Fiche de révision : Understanding Kidney and Urinary Tract Diseases

📋 Course Outline

1. Types and phases of Acute Kidney Injury (AKI)
2. AKI grading and urine output-based sub-grading
3. Etiology and biomarkers of AKI: prerenal, intrinsic, postrenal
4. Clinical diagnosis and laboratory findings in AKI
5. Medical management of AKI including fluid therapy and supportive care
6. Chronic Kidney Disease (CKD) clinical management and staging
7. Glomerulonephritis (GN): pathophysiology, diagnosis, and treatment
8. Familial and congenital renal diseases and their management
9. Feline Lower Urinary Tract Disease (FLUTD) management and prevention
10. Urinary retention: causes, diagnosis, and treatment options
11. Urinary incontinence: etiology, diagnosis, and therapeutic approaches
12. Urethral obstruction in lower urinary tract disease: treatment and controversies

📖 1. Types and phases of Acute Kidney Injury (AKI)

🔑 Key Concepts & Definitions

• INDICATIONS : Clinical signs and laboratory findings that suggest the presence of acute kidney injury and guide the need for intervention.
• Acute Kidney Injury (AKI) : A sudden loss of kidney function characterized by four phases: induction, extension, maintenance, and recovery, each with specific pathophysiological changes.
• Eiras Acute Kidney Injury : A framework describing AKI phases including ischemic or nephrotoxic insult, injury with altered renal perfusion and hypoxia, established damage with decreased glomerular filtration rate, and renal tissue regeneration.
• Purposes- Ana Eiras Acute Kidney : The understanding of AKI phases facilitates timely intervention and prognosis assessment.

📝 Essential Points

• AKI involves a sudden loss of kidney function with distinct phases.
• The induction phase involves ischemic or nephrotoxic insult until renal changes occur, with variable duration; early intervention may prevent progression.
• The extension phase includes injury with altered renal perfusion, ongoing hypoxia, inflammation, and epithelial/endothelial injury.
• The maintenance phase is when critical damage is established, resulting in decreased GFR, renal hypoperfusion, azotemia, and uremia.
• The recovery phase involves renal tissue regeneration and repair with variable restoration of function.
• For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Etiology Prerenal AKI (hemodynamic) Decreased GFR + normal injury biomarkers HIPOVOLEMIA - hemorraghe: trauma, surgical - GI losses: vomiting , diarrhea - renal fluid loss: drug/osmotic diuresis, diabetes insipidus, adrenal insufficiency - Increased fluid loss: hyperthermia, burns - “third space” : pancreatitis, hypoalbuminemia, ascites - Drugs: diuretics.
• EXTENSION Injury with alterations in renal perfusion, continued hypoxia, 2nd inflammation, ongoing epitelial/endotelial injury 3.

💡 Key Takeaway

Understanding the distinct phases of AKI is crucial for timely intervention and prognosis.

📖 2. AKI grading and urine output-based sub-grading

🔑 Key Concepts & Definitions

AKI grading primarily relies on blood creatinine levels to assess the severity of kidney injury. Elevated creatinine indicates decreased renal function, with the degree of increase correlating to the AKI stage. Urine output (UOP) sub-grading distinguishes between non-oligoanuric and oligoanuric AKI in hospitalized patients, where decreased urine production reflects more severe impairment.

Non-oligoanuric AKI refers to cases with relatively preserved urine output despite increased creatinine, whereas oligoanuric AKI involves significantly reduced urine production, often necessitating renal replacement therapy. Recognition of non-azotemic AKI allows for early intervention before marked azotemia develops.

📝 Essential Points

• AKI grading is primarily based on blood creatinine levels, with increased creatinine indicating active kidney injury. In hospitalized patients, urine output sub-grading helps differentiate non-oligoanuric from oligoanuric AKI, guiding clinical decisions such as the need for renal replacement therapy. For example, dogs with IRIS AKI Grade 1 have approximately a 60% risk of in-hospital mortality compared to dogs without AKI, emphasizing the importance of early detection.

• Recognition of non-azotemic AKI is crucial for early intervention, which can improve outcomes. Monitoring urine output and creatinine levels over time allows for accurate staging and sub-grading, informing prognosis and management strategies.

💡 Key Takeaway

Grading AKI by blood creatinine levels and urine output-based sub-grading enhances prognosis accuracy and informs clinical management, enabling timely intervention and potentially improving survival outcomes.

📖 3. Etiology and biomarkers of AKI: prerenal, intrinsic, postrenal

🔑 Key Concepts & Definitions

• Prerenal AKI : A category of acute kidney injury caused by renal hypoperfusion without damage to the renal parenchyma, characterized by decreased glomerular filtration rate (GFR) and normal injury biomarkers.
• Intrinsic renal AKI : A form of acute kidney injury resulting from ischemia or nephrotoxins that cause damage to the renal parenchyma, leading to decreased GFR and elevated injury biomarkers.
• 2025/2026 : MS IX URINARY SYSTEM – medical approach 2025/2026 - MS IX.

📝 Essential Points

• Prerenal AKI results from renal hypoperfusion without parenchymal damage, showing decreased GFR with normal injury biomarkers.
• Intrinsic renal AKI involves ischemia or nephrotoxins causing renal parenchymal damage, with decreased GFR and elevated injury biomarkers.
• Postrenal AKI is caused by acute urinary tract obstruction.
• Biomarkers such as BUN, creatinine, SDMA, serum cystatin, and microalbuminuria may take up to 72 hours to increase after injury, aiding in AKI categorization.
• Prerenal AKI shows decreased GFR with normal injury biomarkers; intrinsic AKI shows decreased GFR with elevated injury biomarkers.

💡 Key Takeaway

Differentiating AKI etiology using biomarkers is essential for targeted diagnosis and treatment.

📖 4. Clinical diagnosis and laboratory findings in AKI

🔑 Key Concepts & Definitions

Clinical signs of stage 5 AKI encompass gastrointestinal, cardiovascular, and neurologic symptoms, indicating severe systemic involvement. Physical examination findings may include nausea, vomiting, diarrhea, anorexia, oral ulcers, obtundation, coma, or seizures, reflecting the extent of systemic toxicity. Laboratory markers in AKI diagnosis typically show increased blood urea nitrogen (BUN), creatinine, and phosphorus levels, with the BUN/creatinine ratio usually elevated, indicating azotemia. Urinalysis findings often reveal white blood cells and casts, especially in conditions like acute tubular necrosis and pyelonephritis; casts tend to dissolve quickly, necessitating prompt sediment analysis. Urine specific gravity (USG) in AKI generally exceeds 1,018, often surpassing 1,030, and correlates with urine concentrating ability.

📝 Essential Points

• In advanced AKI, clinical signs such as gastrointestinal disturbances (nausea, vomiting, diarrhea, oral ulcers) and neurologic symptoms (obtundation, coma, seizures) are prominent. Physical examination may reveal additional signs like oral ulcers and systemic symptoms. Laboratory findings include increased BUN, creatinine, and phosphorus, with the BUN/creatinine ratio typically high, reflecting azotemia. Creatinine is an insensitive marker of glomerular filtration rate (GFR) in AKI, making BUN and phosphorus more reliable indicators. Urinalysis may show white blood cells and casts, especially in acute tubular necrosis and pyelonephritis; casts dissolve rapidly, so sediment analysis should be prompt. Urine output (UOP) decreases due to activity of RAAS and ADH, with USG often above 1,018 and frequently over 1,030, indicating concentrated urine.

💡 Key Takeaway

Integrating clinical signs with laboratory and urine findings allows for accurate diagnosis and staging of AKI, facilitating timely intervention and management.

📖 5. Medical management of AKI including fluid therapy and supportive care

🔑 Key Concepts & Definitions

• Fluids are also a “drug” - Goals : Maintain hydration status - Water by mouth (or feeding tube) is better than SQ fluids - IMPORTANT → Free water available CKD- Clinical consequences/medical management 2025/2026 - MS IX.

📝 Essential Points

• Anti-nausea drugs such as maropitant and ondansetron are used to manage vomiting.
• Gastric acid suppression with omeprazole or sucralfate helps prevent gastric ulcers.
• For teaching purposes- Ana Eiras Uremic gastritis, nausea, vomiting, diarrhea, oral ulcers Symptomatic Management - usually not needed until later stages (stage 3-4) - Anti-nausea (maropitant, ondansetron)

💡 Key Takeaway

Effective AKI management requires correcting fluid imbalances and supporting gastrointestinal health.

