Wk 10 - Uropathies (Urinary disorders)

AKI

• continuum from inapparent nephron injury or loss to _______________

• prevalence

  • estimated to affect _______________% of _______________ horses

acute renal failure; 3-23; hospitalized

AKI - Risk factors

• decreased _______________ and _______________

• _______________

• _______________

• other causes

renal blood flow; hypoxia; SIRS; nephrotoxicity

AKI - Risk factors

• decreased renal blood flow and hypoxia

  • kidney, esp the _______________, is susceptible to ischemic injury due to:

    • _______________

    • _______________

    • _______________

    • _______________

medulla; hypotension; dehydration; hypovolemia; anemia

AKI - Risk factors

• SIRS

  • systemic inflammation from sepsis or endotoxemia

  • can cause _______________ injury, renal _______________ dysfunction and renal _______________

hypotensive; microcirculatory; cortical necrosis

AKI - Risk factors

• Nephrotoxicity

  • Drugs

    • _______________

    • _______________

    • _______________

    • _______________

    • _______________

  • Others

    • _______________

    • _______________

aminoglycosides; oxytetracycline; bisphosphonates; NSAIDs; polymixin B; myoglobin; hemoglobin

AKI - Risk factors

• nephrotoxicity

  • higher risk in _______________, _______________ horses and with the use of _______________ drugs

foals; older; nephrotoxic

AKI - Risk factors

• other causes

  • _______________ injury

    • e.g. _______________

  • _______________ reactions

  • infections

    • _______________

    • _______________

immune-mediated glomerular; Purpura hemorrhagica; hypersensitivity; Actinobacillus; Lepto

What should you ALWAYS do before admin of aminoglycosides, oxytetracycline, NSAID, biphosphonates or polymixin B?

check CREATININE

T/F: Aminoglycosides are nephrotoxic due to admin of them at high doses

False (toxic due to MULTIPLE ADMIN, NOT high doses)

NSAIDs**

• mechanism of nephrotoxicity

  • inhibition of COX blocks renal autoregulatory response to _______________

  • causes _______________ and _______________

hypoperfusion; medullary crest necrosis; interstitial nephritis

T/F: Selective COX2 inhibitors spare the GIT

True (BUT have similar renal effects as non-selective NSAIDs)

T/F: Selective COX2 inhibitors have less renal effects than non-selective NSAIDs

False (they have SIMILAR renal effects)

AKI

• CS

  • _______________

  • _______________ lethargy

  • _______________

  • _______________ signs

inappetence; persistent (longer than excepted); oliguria; neuro

AKI

• CS

  • oliguria

    • < _______________

  • neuro signs

    • _______________

0.5 ml/kg/hr; uremic encephalopathy

AKI - Dx

• bloodwork

  • _______________ and _______________

• urine output

  • challenging to measure in adult horses

  • _______________ and _______________ are key indicators

inc creatinine; BUN; oliguria; anuria

What are the way you can Dx AKI?

bloodwork (creatinine, BUN), urine output, U/A, imaging

AKI - Dx

• U/A

  • microscopic _______________

  • _______________

  • _______________

  • _______________ USG despite _______________

hematuria; casts; glucosuria; low; hypovolemia

AKI - Dx

• imaging

  • renal _______________ is often unremarkable

  • renal _______________ is NOT recommended

US; biopsy

Decreased urine production is a hallmark of what?

AKI

AKI - Bloodwork

• Creatinine: _______________

• BUN: _______________

• USG: _______________

• FENa (fractional excretion of Sodium): _______________

inc; inc; low (<1.020); inc

AKI - Bloodwork

• Urine output: _______________

• Na: _______________

• K: _______________

• Cl: _______________

• U/A: _______________

oliguria/anuria; dec; inc; dec; proteinurina, hematuria, casts

What does FENa do?

normal = pre-renal

inc = renal

(differentiates pre-renal and renal causes )

