SAM Exam 2: Urinary

Proteinuria

• Marked proteinuria w/ inactive sediment is the hallmark of glomerular disease!!

• Et: hallmark of glomerular dz

  • Lower UT > upper urinary tract

  • Limited by filtration barrier, fixed negative charges, tubular reabsorption/catabolism

• Dt: location of kidney dz, UPC if inactive sediment

  • Glomerular: proteinuria, ↑ cholesterol, ↓ albumin

    • Endothelium

    • Visceral epithelial cells (podocytes)

  • Medullary: isosthenuria, no proteinuria

• Tx: ACE inhibitors, ARBs, Diet

Rules for Diagnosing Proteinuria

1. Indicates glomerular dz vs medullary dz

2. UPC is unreliable in presence of pyuria or hematuria

   • Needs inactive sediment

   • Urine Protein/Creatinine Ratio “UPC”

3. ↓ Upr/Ucr + azotemic + ↓ GFR ≠ improvement

4. Diet protein + ↓ albumin worsens urinary protein loss

Nephrotic syndrome

• What: Poor GN prognostic indicator

• Et/Cs:

  • Proteinuria

  • ↓ hypoalbuminemia and ↑ hypercholesterolemia

    • Plasma [cholesterol + triglyceride] inversely correlated w/ serum [albumin]

  • Edema/ascites

  • Hypercoagulable state 

    • Thromboembolism (15-25%)

    • Loss of anti-thrombin III in urine → inhibit factors II, IX, X, XI, XII

  • Hypertension (50-80% dogs)

    • Retinal hemorrhage/detachment

    • Always check BP

    • Tx: amlodipine, enalapril

Glomerular Anatomy

• Endothelium

  • Neg charges in endothelium, GBM, podocytes

• Glomerular basement membrane (GBM)

  • neg charges in endothelium, GBM, podocytes

  • Type IV collagen for size selectivity

•  Podocytes (visceral epithelial cells)

  • neg charges in endothelium, GBM, podocytes

• Mesangial cells

  • Produce matrix, phagocytic, contractile, modulate injury

    • Microfilaments: Respond to vasoactive substances and alter surface area (angiotensive 2)

Glomerular Nephritis

• Immunologic injury underlies most cases of glomerulonephritis

• Et: infections, neoplasia, genetics, idiopathic

• Sig: old male

  • Membranoproliferative GN: Wheaten terrier, Bernese, Brittany Spaniel

  • BM disorders: English Cocker, Samoyed, Doberman & Bull terrier

• Cs: CKD, liver rupture, hemoabdomen, poor coat, weight loss, small irregular kidneys, nephrotic syndrome, thromboembolism, retinal hemorrhage/detachment, hypercoagulability

• Dt: BP, variable proteinuria/UPC, ↑ cholesterol, ↓ albumin, Azotemia, ↑ P, microalbuminuria (unclear Px factor, vascular dz - increases risk for renal dz), biopsy definitive (Renal cortical tissue, IH, EM, IF)

  • Macroalbuminuria - UPC >0.5

• Tx: ACE inhibitors, Angiotensive receptor blocker, ↓ Na Diet, low dose Aspirin, Clopidogrel!, Mycophenolate, decrease glomerular hydrostatic pressure

• Prognosis: variable, treat the proteinuria

Amyloidosis

• Path: β-pleated sheet deposits

  • Distribution: systemic (most common) > localized (pancreatic islet cells of cats)

    • Cat are 100% medullary, 75% glomerular

  • Protein: AA, AL, ATTR, Aβ2M, AIAPP

• Et: Reactive systemic dz, idiopathic, familial (dogs, cats)

  • chronic infectious and non-infectious inflammatory, neoplasia

• Sig: Mid age, Shar Pei (M), Beagle (G), FoxHound (G), Abyssinian (M), Siamese (M), Oriental (M)

  • Glomerular > Medullary - dogs except shar pei

  • Medullary > Glomerular - cats including Abyssinian

    • Lugol’s iodine can be used to presumptively identify

• Cs: CKD, recurrent fever, tibotarsal swollen joints(shar pei), liver rupture, hemoabdomen, poor coat, small odd kidneys, nephrotic syndrome, thromboembolism, retinal hemorrhage/detachment - sudden blindness (Ab. cats)

  • Cs from kidney involvement + CKD: except shar pei and cats which is liver rupture, hemoabdomen

• Dt: proteinuria/high UPC >10, ↑ cholesterol, ↓ albumin, Azotemia, ↑ P, microalbuminuria (unclear Px factor, vascular dz), biopsy definitive (Renal cortical tissue, IH, EM, IF, Lugos iodine)

