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88 Cards in this Set

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How does the kidney respond to a reduction in ECF?
Tubular reabsorption is increased d/t increased GFR from decreased blood pressure.
Activation of RAAS (Na/water retention)
How does the kidney respond to an increase in ECF?
Na/water excretion d/t decreased reabsorption from increased GFR.
Increased ANP leads to Na/water excretion.
What are the three components to urine concentration?
Countercurrent mechanism
Medullary hypertonicity
ADH and water permeability
What is the medicine definition of isothenuria?
1.008 - 1.025
What three factors contribute to blood pressure regulation? Which do the kidneys have control over?
Sympathetic tone
RAAS (kidneys)
Volume control (kidneys)
Which of the following are true regarding electrolyte regulation in chronic renal failure?
a) supernephrons will help to maintain Na levels
b) hypokalemia indicates >99% of nephron loss
c) decreased GFR leads to P loss
d) 20-30% of cats in CRF have hypokalemia
e) hyperphosphatemia correlates with 80% nephron loss
a) supernephrons will help to maintain Na levels
d) 20-30% of cats in CRF have hypokalemia
e) hyperphosphatemia correlates with 80% nephron loss
(99% nephron loss = hyperkalemia; decreased GFR = P retention)
T or F:
Hyperkalemia in CRF is a terminal event.
True!
Why do some cats with CRF get hypokalemic?
Nobody knows!!! Maybe reduced intake or acidifying diets???
Predict the following in chronic renal failure:
K level
Acid/base status
P level
Ca level
K level (normal to hyper; maybe hypo in cat)
Acid/base status (normal to acidosis)
P level (high)
Ca level (low)
Why does hypocalcemia occur in chronic renal failure?
Hyperphosphatemia stimulates PTH;
Decreased vitamin D
What causes hypercalcemia in patients with chronic renal failure? What is the significance?
Usually increased in complexed fraction (some d/t parathyroid hyperplasia); no clinical significance unless it causes hypercalcemic nephropathy
What are the endocrine functions of the kidney?
Ca homeostasis (excrete P, resorb Ca, and activate vit D under PTH influence)
Release erythropoietin if hypoxic
Irreversible kidney damage occurs in dogs with a creatinine above ________ and in cats __________.
Dogs >2
Cats >2.5-8
What are the 2 theories of renal disease progression?
Neurohormonal activation (cell death via angiotensin II, TGF B1, and NF-kB)
Hyperfiltration (cell injury d/t glomerular hypertension)
What are the 5 goals of managing renal failure?
Maintain hydration
Provide nutritional support
Fix what is fixable
Manage the unfixable
Prolong survival
Which of the following describe kidney disease?
a) any amount of nephron damage
b) no longer able to maintain normal function
c) pathologic process within the kidney
d) can be renal, pre-renal, or post-renal
a) any amount of nephron damage
c) pathologic process within the kidney
Which of the following describe kidney failure?
a) any amount of nephron damage
b) no longer able to maintain normal function
c) pathologic process within the kidney
d) can be renal, pre-renal, or post-renal
b) no longer able to maintain normal function
d) can be renal, pre-renal, or post-renal
What degree of nephron loss causes...
PU/PD?
Azotemia?
Hyperkalemia?
Hyperphosphatemia?
Anemia?
PU/PD (>66-75%)
Azotemia (>75-80%)
Hyperkalemia (>99%)
Hyperphosphatemia (80-99%)
Anemia (85-99%)
What are some causes of large kidneys with feline kidney disease?
Acute kidney dz
Hydronephrosis
FIP
Lymphoma
Polycystic kidney dz
In general, cats with kidney disease ___________ while dogs ____________.
Cats (get anorexia)
Dogs (vomit)
What is considered isothenuria in dogs? Cats?
Dogs (1.008 - 1.025)
Cats (1.008 - 1.030)
Which of the following are true?
a) There is a good correlation between BUN and clinical signs
b) BUN and creatinine both increase at the same rate when dehydrated
c) neither BUN nor creatinine are concentrated, excreted, or resorbed.
d) creatinine is a measurement of GFR
e) BUN is affected by protein input
a) There is a good correlation between BUN and clinical signs
d) creatinine is a measurement of GFR
e) BUN is affected by protein input
(note: BUN is excreted and some is reabsorbed; thus BUN increases more with dehydration)
What are markers of kidney damage in bloodwork?