📖 6. Chronic Kidney Disease (CKD) clinical management and staging

🔑 Key Concepts & Definitions

• Chronic Kidney Disease (CKD) : A progressive kidney disorder characterized by decreased renal function over time, requiring repeated staging every 3-4 months to monitor progression and adjust therapy.
• Stage of disease - Progressive disease : The classification of CKD severity that requires repeated staging every 3-4 months to adjust therapy; progressive disease may necessitate repeat diagnostic work-up to differentiate acute on chronic kidney injury.
• Advanced therapies : Treatment modalities for severe or end-stage CKD including hemodialysis, which involves blood removal through large dialysis catheters placed in jugular veins, passage through an artificial kidney (dialyzer) with anticoagulants, and return of blood to the patient during sessions lasting 5-6 hours.

📝 Essential Points

• Advanced therapies include hemodialysis with large dialysis catheters and artificial kidney machines.
• Feeding tubes such as esophageal tubes support nutrition and hydration in anorexic CKD patients and can be maintained long term.
• For teaching purposes- Ana Eiras Anorexia, weight loss - Feeding tubes (Esophageal tubes) - Water - Medications - Adequate nutrition as well as proper diet (renal) - Patient can still eat with tubes - Can be maintain long term CKD- Clinical consequences/medical management 2025/2026 - MS IX.
• For teaching purposes- Ana Eiras CKD - Advanced Therapies Hemodialysis - remove blood for dialysis - enter into a machine + anticoagulant - Dialyzer (artificial kidney) - Blood back to the patient - Large dialysis cateter in jugular veins until caudal vena cava - Each session 5-6h 2025/2026 - MS IX.

💡 Key Takeaway

Regular monitoring through repeated staging every 3-4 months and the use of advanced supportive therapies like hemodialysis and feeding tubes are essential for effective management of progressive CKD.

📖 7. Glomerulonephritis (GN): pathophysiology, diagnosis, and treatment

🔑 Key Concepts & Definitions

• Diagnosis : A clinical process involving complementary exams such as proteinuria evaluation and renal biopsy, which provides definitive identification of glomerulonephritis but may not be necessary if treatment of the underlying disease resolves proteinuria.
• Nephrotic syndrome : A clinical syndrome defined by the triad of hypoalbuminemia, proteinuria, and hypercholesterolemia, which is pathognomonic of glomerulonephritis.

📝 Essential Points

• Anti-proteinuric drugs such as benazepril and telmisartan reduce proteinuria and control hypertension in GN.
• Immunosuppressive treatments include mycophenolate, cyclophosphamide, short-term glucocorticoids, and cyclosporine.
• For teaching purposes- Ana Eiras Proteinuria → RISK FACTOR FOR PROGRESSIVE DISEASE Proteinuria - Glomerular or Tubular origin - Tubulointerstitial CKD → fewer tubules available to reabsorb small proteins → hyperfiltration for less glomerulus and hypertension→ glomerulosclerosis → worse proteinuria - Glomerular disease: leak of large proteins + exceed capacity to reabsorb them - ASSOCIATED WITH DECREASED SURVIVAL IN CATS (1000 vs 400 days) -Management: Low protein diet (kidney diet) Anti-proteinuric drugs → ACEi (Angiotensin Converting Enzyme inhibitor) – Benazepril → ARB – Telmisartan Blood Thinners (glomerular proteinuria) → clopidogrel Fish oil therapy / Omega-3 CKD- Clinical consequences/medical management 2025/2026 - MS IX.
• Immunossupressive treatment → mycophenolate / cyclophosphamide /short-term glucocorticoids cyclosporine 2025/2026 - MS IX.

💡 Key Takeaway

Targeted diagnosis and multi-modal treatment improve outcomes in glomerulonephritis.

📖 8. Familial and congenital renal diseases and their management

🔑 Key Concepts & Definitions

• Renal agenesis : The congenital absence of one or both kidneys.
• Hypoplastic kidneys : Kidneys with a reduced number of nephrons, leading to decreased renal function.
• Renal dysplasia : A developmental abnormality involving immature nephrons and abnormal differentiation of renal parenchyma, often difficult to distinguish from CKD.
• Consequences/medical management 2025/2026 : Management strategies for these congenital conditions align with CKD protocols; PKD cats should be removed from breeding programs.

📝 Essential Points

• Hypoplastic kidneys have fewer nephrons.
• Renal dysplasia involves abnormal differentiation with immature nephrons and hypertrophy, resembling CKD.
• Polycystic Kidney Disease is the most common genetic renal disease in felines, especially Persian cats, caused by an autosomal dominant mutation.
• Management of these diseases follows CKD treatment protocols; PKD cats should be excluded from breeding.

💡 Key Takeaway

Recognizing genetic renal diseases guides appropriate management and breeding decisions.

📖 9. Feline Lower Urinary Tract Disease (FLUTD) management and prevention

🔑 Key Concepts & Definitions

• Lower Urinary Tract Feline Lower : The anatomical region including the bladder and urethra involved in urine storage and passage.

📝 Essential Points

• Canned food is the only treatment proven to reduce recurrent FLUTD episodes by increasing water intake and diluting urine.
• Stress reduction strategies include avoiding overcrowding, providing enough clean litter boxes, and using Feliway diffusers.
• Synthetic glycosaminoglycans like glucosamine have unproven efficacy but may benefit a small population of cats with FLUTD.
• Amitriptyline, an antidepressant with anti-inflammatory and analgesic effects, is effective in managing chronic FLUTD cases.
• Reduce stress – avoid overcrowding (feline and human) - enough clean litter- boxes in diferent areas - Feliway diffusers 4.
• Amitriptyline : anti-depressant (with anti-inflammatory and analgesic effects) Effective in chronic cases 2025/2026 - MS IX.

💡 Key Takeaway

Dietary management through canned food and environmental stress reduction are central to preventing and treating FLUTD.

📖 10. Urinary retention: causes, diagnosis, and treatment options

🔑 Key Concepts & Definitions

• Urinary retention : A clinical condition characterized by inability to empty the bladder completely or at all, presenting with signs such as dysuria, stranguria, absence of attempts to urinate, enlarged bladder, weak urine stream, or bladder rupture.

📝 Essential Points

• Urinary retention presents with dysuria, stranguria, no attempts to urinate, enlarged bladder, weak urine stream, or bladder rupture.
• Structural causes include intraluminal obstructions such as uroliths and urethral plugs, intramural lesions like neoplasia and granulomatous urethritis, and extramural factors including bladder displacement and perineal hernia.
• Functional causes include hypocontractility of the bladder due to lower motor neuron lesions resulting in a flaccid bladder, upper motor neuron lesions causing a firm bladder, muscle weakness, dysautonomia, and detrusor atony.
• Diagnosis involves neurological examination, rectal palpation of the urethra, urethral catheterization to differentiate structural from functional causes, and imaging techniques such as urethrograms, double contrast cystograms, and ultrasonography.
• Treatment includes intermittent or indwelling catheterization, manual expression for lower motor neuron lesions, surgical interventions like urethrostomy or cystotomy tubes, antibiotics for urinary tract infections, bethanechol to increase bladder contraction in detrusor atony, and alpha-blockers such as prazosin for functional obstruction.
• For teaching purposes- Ana Eiras Lower Urinary Tract Urination/Micturition disorders – Urinary retention & Incontinence Urinary Retention Clinical signs: dysuria, stranguria, no attempts to urination, enlarged bladder, weak urine stream, bladder rupture Etiology: Structural - intraluminal : uroliths (++dogs) , urethral plugs (++cats) Blood clots - Intramural: neoplasia bladder neck or urethra (+dogs) proliferative/granulomatous urethritis (secondary to chronic UTI) stricture/stenosis prostatic disease - Extramural : bladder displacement – perineal hérnia 2025/2026 - MS IX.

💡 Key Takeaway

Differentiating structural from functional urinary retention directs appropriate diagnostic and therapeutic strategies.

📖 11. Urinary incontinence: etiology, diagnosis, and therapeutic approaches

🔑 Key Concepts & Definitions

• Diagnosis : The process of identifying the causes of urinary incontinence through urinalysis including urine specific gravity and cytology, complete blood count, chemistry profile, FeLV testing, imaging techniques such as excretory urography and ultrasonography, and cystoscopy.
• Sphincter mechanism incompetence (SMI) : A condition characterized by failure of the urethral sphincter to maintain closure, leading to urinary incontinence; it is the most common cause in spayed bitches and may be congenital in young dogs.
• Detrusor instability : A disorder involving hypercontractility of the bladder muscle, often of unknown cause in dogs, which can contribute to urinary incontinence.

