Post on 25-Feb-2016
description
transcript
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.
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
RAYNA
RAYNA Hematuria
Trauma, calculi, tumor, cystic disease, nephritis, telangiectasia(permanent dilation of preexisting blood vessels), idiopathic
Ureteral obstructionCalculi, clot, stricture, neoplasia, ureteritis
Canine idiopathic renal hematuria or benign essential hematuria is 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 hematuria in 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, hydronephrosis and hydroureter were found
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
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
IMAGING DIAGNOSIS Ultrasonography Percutaneous antegrade pyelography
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 antegrade pyelography
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 ureteral stenting, 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
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
Virtual computed tomography image of a large mass of the lateral wall of urinary bladder.
Karabacak, et al. 2011
A virtual cystoscopic image of a 0.2 × 0.3 cm lesion in the superior wall of the bladder
Karabacak, et al. 2011
CT URETEROSCOPY
Chou, et al. 2007
TREATMENT Human
Injection of silver nitratePartial nephrectomy
DogsNephrectomy if unilateral
Bilateral cases have a poor prognosisPartial 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
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.
REFERENCES Idiopathic renal haematuria in a 15-year-old Arabian mare L. 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 tomographic virtual cystoscopy Original research 34 O R Karabacak, E Cakmakci, U Ozturk, F Demirel, A Dilli, B Hekimoglu, U Altug, CUAJ • February 2011 , 5(1)
Ureteral fibroepithelial polyp diagnosed preoperatively on virtual CT ureteroscopy Chen-Pin Chou, T. T. Wu,R. B. Levensen, Jer-Shyung Huang, Huay-Ben Pan. Abdom Imaging (2007) 32:421–423