Laboratory Testing in Feline Liver and Renal Disease Shropshire Veterinary Association 24th February 2005 Shropshire Veterinary Association 24th February 2005 Nick Carmichael BVM&S, BSc VetSci(Hons), Diploma VCS (Syd), Diploma RC Path, Diplomate ECVCP, MRCVS BVM&S, BSc VetSci(Hons), Diploma VCS (Syd), Diploma RC Path, Diplomate ECVCP, MRCVS

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Liver anatomy - what matters clinically Liver enzymes - what they mean Liver function tests FBC changes in liver disease - how they help Common feline liver disease patterns Primary Vs secondary liver changes Putting it together Liver anatomy - what matters clinically Liver enzymes - what they mean Liver function tests FBC changes in liver disease - how they help Common feline liver disease patterns Primary Vs secondary liver changes Putting it together Feline Liver Disease

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Hepatic Lobule Anatomy

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Hepatic Portal Anatomy

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Hepatic Lobule Anatomy

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Hepatocyte Enzyme Distribution

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Transaminases & Dehydrogenases ALT AST GLDH ALT AST GLDH Measure integrity of cell membranes Degree of increase correlates with number of hepatocytes involved AST increases correlate with more severe hepatocelullar injury Measure integrity of cell membranes Degree of increase correlates with number of hepatocytes involved AST increases correlate with more severe hepatocelullar injury

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Cholestatic Enzyme Markers

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Hepatocellular ALT:High Low ALP 1/2 life:66 hours 6 hours Steroid induced ALP:Yes No Bilirubinuria:Normal Abnormal Cholangiohepatitis:Rare Common Liver Enzymes In Cats

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Diagnostic Profiles Contains grouped tests related to organ function Tests provide complimentary information Tests included relate to a presenting sign Assists in localisation/ narrowing of the DDx Diagnostic Profiles Contains grouped tests related to organ function Tests provide complimentary information Tests included relate to a presenting sign Assists in localisation/ narrowing of the DDx Screens Contains a single test per organ Single most sensitive test included Test array is fixed Provides yes/no information regarding normality Screens Vs Profiles

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Bilirubin Metabolism & Excretion

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Bilirubin In Cats Measures uptake and excretion of bilirubin Exclude prehepatic jaundice Intra- or post-hepatic cholestasis Direct/indirect bilirubin NBG Bilirubinuria is ALWAYS abnormal in cats

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Bilirubin Assay Interference

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Liver Function Tests Endogenous Albumin, urea, Glucose, Cholesterol, Coagulation Factors, NH3 Endogenous Albumin, urea, Glucose, Cholesterol, Coagulation Factors, NH3

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Bleeding Disorders In Feline Liver Disease Abnormalities of PT and PTT Common, usually mild increase PTT only PTT <100 secs Vitamin K dependant coagulopathy on EHBDO Increased PTT and PT Abnormalities of PT and PTT Common, usually mild increase PTT only PTT <100 secs Vitamin K dependant coagulopathy on EHBDO Increased PTT and PT

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Liver Function Tests

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Bile Acids In Cats Detect Presence of diffuse morphologic change Significant functional impairment Best test for portosystemic shunt Detect Presence of diffuse morphologic change Significant functional impairment Best test for portosystemic shunt Fasting bile acids sensitivity = 49% Bile acid stimulation test sensitivity = 81% Fasting bile acids sensitivity = 49% Bile acid stimulation test sensitivity = 81%

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Red Cell Changes In Liver Disease Immune Mediated Haemolytic Anaemia Normocytic normochromic anaemia Microcytosis without anaemia Acanthocytes Red Cell Parasites Immune Mediated Haemolytic Anaemia Normocytic normochromic anaemia Microcytosis without anaemia Acanthocytes Red Cell Parasites

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology White Cell Changes In Liver Disease White cell Inflammatory/toxic changes Lymphoproliferative disease Infiltrative conditions White cell Inflammatory/toxic changes Lymphoproliferative disease Infiltrative conditions

