Friday, November 25, 2016

Renomegaly - Enlarged Kidneys in Cats

Renomegaly in Cats


Renomegaly (enlarged kidneys) is a fairly common finding in cats.  This article discusses the common causes and potential treatments.





            I’m not the only veterinarian who has noticed that odd veterinary cases tend to come in twos and threes.   I can go months or even years without seeing a particular ailment, and then I’ll get two in the same week, sometimes even in the same day. 

            Last week I examined a 12 year-old cat for decreased appetite and weight loss.  From the cat’s scrawny appearance on the exam table, it was obvious that he had lost substantial weight.  On abdominal palpation, I immediately felt two markedly enlarged kidneys.   My very next appointment was a middle-aged cat for routine examination and vaccines.  The physical exam findings were normal, except when I felt the abdomen.  The right kidney was normal sized.  The left kidney, however, was at least three times the size of the right one. 

            Renomegaly (“reno” means “kidney”, “mega” means “increased size”) is the medical term for enlarged kidneys.  Renomegaly is not a diagnosis.  It is a physical exam finding.  Once identified, the judicious use of diagnostic tests such as x-rays, ultrasound, cytology, or biopsy often leads to a relatively quick diagnosis, because the list of disorders causing renomegaly in cats is fairly narrow. (see sidebar)  The characteristics of the kidney enlargement are helpful in formulating the list of possible causes. For example, renomegaly can be unilateral (one kidney affected) or bilateral (both kidneys affected).  It can be diffuse (the entire kidney is involved) or focal (only one part of the kidney is affected).  Renomegaly can also be described, based on the severity of the enlargement, as being mild, moderate, or severe.  

            Acute renal failure (ARF) typically causes bilateral, smooth, swollen painful kidneys.  Common causes include ingestion of toxins (with ethylene glycol or antifreeze being the most notorious), hypovolemic shock (inadequate perfusion of the kidneys), and pyelonephritis (bacterial kidney infection).

            Renal lymphoma is the most common cancer affecting the kidneys.  Affected cats are typically middle aged or elderly.  The degree of enlargement is moderate to severe, and both kidneys are involved.  Cats with renal lymphoma often have poor appetite, weight loss, excessive thirst and urination, lethargy, and pale gums. These signs are usually due to renal failure as a result of the lymphoma.  Some of these signs, however, may also be due to concurrent lymphoma in other organs such as the gastrointestinal tract and central nervous system.  Approximately 50% of cats with renal lymphoma are also infected with the feline leukemia virus.

            Feline infectious peritonitis (FIP) is an insidious viral disease that is nearly always fatal in cats.  Cats infected with FIP can develop either the “wet” form of the disease, in which the abdomen (and occasionally the chest cavity) fills with fluid, or the “dry” form, in which clusters of inflammatory cells, called granulomas, infiltrate various organs of the body.  The kidneys are a common target for these granulomas, and many cats with the dry form of FIP will have palpably enlarged, irregular kidneys.   There is no treatment for FIP, although an investigational drug called Polyprenyl Immunostimulant may show some promise in treating the dry form of the disease.  Further studies on this drug are needed.

            Sometimes, a cat will suffer some type of damage to one of the kidneys, resulting in a gradual loss of function in that kidney.  The loss of functional kidney tissue in the affected kidney continues over time, and the kidney gets smaller and smaller, as scar tissue forms in the kidney.  The cells of the opposite kidney become enlarged as the opposite kidney now has to do the work of both kidneys.  This enlargement is called compensatory hypertrophy and tends to be relatively mild.

            Polycystic kidney disease (PKD) is an inherited disorder in Persian cats and Persian crosses.  In cats with PKD, normal renal tissue is displaced by multiple enlarging cysts.   In most affected cats, clinical signs don’t develop until kidney failure develops, at which point the cat may show anorexia, increased thirst and urination, weight loss, and vomiting.  A more detailed discussion of polycystic kidney disease can be found in next month’s issue of Catnip (or whatever issue you decide to publish the article I’m scheduled to write).

            Primary renal cancer is uncommon in companion animals, accounting for less than 2.5% of all tumors in dogs and less than 1.7% of all tumors in cats.  As noted above, lymphoma is the most common renal cancer in cats.  It tends to affect both kidneys.  Other cancers affecting the kidney in cats include renal carcinoma, renal adenoma, and nephroblastoma.  These rare tumors are almost always unilateral.