📝 Essential Points

• Urinary incontinence manifests as inability to retain urine, recurrent urinary tract infections, and ventral or perineal dermatitis.
• Etiologies include poor bladder storage, bladder hypercontractility due to urinary tract infections, inflammation, or neoplasia, bladder hypoplasia, ectopic ureters, patent urachus, uretero-vaginal fistulas, vestibulo-vaginal stenosis, and sphincter mechanism incompetence, which is most common in spayed bitches.
• Treatment includes surgery for anatomical causes, antispasmodics like oxybutynin for detrusor instability, and phenylpropanolamine or synthetic estrogens for sphincter mechanism incompetence, with caution for side effects and recognition that 10-40% of SMI cases may be refractory.

💡 Key Takeaway

A comprehensive evaluation of urinary incontinence enables tailored medical and surgical treatments.

📖 12. Urethral obstruction in lower urinary tract disease: treatment and controversies

🔑 Key Concepts & Definitions

• Urethral obstruction : A blockage in the urethra that prevents urine flow, commonly caused by urethral spasm, plugs, urinary calculi, neoplasia, or strictures, leading to life-threatening electrolyte and acid-base disturbances if untreated.
• Decompressive cystocentesis : A procedure involving puncture of the urinary bladder to immediately empty it and relieve pressure, which is controversial due to risks of bladder trauma and rupture but may facilitate retrohydropropulsion and catheterization in select cases.

📝 Essential Points

• Treatment priorities include fluid therapy to correct hypovolemia, dehydration, and hyperkalemia before urinary catheter placement.
• Relief of obstruction requires sedation or anesthesia; catheterization may dislodge plugs in some cases.
• Management of hyperkalemia includes calcium gluconate and insulin/dextrose administration.
• Analgesia is a priority to reduce urethral spasms, using opioids like methadone, fentanyl, or buprenorphine.
• For teaching purposes- Ana Eiras Lower Urinary Tract -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT Arguments FOR - Immediate emptying of the urinary bladder - Relieves bladder pain - Facilitates retrohydropropulsion of obstructive material - Decreases intraluminal pressure to aid passage to urinary catheter - Enables an uncontaminated sample to be obtained for UA Arguments AGAINST - Risk of iatrogenic trauma to the urinary bladder wall, potentially leading to rupture and uroabdomen - May not facilitate the process or reduce the time involved in, placing a urinary catheter - - May delay placement of an urinary catheter 2025/2026 - MS IX.
• FLUID THERAPY → revert hypovolemia, dehydration and restore renal perfusion → correct hyperkalemia → SHOULD NOT BE DELAYED UNTIL URINARY CATH.

💡 Key Takeaway

Balancing urgent decompression and complication risks is key in managing urethral obstruction.