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Common Feline Liver Diseases The big 5 Cholangiohepatitis: –acute, chronic, lymphocytic Hepatic lipidosis Pancreatitis Hepatic neoplasia Extrahepatic bile duct obstruction The big 5 Cholangiohepatitis: –acute, chronic, lymphocytic Hepatic lipidosis Pancreatitis Hepatic neoplasia Extrahepatic bile duct obstruction

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Acute Cholangiohepatitis Clinical features Often young to middle aged cats, male Non specific clinical signs –Fever, depression, dehydration Acute illness with pyrexia Clinical features Often young to middle aged cats, male Non specific clinical signs –Fever, depression, dehydration Acute illness with pyrexia  T.Bilirubin, ALT, ALP, AST, GGT, bile acids Inflammatory leucogram

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Histopathology of Acute Cholangiohepatitis

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Toxic Band Neutrophils In Acute Cholangiohepatitis

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Chronic Cholangiohepatitis Clinical features Often middle aged - older cats Non specific clinical signs Often concurrent pancreatic and small intestinal inflammation “Triaditis” Clinical features Often middle aged - older cats Non specific clinical signs Often concurrent pancreatic and small intestinal inflammation “Triaditis”  T.Bilirubin, ALT, ALP, AST, GGT, bile acids, mild NR anaemia, lymphocytosis Can progress to biliary cirrhosis

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Lymphocytic Cholangitis Clinical features Young to middle aged cats, often persians Usually BAR and afebrile Abdominal effusion with high protein count Clinical features Young to middle aged cats, often persians Usually BAR and afebrile Abdominal effusion with high protein count  T.Bilirubin, ALT, ALP, AST, GGT, bile acids, hyperglobulinemia Differentiate from FIP

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Hepatic Lipidosis Clinical features Usually >2yrs old, obese, indoor cats Preceded by partial/complete anorexia Jaundice, vomiting, dehydration Can have encepalopathy:depression, ptyalism Clinical features Usually >2yrs old, obese, indoor cats Preceded by partial/complete anorexia Jaundice, vomiting, dehydration Can have encepalopathy:depression, ptyalism  T.Bilirubin, ALT, ALP, AST, bile acids, but not GGT Cytology can help confirm diagnosis

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Histopathology Of Hepatic Lipidosis

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Liver Aspirate Cytology

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Nasogastric Feeding

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Feline Pancreatitis / Biliary Tract Disease

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Feline Pancreatitis Clinical features Vague and non specific –Lethargy, anorexia, dehydration Vomiting & abdominal pain less common 30% May have abdominal mass 23%, dyspnoea 20% May have concurrent bowel/biliary tract disease 40% of cats with lipidosis have pancreatitis Clinical features Vague and non specific –Lethargy, anorexia, dehydration Vomiting & abdominal pain less common 30% May have abdominal mass 23%, dyspnoea 20% May have concurrent bowel/biliary tract disease 40% of cats with lipidosis have pancreatitis

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Feline Pancreatitis Laboratory findings +/- inflammatory leucogram Mild liver enzymes and bilirubin elevations Amylase and lipase usually WNL fTLI sensitivity 30%, specificity 83% fPLI sensitivity 70%, specificity 83% Laboratory findings +/- inflammatory leucogram Mild liver enzymes and bilirubin elevations Amylase and lipase usually WNL fTLI sensitivity 30%, specificity 83% fPLI sensitivity 70%, specificity 83%

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Extrahepatic Bile Duct Obstruction Causes –stricture/fibrosis, neoplasia, inspisated bile, bile stones Clinical signs –Anorexia, depression, vomiting, icterus, hepatomegally Causes –stricture/fibrosis, neoplasia, inspisated bile, bile stones Clinical signs –Anorexia, depression, vomiting, icterus, hepatomegally  ALT, ALP, GGT, T. Bilirubin, bile acids Acholic faeces, vitamin K responsive coagulopathy, absence of urobilinogen