• Tx: none to be benifical, relentless Px is the rule

Pathophysiology of Acute Renal Failure

• Types:

  • Pre-renal: hypoperfusion, Physiologic oliguria, Reversible

  • Intrinsic: nephrotoxic nephrosis, nephritis, ischemia

  • Post-renal: obstruction

MOA: obstruction, tubular backleak, intraluminal crystal deposition

• Ischemic nephrosis: tubular degeneration, acute tubular necrosis, afferent arteriole constriction, vasomotor nephropathy, Systemic Arterial Hypotension = NOT REQUIRED

  • dehydration, shock, anesthesia, sepsis, hemorrhage, trauma, ACE inhibitors, myoglobinuria, NSAIDs.

• NSAIDs: impair renal vasodilation, worsen ischemic injury

  • No direct renal damage; GI bleeding and impaired renal autoreg

• Nephrotoxins: direct tubular cell injury rather than ischemia, low ATP, cell death, renal vasoconstriction

  • Ethylene glycol, aminoglycosides, cisplatin, NSAIDs, Easter lily (C), heavy metals(arsenic, lead), grapes/raisins (D), hypercalcemia (rodentaside)

• ** Simultaneous exposure: nephrotoxins & ischemia increases risk of renal injury

• Nephritis: lepto (D)

Diagnosis of AIRF

• History: Absence of longstanding PU/PD, potential for renal ischemia or nephrotoxin exposure, oliguria, polyuria, non specific signs

• PE: normal BCS, uremic breath, oral ulcers, hypothermia(nephrosis) or hyperthermia (nephritis), back pain(renal pain)

  • Absence of pallor MM

  • No evidence of lower urinary tract obstruction

• Labs: chemistry/cbc/UA/renal size(normal to large)/renal biopsy

  • labs BEFORE treatment = helpful

    • uremia usually are more severe than in pre-renal azotemia

  • CBC: increased BUN, creatinine, phosphorus (severe)

    • hyperkalemia severely impaired renal excretory function and oliguria

• Hemogram: Anemia = NOT early on (more common with CKD)

  • TP = normal to elevated (hydration)

  • +/- thrombocytopenia (Lepto)

  • Inflammatory / stress leukogram

• UA: DILUTE very early on 1.007-1.017

  • Does NOT differentiate AIRF from CKD (both have low USG)

  • Proteinuria, Hematuria, May see glucosuria w/ normal blood glucose

  • Increased WBC, RBC, tubular epithelial cells = Non-specific reaction to renal injury

• Blood gases: Moderate / severe metabolic acidosis during

  maintenance phase of AIRF

Maintenance Phase of AIRF

• severe decrease in RBF and GFR

  • RBF returns to normal → GFR remains low

• Urine output

  • Oliguria

  • Normal urine output

  • Polyuria

• Patient experiences a 1-3 week course before restoration of renal function can occur

• Removal of the inciting cause at this point will NOT result in immediate return of renal function

• severe baseline azotemia during the maintenance phase often are NOT successfully managed without dialysis

Recovery Phase of AIRF

• Return of normal BUN & Creatinine = POSSIBLE

  • decreased GFR may persist → sometimes

• Partial improvement = CKD

• Urinary concentrating defect may persist

• Death / euth:

  • Hyperkalemia → fluids, insulin, calcium gluconate, sodium bicarb

    • dialysis if persistent

  • Metabolic acidosis

  • Severe azotemia

• Tx: Meticulous attention to fluid therapy

  • Potassium affects RESTING potential

  • Calcium affects THRESHOLD potential

Ethylene Glycol

• Alcohol dehydrogenase → the problem (1st-2nd metabolism) then moves to Lactate dehydrogenase (after glycolate) **

• Et: AKI; glycolate/glyoxylate → Ca oxalate crystals : causes obstruction intraluminal or intracellular

• Cs:

  • Neuro (<12h) → intervene here

  • Cardio(12-24h) → intervene here 

  • Renal (24-72h) → when the problem occurs

    • profound oligo-anuric AIRF (almost always fatal once established)

• oligo-anuric AIRF (fatal)

• Dt: dilute urine, oxalate crystalluria, ↑ Anion Gap/OG, ↓ Ca, progressive azotemia

  • False + : Propylene glycol, glycerol, metaldehyde

  • False - : <30mins after ingestion, >12h after

• Tx: TIME! w/in 4 hours of ingestion Decontaminate/GI lavage, ethanol, fomepizole(4-methylpyrazole)!!, dialysis(furosemide)