            Renal abscesses and hematomas are uncommon causes of renomegaly in cats.  An abscess is a pocket of pus that develops within the kidney, either due to a blood borne infection, or via extension from an infected focus in a nearby organ.  Other causes include blunt abdominal trauma, penetrating wounds, or surgical contamination.  A hematoma is a solid swelling composed of clotted blood.  They usually occur secondary to trauma.

            Urine that is formed in the kidneys travels down the ureters into the bladder, and then out the urethra. If the flow of urine is obstructed, the urine builds up, causing dilation that begins in the central portion (the medulla) of the kidney.  The kidney tissue surrounding the medulla gets compressed from the pressure, until the kidney becomes a non-functional, fluid-filled sac, unless the obstruction is relieved.  Unilateral hydronephrosis results from obstruction involving a single ureter or kidney.  Common causes include a ureteral stone, a ureteral stricture, or accidentally tying off the ureter during spay surgery.  Cats that develop a stone in one ureter occasionally develop stones in the other ureter as well, which can lead to bilateral hydronephrosis.  The most common cause of unilateral hydronephrosis in cats is “idiopathic”, a nice way of saying that we have no idea why it happens.  Obstruction further down, at the level of the bladder or urethra, would be expected to cause bilateral hydronephrosis, however, even though urethral obstruction is very common in male cats, this obstruction is usually diagnosed quickly enough to precede any significant renomegaly. 
 
            [The kidney is surrounded by a tough fibrous capsule.  Occasionally, fluid can accumulate beneath the kidney capsule.  This will cause the kidney to feel enlarged on palpation.  Although these disorders technically are not causing enlargement of the kidney itself, they usually cannot be differentiated from true renomegaly based on abdominal palpation alone, or by x-rays.  Only by abdominal ultrasound can it be shown that the enlargement is due to the presence of fluid beneath the capsule of the kidney.  The most common sub-capsular disorders are sub-capsular hematomas and perinephric (perry-NEF-rick) pseudocysts.  Sub-capsular hematomas usually occur after blunt abdominal trauma or as a complication of kidney biopsy.  Perinephric pseudocysts  (“peri” = surrounding; “nephric” = pertaining to the kidney; “pseudo” = false) are accumulations of fluid just beneath the fibrous capsule that surrounds the kidneys.  They are called pseudocysts because they look like cysts, but unlike true cysts, they lack an epithelial lining.  One or both kidneys may be affected. Exactly why they develop is unknown.  About 75% of cats with perinephric pseudocysts also have some degree of chronic renal failure.] 

            As stated above, the list of causes of renomegaly is fairly narrow.  The age and breed of the cat is helpful in narrowing the list even further.  For example, young cats are more likely to have congenital problems or FIP.  Cancer is more common in older animals.  A high index of suspicion for PKD should be present if the patient is a Persian cat. 

            Physical exam findings also help narrow the list further.  Severe enlargement  is most likely caused by hydronephrosis, cancer, PKD, perinephric pseudocysts, or FIP.  If the kidneys feel irregular in shape, FIP, lymphoma, and other cancers are higher on the differential list.  Smooth kidneys are usually present in acute renal failure, hydronephrosis and compensatory hypertrophy.  If the cat shows pain when the kidneys are palpated, acute renal failure, kidney infection, and kidney abscess move up higher on the differential list. 

            Many of the illnesses that result in renomegaly will cause abnormalities on routine blood and urine tests. Occasionally, these tests alone will reveal the diagnosis.  In most cases, however, laboratory tests alone are inadequate for achieving a diagnosis for renomegaly.   X-rays give information about the size, shape and location of the kidneys, however, plain x-rays may not provide adequate detail.  A technique called excretory urography, in which a contrast agent is given intravenously, can enhance the appearance of the kidneys on the x-rays, giving more details regarding the cause of the renomegaly.   Ultrasound provides a rapid, non-invasive assessment of the kidneys, allowing evaluation of the internal structures of the kidneys.  Both techniques (x-rays and ultrasound) have their specific benefits and limitations. 

