Renal Challenges in Pets: Ultrasound Cases with Wendy Blount, DVM

1. Urinary Ultrasound Cases Wendy Blount, DVM

2. Sahara 6 yr CM Golden Retriever • CC: presented to regular vet for dental prophy • Bloodwork showed BUN 108, creat 4.6, phos 8.8 • Referred for possible treatment • UA – SG 1.010 • Sediment: WBC 10-20/HPF • No bacteria seen

3. Sahara • Abdominal Ultrasound

4. Sahara • Abdominal Ultrasound

5. Sahara • Abdominal Ultrasound • Little/no distinction in echogenicity between cortex and medulla, isoechoic with fat • DDx – nephritis, nephrosis • Subjectively small kidneys, irregular borders • Pylectasia • Urine culture/sensitivity and Lepto titers submitted

6. Sahara • Treatment – pending test results • Amoxicillin 750 mg PO BID x 3 weeks • Enrofloxacin 138 mg PO BID x 2 weeks • AlOH powder ¼ tsp on food BID • Urine culture & sensitivity – no growth

7. Sahara • L. Pomona 1:100 • L.icterohaemorrhagiae 1:100 • L.canicola NEGATIVE • L.grippotyphossa 1:3200 • L.hardjo NEGATIVE • L.bratislava NEGATIVE • L.autumnalis 1:1600

8. Sahara • Treatment • After amoxicillin complete, doxycycline 300 mg PO BID x 3 weeks (with food), to eliminate carrier state • Weaned off AlOH as phosphorus returned to normal • Outcome: • azotemia resolved over 30 days, and renal values remained normal for 3 years • Teeth were cleaned 90 days later than planned • Chronic renal failure began at 9 years of age

9. Lessons from Sahara • Uremic halitosis and/or gingival ulceration due to uremia can prompt owners to request dental cleaning • Pre-anesthetic bloodwork can become tiresome, but occasionally can be lifesaving • It’s not possible to diagnose renal failure without a urinalysis • Benign urine sediment, or even negative urine culture does not rule out pyelonephritis • Doxycycline is required to eliminate Lepto carrier DON’T FORGET THE LEPTO TITERS FOR RF!!

10. DDx Hyperechoic Renal Cortex • Relative to fat, liver and/or spleen • Acute toxicity – ethylene glycol, raisins, NSAID overdose, Lily, hypercalcemia, etc. • Glomerular disease – glomerulonephritis, amyloidosis • Chronic Interstitial nephritis • Pyelonephritis or pyogranulomatous nephritis • End stage kidney disease • Non-pathologic fat deposition in the cat

11. DDx Medullary Rim Sign • Prominent hyperechoic line at the corticomedullary junction

12. DDx Medullary Rim Sign • Prominent hyperechoic line at the corticomedullary junction • Mineral deposition at CM junction • DDx: • Ethylene glycol toxicity • Hypercalcemic nephropathy • Pyogranulomatous nephritis (FIP, fungal, etc.) • Leptospirosis • Chronic interstitial nephritis

13. DDx Pyelectasia • Dilation of the renal pelvis • >3 mm in the cat • >4 mm in the dog

14. DDx Pyelectasia • Pyelonephritis • Urinary obstruction (early hydronephrosis) or distended urinary bladder • IV fluid therapy • PU-PD • Diuretic therapy • Congenital defect Absence of pyelectasia does not rule out pyelonephritis

15. Pyelonephritis + CRF/ARF Left Kidney

16. Pyelonephritis + CRF/ARF Right Kidney

17. Pyelonephritis + CRF/ARF Right Kidney

18. DDx Perirenal Fluid • Nephritis – infectious, inflammatory • FIP, pyelonephritis, leptospirosis • Acute nephrosis – renal toxicity • Renal lymphoma • Perirenal pseudocyst • Ruptured upper urinary tract • Hemorrhage - trauma or coagulopathy • Aspiration of the fluid for cytology can be helpful in diagnosis and treatment • If abscessed, peritonitis is a risk

19. Urohydropropulsion Guidelines If you can pass a 9Fr catheter, you can safely void stones up to 3mm in diameter http://www.cliniciansbrief.com/article/canine-urohydropropulsion

20. Sasha 5 yr SF DSH • CC: repeated episodes of sterile cystitis as a young cat • Thorough work-up included exam, bloodwork, UA, Urine culture, abdominal rads and abdominal US • Struvite stone removed from the bladder 2 years ago– not cultured • In remission since then • Recurrence of stranguria, hematuria, periuria in the past week • Feeds c/d multicare, but mixes in Meow Mix to make it that high dollar food go farther