  • within 2-4h is best Prognosis

    • ethanol → within 4h ingestion 

    • fomepizole 4-methylpyrazole → within 8h ingestion

      • Cats: within 3h of ingestion  

Leptospirosis

• Et: L. cterohaemorrhagiae + L. canicola 

  • filamentous, motile, spirochete bacteria

  • urine, wildlife(rodents), zoonotic

• Path: leptospiremia (2-12d) → ARF, hepatitis, DIC

  • Affect kidney and liver

• Cs: fever, vomiting, dehydration, pain, ARF (oliguria, PU/PD), icterus, vasculitis, DIC, jaundice, AHF, hepatic fibrosis

  •  #1 cause of ARF/nephritis → infects renal tubule

• Dt: serology (MA titers ≥1:800) → antibody, PCR → antigen

  • Antibody titer - most common 

• Tx: Doxycycline, penicillin (↓ trans), hemodialysis, multivalent vax

  • Good Px if Tx early

Chronic kidney Disease

• Et: Chronic tubulointerstitial nephritis(idiopathic), genetics

  • No longer able to maintain: excretory, regulatory, endocrine functions

  • Nitrogen, fluid, lyte, acid-base, hormome imbalance

• Cs: Anorexia/weight loss, PU/PD, vomiting, oral lesions, pale MM, dehydration, osteodystrophy(2ndary), edema, hypertension, retinal detachment, murmurs, mineralization, cachexia, Proteinuria & hypertension = Poor Prognosis

• Dt/Labs: Small/ odd kidneys, nonregen-anemia/lymphopenia, isosthenuria, azotemia, ↑ P, odd PT gland, biopsy (diffinitive)

  • Serum EPO: low to normal 

    • 30% – 65% of cats with CRF have associated anemia

      • Don’t judge pre multi day fluid tx for those w/ decompensated CRF

• Tx: MAKE patient feel better #1, ↓ Diet P!!/Na, ↑ diet protein/ omega 3/ K, P binders(diet fails), ACE inhibitors, Calcitriol, erythropoietin, appetite stim, ACE inhibition: amlodipine/enalapril

  • Chronic progressive: Dogs live less (<1y) than cats

Progression of CRF

• Intraglomerular hypertension (SNGFR)

• Increases in phosphorus, PTH, BP

• Systemic hypertension → treat: BP consistently > 160 mm Hg

• Ocular, cardiovascular

• Renal 2nd hyper-PTH

• Renal mineralization (Ca x P product)

• UTI

Renal Secondary Hyperparathyroidism

• A genetic condition affecting young, growing dogs, primarily in Terrier breeds

• bony overgrowth in the jaw, and Fibrous Osteodystrophy

• metabolic disorder, often due to kidney failure and secondary hyperparathyroidism, which causes the jawbone to soften and expand

Staging Chronic Kidney Disease

• Staged @ stable and hydrated

• IRIS Staging: Creatinine-based / SDMA

  • I: <1.4 (D) <1.6

    • no azotemia, normal creatinine

  • II: 1.4-2.8 (D), 1.6-2.8(C)

    • mild azotemia

  • III: 2.9-5 (both)

    • mod. azotemia

  • IV: >5 (both)

    • severe azotemia

• Substaging: proteinuria (degree) → UPC & systemic hypertension (magnitude)

• Cats progress slower then dogs!!

  • Cats hang out in stage 1-2

  • Dogs hang out in stage 3-4

Feline Idiopathic Cystitis

• Stress, genetics —> “get better” in 5-10 days regardless of tx

• Et: Bladder/urethra hemorrhagic inflam, idiopathic!!

  • Leaky urothelium, MCl infiltration, overactive PSN

  • NOT associated w/ bacteria!! or narrow urethra (males)

• Sig: fixed, 2-6y, Persians, dry food, stress, indoors

• Cs: Inappropriate urination, stranguria, ± hematuria, pain bladder/small, Pollakiuria

  • “FISHY” signs wax + wane

• Dt: US of Sm thick bladder, ↑ USG, non septic UA

  • Crystals normal in cats, always check for them

• Tx: ↑ drinking, anti-stress envrio, Feliway, analgesia, ace, phenoxybenzamine, amitriptyline, buspirone, wet food

  • Spontaneous recovery (5-10d), common reoccurrence, no cure

  • Acidifying or ↓ Mg does NOT work

• FIC is NOT caused by bacteria!!!

