Case 1
10 yo M-n PBGV
Presents for wellness, Cr = 2.5 mg/dL, USG 1.018
Is this kidney dz?
Other useful values?
Can we stage this?
Other recom DX?
- Kidney dz: inappropriate USG for being azotemic
- Other useful values
- BUN
- Phos
- K, Na, Cl, Ca
- TCO2
- Alb
- Hct
- Can’t stage b/c we only have 1 time point
- Other recom DX
- Recheck
- Full U/A
- urine culture, UPC
- +/- imaging
- +/- infectious dz testing
Case 1
Communication with client?
Management at this time?
Plan for high UPC?
- communication with client
- likely permanent, progressive, can be managed sometimes for years
- best with regular monitoring and likely new treatments in future
- Management strategy
- +/- diet
- +/- monitoring weights - fluids
- Plan for high UPC:
- further evaluate
- localization: double check labs/PE/HX for pre/post renal factors
- persistence: recheck 2-3 weeks
- magnitute: see if avg is > 0.5
- No Tx yet
- further evaluate
Case 1
Managing UPC = 1.2
- +/- infectious dz testing
- +/- bx
- likely use ACEi
- +/- thrombophrophylaxis
- No immunosuppression now
- Monitor over time
- goal: UPC , 0.5 or 50% reduction
- side effects: watch for inc K+ and/or inc Cr
Case 2
1 yr F/S Golden retriever
PC: constant accidents in house esp when sleeping or left alone.
What HX questions to ask?
- Duration of CS
- since adopted 3 months ago, unkown prior hx
- Characterize: dribbling, constant leakage, puddles when rising, etc…
- mostly small puddles found, constant leaking not noted
- Any odor, discoloration?
- no
- Does she ever urinate normally?
- yes
- Other clinical signs?
- no
Case 2
What specific things will be evaluated related to this dogs signs on PE?
- Observation of micturation
- normal stream
- Bladder palpation
- small to normal, non painful, no obvious urine expression
- External urogenital eval
- wet hair around vulva, ‘prepubertal’ conformation w/dorsal skin fold
- Rectal
- no obvious urinary abnormalities
Case 2
DDX
- USMI
- Ectopic ureters
- LMN condition
- Other functional abn
- Secondary UTI, other structural dz
Case 2
DX plan?
DX plan if limited funds?
- DX plan
- UA
- Urine culture
- Chem, CBC
- for causes PU/PD or infection
- Imaging: AXR +/- AUS +/- other (CT, endoscopy)
- DX plan if limited $
- UA, U culture
- empiric tx: 80-90% success rate
- PPA
- estrogen
Case 2
Patient improves with PPA but not 100%, imaging susp for unilateral ectopic ureter.
Treatment options?
Prognosis?
Discussion with clients?
- Tx options
- laser sx: 50% success rate
- may need meds as well: 75% success rate
- hydraulic occluder: 90% success rate
Case 3
3 yr F-s Mix breed dog
Asking to go out a lot more often last couple days, has one accident in house of stinky pink urine, cried when picked up.
What HX questions should you ask?
- Characterize: PU vs pollakiuria
- havent noted PU, seems like mostly small amounts of urine
- Any straining / discomfort
- hard to tell, don’t watch dog outside
- Has anything like this happened in the past?
- no
- Other CS, tenesmus
- no / not sure
Case 3
What specific things on PE will be evaluated related to this dog’s signs?
- Observation of micturation
- normal stream, urine is red the whole time
- Bladder palpation
- small and uncomfortable
- External urogenital eval
- pre-pubertal conformation w/dorsal skin fold
- Rectal
- no obvious urinary abnormalities
Case 3
Can you localize the problem?
Initial DDX?
- Yes: LUT
- can’t rule out additional upper UT involvement
- Initial DDX
- UTI
- Urolithiasis
- Neoplasia
- Renal hematuria - clots
Case 3
DX plan?
DX plan in limited money?