🧩 Additional Source Details

1. Study this source detail: IX URINARY SYSTEM – medical approach 2025/2026 - MS IX. For teaching purposes- Ana Eiras Master’s Degree in Veterinary Medicine CU: Medicine & Surgery VIII Ana Eiras, DVM [email protected] 2025/2026 - MS IX. For te (Source: "IX URINARY SYSTEM – medical approach 2025/2026 - MS IX. For teaching purposes- Ana Eiras Master’s Degree in Veterinary Medicine CU: Medicine & Surgery VIII Ana Eiras, DVM [email protected] 2025/2026 - MS IX. For teaching purposes- Ana Eiras Check-in 2025/2026 - MS IX. For teaching purposes- Ana Eiras TYPES OF KIDNEY DISEASE • Acute Kidney Injury")
2. Study this source detail: EARLY INTERVENTION MAY PREVENT PROGRESSION 2.EXTENSION Injury with alterations in renal perfusion, continued hypoxia, 2nd inflammation, ongoing epitelial/endotelial injury 3.MAINTENANCE critical amount of damage has been (Source: "EARLY INTERVENTION MAY PREVENT PROGRESSION 2.EXTENSION Injury with alterations in renal perfusion, continued hypoxia, 2nd inflammation, ongoing epitelial/endotelial injury 3.MAINTENANCE critical amount of damage has been established Results in decreased GFR and renal hypoperfusion → AZOTEMIA and UREMIA 4.RECOVERY Renal tissue undergoes regeneration and")
3. Study this source detail: teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Divided into 3 categories based in the underlying etiology - Prerenal (hemodynamic) AKI: renal hypoperfusion – renal parenchyma is not damage - Intrinsic Renal AKI: (Source: "teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Divided into 3 categories based in the underlying etiology - Prerenal (hemodynamic) AKI: renal hypoperfusion – renal parenchyma is not damage - Intrinsic Renal AKI: ischemia or nephrotoxin – damages the renal parenchyma - Postrenal or Obstructive AKI: acute obstruction of the urinary tract Biomarkers")
4. Study this source detail: damage Elevated CREA PRERENAL AKI Active structural injury and decreased renal function Elevated CREA INTRINSIC RENAL AKI 2025/2026 - MS IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Etiology Prerenal AK (Source: "damage Elevated CREA PRERENAL AKI Active structural injury and decreased renal function Elevated CREA INTRINSIC RENAL AKI 2025/2026 - MS IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Etiology Prerenal AKI (hemodynamic) Decreased GFR + normal injury biomarkers HIPOVOLEMIA - hemorraghe: trauma, surgical - GI losses: vomiting ,")
5. Study this source detail: - MS IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Etiology Intrinsic AKI Decreased GFR + injury biomarkers 4 processes: large renal vessels, renal microvasculature and glomerulus, acute tubular necrosis (Source: "- MS IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Etiology Intrinsic AKI Decreased GFR + injury biomarkers 4 processes: large renal vessels, renal microvasculature and glomerulus, acute tubular necrosis or tubulointersticium Sepsis (generalized vasodilation produce of free radicals and DIC) Heatstroke (hypoperfusion, thermal injury,")
6. Study this source detail: biomarkers Uroabdomen – trauma → intrinsic AKI could occur - distended bladder (males) → > risk of rupture - palpable bladder DOES NOT RULE OUT urine leak - urine leak causes hyperkalemia Ureteral and Urethral obstructio (Source: "biomarkers Uroabdomen – trauma → intrinsic AKI could occur - distended bladder (males) → > risk of rupture - palpable bladder DOES NOT RULE OUT urine leak - urine leak causes hyperkalemia Ureteral and Urethral obstructions - urolithos debris (Plug) - neoplasia 2025/2026 - MS IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Diagnosis")
7. Study this source detail: tubular necrosis, pyelonephritis, nephrotic syndrome Casts may be present → often dissolve in several hours → prompt analysis of the sediment UOP – decreases (due to RAAS and ADH activity) with USG > 1,018 (often > 1,030 (Source: "tubular necrosis, pyelonephritis, nephrotic syndrome Casts may be present → often dissolve in several hours → prompt analysis of the sediment UOP – decreases (due to RAAS and ADH activity) with USG > 1,018 (often > 1,030) 2025/2026 - MS IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Diagnosis Uroabdomen: azotemia, metabolic acidosis,")
8. Study this source detail: with lower Na concentration Fluid rate: “agressive fluidtherapy” - induce diuresis is NOT evidence based Increasing diuresis not necessarily improve GFR should maintain renal perfusion → increase UOP by reducing RAAS act (Source: "with lower Na concentration Fluid rate: “agressive fluidtherapy” - induce diuresis is NOT evidence based Increasing diuresis not necessarily improve GFR should maintain renal perfusion → increase UOP by reducing RAAS activity (Maintaining adequate blood flow to the kidneys helps reduce the compensatory activation of RAAS. As RAAS activity decreases, the")
9. Study this source detail: : feeding diets low in K could help in modest hyperK - HypoK: can occur in patients with polyuric AKI → fluid supplementation or oral - Calcium : AKI more likely has hypoCa ( and associated with poor prognosis) Supplemen (Source: ": feeding diets low in K could help in modest hyperK - HypoK: can occur in patients with polyuric AKI → fluid supplementation or oral - Calcium : AKI more likely has hypoCa ( and associated with poor prognosis) Supplementation when are clinical signs (tremors, ataxia, pain, facial rubbing, etc) - HyperPhos: due to reduce GFR → reduced PHOS with diet")
10. Study this source detail: for SQ edema, increase in respiratory rate and effort, abdominal pain, pleural effusion/pulmonar edema - Tx depends on hydration status and volemia → hypovolemic : IV bolus of isotonic solutions → dehydrated patients: co (Source: "for SQ edema, increase in respiratory rate and effort, abdominal pain, pleural effusion/pulmonar edema - Tx depends on hydration status and volemia → hypovolemic : IV bolus of isotonic solutions → dehydrated patients: correct in 6-8h - Mannitol → to convert oligoanuria into PU → 0,25-1g/kg over 15-20minutes and repeat q 4-6h IF improvement of UOP -")
11. Study this source detail: and/or peritoneal infections severe catabolic states → HYPOALBUMINEMIA COMPLICATIONS: peritonites, cateter oclusion, excessive protein loss, pleural effusion DDS (dialysis disequelibrium syndrome) → rapid removal of UREA (Source: "and/or peritoneal infections severe catabolic states → HYPOALBUMINEMIA COMPLICATIONS: peritonites, cateter oclusion, excessive protein loss, pleural effusion DDS (dialysis disequelibrium syndrome) → rapid removal of UREA and waste products → influx of water into brain cells - Hemodialysis : more efficiently to remove uremic toxins →blood passes through a")
12. Study this source detail: KIDNEY DISEASE (CKD) Degenerative condition with progressive loss of kidney function Structural and/or functional abnormalities → continuously present for > 3months Usually irreversible, even with treatment After correct (Source: "KIDNEY DISEASE (CKD) Degenerative condition with progressive loss of kidney function Structural and/or functional abnormalities → continuously present for > 3months Usually irreversible, even with treatment After correcting reversible diseases (pre and postrenal) → improvement of the kidney MAY NOT OCCUR → compensatory and adaptative mechanisms lead to")
13. Study this source detail: over life VS one specific cause CATS: Combination of risk factors / no cause identified Tubulointersticial nephritis: age viral infection (FIV) extrarenal disease (hiperT4, dental disease, systemic hypertension, heart di (Source: "over life VS one specific cause CATS: Combination of risk factors / no cause identified Tubulointersticial nephritis: age viral infection (FIV) extrarenal disease (hiperT4, dental disease, systemic hypertension, heart disease, stress, vacines, diet, ischemia, hypoxia, etc....) Tubular lipids → may have a role → damage and cell death → lipid release →")
14. Study this source detail: IX. For teaching purposes- Ana Eiras CKD - Staging STAGE: CREATININE - 2 results obtained several weeks apart - dogs and cats fasted - hydrated SDMA - useful for dogs/cats with reduce muscle mass SUBSTAGE : UPC ratio - 2 (Source: "IX. For teaching purposes- Ana Eiras CKD - Staging STAGE: CREATININE - 2 results obtained several weeks apart - dogs and cats fasted - hydrated SDMA - useful for dogs/cats with reduce muscle mass SUBSTAGE : UPC ratio - 2-3 values over a period of weeks - sediment shloud be innactive - border line proteinuria → re-check 2months ARTERIAL BLOOD PRESSURE – 2 to")
15. Study this source detail: IRIS Guidelines 2025/2026 - MS IX. For teaching purposes- Ana Eiras Diet therapy - Main stay of therapy - Low in protein and PHOS , Low in Na - Enriched with omega-3 fatty acids - DIET REDUCES RISK OF UREMIC CRISIS (72-9 (Source: "IRIS Guidelines 2025/2026 - MS IX. For teaching purposes- Ana Eiras Diet therapy - Main stay of therapy - Low in protein and PHOS , Low in Na - Enriched with omega-3 fatty acids - DIET REDUCES RISK OF UREMIC CRISIS (72-99%) AND DELAY PROGRESSION OF DISEASE - Canned VS dry (less important) - dry food could be moist with water to increase water intake")
16. Study this source detail: the levels by hormonal pathways and progressing the disease) HyperPHOS, HyperCa/HypoCa , HypoMg, Renal Osteodystrophy , Soft tissue mineralization, Nephrolithiasis CKD- Clinical consequences/medical management 2025/2026 (Source: "the levels by hormonal pathways and progressing the disease) HyperPHOS, HyperCa/HypoCa , HypoMg, Renal Osteodystrophy , Soft tissue mineralization, Nephrolithiasis CKD- Clinical consequences/medical management 2025/2026 - MS IX. For teaching purposes- Ana Eiras Phosphate Binders - HOW TO CHOOSE ONE? - Aluminum hydroxide → 1st line of choice - Lanthanum")
17. Study this source detail: PHOS every 4-6weeks until is stable → every 12weeks HyperPHOS, HyperCa/HypoCa , HypoMg, Renal Osteodystrophy , Soft tissue mineralization, Nephrolithiasis CKD- Clinical consequences/medical management 2025/2026 - MS IX. (Source: "PHOS every 4-6weeks until is stable → every 12weeks HyperPHOS, HyperCa/HypoCa , HypoMg, Renal Osteodystrophy , Soft tissue mineralization, Nephrolithiasis CKD- Clinical consequences/medical management 2025/2026 - MS IX. For teaching purposes- Ana Eiras Vitamin D Metabolism is very complex → Animals with CKD have reduced levels of vitamin D Kidney")
18. Study this source detail: purposes- Ana Eiras Potassium and Acidosis Uremic toxins often cause acidosis → produced in GIT colon via protein fermentation → interferes with cell function →leads to anorexia, nausea → supplementation with alkalinizer (Source: "purposes- Ana Eiras Potassium and Acidosis Uremic toxins often cause acidosis → produced in GIT colon via protein fermentation → interferes with cell function →leads to anorexia, nausea → supplementation with alkalinizers → renal diet, K citrate, Na bicarbonate Low potassium commonly seen in cats → can worsen kidney function (promote PU) → decreasing renal")
19. Study this source detail: to the patient) Anemia CKD- Clinical consequences/medical management 2025/2026 - MS IX. For teaching purposes- Ana Eiras Hypertension Management of Blood Pressure - Hypertension common in CKD -30% of dogs -60% of cats - (Source: "to the patient) Anemia CKD- Clinical consequences/medical management 2025/2026 - MS IX. For teaching purposes- Ana Eiras Hypertension Management of Blood Pressure - Hypertension common in CKD -30% of dogs -60% of cats - Consequences of high blood pressure - Further kidney damage - Heart damage - Eye damage/blindness - Neurologic damage /strokes -")
