Urinary

Question 1

clinical presentations of UT disease

Answer 1

stranguria - straining to urinate
hematuria - blood in urine
dysuria - discomfort/diffulcty when urinating
pollakuria - frequent abnormal urination
periuria - urination at inappropriate sites
anuria - failure of urine production by kidneys
oliguria - reduction in urine production
polyuria - increased urine production

Question 2

stranguria

Answer 2

dogs - bacterial cystitis/urethritis, urinary calculi
cats - idiotpathic cystitis (stress) urolithiasis

if bladder large then bad

bladder inflammation - small bladder, thick wall, small squeeze elicits urination
bladder atony/lower motor neuron disease - large flaccid bladder, gentle squeeze elicits urination
obstruction - large tense bladder, urine not easily expressed
calcuil or mass - irregular hard masses felt, may have grating feeling

Question 3

hematuria

Answer 3

trauma
rodenticides
genital sources
coagulopathies - bleeding from other sites

initial hematuria - lower UT
terminal hematuria - upper UT
total hematuria - upper UT, diffuse bladder disease, prostate or proximal urethra, coagulopathies

differentiate from hemoglobinuria and myoglobinuria

Question 4

methods of urine collection

Answer 4

free catch - easy, owner can do, non traumatic or invasive, but risk of non-complicance, contamination, variable volume, risk of damage if manual expression

cystocentesis - quick, easy in cats, aseptic (culture), lower risk of infection than catheter, but a bit harder, may cause haemorrhage - contraindicated in severe bladder disease or coagulopathy

catheter - low bacterial contamination, big sample, but harder to do, risk of infection, not for culture because lower UT contamination. difficult in female cat - blind insertion

Question 5

urinalysis artefacts

Answer 5

crystals - calcium oxalate, struvite

refrigeration artefacts - in vitro crystal formation, inhibition of enzyme reactions, falsely increased USG

room temperature artfacts - bacteria - overgrowth, metabolised chemicals, altered culture results

Question 6

urine collection timing

Answer 6

early morning most concentrated (expect higher USG)
highest yield of cells
cells may be altered because of prolonged exposure to pH and osmolarity of urine (sitting in bladder longer)
glucouria may be more prominant post prandial

Question 7

urinalysis - areas assessed

Answer 7

USG - loop of henle and distal tubule
dipstick - proximal tubules and grlomerular function
biochem - glomerular function

Question 8

normal USG

Answer 8

dog - 1.015 - 1.045
cat - 1.045 - 1.060

in light of hydration -
isothenuria - 1.008 - 1.012
hyposthenuria - <1.008
well concentrated - >1.030

Question 9

normal pH

Answer 9

high - >7.5 - UTI with urease producing bacteria –> metabolic alkalosis (but normal in herbivores)

low - <7 - UTI with acid producing bacteria –> metabolic acidosis (normal in carnivores)

Question 10

crystalluria

Answer 10

precipitate when urine saturated with dissolved minerals
may get without disease
prolonged storage or cold artefact

magnesium ammonium phosphate - struvite - UTI or diet

cystine - hexagonal - abnormal, proximal tubular defect in amino acid transport

calcium oxalate dihydrate - envelope shape - acidic urine, urolithiasis, hypercalcuria, hyperoxaluria

calcium oxalate monohydrate - picket fence - ethylene glycol ingestion (may be normal in horses)

calcium carbonate - yellow brown crystals, alkaline urine - common in horses

bilirubin - orange-reddish brown - routinely seen in low numbers in dogs, abnormal in cats

ammonium biurate crystals - routine in dalmatians

Question 11

renal tubular casts

Answer 11

proteinaceous plugs of dense mesh like mucoprotein
accumulate in distal nephron

normal in low numbers
increased - tubular disease

Question 12

epithelial cells of UT

Answer 12

Transitional - renal pelvis, bladder, ureter, proximal 2/3 urethra

squamous - distal 1/3 urethra

Question 13

pyuria

Answer 13

high leukocyte count

Question 14

uroliths

Answer 14

calculus in urinary tract
usually calcium carbonate in horses and rabbits
ammonium sulphate or calcium oxalate in dogs and cats

