Urinary system, renal and urinary diseases

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Urinary system, renal and urinary diseases
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2014-06-11 22:24:45
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cpp cal poly pomona clinical pathology AHS 305
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dr wallace spring 2014 clinical pathology lecture 11 powerpoint
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  1. functions of the kidney
    • Eliminate waste and toxins from the body – main function
    • Produce erythropoietin (EPO) for red blood cell production
    • Control blood pressure – renin-angiotensin system
    • Help control blood pH and sodium and potassium balance
  2. The Nephron
    • Functional unit of the kidney
    • Each kidney may contain as many as a million 
    • Plasma is filtered at the glomerulus, a specialized capillary tuft surrounded by the proximal end of the renal tubule
    • The tubule is divided into functionally and structurally different portions
    • In mammals, the proximal and distal portions lie in or near the kidney cortex with an intermediate loop and the final collecting ducts in the medulla
  3. Bowmans Capsule
    • Contains the primary filtering device of the nephron, the glomerulus
    • Blood is transported into the Bowman's capsule from the afferent arteriole which branches off of the interlobular artery
    • Within the capsule, the blood is filtered through the glomerulus and then passes out via the efferent arteriole
    • Meanwhile, the filtered water and aqueous wastes are passed out of the Bowman's capsule into the proximal convoluted tubule
  4. The Glomerulus
    • The main filter of the nephron - located within the Bowman's capsule
    • Resembles a twisted mass of tiny tubes through which the blood passes
    • Semipermeable, allowing water and soluble wastes to pass through and be excreted out of the Bowman's capsule as urine
    • The filtered blood passes out of the glomerulus into the efferent arteriole to be returned to the renal vein
  5. Glomerular Filtration Rate
    • 20% of the body’s blood volume must be filtered through the kidneys every minute
    • Decreased GFR results in an increase in toxins in the form of ammonia – azotemia
    • GFR is screened by testing urea and creatinine
  6. Urea (BUN) is...
    • Blood Urea Nitrogen (BUN) – two ammonia molecules, toxin which produced during normal
    • protein metabolism
  7. Createning (CREA)
    amino acid which is a metabolite of muscle, produced from normal muscle metabolism
  8. Azotemia
    increased blood ammonia which is assessed by measuring BUN and creatinine
  9. Possible causes of azotemia
    • Decreased delivery of blood to the kidney = Prerenal
    • Renal Failure = Renal
    • Decreased outflow of urine (obstruction) = Postrenal
  10. Prerenal Azotemia
    • NOT primary renal disease
    • SECONDARY - reduced renal perfusion 
    • Hypoadrenocorticsm -> loss of Na+ -> loss of water -> hypovolemia -> dehydration -> reduced renal perfusion -> AZOTEMIA
    • Azotemia with CONCENTRATED urine > 1.030 in dogs and > 1.035 in cats
  11. Signs of prerenal azotemia
    • Due to a low hypovolemia or hypotension
    • Shock,
    • cardiac failure,
    • dehydration,
    • vomiting and/or diarrhea,
    • hypoadrenocorticism,
    • PU without PD,
    • heat stroke,
    • blood loss,
    • septicemia, etc.
  12. side effects of prerenal azotemia
    • Must be corrected quickly with fluid support and treating underlying cause otherwise: 
    • ->decreased blood flow to kidneys
    • -> renal ischemia
    • -> loss of nephrons
    • -> renal failure
  13. Urine specific gravity in renal azotemia
    Urine specific gravity is same as blood (Isosthenuric) at 1.008-1.015
  14. Renal azotemia with primary kidney origin
    • RENAL DISEASE
    • acute or chronic
    • 65-75% damage to both kidneys
    • loss of ability to concentrate urine
  15. post-renal azotemia
    • Results from obstruction or rupture of urine outflow tracts
    • –Renal pelvis, ureters, bladder, or urethra
    • –Urolithiasis, trauma è most common
    • -Obstruction can progress to rupture
  16. Name the three types of renal azotemia
    • Prerenal
    • Intrarenal
    • Postrenal
  17. Cause of acute prerenal azotemia
    • sudden and severe drop in blood pressure (shock)
    • interruption of blood flow to the kidneys from severe injury or illness
  18. Cause of acute intrarenal azotemia
    • direct damage to the kidneys by inflammation,
    • toxins,
    • drugs,
    • infection 
    • reduced blood supply
  19. Cause of postrenal azotemia
    • sudden obstruction of urine flow due to enlarged prostate,
    • kidney stones,
    • bladder tumor
    • injury
  20. Progression of renal disease
    • Renal disease
    • -> toxins build up = azotemia
    • -> pet becomes UREMIC
    • -> pet feels sick, toxic, v/d, anorexic, etc.