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Feline Hepatic Neoplasia Primary - rare Hepoatocellular carcinoma Cholangiocellular carcinoma Metastatic - common Lymphoma Myeloproliferative disease Mast cell neoplasia Haemangiosarcoma Primary - rare Hepoatocellular carcinoma Cholangiocellular carcinoma Metastatic - common Lymphoma Myeloproliferative disease Mast cell neoplasia Haemangiosarcoma

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Feline Hepatic Neoplasia Variable clinical and physical signs Biochemical abnormalities - variable Differentiate from bile duct adenomas, hepatic cysts Variable clinical and physical signs Biochemical abnormalities - variable Differentiate from bile duct adenomas, hepatic cysts

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Reactive/Induced Hepatic Changes Liver changes without significant liver disease Endocrine disease –hyperthyroidism, Diabetes mellitus Bystander hyperbilirubinaemia –dehydration, sepsis, anorexia Reactive/secondary hepatopathies –hypoxia, endotoxaemia, ?lymphocytic portal hepatitis Liver changes without significant liver disease Endocrine disease –hyperthyroidism, Diabetes mellitus Bystander hyperbilirubinaemia –dehydration, sepsis, anorexia Reactive/secondary hepatopathies –hypoxia, endotoxaemia, ?lymphocytic portal hepatitis

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Systemic Infections Involving The Liver Feline Infectious Peritonitis –Clinical signs, profile changes, FCoV, cytology Toxoplasmosis –Clinical signs, profile changes, toxoplasma IgM &IgG Imported diseases –Cytauxzoonosis, Hepatozoonosis Feline Infectious Peritonitis –Clinical signs, profile changes, FCoV, cytology Toxoplasmosis –Clinical signs, profile changes, toxoplasma IgM &IgG Imported diseases –Cytauxzoonosis, Hepatozoonosis

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Making The Diagnosis Is primary liver disease likely? Check an appropriate profile including a FBC If liver changes are present –Rule out extrahepatic causes of the changes –Bile acid stimulation test (if not icteric) For triaditis add PLI, folate and cobalamin Consider cytology if appropriate Often laparotomy & biopsy recommended Is primary liver disease likely? Check an appropriate profile including a FBC If liver changes are present –Rule out extrahepatic causes of the changes –Bile acid stimulation test (if not icteric) For triaditis add PLI, folate and cobalamin Consider cytology if appropriate Often laparotomy & biopsy recommended

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Luna Granville Biochemistry Total protein * 50 g/L Low ( ) Albumin * 17 g/L Low ( ) Globulin 33 g/L ( ) Albumin Globulin ratio * 0.5 Low ( ) Sodium mmol/L ( ) Potassium * 2.7 mmol/L Low ( ) Na:K ratio * 54 High ( ) Chloride * 115 mmol/L Low ( ) Total calcium 2.15 mmol/L ( ) Phosphate * 0.93 mmol/L Low ( ) Urea 6.1 mmol/L ( ) Creatinine 99 umol/L ( ) Alk Phos * 994 U/L High ( ) ALT * 299 U/L High ( ) Gamma GT 8 U/L ( ) Total bilirubin * 49 umol/L High ( ) Bile acids * 77.9 umol/L High ( ) Glucose * 11.8 mmol/L High ( ) CK * 209 U/L High ( ) Cholesterol 4.3 mmol/L ( ) Biochemistry Total protein * 50 g/L Low ( ) Albumin * 17 g/L Low ( ) Globulin 33 g/L ( ) Albumin Globulin ratio * 0.5 Low ( ) Sodium mmol/L ( ) Potassium * 2.7 mmol/L Low ( ) Na:K ratio * 54 High ( ) Chloride * 115 mmol/L Low ( ) Total calcium 2.15 mmol/L ( ) Phosphate * 0.93 mmol/L Low ( ) Urea 6.1 mmol/L ( ) Creatinine 99 umol/L ( ) Alk Phos * 994 U/L High ( ) ALT * 299 U/L High ( ) Gamma GT 8 U/L ( ) Total bilirubin * 49 umol/L High ( ) Bile acids * 77.9 umol/L High ( ) Glucose * 11.8 mmol/L High ( ) CK * 209 U/L High ( ) Cholesterol 4.3 mmol/L ( ) Signalment: 15yrs, DSH, MN History: Long term vomiting, weight loss. Recent anorexia and hypersalivation. Very weak. Signalment: 15yrs, DSH, MN History: Long term vomiting, weight loss. Recent anorexia and hypersalivation. Very weak.