bladder - cystolith
lower UT signs - dysuria, pollakuria, hematuria
may be palpable

ureters - uretoerolith
renomegaly and failure if bilateral

kidney - nephrolith
incidental usually
may have pyleophritis, pain, pyuria, pyrexia

urethra - urethrolith
lower UT signs
abdominal discomfort
licking
most severe - obstruction –> post renal azotemia –> acute kidney injury –> uremia
urethra palpable per rectum

Question 15

urolith diagnosis

Answer 15

palpation

radiograph -
radiopaque - struvite, calcium oxalate, calcium phsphate
radiolucent - ammonium urate, cystine

ultrasound - easy to miss them

Question 16

emergency treatment - urinary obstruction

Answer 16

emergency unless only partial
stabilise - manage hyperkalemia, fluid therapy
retrograde hydorpropuslsion - push stones backwards with catheter
urethrostomy - for recurrent problems

Question 17

blood volumes

Answer 17

dog - 88ml/kg
cat - 66ml/kg

Question 18

aims of fluid therapy

Answer 18

maintenance of normal physiology
improvement of organ function
correction of electrolyte disturbances
corretion of hypovolemia
correction of acid base disturbances

Question 19

maintenance fluid rate

Answer 19

2.5ml/kg/hour = 60ml/kg/day

Question 20

estimating fluid losses

Answer 20

no signs - <5% deficit
tacky mm - 5-6%
skin tent, sunken eyes - 6-8%
increased pulse, cold peripheries - 8-10%
weak pulses - 10-12%
collapse - 12-15%

Question 21

types of fluid

Answer 21

CRYSTALLOIDS

isotonic - lactated ringers
shock, diruesis, anaesthesia, maintenance

hypotonic - sodium chloride
not used often

hypertonic - saline
drains water from interstitial space
restoration of BP, increased myocardial contractility, CO and oxygen delivery
large animals mostly

COLLOIDS

hetastarch
supports circulating blood volume
severe hypovolemia
more rapid initial re-expansion of volume and supports circulation longer than colloids, but no evidence actually better

BLOOD PRODUCTS
whole blood, packed RBCs, fresh frozen plasma, cryoprecipitate

Question 22

speed of fluid admin

Answer 22

shock - 60-90ml/kg/hour or 1/2 deficit in first 1-2 hours and rest over 24-48 hours

chronic losses - replace over 3-4 days

anaesthetic maintenance -
dogs - 5-20ml/kg/hour
cats - 3-9ml/kg/hour

Question 23

IV complications

Answer 23

extravasation
thrombosis
thrombophlebitis
infection
emboli
exsanguination

Question 24

contraindications - fluid therapy in anaethestetic

Answer 24

cardiac patients - risk of volume overload
risk of anaphylactic repsonse
risk of interference with clotting tests (colloids)
may cause fluid overload in cats
cost

Question 25

PUPD - primary polyuria

Answer 25

most common lack of ADH production by hypothalamus --> can't concentrate urine - primary central diabetes insipidus inability of renal cells to respond to ADH - nephrogenic diabetes insipidus inability of renal cells to repsond to ADH secdonary to another process - reduced sensitivity - e coli toxins, cushings interference with ADH action - hypercalcemia, hypokalemia ADH receptor downregulation - obstruction at ureter or bladder, hypokalemia osmotic diuresis - increased concentration of solutes in glomerular filtrate to more water excreted - medications - mannitol diabetes mellitus CKD post obstructive diruesis (measure BUN) liver failure reduced medullary concentration gradient -controlled by Na+ and urea in medulla IVFT Steroids liver failure Addisons