20. Study this source detail: → Free water available CKD- Clinical consequences/medical management 2025/2026 - MS IX. For teaching purposes- Ana Eiras Uremic gastritis, nausea, vomiting, diarrhea, oral ulcers Symptomatic Management - usually not need (Source: "→ Free water available CKD- Clinical consequences/medical management 2025/2026 - MS IX. For teaching purposes- Ana Eiras Uremic gastritis, nausea, vomiting, diarrhea, oral ulcers Symptomatic Management - usually not needed until later stages (stage 3-4) - Anti-nausea (maropitant, ondansetron) - Gastric acid suppression (omeprazol , sucralfate) - Appetite")
21. Study this source detail: - Progressive disease may - Repeat work-up because of Acute on CKD 2025/2026 - MS IX. For teaching purposes- Ana Eiras CKD - Advanced Therapies Hemodialysis - remove blood for dialysis - enter into a machine + anticoagul (Source: "- Progressive disease may - Repeat work-up because of Acute on CKD 2025/2026 - MS IX. For teaching purposes- Ana Eiras CKD - Advanced Therapies Hemodialysis - remove blood for dialysis - enter into a machine + anticoagulant - Dialyzer (artificial kidney) - Blood back to the patient - Large dialysis cateter in jugular veins until caudal vena cava - Each")
22. Study this source detail: purposes- Ana Eiras Glomerulonephritis (GN) Middle age to older dogs Familial glomerular diseases → labrador / golden retriever Clinical signs: depends on severity of proteinuria and presence/absence of azotemia weight l (Source: "purposes- Ana Eiras Glomerulonephritis (GN) Middle age to older dogs Familial glomerular diseases → labrador / golden retriever Clinical signs: depends on severity of proteinuria and presence/absence of azotemia weight loss, lethargy, or ~ to CKD (PU/PD, anorexia, vomiting, halitosis...) Severe proteinuria → ascite, peripheral edema, thromboembolism,")
23. Study this source detail: the definitive diagnosis of GN → may not be needed if treatment of underlying disease resolve proteinuria Treatment 1. potential underlying disease – infecious diseases (Leishmania, hemoparasites, etc) 2. reduction of pr (Source: "the definitive diagnosis of GN → may not be needed if treatment of underlying disease resolve proteinuria Treatment 1. potential underlying disease – infecious diseases (Leishmania, hemoparasites, etc) 2. reduction of proteinuria → anti-proteinuric drugs when UPC > 0,5 in DOGS and > 0,4 in CATS → Benazepril (0,5-1mg/kg q24h PO in cats ) → weak")
24. Study this source detail: is achieve UPC < 0,5 and increase of ALB to > 2,5g/dL Complications Edema → DOGS when ALB < 1,5g/dL → Evaluate hydration and vascular volume (body weight, skin turgour, mucous membranes color , CRT, temperature, heart ra (Source: "is achieve UPC < 0,5 and increase of ALB to > 2,5g/dL Complications Edema → DOGS when ALB < 1,5g/dL → Evaluate hydration and vascular volume (body weight, skin turgour, mucous membranes color , CRT, temperature, heart rate, pulse, BP) → use diuretics just when cavitary effusion (spironolactone) Systemic Hypertension Thromboembolism Hyperlipidemia")
25. Study this source detail: differentiation of renal parenchyma (immature nephrons, compensatory hyperthrophy nephrons ) - difficult to distinguish from CKD - Tx is the same CKD (this patients are more resilient to azotemia) - Policystic Kidney Dis (Source: "differentiation of renal parenchyma (immature nephrons, compensatory hyperthrophy nephrons ) - difficult to distinguish from CKD - Tx is the same CKD (this patients are more resilient to azotemia) - Policystic Kidney Disease ( PKD) - Most common genetic disease in feline → Persian cats and crossed breeds → genetic test + US findings - Autossomal")
26. Study this source detail: retroperitoneal masses, retroperitoneal fibrosis, bladder neoplasia, acidental surgical ligation OVH 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract URETER Ureteroliths - migration of nephroliths (Source: "retroperitoneal masses, retroperitoneal fibrosis, bladder neoplasia, acidental surgical ligation OVH 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract URETER Ureteroliths - migration of nephroliths fragments into the ureter -Spontaneous passage: cats ureter diameter → 0,3-0,4mm - Medical Expulsive Therapy (MET) → is an option")
27. Study this source detail: Félix Urolithiasis 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder Urolithiasis CATS DOGS Calcium Oxalate/Phosphate (Source: "Félix Urolithiasis 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder Urolithiasis CATS DOGS Calcium Oxalate/Phosphate Struvite Stuvite Compound uroliths Cystine Purine (xanthine, urate) Calcium Oxalate/Phosphate Purine (xanthine, urate) 2025/2026 - MS IX.")
28. Study this source detail: a risk factor 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis DOGS Xantine Rare (0,1%) Deficiency in xhantine dehydrogenase (converts xanthine → uric acid >>> 75% of cases are iatroge (Source: "a risk factor 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis DOGS Xantine Rare (0,1%) Deficiency in xhantine dehydrogenase (converts xanthine → uric acid >>> 75% of cases are iatrogenic : Allopurinol Urate 5% Decreased hepatic conversion of uric acid to allantoin → hyperuricosuria → >>> risk Neutered")
29. Study this source detail: VS - ALKALINE → struvite - Proteinuria- common - Crystalluria – don’t accurately predict uroliths presence/composition - ABSENCE OF CRYSTALS DOES NOT RULE OUT PRESENCE OF UROLITHS Struvite, CaOx and amorphous phosphate o (Source: "VS - ALKALINE → struvite - Proteinuria- common - Crystalluria – don’t accurately predict uroliths presence/composition - ABSENCE OF CRYSTALS DOES NOT RULE OUT PRESENCE OF UROLITHS Struvite, CaOx and amorphous phosphate occur in healthy dogs WITHOUT urolithiasis Cystine and urate → when present are always abnormal - Blood: hematuria is common -")
30. Study this source detail: IMPORTANT TO IDENTIfY PATHOGENESIS, CLINICAL MANAGEMENT AND PROGNOSIS UROLITH TYPE DIAGNOSTICS TREATMENT AND PREVENTION ALL 1. Repeat urinalysis at 1 and 3-6 months, until target pH and concentration are achieved 2. Repe (Source: "IMPORTANT TO IDENTIfY PATHOGENESIS, CLINICAL MANAGEMENT AND PROGNOSIS UROLITH TYPE DIAGNOSTICS TREATMENT AND PREVENTION ALL 1. Repeat urinalysis at 1 and 3-6 months, until target pH and concentration are achieved 2. Repeat imaging at 1 and 3-6 months to identify recurrence at an early stage, when minimally invasive removal methods are an option 1. Promote")
31. Study this source detail: in recurrent stone formers or dogs with elevated total serum calcium 2. Genetic testing for hereditary CaOx1 in English Bulldogs and related breeds 1. No diet can dissolve calcium oxalate uroliths, but therapeutic diets (Source: "in recurrent stone formers or dogs with elevated total serum calcium 2. Genetic testing for hereditary CaOx1 in English Bulldogs and related breeds 1. No diet can dissolve calcium oxalate uroliths, but therapeutic diets are formulated to decrease recurrence risk 2. Potassium citrate supplementation∗ for recurrent stone formers or those with persistently low")
32. Study this source detail: reduce cystinuria Urate 1. Bile acids test for dogs with suspicion for a portosystemic shunt 2. Genetic testing for HHU in breeds with a high prevalence (Dalmatian, Black Russian Terrier, English Bulldog) and those with (Source: "reduce cystinuria Urate 1. Bile acids test for dogs with suspicion for a portosystemic shunt 2. Genetic testing for HHU in breeds with a high prevalence (Dalmatian, Black Russian Terrier, English Bulldog) and those with normal bile acid test results 1. Low purine, alkalinizing diet 2. Potassium citrate supplementation if urine remains acidic 3. Allopurinol")
33. Study this source detail: → Sx removal CaOx : CANNOT BE MEDICALLY DISSOLVED Therapeutic diets are indicated TO REDUCE THE RISK OF RECURRENCE but don’t treat uroliths already formed 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary (Source: "→ Sx removal CaOx : CANNOT BE MEDICALLY DISSOLVED Therapeutic diets are indicated TO REDUCE THE RISK OF RECURRENCE but don’t treat uroliths already formed 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis Treatment - DISSOLUTIONS Urate: CAN BE MEDICALLY DISSOLVED → LOW PURINE ALKALINIZING DIETS + ALLOPURINOL In")
34. Study this source detail: SIGNS / URETHRAL OBSTRUCTION / RECURRENT INFECTIONS 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis Treatment – PREVENTION Client education Re-checks – UA (every 3-6montHs) INCREASE W (Source: "SIGNS / URETHRAL OBSTRUCTION / RECURRENT INFECTIONS 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis Treatment – PREVENTION Client education Re-checks – UA (every 3-6montHs) INCREASE WATER INTAKE → reduce supersaturation of the urine USG < 1,020 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract")
35. Study this source detail: purposes- Ana Eiras Lower Urinary Tract Feline Lower Urinary Tract Diseases (FLUTD) = Feline Urologic Syndrome (FUS) Young cats → >65% cases no underlying cause Dificult to manage Clinical signs ~3-7days resolve spontane (Source: "purposes- Ana Eiras Lower Urinary Tract Feline Lower Urinary Tract Diseases (FLUTD) = Feline Urologic Syndrome (FUS) Young cats → >65% cases no underlying cause Dificult to manage Clinical signs ~3-7days resolve spontaneouly UNLESS urethral obstruction occurs BUT RECURRENCE IS FREQUENT Risk factors (YOUNG CATS X FLUTD) - Persian cats - OBESITY - Neutered")
36. Study this source detail: signs have struvite Caution: over-treatment of struvite → CaOx crystals Role in Plug formation 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Feline Lower Urinary Tract Diseases (FLUTD) = Feline (Source: "signs have struvite Caution: over-treatment of struvite → CaOx crystals Role in Plug formation 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Feline Lower Urinary Tract Diseases (FLUTD) = Feline Urologic Syndrome (FUS) Possible causes : 3. Vesicourachal diverticula or urachal diverticula - macroscopic out-pouchings of the bladder")
37. Study this source detail: water the intake: less concentrated urine → adding flavouring, fountais, etc 3. Reduce stress – avoid overcrowding (feline and human) - enough clean litter- boxes in diferent areas - Feliway diffusers 4. Synthetic GAG’s: (Source: "water the intake: less concentrated urine → adding flavouring, fountais, etc 3. Reduce stress – avoid overcrowding (feline and human) - enough clean litter- boxes in diferent areas - Feliway diffusers 4. Synthetic GAG’s: efficacy not proven, small population may benefit Glucosamine → nutraceutical 5. Amitriptyline : anti-depressant (with anti-inflammatory")
38. Study this source detail: : uroliths (++dogs) , urethral plugs (++cats) Blood clots - Intramural: neoplasia bladder neck or urethra (+dogs) proliferative/granulomatous urethritis (secondary to chronic UTI) stricture/stenosis prostatic disease - E (Source: ": uroliths (++dogs) , urethral plugs (++cats) Blood clots - Intramural: neoplasia bladder neck or urethra (+dogs) proliferative/granulomatous urethritis (secondary to chronic UTI) stricture/stenosis prostatic disease - Extramural : bladder displacement – perineal hérnia 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urinary")
39. Study this source detail: Lower Urinary Tract Urinary Retention Diagnosis - neuro exam - rectal palpation of urethra - urethral catheterization → HELP TO DIFFERENTIATE BETWEEN STRUCTURAL AND FUNCTIONAL - Imaging → urethrograms, double contrast cy (Source: "Lower Urinary Tract Urinary Retention Diagnosis - neuro exam - rectal palpation of urethra - urethral catheterization → HELP TO DIFFERENTIATE BETWEEN STRUCTURAL AND FUNCTIONAL - Imaging → urethrograms, double contrast cystogram / US of prostate and bladder trígone - urethroscopy Treatment - intermitent catheterisation (+) or indwelling - manual expression")
40. Study this source detail: lack of urine retention, UTI, ventral or perineal dermatitis Etiology: - urine retention disorders - poor bladder storage function - hypercontractility ( UTI, inflammatory lesions, neoplasia, ect) - bladder hypoplasia /e (Source: "lack of urine retention, UTI, ventral or perineal dermatitis Etiology: - urine retention disorders - poor bladder storage function - hypercontractility ( UTI, inflammatory lesions, neoplasia, ect) - bladder hypoplasia /ectopic ureteres - detrusor instability – unknown cause in dogs - anatomic – ectopic ureteres that terminate in urethra, vagina or")