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Luna Granville Biochemistry Feline TLI * High ( ) Alk Phos * 435 U/L High ( ) ALT * 280 U/L High ( ) Endocrinology B ng/L ( ) Folate * 5.9 ug/L Low ( ) Biochemistry Feline TLI * High ( ) Alk Phos * 435 U/L High ( ) ALT * 280 U/L High ( ) Endocrinology B ng/L ( ) Folate * 5.9 ug/L Low ( ) Signalment: 15yrs, DSH, MN History: Long term vomiting, weight loss. Recent anorexia and hypersalivation. Very weak. Signalment: 15yrs, DSH, MN History: Long term vomiting, weight loss. Recent anorexia and hypersalivation. Very weak.

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Luna Granville Haematology RBC * 3.01 x10^12/L Low ( ) Hb * 5.4 g/dl Low ( ) HCT * 15.1 % Low ( ) MCV 50.0 fl ( ) MCH 17.8 pg ( ) MCHC 35.5 g/dl ( ) Platelets * 162 x10^9/L Low ( ) WBC * x10^9/L High ( ) Neutrophils 63% 12.35x10^9/L ( ) Lymphocytes * 37% 7.26x10^9/L High ( ) Monocytes 0.% 0.00 x10^9/L ( ) Eosinophils 0.% 0.00 x10^9/L ( ) Nucleated RBC's ^9/L ( ) PT * 13.7 Seconds High ( ) APTT * 28.4 Seconds High ( ) Haematologist Comment: Red cells appear normochromic with increased anisocytosis (+) and poikilocytosis (+). There is no evidence of increased polychromasia despite the presence of occasional late normoblasts. No abnormal white cells were seen and platelets appeared in adequate numbers on the smears and of normal morphology. There was no evidence of platelet clumping on the EDTA smear. Haematology RBC * 3.01 x10^12/L Low ( ) Hb * 5.4 g/dl Low ( ) HCT * 15.1 % Low ( ) MCV 50.0 fl ( ) MCH 17.8 pg ( ) MCHC 35.5 g/dl ( ) Platelets * 162 x10^9/L Low ( ) WBC * x10^9/L High ( ) Neutrophils 63% 12.35x10^9/L ( ) Lymphocytes * 37% 7.26x10^9/L High ( ) Monocytes 0.% 0.00 x10^9/L ( ) Eosinophils 0.% 0.00 x10^9/L ( ) Nucleated RBC's ^9/L ( ) PT * 13.7 Seconds High ( ) APTT * 28.4 Seconds High ( ) Haematologist Comment: Red cells appear normochromic with increased anisocytosis (+) and poikilocytosis (+). There is no evidence of increased polychromasia despite the presence of occasional late normoblasts. No abnormal white cells were seen and platelets appeared in adequate numbers on the smears and of normal morphology. There was no evidence of platelet clumping on the EDTA smear. Signalment: 15yrs, DSH, MN History: Long term vomiting, weight loss. Recent anorexia and hypersalivation. Very weak. Signalment: 15yrs, DSH, MN History: Long term vomiting, weight loss. Recent anorexia and hypersalivation. Very weak.