Question 26

PUPD - primary polydipsia

Answer 26

uncommon in small animals - more horses cerebrocotrical dysfunction - central lesion in hypothalamus (thirst centre) also endocrine disorders

Question 27

PUPD ddx

Answer 27

diabetes mellitus CKD liver failure central diabetes insipidus nephrogenic diabetes insipidus hypercalcemia hypokalemia iatrogenic Addisons Cushings e coli toxicity

Question 28

PUPD pathophysiology

Answer 28

plasma osmolality - determines blood pressure osmolality integrated into thirst centre of brain hypothalamus --> produces ADH --> kidneys --> regulates reuptake of water so need functioning hypothalamus and kidneys

Question 29

CKD

Answer 29

older animals signs - weight loss inappetance PUPD oral ulcers - poor prognosis diagnosis - biochem, hematology - renal azotemia, non-regenerative anemia, hypokalaemia, hyperphospahtemia USG - low proteinuria BUN and serum creatinine stage 1 - no clinical signs 2-4 - easier to pick up on exam

Question 30

pyelonephritis

Answer 30

inflammation of renal pelvis with or without bacterial infection signs - PUPD - bacterial endotoxins interfere with ADH and inflammation interferes with medullary osmotic gradient lower UT signs - hematuria, pollakuria, dysuria, stranguria renal, lumbar, spine pain renomegaly lethargy diagnosis - ultrasound hematology - left shift inflammatory leukogram urine culture and sensitivity

Question 31

pyometra

Answer 31

usually e coli infection older entire bitches signs - open - mucoid to purulent discharge at vulva closed - lethargy, pyrexia, inappetence, vomiting and diarrhoea, PUPD diagnosis - left shift leukogram - presence of immature neutrophils in blood - increased demand azotemia imaging

Question 32

hyperthyroidism

Answer 32

cats over 7yo signs - PUPD polyphagia with weight loss behavioral chanegs intermittent vomiting and diarrhoea diagnosis - decreased BCS tachycardia, murmur, gallop rhythm goitre increased ALT and T4

Question 33

Cushings

Answer 33

middle aged older dog signs - PUPD Polyphagia pot belly skin thinning hair coat changes diagnosis - increased ALP USG <0.020 acth STIM loe dose dexamethasone suppression test urine cortisol:creatinine

Question 34

Addisons

Answer 34

younger dogs signs - vague waxing and waning GI signs collapse shock diagnosis - Na:K ratio <23 ACTH stim

Question 35

diabetes mellitus

Answer 35

signs - weight loss polyphagia lethargy PUPD Diagnosis - hyperglycemia urine - glucose, ketones fructosamine in blood - expensive

Question 36

hypercalcemia

Answer 36

signs - PUPD variable depending on cause Causes (HOGSINYARD) - Hyperparathyroidism osteolysis granulomatous disease spurious sample idiotpathic - cats neoplasia young animals - growth addisons renal disease hypervitaminosis D diagnosis - increased total calcium

Question 37

liver disease

Answer 37

signs - PUPD non specific depending on cause diagnosis - increased liver enzymes decreased urea, cholesterol, albumin and glucose bile acid stim imaging

Question 38

normal drinking

Answer 38

40-60ml/kg per day (abnormal = 2x maintenance - 100ml/kg/day)

Question 39

biochem

Answer 39

urea/creatinine - renal failure hyperglycemia - diabetes mellitus T4 - hyperthryoidism hypercalcemia - neoplasia and others high ALP/cholesterol - cushings

Question 40

azotemia

Answer 40

increased nitrogenous compounds in blood - urea and creatinine pre-renal - dehydration/hypovolemia, shock - blood indicators of dehydration (PCV, total protein, lactate) renal - glomerular disease, tubular disease, interstitial disease - blood indicators of dehydration post renal - obstruction, rupture of UT - dysuria, usually reversible

