Page 740 - Small Animal Clinical Nutrition 5th Edition

768 Small Animal Clinical Nutrition

lymphoma in cats, may be a cause of CKD. Drugs that may
Table 37-3. Elements of the physical examination that
VetBooks.ir should be emphasized in patients with suspected chronic cause nephrotoxicosis include antimicrobials (aminoglyco-
sides), antifungals (amphotericin B), analgesics (aspirin,
kidney disease.
Body weight and body condition score ibuprofen and phenylbutazone), immunosuppressive agents
(penicillamine) and chemotherapeutic drugs (cisplatin, metho-
Cardiovascular system: Abnormal heart sounds? Increased
tortuosity of superficial veins? Systemic blood pressure trexate and daunorubicin) (Grauer, 1996). Geriatric patients
(direct or indirect measurement) abnormalities? Pulse rate may be at greater risk for drug-induced nephrotoxicity because
and character? of a decline in kidney function associated with aging, use of
Cervical region: Thyroid masses (cats)?
Fundus: Retinal detachment? Hemorrhage? Increased multiple drugs with nephrotoxic potential and altered metabo-
tortuosity of arteries? Retinal edema? Lipemia retinalis? lism and excretion that occurs in older patients.
Genitourinary tract (urethra, prostate gland, penis, prepuce,
vulva): Shape? Position? Pain? Discharge?
Hydration status
Kidneys: Both palpable? Size? Shape? Position? Surface PATIENT ASSESSMENT
contours? Pain? Bilaterally symmetrical?
Musculoskeletal: Muscle masses? Evidence of osteodystrophy? History
Oral examination: Mucosal ulcers? Pallor? Necrosis or
discoloration of tongue? Historical findings in patients with CKD may include
Temperature, pulse, heart and respiratory rates polyuria/polydipsia (less frequent in cats than dogs), lethargy,
Urinary bladder: Size? Position? Shape? Pain? Thickness of
wall? Intraluminal masses? Grating sensation? inappetence, vomiting, weight loss, nocturia, constipation, diar-
rhea, acute blindness (associated with hypertension) and
seizures or coma (terminal uremia). Cats also may have ptyal-
ism and muscle weakness with cervical ventriflexion due to
hypokalemic myopathy. In a retrospective study of cats with
Table 37-4. Diagnostic tests for evaluating patients with
suspected chronic kidney disease. CKD, polyuria and polydipsia were observed in 40%, vomiting
in 52%, inappropriate urination in less than 10% and diarrhea
Bacterial urine culture in 3% (Lulich et al, 1992). Nonspecific signs such as inappe-
Complete blood cell count
Diagnostic imaging (abdominal radiography and/or tence and weight loss also are common in dogs and cats with
ultrasonography) CKD. Rarely, signs of thromboembolic disease (e.g., severe res-
Excretory urography, if indicated for obstructive uropathy piratory distress, posterior paresis) may be present in patients
Renal biopsy, if indicated for evaluation of persistent proteinuria
or suspected renal neoplasia with nephrotic syndrome (i.e., proteinuria, hypoalbuminemia,
Serum biochemistry profile hypercholesterolemia and ascites/peripheral edema). Occur-
Systemic blood pressure measurement rence of clinical signs may depend on the stage of CKD at diag-
Urinalysis, including microscopic examination of urine sediment
Urine protein-creatinine ratio nosis. Dogs and cats with stage 1 CKD generally have no or
minimal clinical signs. However, polyuria/polydipsia may occur
in some patients during this stage. Systemic clinical signs
become more obvious in stages 3 and 4.
breeds (beagles, Chinese Shar-Peis) and related Abyssinian cats
(Chew et al, 1982; Boyce et al, 1984; Bowles and Mosier, 1992; Physical Examination
DiBartola et al, 1986, 1990). Histologic findings in renal tissue A thorough physical examination is indicated for patients
from beagles include moderate to severe glomerular amyloido- with suspected CKD, with emphasis on those items listed in
sis with inconsistent mild medullary interstitial amyloidosis Table 37-3. Dehydration (70%) and decreased body condition
(Bowles and Mosier, 1992). Medullary amyloid was identified (58%) were the most common abnormal physical examination
in all Chinese Shar-Pei dogs and nine dogs (64%) had glo- findings in a clinical series of cats with CKD (Lulich et al,
merular involvement (DiBartola et al, 1990). In 15 Abyssinian 1992). An abnormally large kidney was detected by palpation
cats involved in one study, amyloid was deposited in the in 25% of cases and an abnormally small kidney in 16% of
medullary interstitium of all cats and 11 cats had glomerular cases in this series. Gingivitis, halitosis and oral ulcers were
involvement (DiBartola et al, 1986). occasionally reported. Firm swellings in the nasomaxillary
region, including the maxillary and mandibular gingival sur-
Acquired Kidney Diseases faces and extending to frontal sites, may be present in young
CKD may result from a variety of systemic conditions that dogs with stage 4 CKD. These changes result from renal
cause kidney damage or there may be no apparent underlying osteodystrophy. Ascites or peripheral edema may be identified
cause. Infectious, inflammatory and immune-mediated diseases in patients with nephrotic syndrome; this finding is more
(e.g., leptospirosis, rickettsial diseases, pyelonephritis, amyloi- common in dogs than cats.
dosis) may cause inflammation of the renal interstitium or The primary abnormal findings in some patients with CKD
glomeruli. Glomerulonephritis secondary to systemic infec- are due to ocular changes (e.g., retinal hemorrhage and detach-
tious, inflammatory or neoplastic diseases may be a common ment) associated with hypertension. In one study, 15 of 23 cats
cause of CKD, especially in dogs. Renal neoplasia, particularly (65%) with CKD had indirect blood pressure measurements