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Tom Morrison Biochemistry Total protein 80 g/L ( ) Albumin 24 g/L ( ) Globulin 56 g/L ( ) Albumin Globulin ratio * 0.4 Low ( ) Sodium mmol/L( ) Potassium 4.7 mmol/L ( ) Na:K ratio 33 ( ) Chloride 124 mmol/L ( ) Total calcium 2.35 mmol/L ( ) Phosphate 1.27 mmol/L ( ) Urea * 15.1 mmol/L High ( ) Creatinine 160 umol/L ( ) Alk Phos * 178 U/L High ( ) ALT * 185 U/L High ( ) Gamma GT 6 U/L ( ) Total bilirubin 6 umol/L ( ) Bile acids * 5.2 umol/L High ( ) Glucose 5.8 mmol/L ( ) CK 57 U/L ( ) Cholesterol 2.8 mmol/L ( ) Biochemistry Total protein 80 g/L ( ) Albumin 24 g/L ( ) Globulin 56 g/L ( ) Albumin Globulin ratio * 0.4 Low ( ) Sodium mmol/L( ) Potassium 4.7 mmol/L ( ) Na:K ratio 33 ( ) Chloride 124 mmol/L ( ) Total calcium 2.35 mmol/L ( ) Phosphate 1.27 mmol/L ( ) Urea * 15.1 mmol/L High ( ) Creatinine 160 umol/L ( ) Alk Phos * 178 U/L High ( ) ALT * 185 U/L High ( ) Gamma GT 6 U/L ( ) Total bilirubin 6 umol/L ( ) Bile acids * 5.2 umol/L High ( ) Glucose 5.8 mmol/L ( ) CK 57 U/L ( ) Cholesterol 2.8 mmol/L ( ) Signalment: 15yrs, male, DSH History: Exploratory laporotomy confirms mass developing in one of the liver lobes Signalment: 15yrs, male, DSH History: Exploratory laporotomy confirms mass developing in one of the liver lobes

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Haematology RBC 8.87 x10^12/L ( ) Hb 13.4 g/dl ( ) HCT 45.9 % ( ) MCV 52.0 fl ( ) MCH 15.1 pg ( ) MCHC * 29.2 g/dl Low ( ) Platelets 512 x10^9/L ( ) WBC x10^9/L ( ) Neutrophils 73% x10^9/L ( ) Lymphocytes 19% 2.64 x10^9/L ( ) Monocytes 1% 0.14 x10^9/L ( ) Eosinophils 6% 0.83 x10^9/L ( ) Basophils 1% 0.14 x10^9/L ( ) Haematologist Comment Red cells appear normocytic and normochromic. White cells appear of normal morphology and unremarkable. Platelets appear of normal morphology and in adequate numbers on the smears with no evidence of platelet clumping on the EDTA smear. Thank you for the fresh film sent with Tom's request. Endocrinology Total T nmol/L ( ) Haematology RBC 8.87 x10^12/L ( ) Hb 13.4 g/dl ( ) HCT 45.9 % ( ) MCV 52.0 fl ( ) MCH 15.1 pg ( ) MCHC * 29.2 g/dl Low ( ) Platelets 512 x10^9/L ( ) WBC x10^9/L ( ) Neutrophils 73% x10^9/L ( ) Lymphocytes 19% 2.64 x10^9/L ( ) Monocytes 1% 0.14 x10^9/L ( ) Eosinophils 6% 0.83 x10^9/L ( ) Basophils 1% 0.14 x10^9/L ( ) Haematologist Comment Red cells appear normocytic and normochromic. White cells appear of normal morphology and unremarkable. Platelets appear of normal morphology and in adequate numbers on the smears with no evidence of platelet clumping on the EDTA smear. Thank you for the fresh film sent with Tom's request. Endocrinology Total T nmol/L ( ) Tom Morrison Signalment: 15yrs, male, DSH History: Exploratory laporotomy confirms mass developing in one of the liver lobes Signalment: 15yrs, male, DSH History: Exploratory laporotomy confirms mass developing in one of the liver lobes