Feline Idiopathic Cystitis: Pathophysiology

• Abnormal bladder permeability

• Altered glycosaminoglycan layer (GAG)

• Mast cell infiltration

• Upregulated sympathetic outflow

• Increased sensory nerve terminals and substance P

Urethral Obstruction in Cats

• Et: Urethral plug, struvite, Ca oxalate, neoplasia, idiopathic

  • ↑ Intratubular pressure, ↓ GFR, ↓ Renal perfusion

• Cs: early/partial: stranguria, pollakiuria, hematuria, late/complete: vomiting, anorexia, Lg painful bladder- difficult to express, resistance to catheterization, arrythmias

  • Acute reversible oliguric renal failure

• Dt: ↕ Azotemia, ↑ P, ↑ K (Tented T), met. acidosis, ↓ Na, Ca

  • Normal P range = 2.5-5.5 mg/dl

• Tx: Fix ↑ K, BES fluids, decompressive cystocentesis, hydropulpulsion, analgesia, catheter + pain meds, perineal urethrostomy (>3 reoccurances)

  • Med emerg: complete obst. → Uremia + death 3-5d w/o tx, self limiting diuresis 2-7d post 

    • Treat while running tests 

    • Sx does not prevent reoccurance or FIC

• Balanced electrolyte solutions (e.g. lactated Ringers solution, Normosol-R) but can use NaCl if you have to

Post-obstructive diuresis

• Self-limiting

• Lasts 2 to 7 days

• kidneys produce an excessive, inappropriate volume of urine after a urinary tract obstruction is relieved

What causes azotemia in cats with urethral obstruction?

• increased Intratubular pressure

• Low GFR

• Low Renal perfusion

Cathaterization

• Remove if:  

  • Relatively easy

  • Urine is clear after flushing  

  • Minimally sick cat  

• Place if:  

  • Difficult to do

  • Urine still very bloody or cloudy after flushing  

  • Very sick cat

• Rx: use analgesia, avoid antimicrobials while catheter is in place

• Dt: watch urine output and monitor for hypokalemia→ add KCl

• Watch for: post obx diuresis, urethral spasm (give ace)

Urinary Stones in Small Animals

• Types

  • Dogs: Struvite > Oxalate > Urate > Cystine

  • Cats: Oxalate > Struvite > Urate > Cystine

• Cs: location, duration, UTI dependent

  • Kidney: none, flank pain, hematuria, infection, renal failure

  • Ureter: silent or acute obx/post-renal azotemia

  • Bladder: dysuria, pollakiuria, hematuria

  • Urethra: obx, post-renal azotemia, dysuria

    • Sx discouraged for urethral stones

• Radio-opque: struvite, oxalate 

• Tx: Dissolution for struvite, urate, cystine 

  • Unlikely to cause obx = do not remove 

  • Likely to cause an obx = remove w/ lithotripsy and basket retrieval

    • Urethral sx is discouraged

Struvite Uroliths

• Due to infection

• Et: + Urease bacti UTI (D), Alkaline urine

  • staph, proteus, pseudomonas, klebsiella infection

• Sig: Dogs → bladder

• Cs: location, duration, UTI dependent

• Dt: radiopaque, culture, UA

• Tx: Dissolution diet + antibiotics, catheter, urohydropropulsion, Sx

  • eradicate UTI, recurrence >20%

  • Urine pH <6.8

Calcium Oxalate Uroliths

• Et: bladder (D), kidney/ureter/bladder (C), ↑ calciuria

  • Cushing’s, idiopathic ↑ Ca (cats)

  • Increasing incidence

• Sig: Old, fixed, male, cats, sm dog, Persian, Himalayan, acidifying diet, indoor

• Cs: location, duration, UTI dependent

• Dt: radiopaque, UA

• Tx: catheter, urohydropropulsion, Sx, hydrate, citrate supp, thiazides, Rx diet

  • dissolution NOT possible, ↑ reoccurance, avoid acidifying/excess protein diets

• Altered calcium metabolism can result in increased urinary excretion of calcium (hypercalciuria)

Urate Uroliths

• Et: ammonium acid urate, Bladder/urethra

  • Hepatic urate transport dz in Dalmatians

  • Radiolucent 

• Sig: Dalmatians, Bulldogs, Portosystemic shunts, males, mid age

  • Defective” uric acid metabolism

  • Converted to allantoin by dogs other than Dalmatians

• Cs: location, duration, UTI dependent

• Tx: ↓ purine/protein diet, allopurinol, alkalinization, catheter, urohydropropulsion, Sx