AKI - Initial treatment

• correct _______________

• _______________

• give _______________ and _______________ after above

primary disorder; IVF; inotropes; vasopressors

AKI - Initial Tx

• IVF

  • to normalize intravascular volume, BP, _______________ and _______________

• inotropes and vasopressors for _______________ AFTER _______________

renal blood flow; GFR; persistent hypotension; fluid replacement

Treating ARF (acute renal failure)

• treat _______________

  • Abx, Sx, etc

• _______________

  • give _______________ → diuresis

  • oliguria or anuria → _______________

predisposing disease; IV volume expansion; crystalloids; single dose of furosemide

AKI - Monitoring and support

• _______________ by _______________% within _______________ indicates REVERSIBLE AKI

dec creatinine (serum); 30-50; 24-72hr

AKI - Monitoring and support

• aim to induce _______________ and _______________ in oliguria/anuria cases

• _______________ test for predicting _______________ and outcome of AKI

diuresis; polyuria; furosemide challenge; severity

AKI - Tx

• _______________ can be done in SELECT cases with persistent _______________ and high _______________ levels

peritoneal dialysis; oliguria; nephrotoxic drug

AKI - Prognostic indicators

• early detection and management improve outcomes

• better prognostic indicator

  • _______________ > _______________

IVFT response; severity of initial INC creatinine

AKI - Prognostic indicators

• _______________ with _______________ = guarded to poor prognosis

• _______________ = GRAVE prognosis

persistent azotemia; oliguria/anuria; uremic encephalopathy

AKI - Prognostic indicators

• persistent azotemia with oliguria/anuria = _______________ prognosis

• uremic encephalopathy = _______________ prognosis

guarded to poor; grave

AKI - prognosis (long-term outlook)

• sCr (serum creatinine) may normalize within _______________ post-injury

• horses with _______________ sCr

  • likely have sufficient real function for a _______________ lifespan

  • but may have residual _______________ predisposing them to future renal issues

2-6m; near-normal; normal; damage

AKI

• Prevention

  • close monitoring of _______________ in at-risk patients

  • management

    • prompt correction of primary dz, _______________ and _______________

    • cautious use of _______________ and avoiding simultaneous use of multiple nephrotoxic agents

creatinine; hypovolemia; hypotension; nephrotoxic drugs

CKD

• definition

  • _______________ disease of the kidneys lasting more than _______________

• staging

  • based on _______________ levels

  • similar to _______________ staging system for small animals

irreversible, progressive; 3m; sCr; IRIS

CKD - causes

• _______________ of development

• chronic _______________

• _______________

• _______________ causes

• _______________ kidney disease

anomalies; interstitial nephritis; glomerulonephritis; infiltrative; end-stage

CKD - causes

• anomalies of development

  • renal _______________

  • renal _______________

  • renal _______________

  • _______________ disease

agensis; hypoplasia; dysplasia; polycystic kidney

CKD - causes

• chronic interstitial nephritis (CIN)

  • often follows _______________ from ischemia or nephrotoxicity → interstitial _______________

  • can also result from _______________ → _______________

  • _______________ often found with CIN

acute tubular necrosis; fibrosis; ascending UTIs; pyelonephritis; nephrolithiasis

CKD - causes

• glomerulonephritis

  • _______________ inflammation

    • often associated with _______________ infections or _______________ conditions

    • causes _______________ and _______________

immune-mediated; chronic; autoimmune; proteinuria; hematuria

CKD - causes

• infiltrative causes

  • _______________

  • _______________

  • _______________

  • _______________

neoplasia (LSA, carcinoma); nephroblastoma; amyloidosis; Halicephalobus gingivalis

CKD - causes

• end-stage kidney disease

  • final stage of CKD

  • characterized by _______________ kidneys with _______________ surface and _______________ capsule

pale, shrunken, firm; irregular; adherent

CKD

• CS

  • general

    • loss of _______________

    • decreased performance

    • _______________

  • urinary

    • mild to moderate _______________

  • CV

    • _______________

body condition; ventral edema; PU/PD; HYPERtension

CKD

• CS

  • oral cavity

    • _______________

    • _______________

    • oral _______________

  • GI

    • _______________

dental tartar; gingivitis; ulcers; ulcers

CKD - Dx

• subclinical detection

  • often _______________

  • most horses show ______________ (_______________) when CS 1st recognized

incidental; moderate to severe azotemia; IRIS stage III and IV)