            In many cases, a definitive diagnosis for renomegaly requires obtaining a sample of the affected kidney tissue.  This is usually done either by a technique called fine-needle aspiration (FNA) or by biopsy.  Fine-needle aspiration is a procedure in which a needle, attached to a syringe, is inserted into kidney, using ultrasound guidance.  Suction is applied to the syringe so that cells from kidney are aspirated or sucked into the hub of the needle.  The contents are then sprayed onto a microscope slide and are sent to the laboratory for interpretation.  The advantage of this procedure is that it fairly non-invasive and inexpensive.  A disadvantage is that the aspirate may not yield enough cells to make a diagnosis.  If the aspirate doesn’t yield a diagnosis, a biopsy specimen needs to be obtained.  This can be done either through exploratory surgery, or less invasively through a variety of methods, such as laparoscopy (a procedure in which a fiber-optic device is inserted through a small hole in the abdominal wall, allowing a direct view of the abdominal organs), or through the use of a special biopsy needle, under ultrasound guidance, that allows for a small sample of kidney tissue to be obtained.  Once a diagnosis is obtained, a more specific treatment regimen can be devised.  Prognosis depends on the diagnosis.

            Renomegaly is not an unusual finding in cats.   A variety of conditions can lead to renomegaly, such as infiltration of the kidneys by inflammatory cells or cancer cells, structural abnormalities, hereditary conditions, and obstructive disorders.  Because the list of disorders causing renomegaly is narrow, veterinarians can often quickly arrive at a diagnosis, and treatment can be instituted. 



Sidebar: causes of renomegaly in cats

·      Acute renal failure
·      Lymphoma
·      Renal cancer (non-lymphoma)
·      Polycystic kidney disease (PKD)
·      Feline Infectious Peritonitis (FIP)
·      Compensatory hypertrophy
·      Renal abscesses and hematomas
·      [Perinephric pseudocysts]
·      Hydronephrosis



Sunday, November 13, 2016

Polycystic Kidney Disease


Polycystic Kidney Disease





            Polycystic kidney disease (PKD) is a slowly progressive inherited kidney disorder that affects Persian and Persian-related breeds.  It is the most prevalent inherited genetic disease in cats.  The prevalence of PKD varies in several countries, ranging from 36% (Slovenia) to 49.2% (United Kingdom).  In the United States, the prevalence of PKD in Persian and Persian-related cats is approximately 38%


            Although most normal cats eventually develop signs of kidney disease as they age, cats with PKD experience the signs of chronic kidney disease (CKD) at an earlier age.  Typically, cats begin to show the first signs of CKD around the age of 13 or 14.  Cats with PKD, on average, will develop signs of CKD around 7 years of age. 

            The job of the kidney is to filter toxins from the bloodstream and put them into the urine.  As cats age, normal kidney tissue is slowly replaced by scar tissue, and the kidneys gradually become less effective at filtering.  As the scar tissue contracts, the kidneys become progressively smaller in size.  The kidneys of cats that are affected by PKD also gradually lose their ability to filter, however, the kidneys of these cats become enlarged rather than become smaller.  This is due to the existence of multiple cysts (hence the “polycystic” in the name) that are present in both kidneys at birth. The cysts grow slowly over time, causing the kidneys to enlarge. These cysts compress the kidney tissue surrounding them, reducing their function.  The cysts can vary in size from less than 1 mm to greater than 1 cm.  Because the cysts enlarge over time, older cats will have larger cysts.  Cats with PKD occasionally will develop cysts in the liver as well, although this has no clinical consequence.

            The signs of CKD in cats include increased thirst and urination, poor appetite, weight loss, vomiting, and lethargy. Blood and urine tests will confirm that a cat has chronic kidney disease, but they do not establish that PKD is the underlying cause.  Late in the course of the disease, the detection of enlarged, irregular kidneys in a Persian or Persian-related cat is certainly suggestive that PKD is present, however, early in the course of disease the cysts are not detectable on physical examination.  To make a diagnosis of PKD early in the course of a cat’s life, some sort of diagnostic imaging procedure will need to be employed, with ultrasound being the most sensitive and noninvasive technique for this.

