scott@vtx-cpd.com

Replying to Lara Brunori 18/11/2024 - 13:36

Hi Lara,

Thank you again for your response. I wanted to provide an update with additional details. We checked ionized calcium, and it was marginally increased at 1.40 mmol/L (reference: 1.13–1.38 mmol/L). This might be age-related as Siichba is still a growing kitten, but we’re keeping it in mind. To help manage this and potentially reduce calcium excretion into the urine, we’ve recommended adding 1 gram of bloomed chia seeds daily to Siichba’s diet.

Based on the findings and concerns for stone formation, we suspect struvite stones as the most likely culprit given Siichba’s age (<6 months). We’ve initiated a therapeutic diet starting with feline c/d for two weeks, transitioning to feline i/d, which is nutritionally complete for kittens and designed to manage urinary health while preventing recurrence. We’re monitoring closely for any signs of worsening hydronephrosis or ureteral obstruction, as these could progress to renal insufficiency or failure. Currently, the blood work does not suggest renal dysfunction, but we are being proactive in case this changes.

Pending the repeat urine culture results via cystocentesis, we’ll decide on whether to continue antibiotics or adjust based on sensitivity findings. Regular rechecks, including imaging and urinalysis, will help us track changes in the stones’ size, position, and composition.

Your point about considering minimally invasive techniques like lithotripsy is well-taken—it would certainly be ideal if dissolution fails or calcium oxalate stones are confirmed. I’d love to hear your thoughts on this plan and any further suggestions you might have!

All the best,
Scott

Replying to Talia C. 18/11/2024 - 07:25

Dear Talia,

Thank you for your thoughtful message and for sharing your experiences! It’s always fascinating to hear perspectives from different regions, and it seems cystoliths are a universally challenging topic! I’ll do my best to address your points below:

Mixed Cystoliths
Your example of the pug with a history of PSS and mixed struvite-urate stones highlights just how unpredictable these cases can be. Mixed stones are particularly frustrating because they defy straightforward dissolution protocols and often require multifaceted management. In these cases, I try to focus on minimizing recurrence through individualized dietary and urinary pH strategies, though success can be limited by the complex interplay of factors.

Retrograde Hydropropulsion
I completely agree—retrograde hydropropulsion is a fantastic tool, especially for managing small stones and avoiding repeated cystotomies. I’ve found it to be particularly useful for recurrent cases, provided the stones are small and accessible. Your point about timing the procedure when stones are very small is critical to its success, and it’s great to hear it’s working well in your practice.

Calcium Oxalate (CaOx) Stones
CaOx stones are indeed a challenge, especially in dogs, as there’s no effective dissolution strategy. I sympathize with the frustration of recurrent cases, particularly in compliant owners doing everything right. For these patients, I emphasize regular monitoring with imaging (as you already do), ensuring a low urine specific gravity (USG <1.020 ideally), potassium citrate is often helpful if tolerated, though I understand the dilemma with diarrhea in some cases. In such instances, exploring alternative alkalinizers might be worth a try. Hydrochlorothiazide as a diuretic may help in reducing urinary calcium excretion, though it requires careful monitoring for side effects. It’s always a balancing act, but I find client education about the likelihood of recurrence helps manage expectations.

Cystoscopy and Antibiotic Use
Cystoscopy can be invaluable in chronic or refractory UTI cases, as your example demonstrates. The narrowed urethra you found is a great illustration of how underlying anatomical issues can perpetuate UTIs. Whether to repeat cystoscopies is a really interesting question. I think a lot of the time we don't get to repeat these procedures because of financial constraints for the owners. It also depends on what we’re looking for. If we’re just visualizing generalized inflammation, I’m not sure a repeat cystoscopy is always warranted. On the other hand, if we’re biopsying inflammatory areas and the problem isn’t resolving with our treatment, that might justify repeating the cystoscopy. In many cases, I think we’re addressing the inflammation we see and ruling it out as the cause of the problem.

UTI and Prednisolone
Chronic immunosuppression is always a tightrope walk in these cases. For patients like your Frenchie with recurrent UTIs due to incomplete bladder emptying, I often consider the following: bladder management, encouraging manual expression or intermittent catheterization if incomplete emptying is severe; antibiotic stewardship, regular cultures to guide targeted therapy, and I sometimes use prophylactic low-dose antibiotics if the recurrences are frequent and clinically significant; corticosteroid dose, if possible, I aim to taper to the lowest effective dose. In combination with leflunomide, it might be worth evaluating whether the steroid dose could be reduced further; adjunctive measures, cranberry extract, D-mannose, or other supportive therapies. Regarding urinary tract infections and steroid use, I think it really depends on the case. With the French bulldog you’re describing, could you consider interventions to help the dog empty the bladder better? Residual bladder volume is definitely an issue in cases like this. Could you consider a drug such as bethanechol to improve detrusor muscle contractility or other medications to help with bladder emptying? Addressing incomplete bladder emptying may significantly reduce the risk of recurrent infections.

Thank you again for your kind words and for taking the time to share your cases and thoughts.

Warm regards,

Scott

Replying to Talia C. 18/11/2024 - 16:53

Thing is…

This case is doing really well! I suppose it is challenging as it is very expensive and there is not a huge amount of evidence out there.

The owners are very dedicated and happy to continue with the treatment. It is not a treatment I would have started, but if the patient is doing well, it is hard not to justify continuing for now.

Scott 🙂

Replying to Lesley M. 18/11/2024 - 23:03

This is really helpful!

Do you have the link for the article? I am not able to find it.

Super helpful though, thank you for sharing. It does seem high no? Especially when we are often just talking about the ingestion of one or two grapes?

Scott 🙂