- DX plan
- UA
- Urine culture
- Imaging: AXR +/- AUS
- +/- other endoscopy
- chem, CBC
- could give us info about risk factors
- DX plan if limited money
- UA, and U culture
- empiric tx?
Case 3 results
- UA (dipstick)
- protein 3+
- blood / heme = 3+
- UA (sediment)
- WBC = 8-12/hpf (inc)
- RBC = TNTC
- Many struvite crystals
- AXR
- 2 radiopaque stones
- stones in both kidneys
- Urine culture positive for proteus (urease prod bact)
Is it reasonable to suspect stones are struvite based on crystalluria? How certain?
Complicated or uncomplicated UTI?
- Yes reasonable to guess struvites
- can’t be certain
- Yes complicated b/c of stones
Case 3
Plan
When recheck?
- Antibiotics
- until stones resolved (6-8+ weeks)
- Dissolution diet
- Monitoring
- Clinical signs
- stone growth or dissolution
- 1 month recheck
- imp clinically w/in few days
- culture neg
- still some hematuria
- rads show 3 stones
Case 3
Why are the stones bigger now?
Options for tx?
What about kidney stones?
- Bigger because may have had oxalates first and gotten secondary infection
- new stone type could be in response to diet
- TX options
- sx
- lithotripsy
- stones too big for catheter sampling
- Kidney stones
- leave in place for now
- wait to see if necessary to remove later
Case 4
14 yr F DSH
vomited multiple times last couple days, seems to feel very sick, brough in to emergency clinic as walk in
Triage?
- Need to get an idea of how sick the cat is
- ask some questions
- check some physical exam parameters
- check some point-of-care test results
Case 4
specific questions to ask, tests to perform?
Emergency actions?
- HR/pulse, RR/RE, Temp, Bladder palpation
- azo stick off the charts high
- obvious exposure to ethylene glycol?
- Has the cat urinated recently?
- Other primary clinical signs?
- +/- Azo, BG, PCV/TS
- No emergency actions
Case 4
specific things to evaluate on PE?
- Drinking, urinating?
- drinking less last couple of days
- Bladder palpation
- small
- Kidney palpation
- mildly enlarged, uncomfortable
Case 4
1st steps
- Collect dx samples
- UA (USG at a min)
- Chem, CBC
- Urine culture
- imaging
- EG testing
- ID life-threatening disturbances
- hyperkalemia
- acidosis
- ID pre and post-renal factors
- Plan to assess urine output
Case 4
results
- USG: 1.009, 2-3 granular casts, 2+ protein
- Chem: Cr: 12.4, BUN: 268, Phos: 16.5, K: 5.5, TCO2: 15, alb: 3.6
- AXR/AUS: bilaterally enlarged, smooth surface, hyperechoic kidneys
INITIAL TX an monitoring plan?
- azotemia plus isosthenuria means there is a renal component
- TXs
- IVF (Maintenance + replacement + excess losses)
- abx
- anti-emetic / anti-nausea
- monitoring
- weights, urine output, BP
- Serial bloodwork
- esp K and TCO2/HCO3
Case 4
After 6 hours no urination, K now 6.0
What now?
Possibilities?
What do you do next?
- Possibilities
- still dehydrated
- obstructed (bilateral ureteral)
- Pathologic oliguria
- What to do next
- discuss prognosis
- options: fluids, diuretics, other meds, dialysis
-
Clin/lab assess SA (Cooke)36
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Hematuria (Cooke)23
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LA urology (Reuss)38
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LA acute & chronic kidney dz (Reuss)32
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Urinary Tract Infection (Cooke)31
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Urolithiasis (Specht)29
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Urinary tract disorders in horses (Reuss)31
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Urinary disorders in Ruminants (Reuss)29
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LA clinical cases (Reuss)8
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Lower Urinary Tract Problems/dz (Specht)20
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Micturation (Cooke)46
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AKI (Londono)39
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CKD (Specht)28
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Glomerulonephropathies (Specht)14
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Case studies21