Azotemia
Hyperphosphatemia
Hypoalbuminemia
What are markers of kidney damage in the urine?
Isothenuria
Proteinuria
Cylinduria
Hematuria
Inappropriate glucosuria
Cystinuria
What are normal kidney sizes of dogs/cats on radiography?
Dogs (2.5-3.5x L2 on VD)
Cats (2.4-3x L2 on VD)
What are the markers of renal damage viewed via imaging modalities?
Abnormal shape
Abnormal size
Abnormal radiopacity or echogenicity
Abnormal number
What is the most common cause of pre-renal azotemia?
Dehydration
Which of the following will present with primary azotemia?
a) hyperthyroidism
b) Addison's
c) Diabetes immitus
d) Pyometra
e) Hypocalcemia
a) hyperthyroidism
b) Addison's
d) Pyometra
(other causes include: any kidney disease, Cushings in dogs, hyperCa or hypoK, UTI, iatrogenic meds)
Which of the following are signs of chronic kidney disease?
a) small kidneys
b) lumpy kidneys
c) osteomyelitis
d) proteinuria and azotemia
e) regenerative anemia
a) small kidneys (50% of cats have normal to large kidneys though)
b) lumpy kidneys
d) proteinuria and azotemia (also a sign of acute)
(other chronic signs include non-regenerative anemia, osteopenia, hx of PU/PD)
Describe how creatinine increases in dogs and cats as CRF progresses.
Dogs and 50% of cats (creatinine steadily increases with spikes during crises)
Rest of cats (no progression, creatinine <3 then sudden increase; half of these cats die in first crisis)
Predict the creatinine levels of dogs/cats for the following stages of CRF:
Stage 1
Stage 2
Stage 3
Stage 4
Stage 1 (dogs <1.4; cats <1.6)
Stage 2 (<2; <2.8)
Stage 3 (<5)
Stage 4 (>5)
If you see a cat in acute renal failure with a very hyperechoic renal cortex, what is your first differential?
EG toxicity!
What are your major differentials for acute kidney disease?
Toxins, Ischemia, Lepto; maybe SLE or SIRS
What are common nephrotoxins in dogs/cats?
Dogs (grapes and raisins)
Cats (easter lily)
Both (EG, Vit D rodenticides, drugs like nsaids and aminoglycosides)
What are some causes of ischemic injury to the kidneys?
Shock/trauma/anesthesia
Dehydration
NSAIDs
Pigment nephropathy
HyperCa
heat stroke/hyperthermia
sepsis
T or F:
Most infectious, immune mediated and neoplastic causes of acute renal failure also cause chronic renal failure.
True!
What are some broad categorical causes of chronic renal failure?
Post acute kidney dz
Familial dz
Chronic nephritis
Polycystic kidney dz
Glomerulonephritis
Amyloidosis
Nephrolithiasis
What are the major steps in managing a uremic crisis?
Decide if it is renal or not.
Decide if it is acute or chronic.
Can the patient urinate?
Treatment and prognosis
What are some conditions that can present as a uremic crisis?
Addisonian crisis in dogs
Pyometra
Which of the following describes the induction phase of acute renal failure?
a) intervention in this stage can remove the insult and stop kidney damage
b) can last hours to days
c) renal cell death has occured
d) uremic crisis
e) often not recognized
a) intervention in this stage can remove the insult and stop kidney damage
b) can last hours to days
e) often not recognized
Which of the following describes the maintenance phase of acute renal failure?
a) oliguria is common
b) can last days to weeks
c) renal cell death has occured
d) uremic crisis
e) often not recognized
a) oliguria is common
b) can last days to weeks
c) renal cell death has occured
d) uremic crisis
(this is usually the stage where vet intervention is sought; intervention doesn't reverse process)
Which of the following describes the recovery phase of acute renal failure?
a) cellular swelling and tubular debris lead to oliguria
b) can last days to weeks
c) improved GFR
d) intervention can reverse the process
e) extreme polyuria
c) improved GFR
e) extreme polyuria
Complete recovery from acute renal failure is possible as long as which structure is preserved?