  • ↑ reoccurance

Cystine Uroliths

• Et: Bladder/urethra

  • UTI complicates, not predisposes

  • Radiolucent

• Sig: 4-6y, male Bulldogs, Dachshunds, Irish Terriers, Newfie, Bassets

  • ↓ w/ age, least common

• Cs: location, duration, UTI dependent
  Tx: ↓ protein diet, alkalinization, neutering, catheter, Sx

  • ↑ recurrence, neuter

Voiding hydropulsion

• Stones must be small

  • < 4 mm in female dog

  • < 2 mm in male dog

Renal Tumors

• Et: rare - primary, malignant, (common)metastatic carcinomas/adenocarcinomas, lymphoma

• Sig: Older, GSD

• Cs: anorexia, weight loss, abdominal mass, hematuria → painless

  • Polycythemia (↑ EPO), leukemoid rxn, ↓ glucose, hypertrophic osteopathy → Transitional cell carcinoma

Bladder Tumors

• Et: Transitional Cell Carcinoma

  • Trigone > Fundus

  • Locally invasive and metastasize (lungs) → prone to seeding

• Sig: Dogs, old, Scottish Terrier, recurrent UTI

  • Cats are low risk

• Cs: Dysuria, stranguria, pollakiuria, hematuria, incontinenc

  • Most dogs = T2/T3 at presentation

  • RECAL EXAM! esp. females w/ dysuria

• Dt: hematuria, pyuria, malignant epithelial cells, urine culture, Cytology/biopsy, BRAF test (cells w/ mutation, high specificity/sensitivity), imaging

  • can cause obstruction and hydronephrosis

• Risk of seeding during Sx, biopsy, cysto

• Tx: Partial cystectomy (<80%), piroxicam, chemo, radiation

  • Palliative: Tube cystostomy (chronic UTI risk), Urethral stenting

  • Piroxicam is a non-COX-specific NSAID - Not directly cytolytic

Urethral Tumors

• Rare

• Et: TCC > SCC

• Sig: old dogs, females

• Cs: LN metastasis, urethral obstruction, UTI

• Dt: Rectal examination is KEY part of physical

  examination!

  • Metastasis to regional lymph nodes

• Tx: Tube cystostomy, Piroxicam

Urinary Tract Infection (Cystitis)

• Et: single ascending G- organism, e-coli (most common)

  • Bowel flora 

• Cs: hematuria, pollakiuria, dysuria, stranguria, urge incontinence, inappropriate small volume urination

• Dt: PE, History, prostate exam (M), peri-vulvar conformation (F), UA, alkaline pH (+ urease bacti), cysto + culture

• Tx: Antibiotics, hydrate

  • First: Amoxicillin, Sulfa(kcs), Cephalexin, Cefadroxil

  • Second: Amoxicillin/clavulanate, FQ(resistant)

  • Third: cephalosporins(simplicef), Aminoglycosides(kidney/ear toxic), convenia

• Urine concentration may be 10-100 times higher than blood concentration

Urine Cultures

• Why: UTI

  • Baci suggestive not diagnostic

  • Not done if subclinical 

• How: 

  • Cysto: >1,000 CFU/ml = infection

    • Gold standard

  • Catheter: >10,000–30,000 CFU/ml = infection

ISCAID UTI Guidelines

• Sporadic Cystitis: uncomplicated, isolated UTI w/ lower UT signs

  • Sig: RARE in cats and intact males

  • Dt: LUT signs + UA + culture

  • Tx: Amoxicillin (#1), amoxi-clav, TMS

    • No benefit from nutraceuticals (cranberry, D-mannose)

      • 3-5d duration 

• Recurrent Cystitis: ≥3 in 12m or ≥2 in 6m

  • Et: Recessed vulva, ectopic ureters, PU sx, Cushing’s, DM, neoplasia, catheterization

  • Dt: culture, imaging, cystoscopy

  • Tx: targeted antibiotics for 14d duration 

• Pyelonephritis: upper UTI

• Bacterial Prostatitis: infection of prostate

• Subclinical bacteriuria:

  • Et: + culture but no CS (diagnostic culture not req)

  • Tx: None (unless pre-op or spinal cord injury)

    • NOT associated w/ cystitis dev or poor survival

Canine Urinary Incontinence

• Et:

  • Neuro: UMN/LMN bladder, Detrusor-urethral dyssynergia, Dysautonomia - large bladder