CKD - Dx

• bloodwork:

  • creatinine: _______________

  • BUN: _______________

  • _______________

  • _______________

  • _______________

INC; INC; mild anemia; INC Ca; DEC P

CKD - Dx

• U/A

  • _______________

  • _______________

  • _______________

isothenuria (1.008 - 1.014); proteinuria; hematuria

CKD - Dx

• imaging

  • _______________ kidneys on US

  • _______________ with _______________

small, irregular; enlarged ureters; ureteroliths

CKD - general management

• free access to _______________

• dietary adjustments

  • _______________ pasture

  • increased _______________

  • add _______________

  • monitor _______________

fresh water; good quality; carbs; fats; protein

CKD - general management

• avoid _______________ supplementation

• management of hypercalcemia with LOW Ca feeds

  • _______________ instead of _______________

excessive salt; grass hay; alfalfa

CKD - general management

• potential use of _______________ and _______________

• supportive care

  • monitor _______________, appetite, hydration status and renal function

omega-3 fatty acids; vit E; body condition

CKD - medical Tx

• _______________ for any acute component or dehydration

• glomerulonephritis

  • give _______________

• give _______________

• _______________ if it is causing persistent sepsis, pain, or obstructing urine flow

IVFT; corticosteroids; ACEi (benazepril, ramipril); nephrolith removal

What do ACEi do to help with CKD?

control BP, dec proteinuria, slow fibrosis

Bladder rupture

• causes

  • _______________

  • _______________ injuries

  • _______________

trauma; foaling; obstructive urolithiasis

Bladder rupture

• CS

  • abdominal distention

  • _______________ signs

  • dysuria

• Dx

  • abdominal US

    • will see _______________

  • urine output

    • _______________ or _______________

colic; free abdominal fluid; decreased; absent

Bladder rupture - Dx

• abdominocentesis

  • _______________:

    • fluid > serum

  • ratio _______________

• bloodwork

  • _______________

  • _______________

  • _______________

creatinine; >2; azotemia; hyperK; hypoNa

Bladder rupture

• Tx

  • _______________

  • supportive

    • _______________

    • _______________

Sx; IVF; Abx

If you have a foal come in with uroperitoneum, hyperkalemia, hyponatremia and azotemia what is the FIRST thing you should do?

stabilize (NOT Sx emergency and need to stabilize FIRST)

Ureteral (urethra??) rupture → _______________ → _______________

SQ urine; PAIN

Urolithiasis

• types

  • _______________ = most common

  • _______________ = less common

Ca carbonate; Ca oxalate

Urolithiasis

• pathogenesis

  • dietary factors

    • _______________ intake

    • imbalanced _______________

  • _______________

  • _______________

  • _______________ predisposition

high Ca; Ca:P ratio; dehydration; UTI; genetic

Urolithiasis

• CS

  • _______________

  • _______________

  • _______________

hematuria; dysuria; pollakiuria

Urolithiasis

• CS

  • _______________ signs

  • _______________

  • decreased _______________

colic; urine scalding; performance

Urolithiasis - Dx

• Hx and CS

• PE

  • palpation of _______________ and _______________

• U/A

  • presence of ______________ and _______________

  • _______________

bladder; urethra; crystals; blood; INCREASED pH

Urolithiasis - Dx

• Imaging

  • _______________ to visualize stones (bladder, kidney, ureter)

• _______________

US; cystoscopy

Urolithiasis - Tx

• _______________

• _______________

• _______________

medical management; Sx removal; lithotripsy

Urolithiasis - Tx

• medical management

  • dietary modifications

    • reduce _______________ intake

    • adjust _______________

  • increase _______________

  • pain management

    • _______________

Ca; Ca:P ratio; water intake; NSAID