Question 41

renal failure - pathophysiology

Answer 41

excretory failure - due to diminished GFR - increased BUN and creatinine (azotemia) metabolism failure - failure to catabolise polypeptide hormones insulin, glucagon, GH failure to synthesis - failure to make calcitrol --> secondary hyperparathyroidism failure to make erythropoietin --> anemia accumulation of uremic toxins - urea - weakness, anoerxia, vomiting, glucose intolerence creatinine - weight loss, platelet dysfunction PST, insulin, GH - osteodystophy, hyperinsulinemia, insulin resistance others --> anorexia, uremic breath, encephalopathy, impaired, erythropoiesis, abnormal platelet function acid:base homeostasis - inability to reabsorb bicarb --> metabolic acidosis systemic hypertension - RAAS dysfunction - effect on systemic blood pressure

Question 42

approach to renal failure - exam and testing

Answer 42

clinical exam - dehydration - tacky mm, CRT CV status signs of bleeding disorders assess lower UT fundus - signs of hypertension abdominal palpation transrectal to assess left kidney (horses and cattle) biochem and hematology - azotemia - BUN and creatinine electrolyte abnormalities anemia acid-base imbalance platelet disorders USG - low response to fluid therapy - pre-renal should resolve proteinuria and protein:creatinine ratio

Question 43

chronic vs acute kidney failure

Answer 43

acute - sudden onset polyuria --> oliguria/anuria may not have time to get to advanced uremia signs may have signs of urinary or abdominal trauma may have history of ingestion of a known toxin chronic - long term weight loss PUPD uremia history of vomiting progressive weakness and pale mm

Question 44

uremia signs

Answer 44

PUPD dehydration anorexia weight loss vomiting halitosis oral ulceration GI bleeding weakness/lethargy pale mm neurological signs

Question 45

bird - dropping colours

Answer 45

white urates - normal green - biliverdinuria - severe hepatic disease golden/brownish-yellow - hepatic disease or vitamin administration red/brown - lead toxicity, nephritis, polyomavirus, warfarin type poisons

Question 46

Feline Urinary Tract Disease (FLUTD)

Answer 46

collection of conditions affecting bladder or urethra in cats - urolithiasis bacterial infection urethral plugs anatomical defects neoplasia feline idiopathic cystitis

Question 47

FLUTD - signallment

Answer 47

usually <10yo neutered overwight inactive mainly indoor dry diet multi cat house stress

Question 48

FLUTD - pathogenesis

Answer 48

unknown, suggested - neurogenic inflammation mucosal defects - increased bladder wall permeability neuroendocrine imbalance crystalluria struvite present in over half of cases but also in lots of healthy cats

Question 49

FLUTD - role of stress

Answer 49

neuroendocrine trigger environmental change --> stress --> change in bladder lining --> pain, swelling, vascular leakage, irritation --> more stress --> repeat substances in urine exacerbate inflammation inadequate response of nervous system to cortisol feedback

Question 50

FLUTD - signs

Answer 50

lower UT - dysuria pollakuria hematuria stranguria periurea behavioural - loss of litter training aggression excessive grooming appearance of constipation stilted gait - discomfort abdominal pain

Question 51

FLUTD - diagnosis

Answer 51

history and signalment important physical exam - non-obstructed - small bladder, no systemic signs unless concurrent disease obstructed - distended firm bladder, dicoloured and swollen penis, dehydration, systemic illness, bradycardia rule out uroliths, neoplasia and infection urinalysis hematology and biochem - unremarkable radiography ultrasound - bladder cytoscopy Diagnosis of exclusion

Question 52

FLUTD - Urethral Obstruction

Answer 52

uroliths - struvite or calcium oxalate urethral plugs - protein colloid mucoids (RBCs, WBCs and crystal material on cytology) idiopathic - functional or non-physical obstruction - spasm, mucosal oedema

Question 53

FLUTD - management

Answer 53

pain relief - 5-7 days flush bladder - saline or lidocaine increase water intake long term decrease stress environmental enrichment cystease - may protect bladder lining