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Tom Morrison Progression Biochemistry Total protein 75 g/L ( ) Albumin 24 g/L ( ) Globulin 51 g/L ( ) Albumin Globulin ratio * 0.5 Low ( ) Urea * 23.4 mmol/L High ( ) Creatinine 144 umol/L ( ) Alk Phos * 393 U/L High ( ) ALT * 144 U/L High ( ) AST 30 U/L ( ) GLDH 6 U/L ( ) Gamma GT 8 U/L ( ) Total bilirubin 3 umol/L ( ) Bile acids * 5.9 umol/L High ( ) Glucose 4.9 mmol/L ( ) Cholesterol 2.9 mmol/L ( ) Biochemistry Total protein 75 g/L ( ) Albumin 24 g/L ( ) Globulin 51 g/L ( ) Albumin Globulin ratio * 0.5 Low ( ) Urea * 23.4 mmol/L High ( ) Creatinine 144 umol/L ( ) Alk Phos * 393 U/L High ( ) ALT * 144 U/L High ( ) AST 30 U/L ( ) GLDH 6 U/L ( ) Gamma GT 8 U/L ( ) Total bilirubin 3 umol/L ( ) Bile acids * 5.9 umol/L High ( ) Glucose 4.9 mmol/L ( ) Cholesterol 2.9 mmol/L ( ) Signalment: 15yrs, male, DSH History: Exploratory laporotomy confirms mass developing in one of the liver lobes..1 Month Later Signalment: 15yrs, male, DSH History: Exploratory laporotomy confirms mass developing in one of the liver lobes..1 Month Later

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Smokey Bridges Biochemistry Total protein 80 g/L ( ) Albumin * 18 g/L Low ( ) Globulin * 62 g/L High ( ) Albumin Globulin ratio * 0.3 Low ( ) Sodium 155.0mmol/L ( ) Potassium 5.5 mmol/L ( ) Na:K ratio * 28 Low ( ) Chloride 118 mmol/L ( ) Total calcium * 1.83 mmol/L Low ( ) Phosphate 1.77 mmol/L ( ) Urea * 25.5 mmol/L High ( ) Creatinine * 246 umol/L High ( ) Alk Phos 7 U/L ( ) ALT 31 U/L ( ) Gamma GT 6 U/L ( ) Total bilirubin * 32 umol/L High ( ) Bile acids * 6.2 umol/L High ( ) Glucose 5.4 mmol/L ( ) CK 139 U/L ( ) Cholesterol 5.0 mmol/L ( ) Biochemistry Total protein 80 g/L ( ) Albumin * 18 g/L Low ( ) Globulin * 62 g/L High ( ) Albumin Globulin ratio * 0.3 Low ( ) Sodium 155.0mmol/L ( ) Potassium 5.5 mmol/L ( ) Na:K ratio * 28 Low ( ) Chloride 118 mmol/L ( ) Total calcium * 1.83 mmol/L Low ( ) Phosphate 1.77 mmol/L ( ) Urea * 25.5 mmol/L High ( ) Creatinine * 246 umol/L High ( ) Alk Phos 7 U/L ( ) ALT 31 U/L ( ) Gamma GT 6 U/L ( ) Total bilirubin * 32 umol/L High ( ) Bile acids * 6.2 umol/L High ( ) Glucose 5.4 mmol/L ( ) CK 139 U/L ( ) Cholesterol 5.0 mmol/L ( ) Signalment: 8yrs, Female, DSH History: Acute inappetence, lethargy, polyuria. Slight weight loss. Mucosae pale. Signalment: 8yrs, Female, DSH History: Acute inappetence, lethargy, polyuria. Slight weight loss. Mucosae pale.

