scott@vtx-cpd.com
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Replying to Lesley M. 22/11/2024 - 22:36
Thank you so much and thank you again for sharing via email.
I will make sure to post here!
Scott 🙂
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,
ScottReplying to Talia C. 18/11/2024 - 07:46
Dear Talia,
Thank you for sharing your experience and for providing such a detailed breakdown of cystinuria genetics! The case of your miniature Bull Terrier is a great example of how combining chemical and surgical castration with dietary management can lead to excellent outcomes. It’s encouraging to hear that voiding hasn’t been needed for over a year—a testament to the success of the combined approach!
The information you found on the genetic aspects of cystinuria is fascinating and adds depth to our understanding of the condition. The distinctions between different types of cystinuria (e.g., Type I, II, III) and their inheritance patterns really highlight how diverse and complex this condition can be, particularly when androgen dependency comes into play.
Thanks again for sharing this!
Best regards,
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 Laura Jones 18/11/2024 - 11:29
Thank you again pal!
We appreciate you!!!
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 Talia C. 18/11/2024 - 17:06
Dear Talia,
I hope you are well!
Thank you for your detailed case description—this is indeed a challenging situation, and it’s great that you’ve already ruled out hyperadrenocorticism.
Primary Polydipsia vs. Other Causes:
Primary polydipsia (PD) can be difficult to confirm, especially in a multi-dog household where water intake cannot be accurately monitored. The USG variation in this case is interesting—morning concentration suggests some renal concentrating ability, but the subsequent low values during the day raise concerns about inappropriate diuresis.
While the morning USG of 1.028 shows some concentrating ability, it is still not maximally concentrated (e.g., >1.040).
The marked decrease in USG during the day suggests either significant water consumption or a potential inability to concentrate due to an underlying cause.Given she is intact, consider whether hormonal factors related to her recent heat in May 2024 could play a role. While pyometra seems unlikely based on your ultrasound findings, conditions like oestrogen influence on the kidneys may contribute to altered water balance? It might be worth repeating the ultrasound. Could there be something more subtle happening in the uterus.
To further investigate the cause of her PU/PD, advanced imaging such as an abdominal ultrasound and thoracic radiographs would be logical next steps. These could help identify any occult disease or structural abnormalities contributing to her clinical signs, particularly given her history of recurrent UTIs. Alongside imaging, a desmopressin (DDAVP) trial would be a non-invasive way to explore the possibility of central diabetes insipidus (CDI). If her urine becomes concentrated after desmopressin administration, this would support a diagnosis of CDI.Additional diagnostic options include measuring SDMA (symmetric dimethylarginine) to detect early renal dysfunction, which may not be apparent on routine biochemistry. Iohexol clearance testing could also be considered as a precise method for assessing glomerular filtration rate (GFR) if renal insufficiency remains a concern. Evaluating her renal function through a urine protein-to-creatinine ratio (UPC) would provide further insight into any subtle renal disease not evident on bloodwork or routine urinalysis.
Even though a water deprivation test is often used to differentiate between primary polydipsia, CDI, and nephrogenic diabetes insipidus (NDI), I would avoid this in her case due to the risk of dehydration and the availability of safer diagnostic approaches. This combination of imaging, targeted renal assessments, and a DDAVP trial offers a systematic and minimally invasive pathway to better understand her condition.
Does that make sense?
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 🙂
Replying to Dan T. 19/11/2024 - 12:11
Thank you again Dan!
Such a pleasure to work with you and your team.
Scott 🙂
How do you clean your Diamond Burr?
Honestly a question I have never considered on a Sunday!!!
Haha! Thanks for sharing!
Scott
Hello everyone!
I hope you are all well. My name is Scott, I am a specialist in small animal internal medicine. I know nothing about cardiology, but am very happy to help with any questions that might have a medicine slant.
I hope you all enjoy the course.
Scott 🙂
Hey.
Another great question!
I will make sure Georgina sees this!
Scott 🙂
Replying to Sarah W. 11/11/2024 - 20:50
Great!
Really glad to hear you are enjoying it!
We are always happy to hear if you have any other content ideas too!
Scott 🙂
Replying to Laura Jones 27/10/2024 - 09:23
I also love adding a wee bit of chia seeds to manage calcium! There’s a great case report on this in Frontiers in Veterinary Science (2020) titled “Managing Feline Idiopathic Hypercalcemia With Chia Seeds (Salvia hispanica L.): A Case Series” by Fantinati and Priymenko (doi: 10.3389/fvets.2020.00421). They found that supplementing with chia seeds (2g/cat/day) helped normalize ionized calcium levels in three cats after dietary changes alone weren’t effective. It’s definitely an interesting non-pharmacological approach worth keeping in mind. 😊
Replying to Laura Jones 27/10/2024 - 09:28
This is really useful.
Thank you for sharing! I will let you know how we get on with them!
Scott 🙂
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