21. Sasha 6 yr SF DSH • CC: repeated episodes of sterile cystitis as a young cat • Thorough work-up included exam, bloodwork, UA, Urine culture, abdominal rads and abdominal US • Struvite stone removed from the bladder in 2013 – not cultured • In remission for 2 years • Recurrence of stranguria, hematuria, periuria in the past week • Feeds c/d multicare, but mixes in Meow Mix to make it that high dollar food go farther

22. Sasha • UA - hematuria, SG 1.022, no bacteriuria, no crystals, WBC TNTC • Abdominal radiographs

23. Sasha • UA - hematuria, SG 1.022, no bacteriuria, no crystals, WBC TNTC • Abdominal radiographs

24. Sasha • UA - hematuria, SG 1.022, no bacteriuria, no crystals, WBC TNTC • Abdominal radiographs

25. Sasha • UA - hematuria, SG 1.022, no bacteriuria, no crystals, WBC TNTC • Abdominal radiographs – right kidney smaller (29mm) and with mildly irregular margins than the left (43mm) • Abdominal ultrasound Left Kidney

26. Sasha • UA - hematuria, SG 1.022, no bacteriuria, no crystals, WBC TNTC • Abdominal radiographs – right kidney smaller (29mm) and with mildly irregular margins than the left (43mm) • Abdominal ultrasound

27. Sasha • UA - hematuria, SG 1.022, no bacteriuria, no crystals, WBC TNTC • Abdominal radiographs – right kidney smaller (29mm) and with mildly irregular margins than the left (43mm) • Abdominal ultrasound

28. Sasha • UA - hematuria, SG 1.022, no bacteriuria, no crystals, WBC TNTC • Abdominal radiographs – right kidney smaller (29mm) and with mildly irregular margins than the left (43mm) • Abdominal ultrasound – right hydronephrotic kidney • Filled with flocculent fluid • Right ureter 2.5mm • Right nephrectomy

29. Sasha • UA - hematuria, SG 1.022, no bacteriuria, no crystals, WBC TNTC • Abdominal radiographs – right kidney smaller (29mm) and with mildly irregular margins than the left (43mm) • Abdominal ultrasound – right hydronephrotic kidney • Filled with flocculent fluid • Right ureter 2.5mm • Right nephrectomy – filled with purulent fluid • Stricture in the right ureter

30. Sasha • recovery – severe stranguria for 2 days post-op • BUN 80, creat 2.6 the day after surgery • Since then, BUN has ranged from normal to the 40’s • Creat and phos normal • One episode of cystitis 60 days after surgery • Did well for 2 years after surgery, euthanized for renal failure 4 years after surgery

31. Lessons from Sasha • Repeating work-up of documented problems can reveal new problems, even when symptoms have not changed • Upper urinary tract inflammatory disease can result in lower urinary tract symptoms • Nothing good comes of leaving a hydronephrotic kidney in place • Hydronephrotic kidneys can be, but are not always enlarged • Even when end stage

32. Lessons from Sasha • The most common cause of hydronephrosis in the cat is a stone lodged in the ipsilateral ureter • DDx – stricture, tumor in ureters or bladder trigone • Hydroureter can be congenital, associated with ectopic ureter • Hydronephrosis is often subclinical until another problem surfaces, causing clinical signs • The other ureter is blocked by a stone • Downstream inflammation causes lower urinary tract symptoms, or cat becomes septic

33. Summary • PowerPoints – Kidney Ultrasound Cases • .pdf of PowerPoint – Kidney Ultrasound Cases(1 and 6 slides per page) • Client Handouts – Calcium Oxalate Diet • Videos – Case Examples, Urohydropropulsion

34. Acknowledgements Stephanie Lisciandro, ACVIM (Int Med) Chapter 5: Focused or COAST3 – KidneysFocused Ultrasound Techniques for the Small Animal PractitionerEditor Greg Lisciandro – 2014 Eastex Vet Clinic Drs. Weatherly, Richards & Acuna “Sahara,” “Molly,”and many case example images & videos

35. Acknowledgements Animal Medical Center of Jacksonville Dr. Ira Lee Stephens - “Sahara” North Street Veterinary Clinic Dr. Cheryl Russell - “Molly” Ward Animal Hospital “Molly” Southwood Drive Animal Clinic Drs. Shawn Penn & Doug Ashburn “Sasha” & Many case example images