41. Study this source detail: - anatomic causes – Sx - detrusor instability – antispasmodic (oxybutynin) - SMI – phenylpropanolamine (Propalin) → care with hypertension -- synthetic oestrogens → bione marrow Effect - refractory SMI (10-40% of cases) (Source: "- anatomic causes – Sx - detrusor instability – antispasmodic (oxybutynin) - SMI – phenylpropanolamine (Propalin) → care with hypertension -- synthetic oestrogens → bione marrow Effect - refractory SMI (10-40% of cases) 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder neoplasia –DOGS Transitional Cell Carcinoma (TCC)")
42. Study this source detail: neoplasia CATS Less common than dogs TCC is the most common but trígone are is less affected 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder neoplasia - DOGS Transitional Cell Carcinoma (T (Source: "neoplasia CATS Less common than dogs TCC is the most common but trígone are is less affected 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder neoplasia - DOGS Transitional Cell Carcinoma (TCC) Diagnosis and Staging: UA (ideally AVOID CYSTOCENTESIS → risk of seeding !) - Urinary sediment may reveal tumor cells ~30% BUT if is")
43. Study this source detail: Ana Eiras Lower Urinary Tract Bladder neoplasia DOGS Transitional Cell Carcinoma (TCC) Treatment: Sx → prof. David Vicente Just indicated when trígone is not involved Urinary outflow obstruction → permanet cystotomy tube (Source: "Ana Eiras Lower Urinary Tract Bladder neoplasia DOGS Transitional Cell Carcinoma (TCC) Treatment: Sx → prof. David Vicente Just indicated when trígone is not involved Urinary outflow obstruction → permanet cystotomy tube / urethral stents /Laser debulk with cystoscopy Radiotherapy→ intraoperative or post-operative → consequence of fibrosis and")
44. Study this source detail: electrolyte and acid-base distrurbances >>>> common in male (cats and dogs) Most frequent causes → urethral spasm → urethral plugs → urinary calculi (++ dogs) → neoplasia → strictures 2025/2026 - MS IX. For teaching purp (Source: "electrolyte and acid-base distrurbances >>>> common in male (cats and dogs) Most frequent causes → urethral spasm → urethral plugs → urinary calculi (++ dogs) → neoplasia → strictures 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urethral obstruction - pathogenesis Regardless the underlying cause → the consequences")
45. Study this source detail: correct hyperkalemia → SHOULD NOT BE DELAYED UNTIL URINARY CATH. PLACEMENT → NaCl 0,9% or isotonic LR (K 4-5mmol/l) → Cats → monitoring volume overload 2.RELIEF OF THE OBSTRUCTION 3.Management of hyperkalemia → Ca Glucon (Source: "correct hyperkalemia → SHOULD NOT BE DELAYED UNTIL URINARY CATH. PLACEMENT → NaCl 0,9% or isotonic LR (K 4-5mmol/l) → Cats → monitoring volume overload 2.RELIEF OF THE OBSTRUCTION 3.Management of hyperkalemia → Ca Gluconate → Insulin /dextrose administration 4. Analgesia → IS PRIORITY , reduces urethral spams → methadone 0,2mg/kg, CRI fentanyl,")
46. Study this source detail: the tip of the penis CORRECT 1ST BRADICARDIA/HYPOTENSION AND HYPOVOLEMIA -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract -Decompressive Cy (Source: "the tip of the penis CORRECT 1ST BRADICARDIA/HYPOTENSION AND HYPOVOLEMIA -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT Arguments FOR - Immediate emptying of the urinary bladder - Relieves bladder pain -")
47. Study this source detail: Tract -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT Shouldn’t be considered in all patients that are blocked - Severe hyper K - EKG alterations - Bradicardic patients - To reduce the risk of bladder damage : (Source: "Tract -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT Shouldn’t be considered in all patients that are blocked - Severe hyper K - EKG alterations - Bradicardic patients - To reduce the risk of bladder damage : - -adequate personnel ( ~3 / 4 people) - -22 G needle , 30-90º , - Iddealy just 1 insertion 2025/2026 - MS IX. For teaching purposes-")
48. Study this source detail: IX. For teaching purposes- Ana Eiras Check-in 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras Check-in 2025/2026 - MS IX")
49. Study this source detail: IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Etiology Prerenal AKI (hemodynamic) Decreased GFR + normal injury biomarkers HIPOVOLEMIA - hemorraghe: trauma, surgical - GI losses: vomiting , diarrhea - re (Source: "IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Etiology Prerenal AKI (hemodynamic) Decreased GFR + normal injury biomarkers HIPOVOLEMIA - hemorraghe: trauma, surgical - GI losses: vomiting , diarrhea - renal fluid loss: drug/osmotic diuresis, diabetes insipidus, adrenal insufficiency - Increased fluid loss: hyperthermia, burns - “third spa...")
50. Study this source detail: IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Etiology Postrenal AKI Normal/Decreased GFR + Increased injury biomarkers Uroabdomen – trauma → intrinsic AKI could occur - distended bladder (males) → > ris (Source: "IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Etiology Postrenal AKI Normal/Decreased GFR + Increased injury biomarkers Uroabdomen – trauma → intrinsic AKI could occur - distended bladder (males) → > risk of rupture - palpable bladder DOES NOT RULE OUT urine leak - urine leak causes hyperkalemia Ureteral and Urethral obstructions - urolit...")
51. Study this source detail: IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Diagnosis Uroabdomen: azotemia, metabolic acidosis, hyper K (48h), hypoNa(24h) e hyper Phos Ettingers Textbook of Veterinary Internal Medicine 9th Edition Bo (Source: "IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Diagnosis Uroabdomen: azotemia, metabolic acidosis, hyper K (48h), hypoNa(24h) e hyper Phos Ettingers Textbook of Veterinary Internal Medicine 9th Edition Booksvetsblogspotcom")
52. Study this source detail: IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Treatment Medical therapy - Metabolic acidosis: correct with Na bicarbonate after correcting hypoperfusion - Anti-emetics: maropitant/ondansetron - Gastric a (Source: "IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Treatment Medical therapy - Metabolic acidosis: correct with Na bicarbonate after correcting hypoperfusion - Anti-emetics: maropitant/ondansetron - Gastric acid suppressants: omeprazol (proton pump inhibitor) PO q 12h - Anti-hypertensives : measure BP twice daily → if hypertension → amlodipine...")
53. Study this source detail: IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Prognosis Limited studies of survival in veterinary patients with AKI Mortality rate of 45% in Dogs and 53% in cats Animals with infectious etiologies → supe (Source: "IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Prognosis Limited studies of survival in veterinary patients with AKI Mortality rate of 45% in Dogs and 53% in cats Animals with infectious etiologies → superior survival rate Oliguric patients higher risk of mortality → UOP very important Dogs who survived to AKI ~20-25% had serum CREA back t...")
54. Study this source detail: IX. For teaching purposes- Ana Eiras CKD - Etiology Possible role in fekine CKD 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras CKD - Etiology Possible role in fekine CKD 2025/2026 - MS IX")
55. Study this source detail: IX. For teaching purposes- Ana Eiras Phosphate Binders - PHOS from the diet → absorved to blood stream → excreted by the kidney - With the decreasing kidney function → PHOS levels rises in blood - Stimulation of PTH synt (Source: "IX. For teaching purposes- Ana Eiras Phosphate Binders - PHOS from the diet → absorved to blood stream → excreted by the kidney - With the decreasing kidney function → PHOS levels rises in blood - Stimulation of PTH synthesis → secondary hyperparathyroidism - HyperPHOS → associated with poor survival humans, cats and dogs - IMPORTANT TO GIVE ORAL PHOSPHAT...")
56. Study this source detail: IX. For teaching purposes- Ana Eiras CKD- Clinical consequences/medical management 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras CKD- Clinical consequences/medical management 2025/2026 - MS IX")
57. Study this source detail: IX. For teaching purposes- Ana Eiras Proteinuria → RISK FACTOR FOR PROGRESSIVE DISEASE CKD- Clinical consequences/medical management 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras Proteinuria → RISK FACTOR FOR PROGRESSIVE DISEASE CKD- Clinical consequences/medical management 2025/2026 - MS IX")
58. Study this source detail: IX. For teaching purposes- Ana Eiras CKD - Repeated Staging - Every 3-4 months - Adjust therapy based on stage of disease - Progressive disease may - Repeat work-up because of Acute on CKD 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras CKD - Repeated Staging - Every 3-4 months - Adjust therapy based on stage of disease - Progressive disease may - Repeat work-up because of Acute on CKD 2025/2026 - MS IX")
59. Study this source detail: IX. For teaching purposes- Ana Eiras 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras 2025/2026 - MS IX")
60. Study this source detail: IX. For teaching purposes- Ana Eiras Tubular diseases 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras Tubular diseases 2025/2026 - MS IX")
61. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis DOGS Struvite ~40% >>> secondary to UTI ( bacteria → urease) 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis DOGS Struvite ~40% >>> secondary to UTI ( bacteria → urease) 2025/2026 - MS IX")
62. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis Diagnostic – IMAGING → Prof Marisa Vicente 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis Diagnostic – IMAGING → Prof Marisa Vicente 2025/2026 - MS IX")
63. Study this source detail: 2. Repeat imaging at 1 and 3-6 months to identify recurrence at an early stage, when minimally invasive removal methods are an option 1 (Source: "2. Repeat imaging at 1 and 3-6 months to identify recurrence at an early stage, when minimally invasive removal methods are an option 1")
64. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis Treatment – REMOVAL Minimally invasive procedures → less hospitalization time and faster recovery vs cystotomy - Voiding urohydropropulsion (VUH) - Ba (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urolithiasis Treatment – REMOVAL Minimally invasive procedures → less hospitalization time and faster recovery vs cystotomy - Voiding urohydropropulsion (VUH) - Basket removal -Laser Lithotripsy INDICATED WHEN ARE CLINICAL SIGNS / URETHRAL OBSTRUCTION / RECURRENT INFECTIONS 2025/2026 - MS IX")
65. Study this source detail: 2. Crystalluria: struvite crystals > 50% of cats with FLUTD signs ~50% young cats without signs have struvite Caution: over-treatment of struvite → CaOx crystals Role in Plug formation 2025/2026 - MS IX (Source: "2. Crystalluria: struvite crystals > 50% of cats with FLUTD signs ~50% young cats without signs have struvite Caution: over-treatment of struvite → CaOx crystals Role in Plug formation 2025/2026 - MS IX")
66. Study this source detail: Reduce stress – avoid overcrowding (feline and human) - enough clean litter- boxes in diferent areas - Feliway diffusers 4. Synthetic GAG’s: efficacy not proven, small population may benefit Glucosamine → nutraceutical 5 (Source: "Reduce stress – avoid overcrowding (feline and human) - enough clean litter- boxes in diferent areas - Feliway diffusers 4. Synthetic GAG’s: efficacy not proven, small population may benefit Glucosamine → nutraceutical 5. Amitriptyline : anti-depressant (with anti-inflammatory and analgesic effects) Effective in chronic cases 2025/2026 - MS IX. For teachi...")
67. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urination/Micturition disorders – Urinary retention , Incontinence Incontinence Clinical signs: lack of urine retention, UTI, ventral or perineal dermatitis Etiolo (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urination/Micturition disorders – Urinary retention , Incontinence Incontinence Clinical signs: lack of urine retention, UTI, ventral or perineal dermatitis Etiology: - urine retention disorders - poor bladder storage function - hypercontractility ( UTI, inflammatory lesions, neoplasia, ect) - bladd...")
68. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Incontinence Diagnosis - UA (check USG to rule out PU, neoplastic cells) (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Incontinence Diagnosis - UA (check USG to rule out PU, neoplastic cells)")
69. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urethra - Urethral obstruction Most common emergencies Untreated → LIFE-THREATENING electrolyte and acid-base distrurbances >>>> common in male (cats and dogs) Mos (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urethra - Urethral obstruction Most common emergencies Untreated → LIFE-THREATENING electrolyte and acid-base distrurbances >>>> common in male (cats and dogs) Most frequent causes → urethral spasm → urethral plugs → urinary calculi (++ dogs) → neoplasia → strictures 2025/2026 - MS IX")
70. Study this source detail: Management of hyperkalemia → Ca Gluconate → Insulin /dextrose administration 4. Analgesia → IS PRIORITY , reduces urethral spams → methadone 0,2mg/kg, CRI fentanyl, Buprenorphine (less severe case) 5. Sacrococcygeal epid (Source: "Management of hyperkalemia → Ca Gluconate → Insulin /dextrose administration 4. Analgesia → IS PRIORITY , reduces urethral spams → methadone 0,2mg/kg, CRI fentanyl, Buprenorphine (less severe case) 5. Sacrococcygeal epidural 6. Antispasmodic therapy → phenoxybenzamine OR prazosin 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract http...")
71. Study this source detail: 1 insertion 2025/2026 - MS IX (Source: "1 insertion 2025/2026 - MS IX")
72. Study this source detail: K) → BRADICARDIA → ABSENT P WAVES or decreases amplitude → T waves peaked → hypocalcemia → also contributes to the low threshold of myocite 2025/2026 - MS IX (Source: "K) → BRADICARDIA → ABSENT P WAVES or decreases amplitude → T waves peaked → hypocalcemia → also contributes to the low threshold of myocite 2025/2026 - MS IX")
73. Study this source detail: 6. Antispasmodic therapy → phenoxybenzamine OR prazosin 2025/2026 - MS IX (Source: "6. Antispasmodic therapy → phenoxybenzamine OR prazosin 2025/2026 - MS IX")
74. Study this source detail: com/iris-staging-system Stage 1 or early Stage 2 → one or more of these 1. CREA or SDMA elevation 2. Persistent increased SDMA > 14ug/dL 3. Abnormal kidney imaging 4. Persistent proteinuria Stage 2-4 → both of these 1. C (Source: "com/iris-staging-system Stage 1 or early Stage 2 → one or more of these 1. CREA or SDMA elevation 2. Persistent increased SDMA > 14ug/dL 3. Abnormal kidney imaging 4. Persistent proteinuria Stage 2-4 → both of these 1. CREA and SDMA elevation 2. USG < 1,030 (dogs) < 1,035 (cats) 2025/2026 - MS IX. For teaching purposes- Ana Eiras CKD - Staging STAGE: CREA...")
75. Study this source detail: Persistent proteinuria Stage 2-4 → both of these 1. CREA and SDMA elevation 2. USG < 1,030 (dogs) < 1,035 (cats) 2025/2026 - MS IX. For teaching purposes- Ana Eiras CKD - Staging STAGE: CREATININE - 2 results obtained se (Source: "Persistent proteinuria Stage 2-4 → both of these 1. CREA and SDMA elevation 2. USG < 1,030 (dogs) < 1,035 (cats) 2025/2026 - MS IX. For teaching purposes- Ana Eiras CKD - Staging STAGE: CREATININE - 2 results obtained several weeks apart - dogs and cats fasted - hydrated SDMA - useful for dogs/cats with reduce muscle mass SUBSTAGE : UPC ratio - 2-3 values...")
76. Study this source detail: IX. For teaching purposes- Ana Eiras CKD - Prognosis DOGS CATS 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras CKD - Prognosis DOGS CATS 2025/2026 - MS IX")
77. Study this source detail: IX. For teaching purposes- Ana Eiras Erythropoietin (EPO) - produced by the kidney and stimulate RBC’s production - EPO production is decreased in CKD - Supplementation with Darbepoietin (analogue of EPO) – SQ q4weeks Ir (Source: "IX. For teaching purposes- Ana Eiras Erythropoietin (EPO) - produced by the kidney and stimulate RBC’s production - EPO production is decreased in CKD - Supplementation with Darbepoietin (analogue of EPO) – SQ q4weeks Iron (oral) (adjust to the patient) Anemia CKD- Clinical consequences/medical management 2025/2026 - MS IX")
78. Study this source detail: amine OR prazosin 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract https://journals.sagepub.com/doi/epub/10.1177/1098612X241309176 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary (Source: "amine OR prazosin 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract https://journals.sagepub.com/doi/epub/10.1177/1098612X241309176 2025/2026 - MS IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urethral obstruction - treatment 2.RELIEF OF TH")
79. Study this source detail: 2. USG < 1,030 (dogs) < 1,035 (cats) 2025/2026 - MS IX (Source: "2. USG < 1,030 (dogs) < 1,035 (cats) 2025/2026 - MS IX")
80. Study this source detail: 3. Treat consequences of decreased kidney function 1st STEP : - developing a feasible long-term management plan for dogs and cats - understanding owner goals and their ability to administer medications - Treatment recomm (Source: "3. Treat consequences of decreased kidney function 1st STEP : - developing a feasible long-term management plan for dogs and cats - understanding owner goals and their ability to administer medications - Treatment recommendations should be individualized Owner education is a top priority IRIS Guidelines 2025/2026 - MS IX")
81. Study this source detail: IX. For teaching purposes- Ana Eiras Uremic gastritis, nausea, vomiting, diarrhea, oral ulcers Symptomatic Management - usually not needed until later stages (stage 3-4) - Anti-nausea (maropitant, ondansetron) - Gastric (Source: "IX. For teaching purposes- Ana Eiras Uremic gastritis, nausea, vomiting, diarrhea, oral ulcers Symptomatic Management - usually not needed until later stages (stage 3-4) - Anti-nausea (maropitant, ondansetron) - Gastric acid suppression (omeprazol , sucralfate) - Appetite stimulation (mirtazapine) CKD- Clinical consequences/medical management 2025/2026 -...")
82. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract 2025/2026 - MS IX (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract 2025/2026 - MS IX")
83. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder neoplasia - DOGS Transitional Cell Carcinoma (TCC) Diagnosis and Staging: UA (ideally AVOID CYSTOCENTESIS → risk of seeding (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder neoplasia - DOGS Transitional Cell Carcinoma (TCC) Diagnosis and Staging: UA (ideally AVOID CYSTOCENTESIS → risk of seeding")
84. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder neoplasia DOGS Transitional Cell Carcinoma (TCC) Treatment: Sx → prof (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder neoplasia DOGS Transitional Cell Carcinoma (TCC) Treatment: Sx → prof")
85. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urethral obstruction - treatment 2 (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urethral obstruction - treatment 2")
86. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT Shouldn’t be considered in all patients that are blocked - Severe hyper K - EKG alterations - Bradicardic (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT Shouldn’t be considered in all patients that are blocked - Severe hyper K - EKG alterations - Bradicardic patients - To reduce the risk of bladder damage : - -adequate personnel ( ~3 / 4 people) - -22 G needle , 30-90º , - Iddealy just 1 inse...")
87. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urethral obstruction - treatment -After “unblocking” (sucessfully urinary catheterization) - Remove the catheter → If the procedure was fairly easly - Leave cathet (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Urethral obstruction - treatment -After “unblocking” (sucessfully urinary catheterization) - Remove the catheter → If the procedure was fairly easly - Leave catheter placed → If the procedure was dificult → REPLACE TO A SOFTER CATHETER → attach a closed system + empty bag → Antibiotic SHOULD NOT be...")
88. Study this source detail: IX. For teaching purposes- Ana Eiras Master’s Degree in Veterinary Medicine CU: Medicine & Surgery VIII Ana Eiras, DVM aeiras@egasmoniz (Source: "IX. For teaching purposes- Ana Eiras Master’s Degree in Veterinary Medicine CU: Medicine & Surgery VIII Ana Eiras, DVM aeiras@egasmoniz")
89. Study this source detail: 4. Synthetic GAG’s: efficacy not proven, small population may benefit Glucosamine → nutraceutical 5 (Source: "4. Synthetic GAG’s: efficacy not proven, small population may benefit Glucosamine → nutraceutical 5")
90. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder neoplasia –DOGS Transitional Cell Carcinoma (TCC) Most common (~50-75%) - Etiology : multifactorial , Risk factors: topical insecticies , female sex, obesi (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract Bladder neoplasia –DOGS Transitional Cell Carcinoma (TCC) Most common (~50-75%) - Etiology : multifactorial , Risk factors: topical insecticies , female sex, obesity, breed) -Clinical signs: pollakiuria, hematúria, stanguria or tenesmos")
91. Study this source detail: IX. For teaching purposes- Ana Eiras Lower Urinary Tract -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT Arguments FOR - Immediate emptying of the urinary bladder - Relieves bladder pain - Facilitates retrohydr (Source: "IX. For teaching purposes- Ana Eiras Lower Urinary Tract -Decompressive Cystocentesis → very CONTROVERSIAL SUBJECT Arguments FOR - Immediate emptying of the urinary bladder - Relieves bladder pain - Facilitates retrohydropropulsion of obstructive material - Decreases intraluminal pressure to aid passage to urinary catheter - Enables an uncontaminated samp...")
92. Study this source detail: IX. For teaching purposes- Ana Eiras QUESTIONS (Source: "IX. For teaching purposes- Ana Eiras QUESTIONS")
93. Study this source detail: IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Sudden loss of kidney function → 4 PHASES 1 (Source: "IX. For teaching purposes- Ana Eiras Acute Kidney Injury (AKI) Sudden loss of kidney function → 4 PHASES 1")
94. Study this source detail: IX. For teaching purposes- Ana Eiras CKD- Clinical consequences/medical management GOALS 1 (Source: "IX. For teaching purposes- Ana Eiras CKD- Clinical consequences/medical management GOALS 1")
95. Study this source detail: For teaching purposes- Ana Eiras CKD- Clinical consequences/medical management GOALS 1. Decrease rate of progression 2. Manage clinical signs 3. Treat consequences of decreased kidney function 1st STEP : - developing a f (Source: "For teaching purposes- Ana Eiras CKD- Clinical consequences/medical management GOALS 1. Decrease rate of progression 2. Manage clinical signs 3. Treat consequences of decreased kidney function 1st STEP : - developing a feasible long-term management plan for dogs and cats - understanding owner goals and their ability to administer medications - Treatment r...")
96. Study this source detail: IX. For teaching purposes- Ana Eiras Glomerulonephritis (GN) Diagnosis Renal biopsy →provides the definitive diagnosis of GN → may not be needed if treatment of underlying disease resolve proteinuria Treatment 1 (Source: "IX. For teaching purposes- Ana Eiras Glomerulonephritis (GN) Diagnosis Renal biopsy →provides the definitive diagnosis of GN → may not be needed if treatment of underlying disease resolve proteinuria Treatment 1")

