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