  • Non-Neuro: Ectopic ureters, pelvic bladder, Obx, UTI, idiopathic, PSMI - small bladder

• Sig: Lg female dogs, spayed

• Dt: CBC, Chem, UA, Urine culture, BP, imaging

• Cs:

  • Lg bladder: UMN, LMN, paradoxical

  • Sm bladder: PSMI, urge incontinence, ectopic ureters

• Tx: Phenylpropanolamine(proin), Estrogens(incurin), Testosterone, Collagen, Suburethral sling / TVT-O tape, Hydraulic occluder, Artificial urethral sphincter

Ectopic ureters

• Sig: young(born with it), females, Labs, Goldens, Huskies

• Cs: constant or intermittent dribbling, recurrent UTIs

• Dt: cystoscopy, contrast CT

• Tx: cystoscopic laser ablation, neoureterostomy, ureteroneocystotomy, hydraulic occluder

Drugs for Cardiovascular function

• ACE inhibitors (enalapril, benazepril)

  • Why: Hypertension, proteinuria, CKD, GN, kidney dz, FIC

  • How: ↓ glomerular capillary hydrostatic pressure by ↓ post-glomerular arteriolar resistance

• ARBs (telmisartan)

  • Why: Hypertension, proteinuria, kidney dz, GN

• Amlodipine: hypertension, kidney dz

• Aspirin

  • Why: Thromboembolism, GN

  • How: Inhibits platelet aggregation

• Clopidogrel

  • Why: Thromboembolism, GN

• Diuretics (Furosemide, Mannitol, Dopamine)

• Erythropoietin / Darbepoetin

  • Why: anemia of CKD when PCV <20%

  • Risk: antibody formation

Drugs for Electrolyte Balance

• Hyperkalemia Tx (Na bicarb, Insulin + dextrose, Ca gluconate, Polystyrene sulfonate)

• Phosphate binders (Aluminum salts, Lanthanum carbonate, Sevelamer HCl,

• Ca carbonate, Epakitin, Renalzin)

  • Why: CKD

  • How: Given with food

    • Aluminum: toxic but common

  • Dialysis: Ethylene glycol toxicity, lepto, AKI

Neuromuscular Agents

• Pain management (buprenorphine, butorphanol, fentanyl patch)

  • Why: FIC, Urethral obx

• Appetite Stimulation (Cerenia, Mirtazapine, Capromorelin)

  • Why: CKD

• NSAID (Piroxicam, rimidyl) 

  • How: NSAID, not cytolytic, sm tx window

  • Why: bladder/urethral tumors 

  • Risk: ulcers, never use w/ steroids 

• Urethral relaxants (acepromazine, phenoxybenzamine)

  • Why: FIC

• Tricyclic antidepressant (amitriptyline)

  • Why: FIC

• Anxiolytic (buspirone)

  • Why: FIC

  • How: Stabilizes MC in bladder, ↓ sensory nerve fiber activity

• Phenylpropanolamine (PPA)

  • How: α-adrenergic agonist, ↑ urethral tone

  • Why: Effective in 75–90% incontinence cases

  • Risk: ↑ BP, anxiety

Drugs altering the Immune System

• Chemotherapy

  • Cisplatin: nephrotoxic, NOT in cats

  • Carboplatin: safer alternative

  • Mitoxantrone

  • Doxorubicin

• Mycophenolate

  • Why: Immunosuppression, GN

• NSAID (Piroxicam, rimidyl) 

  • How: NSAID, not cytolytic, sm tx window

  • Why: bladder/urethral tumors 

  • Risk: ulcers, never use w/ steroids

Antimicrobials

• Fluoroquinolones (-floxacin)

  • Why: excellent penetration, second line UTI

  • Risk: Articular cartilage damage (young dogs), retinal toxicity / blindness in cats

• Aminoglycosides (amikacin, gentamicin)

  • Why: resistant cases, third line UTI 

  • Risk: Nephrotoxic & ototoxic

• Penicillins (penicilin, amoxicillin)

  • Why: first line UTI, AKI form lepto

• Cephalosporins (Cephalexin, Cefadroxil)

  • Why: first line UTI

Hormonal Therapy's

• Estrogens (DES, Estriol) incurin

  • Why: incontinence

  • How: use ↓ effective dose

  • Risk: alopecia, estrus signs, BM suppression

• Testosterone

  • Why: incontinence, limited success

• Calcitriol

  • Why: ↓ PTH secretion in CKD

  • How: ↓ serum [PTH]

    • Use only after ↑P is controlled

• Felaway: 

  • Why: FIC