📅 Key Dates

📊 Synthesis Tables

Comparison of AKI Etiologies and Biomarkers

⚠️ Common Pitfalls & Confusions

1. Confusing prerenal AKI with intrinsic AKI due to overlapping clinical signs.
2. Misinterpreting urine output as a sole indicator without considering biomarkers.
3. Overlooking the role of dehydration in AKI etiology.
4. Ignoring the potential for urine leak in cases of uroabdomen.
5. Assuming aggressive diuresis always improves GFR, which is not evidence-based.
6. Confusing urinary retention causes, such as structural vs. functional.
7. Neglecting the importance of timely diagnosis in urinary obstructions.

✅ Exam Checklist

1. Identify phases of AKI and their pathophysiology.
2. Differentiate between prerenal, intrinsic, and postrenal AKI.
3. Recognize clinical signs and laboratory findings in AKI.
4. Understand fluid therapy goals in AKI management.
5. Monitor CKD progression with staging every 3-4 months.
6. Implement dietary and environmental strategies for FLUTD prevention.
7. Diagnose urinary retention causes through neurological and physical exams.
8. Apply appropriate treatment options for urethral obstruction.
9. Use renal biopsy for definitive diagnosis of glomerulonephritis.
10. Manage CKD with long-term strategies including dialysis.
11. Recognize signs of urinary incontinence and their causes.
12. Understand controversies surrounding decompressive cystocentesis.