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Haematology RBC * x10^12/L High ( ) Hb 16.8 g/dl ( ) HCT * 54.4 % High ( ) MCV 48.0 fl ( ) MCH 14.7 pg ( ) MCHC 30.8 g/dl ( ) Platelets * 140 x10^9/L Low ( ) WBC * x10^9/L High ( ) Neutrophils * 94% x10^9/L High ( ) Bands * 2% 0.84 x10^9/L High ( ) Lymphocytes * 2% 0.84 x10^9/L Low ( ) Monocytes * 2% 0.84 x10^9/L High ( ) Eosinophils 0.% 0.00 x10^9/L ( ) Haematologist Comment Red cells appear normocytic and normochromic. Marked leucocytosis with a mild left shift and toxic changes within neutrophils. Mild lymphopenia with occasional enlarged reactive lymphocytes. Mild monocytosis. Platelets appear mildly reduced and of normal morphology. Endocrinology Total T4 * 6.1nmol/L Low ( ) Haematology RBC * x10^12/L High ( ) Hb 16.8 g/dl ( ) HCT * 54.4 % High ( ) MCV 48.0 fl ( ) MCH 14.7 pg ( ) MCHC 30.8 g/dl ( ) Platelets * 140 x10^9/L Low ( ) WBC * x10^9/L High ( ) Neutrophils * 94% x10^9/L High ( ) Bands * 2% 0.84 x10^9/L High ( ) Lymphocytes * 2% 0.84 x10^9/L Low ( ) Monocytes * 2% 0.84 x10^9/L High ( ) Eosinophils 0.% 0.00 x10^9/L ( ) Haematologist Comment Red cells appear normocytic and normochromic. Marked leucocytosis with a mild left shift and toxic changes within neutrophils. Mild lymphopenia with occasional enlarged reactive lymphocytes. Mild monocytosis. Platelets appear mildly reduced and of normal morphology. Endocrinology Total T4 * 6.1nmol/L Low ( ) Smokey Bridges Signalment: 8yrs, Female, DSH History: Acute inappetence, lethargy, polyuria. Slight weight loss. Mucosae pale. Signalment: 8yrs, Female, DSH History: Acute inappetence, lethargy, polyuria. Slight weight loss. Mucosae pale.

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Pinta Ibarra Biochemistry Total protein 58 g/L ( ) Albumin * 20 g/LLow ( ) Globulin 38 g/L ( ) Albumin Globulin ratio * 0.5 Low ( ) Sodium 153.0mmol/L ( ) Potassium 4.4 mmol/L ( ) Na:K ratio 35 ( ) Chloride 121 mmol/L ( ) Total calcium 2.18 mmol/L ( ) Phosphate 2.21 mmol/L ( ) Urea 11.6 mmol/L ( ) Creatinine * 73 umol/L Low ( ) Alk Phos * 113 U/L High ( ) ALT 38 U/L ( ) Gamma GT 8 U/L ( ) Total bilirubin * 16 umol/L High ( ) Bile acids 0.1 umol/L ( ) Glucose * 7.7 mmol/L High ( ) CK 119 U/L ( ) Cholesterol 3.7 mmol/L ( ) Biochemistry Total protein 58 g/L ( ) Albumin * 20 g/LLow ( ) Globulin 38 g/L ( ) Albumin Globulin ratio * 0.5 Low ( ) Sodium 153.0mmol/L ( ) Potassium 4.4 mmol/L ( ) Na:K ratio 35 ( ) Chloride 121 mmol/L ( ) Total calcium 2.18 mmol/L ( ) Phosphate 2.21 mmol/L ( ) Urea 11.6 mmol/L ( ) Creatinine * 73 umol/L Low ( ) Alk Phos * 113 U/L High ( ) ALT 38 U/L ( ) Gamma GT 8 U/L ( ) Total bilirubin * 16 umol/L High ( ) Bile acids 0.1 umol/L ( ) Glucose * 7.7 mmol/L High ( ) CK 119 U/L ( ) Cholesterol 3.7 mmol/L ( ) Signalment: 11yrs, FN, DLH History: Straining to urinate. Cervical mass. Signalment: 11yrs, FN, DLH History: Straining to urinate. Cervical mass.