Basement membrane
Why does chronic renal failure suddenly worsen in dogs? In cats?
Dogs (dehydration, infection)
Cats (stones, dehydration, maybe infection)
T or F:
Diuresis is contraindicated with oliguria.
False!
What does rehydration do for the patient in the uremic crisis?
Corrects any pre-renal azotemia
Maintains life w/renal azotemia
Stabilizes pt w/post renal azotemia
How fast should a patient in a uremic crisis be rehydrated? What other considerations should you take?
4-6 hrs (@ 2-3x maintenance)
Watch out for K
Maybe put in indwelling catheter
What is the normal urine output? On fluids?
Normal (1-2 ml/kg/hr)
Fluids (2-5 ml/kg/hr)
What is the most important aspect for managing polyuric patients?
Maintain hydration
What effect does "washing" the kidneys via diuresis have?
Aids catabolite excretion
Electrolyte correction
Hydration maintenance
When should kidney washing be completed?
a) 48 hour gradual decrease
b) when creatinine = GFR
c) when patient becomes polyuric
d) after patient is rehydrated
e) when BUN drops below 100
b) when creatinine = GFR
e) when BUN drops below 100
Which of the following are NOT appropriate therapies for the oliguric patient?
a) volume expansion
b) mannitol with aminoglycoside toxicity
c) dopamine
d) furosemide
c) dopamine
(note: FUROSEMIDE with AG toxicity is bad)
What is the next step in an oliguric patient that is not responding to diuresis and dialysis is not an option?
Give measured fluids (3-5ml/kg/6hrs + sensible and urinary losses)
Monitor body weight
What concomittent issues in the uremic crisis are fixable? How are these treated?
Stones (get the sucker out)
Infection (Ampicillin empirical therapy; Lepto in dogs)
What are the non-fixable things and how are they treated?
Hyperkalemia (insulin/glucose)
Acidosis (treat pH, not the bicarb)
Hyper P (non Ca fluids, hydroxide binders)
Anemia (transfusion & etc)
Blood pressure (treat hypo/hypertension)
Malnutrition (feed them)
Which three conditions give a poor prognosis in acute intrinsic renal failure?
Persistent oliguria
Creatinine >10 after rehydration
Overhydration
Which of the following are true regarding chronic renal failure?
a) more cats than dogs will be hyperkalemic
b) 50% of cats and dogs w/CRF have normal appearing kidneys
c) Some cats and dogs can have azotemia with concentrated urine
d) Dogs love to vomit more than cats
e) Cats get kidney stones, dogs get UTIs
a) more cats than dogs will be hyperkalemic
d) Dogs love to vomit more than cats
e) Cats get kidney stones, dogs get UTIs
(note: some azotemic cats still concentrate urine; cats are more tolerant of azotemia; and some CATS have normal kidneys)
What should you always check with chronic renal failure?
Proteinuria
Blood pressure
What are indications for performing culture and sensitivity in chronic renal failure?
On initial presentation
If urine is alkaline
Pyuria
Bacteriuria
When is renal-associated GI disease treated? How?
Anorexia/vomiting/dark stool
Tx via H2 blockers, PPIs, metaclopramide, or maropitant
Which of the following does NOT affect chronic renal failure progression?
a) hyperphosphatemia
b) metabolic acidosis
c) hypertension
d) dehydration
e) malnutrition
b) metabolic acidosis
When should anemia be treated?
When PCV<20-25%
What is the chief clinical sign of hypokalemia in cats? Dogs?
Cats (cervical ventiflexion)
Dogs (tetraparesis)
What are guidelines for treating acute metabolic acidosis? Chronic?
Acute (low pH)
Chronic (look at bicarb); treat cats <17 and dogs <19 mMol/L
What is the goal of treating hyperphosphatemia?
Get PTH back to normal without hypercalcemia!
What are the major methods of prolonging survival in the patient in chronic renal failure?
Control blood pressure
Decrease proteinuria
Decrease neuroendocrine activation
Hemodialysis/continual renal replacement therapy/transplant
How is proteinuria in chronic renal failure treated?
ACE inhibitor
Renal friendly diets
What role do ACE inhibitors have on chronic renal failure?
