leg. Keep pet calm. Discard first reading until you get 3 or 4 consistent readings

190

What other tests could you do when investogating CKD?

FNA or kidneys
Renal biopsy
Measure GFR
PTH assay

191

Is CKD reversible?
Is there a cure?

No
No

192

How do you generally manage CKD?

Stop all potentially nephrotoxic drugs
Treat any pre/post-renal abnormalities
Eliminate any ongoing specific disease
Start supportive medical management (to reduce severity and minimise progression)

193

How would you treat a uraemic crisis?

IVFT (Hartmann's or 0.9% NaCl)
Supply ongoing maintenance requirements
Monitor electrolytes and azotaemia
Reduce IVFT as animal starts to eat and drink

194

How would you reduce proteinuria?

Look for any concurrent associated disease
Consider kidney biopsy
Ace inhibitors plus dietary protein reduction
Low-dose aspirin if serum albumin is <20g/L
Monitor response to treatment

195

When are ace inhibitors contraindicated in the treatment of CKD?

In dehydrated or hypovolemic patients

196

When treating CKD, what value do you want to reduce BP to?

<160mHg

197

How do you reduce blood pressure in dogs?

1) ACE inhibitors at standard dose rate
2) ACE inhibitors at double dose
3) Combine ACE inhibitors and calcium channel blockers

198

Give an example of a calcium channel blocker used in the treatment of high blood pressure

Amlodipine

199

How do you reduce blood pressure in cats?

1) Calcium channel blockers at standard dose rate
2) Increase dose of calcium channel blocker (up to 0.5mg/kg/day)
3) Combine ACE inhibitors and calcium channel blocker

200

How can you address dehydration in cats?

Wet diet
Drinking fountains/dripping taps
Large bowl
Chicken/fish flavoured water

201

What are the 3 recommendations for a cat/dog in Stage 1 CKD?

-Combat dehydration
-Control hypertension
-If proteinuric, start ACE inhibitor or ARB (angiotensin-receptor blocker)

202

What are the 3 recommendations for a cat/dog in Stage 2 CKD?

-Start renal diet (if cat, stage 3 if dog)
-Control phosphate to <1.5mmol/l
-Supplement potassium if needed

203

Why are renal diets beneficial?

Reduced protein (reduces PUPD, risk of uremic crisis, acid load)
Reduced phosphate
Omega-3 fatty acids
Fibre
Decreased sodium
Water-soluble vitamins

204

When should renal diet be given to dogs and cats?

Dogs: Stage 3 CKD, or Stage 2 with phosphate >1.5mmol/L, or all dogs with proteinuric CKD
Cats: Stage 2 CKD

205

How can you maximise the chances of a pet accepting a renal diet?

Implement early
Introduce slowly
Don't introduce during times of stress (eg in hospital)
Consider temperature/texture etc
Add flavour enhancers
Try another brand

206

How can you reduce serum phosphate in pets with CKD?

Renal diet best way-restricts phosphate and protein intake
Add phosphate binder if diet alone isn't enough

207

Give some examples of phosphate binders used in the treatment of CKD

Aluminium hydroxide
Calcium acetate
Pronefra

208

What are the target values for serum phosphate in pets in stage 2, 3 and 4 CKD?

Stage 2: <1.5mmol/L
Stage 3: <1.6mmol/L
Stage 4: <1.9mmol/L

209

What value for serum potassium would you aim for in pets with hypokalaemia?

Potassium >4mmol/L

210

How can you avoid hypokalaemia in pets with CKD?

Supplement IVFT with KCl
Oral supplements (potassium gluconate, potassium citrate)

211

What are the recommendations for a cat/dog in Stage 3 CKD?

-Control dehydration
-Control hypertension
-Treat proteinuria
-Start renal diet (dogs)
-Supplement potassium if needed
-Control phosphate to <1.6mmol/L
-Treat nausea and vomiting
-Control metabolic acidosis
-Consider EPO (erythropoietin)
-Consider SC fluids

212

How can you control vomiting/nausea?

Reduce gastric acid secretion with eg ranitidine, famotidine, omeprazole
Antiemetics
Sucralfate (protects the GI tract from stomach acid)

213

Which drugs can you give to stimulate appetite?

Mirtazapine
Cyproheptadine
Consider feeding tube

214

Give some possible complications of SC fluids

Fluid overload
Hypernatraemia (high blood sodium)

215

How can you control constipation?

Correct dehydration
Lactulose 0.5-5ml/cat q 8-24hrs
May need enema

216

How can you control metabolic acidosis?

Renal diet
Sodium bicarbonate
Potassium citrate

217

How often does metabolic acidosis occur in cats with CKD?

<10% of cats with Stage 2 CKD
50% of cats in uraemic crisis

218

How can you manage anaemia in cats with CKD?

Avoid excessive blood sampling
Minimise GI blood loss
Good nutrition
Treat iron deficiency
Transfusions
EPO replacement (recombinant human EPO; supplement iron if you give EPO)

219

What should you supplement if you give EPO to an anaemic cat with CKD?

Iron

220

Give some side effects of EPO given to cats with CKD

Seizures, hypertension, local reactions

221

Why might you give calcitriol in the treatment of CKD?

Can promote hypercalcaemia and hyperphosphataemia. Inhibits PTH
May prolong survival and reduce progression of CKD in dogs

222

What must you do before giving calcitriol in the treatment of CKD?

Control phosphate
Confirm there is no ionised hypercalcaemia present

223

What are the recommendations for a cat/dog in Stage 4 CKD?

As for other stages plus:
-Control phosphate to <1.9mmol/L
-Intensify efforts to provide nutrition
-More likely to require extra fluids (SC or via tube)
-Consider euthanasia

224

How often should you monitor a patient with CKD?

Initially monthly
-Blood tests, urine, BP, appetite, BW

225

What would make you suspect hyperkalaemia on a clinical exam of a pet with acute kidney injury?

Bradycardia

226

Describe the urine of a pet with acute kidney injury

Isosthenuric
Glucosuria, haematuria
Look at sediment for casts, WBCs, bacteriuria, crystals

227

Give some indications for ovariohysterectomy

Elective (prevents unwanted pregnancies/oestrus/risk of mammary neoplasia)
Prevention and treatment of mammary and ovarian diseases
Control of certain diseases (diabetes mellitus, epilepsy, certain dermatoses)

228

What are the benefits of spaying before a first season?

Reduced incidence of mammary neoplasia
Uterine/ovarian vessels are smaller (less haemorrhage)
Reduced operating time?
Reduced inconvenience to owner (less seasons)