Managing feline nephroliths (Proceedings)

Objectives

• Review the type and occurrence of nephroliths and ureteroliths in the cat.

• Review typical workup and diagnostic considerations

• Outline medical vs. surgical management options and their associated complications

Key Points

• The most common type of nephrolith/ureterolith in cats is calcium oxalate.

• A thorough workup of a suspected nephrolith/ureterolith includes bloodwork, urine culture, ultrasound and may include an intravenous pyelogram (IVP) and scintographic GFR studies.

• Many nephroliths can be left in place unless they are causing obstruction.

• Ureteroliths can potentially be managed medically, but success is variable.

• Surgical complications can include uroabdomen, ureteral stricture, and pyelonephritis.

Background

Over the last several years, there has been a shift in the mineral content of uroliths in cats from predominantly magnesium-ammonium phosphate (MAP) to calcium oxalate (CaOx). Of the nephroliths and ureteroliths analyzed by the Minnesota Urolith Center in 2002, 70% of 170 renolith submissions and 98% of ureterolith submissions were CaOx. A combination of age, diet and dynamics of urine flow within the kidney and ureters are just a few of the theories that may explain the increasing prevalence of CaOx in cats. This unfortunate shift presents a therapeutic dilemma for veterinarians as medical dissolution is not possible.

Clinical Workup

CBC

A CBC can identify evidence of chronic renal disease if non-regenerative anemia is present. Likewise, an inflammatory leukogram is more typical of upper urinary tract infections which may exist concurrently.

Biochemistry Panel

The biochemistry panel quantifies the extent, if any, of azotemia, but keep in mind that a cat with a ureteral obstruction may have pre-renal azotemia (dehydration from vomiting or decreased water intake), renal azotemia (underlying chronic renal disease or secondary pressure necrosis from hydronephrosis) and post-renal (a stone obstructing the outflow of urine from the kidney). Pre-renal azotemia can be a significant component and therefore the severity of the situation can only be assessed after appropriate rehydration of the patient with IV fluids.

Urine pH

The urine pH may provide some insight into the type of stone with calcium oxalate being present in acidic urine and struvite being present in alkaline urine. However, the urine pH alone should only guide recommendations rather than provide a definitive diagnosis of the stone itself as stones can be multi-layered depending on the pH environment as the stone grows. Urine culture is always an important aspect of urolithiasis management in the dog and the cat. The presence of a nephrolith or ureterolith (regardless of composition) can serve as a nidus for infection and could be exacerbating renal damage. Secondly, cats with pre-existing renal insufficient are more prone to upper urinary tract infections as they have lost one of their defenses against infection: urine concentration.

Radiographs

Radiographs, ideally taken after the colon has been emptied of feces, are an essential imaging technique in the workup of these cats. However, ultrasound is also necessary to establish the presence of hydronephrosis and dilated ureters and the architecture of both the affected and non-affected kidney if nephroliths/ureteroliths are unilateral. Excretory urograms are also a useful technique to assessing hydronephrosis, although carry with them a risk of acute nephropathies. Antegrade pyelography prevents the nephropathies, but requires ultrasonographic experience and fluoroscopy and carries with it its own set of complications.

Scintigraphy

In areas where scintigraphy is available, GFR studies can help confirm obstruction and ascertain the function of the contralateral kidney, again only if the nephrolith/ureterolith, is unilateral. Scintigraphy cannot determine function of the obstructed kidney.

Medical Management and complications

Medical management is indicated prior to surgery for several reasons. The patient often needs to be rehydrated and electrolyte imbalances or acid-base status corrected as much as possible in order to stabilize the patient prior to surgery. Secondly, aggressive IV fluids alone (2-3 times maintenance if cardiac function is normal) can cause the ureterolith to move into the bladder where it can be more easily removed without the complications associated with pylectomy or ureterotomy. In one study, in 9 of 14 cats that were managed medically and followed with serial radiographs, the ureterolith passed into the urinary bladder. Unfortunately, unlike in humans, the majority of ureteroliths are located in the proximal ureter. In another study, 2 dogs and 5 cats demonstrated retrograde movement of the ureteral stone back toward the renal pelvis, although this did not always improve the patient's status or outcome. The correlation between stone location using antegrade pyelogram and the actual location of the stone at surgery or at necropsy showed 100% correlation with this technique.

Additional Medical Therapies

Glucagon [0.5-0.1 mg/cat], which potentially decreases ureteral peristalsis, may be effective in some cats. Complications, such as vomiting, diarrhea tachypnea, and dyspnea can occur as a result of glucagon therapy. 8 of 25 anuric cats receiving either glucagon alone or in combination with diuretics received glucagon alone and 4 cats with glucagon passed the ureterolith urinary bladder. Because of potential side effects of the drug, the authors recommended additional studies before glucagon could be routinely recommended as therapy for ureteroliths.

The alpha-1 antagonists, like prazosin, have been successfully used to reduce the need for surgery in human, but few prospective studies have been done on prazosin. Amitriptyline has been anecdotally used as well with some success, but prospective evidence is lacking

Surgical Complications

The most common surgical procedures in current use are the ureterotomy and ureteroneocystomy). Both have complications of uroabdomen and post-surgical stricture.

Summary

Although the interval from diagnosis of a nephrolith or ureterolith until the time is surgery in animals is unknown, the human literature supports the idea that a surgeon should intervene if there is no movement of the stone in 3 days. Medical therapy is certainly indicated initially to stabilize the patient and because it may resolve the obstruction without the need for surgery and its associated post-operative complications.

References

Lulich JP, Polzin D, Osborne CA, et al. Urolithiasis and feline renal failure. ACVIM Proceedings, 2003.

Kyles AE, Stone EA, Gookin J, et al. Diagnosis and surgical management of obstructive ureteral calculi in cats; 11 cases (1993-1996). J Amer Vet Med Assoc 1998;213:1150-1156.

Kyles AE, Hardie EM, Wooden BG, et al. Clinical, clinicopathologic, radiographic, and ultrasonographic abnormalities in cats with ureteral calculi: 163 cases (1984-2002). J Amer Vet Med Assoc 2005;226:932-936.

Adin CA, Herrgesell EJ, Nyland TG, et al. Antegrade pyelography for suspected ureteral obstruction in cats: 11 cases (1995-2001). J Amer Vet Med Assoc 2003;222:1576-81.

Kyles AE, Hardie EM, Wooden BG, et al. Management and outcome of cats with ureteral calculi: 153 cases (1984-2002). J Amer Vet Med Assoc 2005 (226):937-944.

Hardie EM, Kyles AE. Management of ureteral obstruction. Vet Clinics of North Amer Sm Anim Pract 2204;34:989-1010.

Dalby AM, Adams LG, Salisbury SK, Blevins WE. Spontaneous retrograde movement of ureteroliths in two dogs and five cats. J Amer Vet Med Assoc. 2006;229:1118-21.

Forman MA, Francey T, Cowgill LD. Use of glucagon in the management of acute ureteral obstruction in 25 cats (Abstract). J Vet Intern Med 2004:18, 417.