            Ultrasound has the potential to detect PKD very early in the course of disease, i.e. as early as 6 to 8 weeks of age.  In some instances, cysts have been detected in kittens as young as 4 weeks old.  In the hands of an experienced ultrasonographer, PKD can be diagnosed with approximately 75% sensitivity in cats less than 16 weeks of age.  This increases to 91% sensitivity in affected cats at 36 weeks of age (because the cysts may be larger and easier to detect). 

            In Persian cats, PKD is inherited as an “autosomal dominant” trait.  This means that if a cat with PKD is bred to a normal cat, 50% of the offspring will develop PKD.  Because kidney disease resulting from PKD develops later in life, an affected cat may have been used to produce a large number of kittens before it becomes ill from PKD itself.  Fortunately, PKD can now be diagnosed via genetic testing.  The test requires submitting a cheek swab or a blood sample to an appropriate testing facility.  When performing the genetic test, cats of any age can be tested. However, if testing kittens that have not yet been weaned, a blood sample is necessary, since nursing kittens will have traces of the mother cat’s DNA in their mouths, which may lead to inaccurate results if using a cheek swab. The genetic test accurately identifies all cats carrying the abnormal gene.

 
            Early identification of PKD, whether through ultrasound or genetic testing, is helpful because it allows the detection of the disorder before cats are bred.  If all affected cats are neutered and spayed once the disorder is detected, PKD could be eliminated completely from breeding populations.  Anyone planning to purchase a Persian kitten from a breeder should ask the breeder to give proof that the cats used to produce the kitten were screened as negative. 

            There is no treatment for PKD per se.  Treatment of the chronic kidney disease that results from PKD is similar to that of cats that develop CKD as a result of the natural aging process, or of any other cause of CKD.  This may include subcutaneous fluid administration, potassium supplementation, phosphorus binders, anti-nausea medications, appetite stimulants, drugs to control elevated blood pressure, drugs to reduce excessive protein loss in the urine, and the feeding of prescription diets that have reduced levels of protein and phosphorus.  Although there is no specific treatment for PKD, the presence of PKD can be reliably demonstrated by ultrasound in an older cat, or via genetic testing in any age cat.  If breeders remove all affected cats from their breeding stock, it should be possible to eradicate the disease from the breed.

           


             





Sunday, October 30, 2016

Chronic Rhinosinusitis in Cats

Chronic Rhinosinusitis in Cats

Chronic infection and inflammation of the nasal cavity and sinuses is a frustrating problem for cats, their owners, and the veterinarian.



            Upper respiratory infections are very common in cats, especially kittens.   Most of these infections are caused by viruses.  Approximately 90% of all upper airway infections in cats are caused by two common viruses:  feline herpesvirus and feline calicivirus.  Some affected cats develop secondary bacterial infections, which can make treatment and recovery longer and more difficult. 

 Acute sinusitis tends to affect young kittens and often causes sneezing, discharge from the eyes, a snotty nose, decreased appetite, lethargy, and usually a fever.  If oral ulcers are present, calicivirus is likely playing a role.  If corneal ulcers are present, the herpesvirus is most likely.  Many cat owners report a change in their cat’s meow, i.e. sounding more hoarse or even silent, or that the purr sounds more raspy. Treatment tends to be based on clinical signs.  Cats with conjunctivitis as a result of their viral infection often require antibiotic eye drops or ointments.  Secondary bacterial infections are treated with oral antibiotics.  Appetite stimulants may be warranted in cats that won’t eat.  Most of these acute infections are self-limiting, and cats usually recover uneventfully.

            Some cats, however, do not recover uneventfully.  Sever viral infection can result in permanent damage to the delicate anatomy in the nasal cavity, which predisposes the cat to recurrent bacterial infections.  Complicating matters, the feline herpesvirus is notorious for taking up permanent residence in the cat’s body.  The virus can periodically emerge from its dormant state, causing a flare-up of clinical signs and further destruction of the fragile turbinate bones in the nasal cavity.  These cats are said to have chronic rhinosinusitis.

