SA Urogenital Flashcards
(228 cards)
1
Q
What is the definition of feline idiopathic cystitis?
A
Abnormal voiding behaviour after exclusion of other disorders
No obvious cause
May be a one-off, or may be chronic/recurrent
2
Q
What are the 2 divisions of feline lower urinary tract disease?
A
Obstructive and non-obstructive
3
Q
Give some causes of non-obstructive feline lower urinary tract disease
A
Idiopathic cystitis (most common) Uroliths Anatomical defects/cancer Behavioural problems Bacterial infection (common in dogs, rare in cats)
4
Q
Give some causes of obstructive feline lower urinary tract disease
A
Idiopathic cystitis
Uroliths
Urethral plus
Bladder stones and bacterial infections
5
Q
What is feline lower urinary tract disease?
A
Collective term for signs of lower urinary tract disease and abnormal voiding behaviour
6
Q
What age of cats is more commonly affected by lower urinary tract disease?
A
Young to middle-aged neutered cats, 2-6 yrs old
7
Q
Give some predisposing factors for feline lower urinary tract disease
A
Obesity
Indoor/sedentary cats
Dry diet
Multi-cat household
8
Q
Give some clinical signs of feline lower urinary tract disease
A
Dysuria (difficulty urinating)
Pollakiuria (increased frequency)
Haematuria
Inability to urinate (urethral obstruction)
Behavioural changes
Periuria (urinating in inappropriate places)
9
Q
How could you gauge whether a cat has obstructive or non-obstructive feline lower urinary tract disease?
A
Palpate the abdomen-large, often painful bladder if obstructed
10
Q
Why should you check the penis of a cat with suspected feline lower urinary tract disease?
A
Can check for signs of self-trauma/crystals/sludge
Penis often blocks at the tip
11
Q
Describe the pathophysiology of feline idiopathic/interstitial cystitis
A
Alterations in neurotransmission to and from the bladder -> triggers inflammation
Reduced glycosaminoglycan layer (protects bladder lining)
12
Q
What is the main trigger of idiopathic/interstitial cystitis?
A
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
Q
Urethral plugs in cats are more common in which sex?
A
Males
Most common cause of obstruction
14
Q
What does a urethral plug consist of?
A
Mucus/glycoprotein matrix, often with other substances trapped in the matrix
15
Q
What types of uroliths are there?
A
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
Q
Is bacterial infection a common or rare cause of feline lower urinary tract disease?
A
Rare
17
Q
How may infection occur (which can lead to feline lower urinary tract disease)?
A
Usually iatrogenic (eg catheterisation) Secondary to urolithiasis, anatomical defects or neoplasia
18
Q
Which kind of cats are more prone to bacterial infection of the urogenital tract?
A
Older cats with CKD and poorly concentrated urine
Diabetics
19
Q
Which neoplasia is more common in the bladder of dogs and cats?
A
Transitional cell carcinoma
More rare in cats than dogs
20
Q
Give some inherited and acquired anatomical defects of the urogenital tract
A
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
Q
What biochem results may you see on a blood sample of a cat with feline lower urinary tract disease?
A
Hyperkalaemia (potassium is normally exreted out in urine)
Hyperphosphataemia (phosphate is normally exreted out in urine)
Metabolic acidosis
Azotaemia
22
Q
How should you examine the urine of a cat with suspected feline lower urinary tract disease?
A
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
Q
What should you make sure you include when radiographing the urinary tract?
A
ALL of the urinary tract, including penile urethra
24
Q
What does US allow you to see when investigating feline lower urinary tract disease?
A
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)