    • -> downward spiral unless toxins are flushed out of system (IV FLUIDS)
  21. Uremia
    multi-systemic toxic syndrome that results from marked loss of kidney function
  22. Renal disease and anemia
    • Renal disease
    • -> less or no EPO produced
    • -> non-regenerative (chronic) anemia
  23. Renal insufficiency
    Buildup of toxins, electrolyte imbalances, dehydration, and even anemia are the cause
    of symptoms:
    • Anorexia
    • Vomiting (emesis)
    • Seizures
    • Ulcers
    • Weakness
  24. Renal Insufficiency and Anorexia
    • Anorexia due to lack of appetite
    • One of the most common reasons pet owners seek medical care for their cats when renal failure is the cause
  25. Renal Insufficiency and Weakness
    an imbalance of K+ adds significantly to weakness
  26. Renal Insufficiency and Vomiting (emesis)
    • Buildup of toxins is the main reason
    • Causes further dehydration and loss of K+, further exacerbating the problem in pets with kidney disease
  27. Renal Insufficiency and Seizures
    If uremia is severe enough the brain can be affected by the toxins that build up
  28. Renal Insufficiency and Ulcers
    • Due to waste products are not being eliminated adequately
    • Prevalent in the digestive system
  29. Symptoms of Renal Insufficiency
    • PU/PD
    • Dilute urine with little color or odor/litter box wetter
    • Nocturia
    • Vomiting & Dehydration
    • Anorexia & Weight loss
    • Muscle weakness & Lethargy
    • Small and irregular kidneys upon abdominal palpation or imaging
    • Large or nodular kidneys if a cyst or cancer present
    • Constipation or diarrhea
    • Hypertension
    • Acute blindness/dilated pupils
    • Cervical ventroflexion in cats
    • Oral ulers, ptyalism, halitosis
    • Gastic ulcers
    • Pale gums/anemia
    • Elevated BUN
    • Elevated Creatinine
    • Albuminuria/Proteinuria
    • Dysuria – anuria, oliguria
  30. Stages of Renal Failure
    • Stage 1 - diminished reserve - GFR decreased by 50% - no clinical abnormalities
    • Stage 2 - chronic renal
    • insufficiency GFR 20 – 50 % of normal – azotemia, anemia, polyuria
    • Stage 3 - chronic renal
    • failure GFR – 20 – 25 % of normal – dehydration, all of the above, hypocalcemia, azotemia, GI, neurologic, and cardiovascular signs
    • Stage 4 - end-stage renal disease < 5% of renal function- all signs of renal failure
  31. Stage 1 of chronic renal failure
    • diminished reserve
    • GFR decreased by 50%
    • no clinical abnormalities
  32. Stage 2 of Chronic Renal Failure
    • chronic renal insufficiency GFR 20 – 50 % of normal
    • azotemia,
    • anemia,
    • polyuria
  33. Stage 3 of Chronic Renal Failure
    • chronic renal failure GFR – 20 – 25 % of normal
    • dehydration
    • all of the above
    • hypocalcemia
    • azotemia
    • GI
    • neurologic
    • cardiovascular signs
  34. Stage 4 of Chronic Renal Failure
    • end-stage renal disease < 5% of renal function-
    • all signs of renal failure
  35. Clinical Tests Used to Assess Kidney Function
    • BUN = blood urea nitrogen
    • Creatinine
    • Phosphorous
    • Potassium
    • Albumin
  36. Renal Insufficiency Lab work
    • Elevated phosphorous could mineralize in tissues
    • Calcium is sometimes decreased
    • High anion gap -> metabolic acidosis
  37. Diagnosis of Urinary Tract Disease
    • •CBC – anemia
    • •Blood chemistry – azotemia, phosphorous, albumin
    • •Urinalysis – urine specific gravity, sediment, culture and sensitivity
    • •Electrolytes – potassium
    • •Blood gases – metabolic acidosis
    • •Radiographs - survey
    • –Contrast studies - excretory urogram, cystography, urethrogram