            Chronic rhinosinusitis affects cats of any age.  The main clinical signs are intermittent or persistent sneezing, nasal discharge (either unilateral or bilateral), and congested breathing.  Discharge from the eyes is usually not present (although it can be, occasionally), and in general, these cats tend to not be systemically ill. Most veterinarians prescribe a short course (7 to 10 days) of antibiotics in cats with upper respiratory disease, and the fact that cats on antibiotics usually show clinical improvement supports their use.  However, clinical signs often recur despite therapy, which implies that bacteria are only one factor in feline upper respiratory disease.  If a 7 to 10 day course of antibiotics fails to resolve the disease, a thorough diagnostic work-up should be pursued before settling on a diagnosis of chronic rhinosinusitis.

            Although the most common cause of chronic rhinosinusitis is a prior, severe herpesvirus infection with subsequent damage to the nasal cavity, a diagnostic workup should be undertaken to rule out potentially treatable conditions, such as fungal infection, cancer, polyps, oronasal fistulas (a physical communication between the mouth and the nasal cavity) and foreign bodies.  This work-up may include bloodwork, a blood test to look for Cryptococcus (the most common fungus affecting the upper respiratory tract in cats), a thorough oral/dental examination, rhinoscopy (visualization of the inside of the nasal cavity and the back of the throat using a rhinoscope, an instrument that can be inserted directly into the nostrils), and a CT scan.  Radiographs may be helpful, but CT scans are preferred as the images they generate are thin, cross-sectional slices of the entire nasal cavity.  If rhinoscopy is performed, biopsy specimens should be submitted for histopathology to rule out cancer, and samples should be obtained for bacterial culture.  If the diagnostic tests rule out the treatable disorders mentioned above, then the diagnosis of idiopathic (i.e. no known cause) chronic rhinosinusitis is confirmed.  Now comes the hard part: trying to manage the disease and keep the cat comfortable.

            Veterinarians often choose antibiotics to treat cats with upper respiratory disease, whether to treat a secondary bacterial infection that is concurrently infecting the cat, or to prevent one from developing. If bacterial culture grows a single organism that isn’t typically found as part of the normal nasal flora, then an antibiotic should be chosen based on the proven effectiveness against that organism, and it should be administered for 6 to 8 weeks.  If multiple organisms are grown on culture, the significance of this questionable, since there are many species of bacteria that normally inhabit the nasal cavity.

            Antifungal drugs aren’t prescribed to treat chronic rhinosinusitis unless a fungal organism is proven to be present.  This is fairly uncommon occurrence.

            If an allergic component is suspected (i.e. the symptoms seem to be somewhat seasonal), antihistamines may be considered. 

            Obviously, if a polyp is diagnosed via rhinoscopy, the polyp should be removed surgically.  If cancer is diagnosed, treatment options can be offered.  The prognosis varies considerably depending on the type and extent of the cancer. 

            Because the herpesvirus is considered to be the main culprit in initiating and perpetuating chronic rhinosinusitis in cats, treatment directed at the virus itself may be beneficial.  Administration of an intranasal herpesvirus and calicivirus vaccine two or three times a year may help to stimulate a local immune response within the nasal cavity.  Oral antiviral drugs, such as famciclovir, have been administered to cats with confirmed herpesvirus infections, with promising results.  The amino acid lysine has been used to reduce the frequency of herpesvirus reactivation in infected cats, however, recent controlled studies are casting doubt on the efficacy of lysine. 

            Anti-inflammatory drugs play a role in the treatment of chronically affected cats.  They reduce airway swelling, improving breathing and making the cat more comfortable.  Glucocorticoids are the most commonly prescribed drug for this, with prednisolone being the drug of choice.   Because these drugs can suppress the immune system, there is concern that the respiratory infection could potentially worsen if these drugs are used continuously over the long term.  Thus, glucocorticoids are best used intermittently.  For example, using prednisolone daily for a week, and then tapering the dosage to every other day for an additional week, would be a reasonable schedule. 

            Supportive care, such as maintaining hydration (to keep nasal secretions less viscous and easier to clear), humidifying the air (for example, isolating the cat in a bathroom while running a hot shower, allowing the cat to breathe in the steamy air), and ensuring proper nutrition (for example, using appetite stimulants such as mirtazapine in affected cats that are eating poorly) are helpful in keeping affected cats happy and comfortable. 

            Cats with chronic rhinosinusitis will never be cured, however, with medical management and supportive care, most cats can have their sneezing and nasal discharge kept to a minimum, and maintain an excellent quality of life.

           




            
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