Reduce proteinuria
Reduce renal fibrosis
Reduce hypertension
What are the 2 main causes of protein losing nephropathy?
Glomerulonephritis
Amyloidosis
What is the hallmark of glomerular disease?
Persistent proteinuria
What are the 4 changes associated with nephrotic syndrome?
Proteinuria
Hypoalbuminemia
Ascites/edmea
Hypercholseterolemia
Which of the following are NOT true?
a) patients w/glomerular disease are likely to be hypertensive
b) azotemia and proteinuria are the hallmarks of glomerulonephritis
c) patients with hypertension are more likely to have glomerular disease
d) not all dogs with proteinuria are azotemic
e) most animals with glomerulonephritis or amyloidosis have thromboemboli
b) azotemia and proteinuria are the hallmarks of glomerulonephritis (NO - ONLY PROTEINURIA)
e) most animals with glomerulonephritis or amyloidosis have thromboemboli (NOT MOST; 12% GN AND 19% AMYLOIDOSIS)
What are normal urine protein:creatinine values in dogs and cats? At what value is glomerular disease likely?
Dogs (< 0.5)
Cats (<0.4)
At levels >2, glomerular disease is LIKELY in dogs (doesn't apply to cats)
How does a cat UPC differ from a dog?
Cat with NORMAL UPC can still have decreased survival while dogs with normal UPC will have increased survival.
When should you test UPC?
Hypoalbuminemia
Positive protein dipstick on UA w/no WBC or hematuria
Breeds w/ high-risk of familial dz
With other diseases associated w/renal involvement causing proteinuria
What diseases with renal involvement will cause proteinuria?
Renal disease
Hypertension
DM
Cushing's
Glomerulonephritis/Amyloidosis
When is kidney biopsy the MOST beneficial? What will it diagnose?
In NON-AZOTEMIC animals with proteinuria;
Biopsy diagnoses amyloidosis, glomerulonephritis, inflammation, familial dz
Which are NOT true regarding glomerulonephritis?
a) intraglomerular immune complexes associated with inflammation
b) can be a local inflammatory process
c) involves antibodies against glomerular basement membranes
d) is more common in dogs
e) commonly found with hypercholesterolemia in cats
a) intraglomerular immune complexes associated with inflammation (NOT ALWAYS INFLAMMATORY)
e) commonly found with hypercholesterolemia in cats (NO, in DOGS)
What infections should you worry about causing GN in dogs?
Lots! The rickettsial diseases, Brucella, Bartonella, Endocarditis, Leishmania, pyometra
What infections should you worry about causing GN in cats?
Viral! FeLV, FIP, FIV
What are lab abnormalities associated with GN? Which is most common?
Proteinuria (most common)
Microalbuminuria
Hypoalbuminemia
Low antithrombin
Hypercholesterolemia (dogs)
T or F:
Hypercholesterolemia is uncommon in cats.
False!
It is common; just not associated with glomerular disease
What are the histopathologic findings in glomerular disease? Which has the best medical response?
Membranous
Proliferative
Membranoproliferative
Glomerulosclerosis
Minimal change disease (only via EM; responds well to steroids)
Which forms of GN respond well to steroids?
GN due to SLE, IgA nephropathy, minimal change disease; cats also respond well
Which of the following are true regarding the treatment of GN?
a) It is suggested that cyclosporine may help
b) ACE inhibitors + diet is the baseline management
c) Doxycycline can help with inflammation
d) ATIII is assumed to be low when albumin is below 2
e) Patients with ATIII values <80% of normal are considered to be in hypercoagulable states
b) ACE inhibitors + diet is the baseline management
d) ATIII is assumed to be low when albumin is below 2
(note; Doxy is for occult rickettsial infections; ATIII<70% of normal is hypercoagulable)
What ATIII and fibrinogen values have a high risk for thromboembolic events? How is this treated?
ATIII<70% of normal
Fibrinogen >300mg/dL
Tx w/aspirin
What is the common signalment for amyloidosis in small animals?
Older dogs, females>males
Shar Pei
(also medullary amyloidosis in Abyssinians)
How can amyloidosis be diagnosed? Treated?
Dx via biopsy w/Congo Red stain
Colchicine prevents amyloidosis; DMSO or MSM may help