    • •Abdominal ultrasound – uroliths, tumors, structural abnormalities
  38. Pylonephritis
    • Acute primary renal disease
    • Infection of the upper urinary tract – kidneys and ureters
  39. Symptoms of Pyelonephritis
    • asymptomatic,
    • PU/PD,
    • abdominal or lumbar pain,
    • signs or lower urinary tract infection,
    • fever,
    • small or enlarged kidneys
  40. Causes of Pyelonephritis
    • Usually from an ascending bacterial infection of aerobic bacteria,
    • E. coli,
    • Staphylococcus,
    • Proteus,
    • Streptococcus,
    • Pseudomonas 
  41. Lower Urinary Tract Infection
    • •Infection of the urinary bladder – aerobic bacteria
    • •More common in female dogs than males
    • •Uncommon in young cats, common in cats greater than 10 years of age
  42. Signs of Lower Urinary Tract Infection
    • asymptomatic,
    • pollakiuria (frequent voiding of small amounts),
    • dysuria (painful of difficult),
    • periuria (urinating in inappropriate places),
    • break in house training,
    • hematuria,
    • cloudy or foul
    • smelling urine
  43. Diagnosis of Lower Urinary Tract Infection
    • •Urinalysis via cystocentesis – hematuria, proteinuria, pyuria
    • •Urine culture necessary for definitive diagnosis
  44. Treatment for Lower Urinary Tract Infection
    appropriate antibiotics
  45. Feline Idiopathic Lower Urinary Tract Disease (iFLUTD)
    • •Also called FLUTD, feline idiopathic cystitis (FIC), old name feline urological
    • syndrome (FUS)
    • •Young to middle aged cats
  46. Signs of iFLUTD
    • dysuria,
    • hematuria,
    • pollakiuria,
    • periuria,
    • outflow obstruction,
    • thickened bladder wall
  47. Causes of IFLUTD
    Stress
  48. Diagnosis of iFLUTD
    Urinalysis – hematuria and proteinuria without significant pyuria (WBC’s) or bacteriuria, crystalluria
  49. Treatment of iFLUTD
    • -Often self-limiting in 4-7 days – reoccurs unpredictably
    • -Change diet to all canned diet which helps to increase urine volume and promote
    • flushing of the bladder
    • -analgesics, anxiolytic drugs, prazosin
  50. Transitional Cell Carcinoma
    • •Most common tumor of the urinary bladder
    • •Usually in the trigone - eventually
    • occludes the urethra
    • •Middle-aged to aged female small breed dogs
  51. Symptoms of Transitional Cell Carcinoma
    • same as iFLUTD
    • dysuria,
    • hematuria, 
    • pollakiuria, 
    • periuria, 
    • outflow obstruction, 
    • thickened bladder wall
  52. Diagnosis of Transitional Cell Carcinoma
    Contrast radiographic studies and ultrasound
  53. Treatment & Prognosis of Transitional Cell Carcinoma
    • -piroxicam (NSAID with antitumor activity), chemotherapy
    • -Progressive – long term survival poor
  54. Uroliths
    Can occur anywhere in the urinary tract
  55. Types of Uroliths
    • Struvite
    • Calcium phosphate
    • Calcium oxalate
    • Urate
    • Cystine
  56. Struvite
    • Uroliths
    • magnesium ammonium phosphate
  57. Urate
    • Uroliths
    • genetic predisposition
    • Dalmations
    • English bulldogs
    • Yorkshire terriers
  58. Treatment
    • depends on composition of uroliths
    • correct urine pH
    • antibiotics
    • surgery
    • change diet
  59. Urinary Incontinence in female dogs
    • –Due to lack of estrogen
    • –Urethral Sphincter Mechanism Incompetence
    • –20% of early spayed female dogs will develop
  60. Other causes of Urinary Incontinenence
    • –Lower urinary tract infection 
    • –Excessive consumption of water -> •Psychogenic polydipsia
    • –Spinal cord disease
    • –Canine cognitive dysfunction
    • –Ectopic ureter (young dogs)

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