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Idiopathic Renal Hematuria

Idiopathic Renal Hematuria. Rayna. 3yo, FS, Portuguese-Water dog Hx : chronic hematuria since 3/22/11. rDVM -urine culture ( neg ),urinalysis-USG = 1.029, hematuria (3+), and struvite crystalluria .

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Idiopathic Renal Hematuria

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  1. Idiopathic Renal Hematuria

  2. Rayna • 3yo, FS, Portuguese-Water dog • Hx: chronic hematuria since 3/22/11. rDVM-urine culture (neg),urinalysis-USG = 1.029, hematuria (3+), and struvitecrystalluria. • Began a course of Clavamox- no improvement. CBC, Chemistry, PT, PTT performed. All WNL • Rayna’s clinical signs persisted (intermittent stranguria, pollakiuria, and hematuria (frequently urinated blood clots.)) Represented to rDVM for an abdominal ultrasound which revealed a bladder mass and it was recommended that Rayna be taken for cystotomy (4/11/11). No mass was visualized while in surgery, however, a large blood clot was within her bladder. surgical biopsy of the bladder wall was submitted for culture (results pending). • At that time, Rayna was referred to NCSU Internal Medicine for further diagnostics. (IMAGING)Cystoscopy was unable to dislodge the clot from within the left ureter, and she was transferred to surgery

  3. Rayna

  4. rayna • Hematuria • Trauma, calculi, tumor, cystic disease, nephritis, telangiectasia(permanent dilation of preexisting blood vessels), idiopathic • Ureteral obstruction • Calculi, clot, stricture, neoplasia, ureteritis

  5. Canine idiopathic renal hematuria or benign essential hematuriais an uncommon condition of severe and recurrent unilateral or bilateral renal bleeding in the absence of trauma or other obvious causes of hemorrhage. • Clinical signs • stranguria, dysuria, and macroscopic blood and blood clots • In humans, the criteria for diagnosis • massive renal hematuriain the absence of renal surgery, radiation therapy, acquired or congenital coagulopathies, trauma, neoplasia, or infection • Renal function, excretory urography, and urinalysis (except for the presence of RBCs) must be normal. • These criteria also apply in dogs; however, in several reported cases, hydronephrosisand hydroureter were found

  6. Report of 14 dogs • Relatively large breeds • 2mo-11y (11 were between 2mo and 3y) • Hematuria from left kidney more common (9 from left, 3 from both, 1 from right) • Higher prevalence of occurrence from left kidney in humans as well • ‘nutcracker’ phenomenon • Left renal vein between the aorta and the superior mesenteric artery compressed by the arteries • Not so in dogs b/c of the position of the cranial mesenteric artery • The left renal artery in dogs is longer than the right, leading to higher frequency of left renal artery compression by surrounding tissues and organs • Possible major etiologic factors in dogs

  7. Also occurs in horses • Uncommon • Possible greater prevalence in arabs • May be self limiting with recurrent episodes of severe hematuria • Case report (Arab) responded with steroids, flunixin and transfusion • suggesting an autoimmune pattern • 3 cases, where a unilateral nephrectomy was performed, 2 represented with similar pathology in the contralateral kidney and had to be euthanized • Report of 13 cases (six Arabs)12 either had fatal hemorrhagic events or were euthanized within two years of first clinical signs

  8. Imaging Diagnosis • Ultrasonography • Percutaneousantegradepyelography • Trauma to the renal cortex (hemorrhage), possible leakage of urine out of the cortex if ureteral obstruction persists • No effects on contralateral kidney • Retrograde ureteropyelography • Contrast remains in the renal collection system – no effect on nephrons • Less invasive than antegradepyelography

  9. Imaging diagnosis • IVP • Patients with ureteral obstructions may exhibit poor filling of an obstructed kidney • Nephrotoxicity risk of the contrast material • a significant number of veterinary patients are azotemic at the time of diagnosis. • With ureteralstenting, the location of the stones is less important if the entire ureter will be bypassed by a stent and most of the stones will not actually be removed • not the case with traditional surgical therapy • GFR studies/scintigraphy • GFR of an obstructed kidney is most often reduced • Predictability of return to function based on scintigraphy can be unclear, potentially underestimating renal function post relief • Measurement of the GFR of the contralateral kidney assists in the decision whether to perform a nephrectomy

  10. CT • Virtual CT Cystoscopy • Evaluation of bladder neck and bladder diverticulum is difficult with cystoscopy. Infection can occur secondary to cystoscopy • ‘The method is minimally invasive’,’does not require a high level of competency on the part of the operator.’ • Catheterized the urinary bladder and drained residual urine. Insufflated bladder with 200 to 600 cc (mean 350 cc) of room air according to the patient’s tolerance • Able to detect lesions up to 2 mm, able to accurately measure tumor size, highly sensitive (able to identify lesions not seen with cystoscopy) • Used with axial images to evaluate invasion and surrounding structures (nodes) • Virtual cystoscopy does not allow for biopsy, difficult to distinguish neoplastic lesions from inflammation and fibrosis, requires catheterization, can not evaluate color of bladder mucosa

  11. Virtual computed tomography image of a large mass of the lateral wall of urinary bladder. Karabacak, et al. 2011

  12. A virtual cystoscopic image of a 0.2 × 0.3 cm lesion in the superior wall of the bladder Karabacak, et al. 2011

  13. CT Ureteroscopy Chou, et al. 2007

  14. Treatment • Human • Injection of silver nitrate • Partial nephrectomy • Dogs • Nephrectomy if unilateral • Bilateral cases have a poor prognosis • Partial occlusion of a renal artery • Induce ischemia in the rami of the renal artery to confirm area of renal hematuria, then permanently occlude • Allows maintenance of some renal function

  15. rayna • Rayna recovered well from her surgical procedure with no complications. During her recovery period, Rayna's urine slowly began to normalize, with only intermittent bouts of bloody urine. • Histo- papillary necrosis as cause of hemorrhage. No organisms identified, but suspect bacterial etiology • Rayna is doing really well at home and has felt great to the point that she is running around and they are going crazy trying to restrict her exercise.

  16. references • Idiopathic renal haematuriain a 15-year-old Arabian mareL. Vits, O. Araya, H. Bustamante, F. Mohr, S. Galecio Veterinary Record (2008) 162, 251-252 • Recurrent Urethral Obstruction Secondary to Idiopathic Renal Hematuria in a Puppy . J. C. Hawthorne, J. J. deHaan, R. L. Goring, S. R. Randall, F. S. Kennedy, E. Stone, K. M. Zimmerman, S. W. McAbee J Am Anim Hosp Assoc 1998;34:511–4. • Ureteral obstructions in dogs and cats: a review of traditional and new interventional diagnostic and therapeutic options A. C. Berent, Journal of Veterinary Emergency and Critical Care 21(2) 2011, pp 86–103 • Virtual cystoscopy: the evaluation of bladder lesions with computed tomographicvirtual cystoscopyOriginal research 34O R Karabacak, E Cakmakci, U Ozturk, F Demirel, A Dilli, B Hekimoglu, U Altug, CUAJ • February 2011 , 5(1) • Ureteralfibroepithelial polyp diagnosed preoperatively on virtual CT ureteroscopyChen-Pin Chou, T. T. Wu,R. B. Levensen, Jer-Shyung Huang, Huay-Ben Pan. AbdomImaging (2007) 32:421–423

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