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Pinta Ibarra Haematology RBC 6.79 x10^12/L ( ) Hb 10.3 g/dl ( ) HCT 32.1 % ( ) MCV 47.0 fl ( ) MCH 15.2 pg ( ) MCHC 32.2 g/dl ( ) Platelets 347 x10^9/L ( ) WBC 8.53 x10^9/L ( ) Neutrophils 71% 6.06 x10^9/L ( ) Lymphocytes 27% 2.30 x10^9/L ( ) Monocytes 1% 0.09 x10^9/L ( ) Eosinophils 1% 0.09 x10^9/L ( ) Haematologist Comment Red cells appear normocytic and normochromic. White cells appear of normal morphology and unremarkable. Normal platelets morphology and numbers - there is some evidence of platelet clumping on th EDTA smear which may have reduced the absolute count somewhat. Thanks for the fresh blood film sent with Pinta's submission. Endocrinology Total T4 * 94.1 nmol/L High ( ) Haematology RBC 6.79 x10^12/L ( ) Hb 10.3 g/dl ( ) HCT 32.1 % ( ) MCV 47.0 fl ( ) MCH 15.2 pg ( ) MCHC 32.2 g/dl ( ) Platelets 347 x10^9/L ( ) WBC 8.53 x10^9/L ( ) Neutrophils 71% 6.06 x10^9/L ( ) Lymphocytes 27% 2.30 x10^9/L ( ) Monocytes 1% 0.09 x10^9/L ( ) Eosinophils 1% 0.09 x10^9/L ( ) Haematologist Comment Red cells appear normocytic and normochromic. White cells appear of normal morphology and unremarkable. Normal platelets morphology and numbers - there is some evidence of platelet clumping on th EDTA smear which may have reduced the absolute count somewhat. Thanks for the fresh blood film sent with Pinta's submission. Endocrinology Total T4 * 94.1 nmol/L High ( ) Signalment: 11yrs, FN, DLH History: Straining to urinate. Cervical mass. Signalment: 11yrs, FN, DLH History: Straining to urinate. Cervical mass.

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Pinta Ibarra Microbiology Urine creatinine mmol/L Urine protein 1.33 g/L Urine protein:creatinine 0.79 ( ) Specific gravity Urine biochemistry pH 7 Protein * ++ Glucose Negative Ketones Negative Urobilinogen Negative Bilirubin Negative Haemoglobin * ++++ Urine sediment RBCs /hpf WBCs *20-30 /hpf Epithelial Occasional epithelial seen Crystals None seen Casts None seen Microbiology Urine creatinine mmol/L Urine protein 1.33 g/L Urine protein:creatinine 0.79 ( ) Specific gravity Urine biochemistry pH 7 Protein * ++ Glucose Negative Ketones Negative Urobilinogen Negative Bilirubin Negative Haemoglobin * ++++ Urine sediment RBCs /hpf WBCs *20-30 /hpf Epithelial Occasional epithelial seen Crystals None seen Casts None seen Urine culture * >100,000 colonies of coagulase negative Staph Marbofloxacin Sensitive Enrofloxacin Sensitive Cephalexin Sensitive Synulox Sensitive Tribrissen Sensitive Clindamycin Sensitive Urine culture * >100,000 colonies of coagulase negative Staph Marbofloxacin Sensitive Enrofloxacin Sensitive Cephalexin Sensitive Synulox Sensitive Tribrissen Sensitive Clindamycin Sensitive Signalment: 11yrs, FN, DLH History: Straining to urinate. Cervical mass. Signalment: 11yrs, FN, DLH History: Straining to urinate. Cervical mass.

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Feline Chronic Renal Disease Biochemistry –Azotaemia –Potassium –Calcium Biochemistry –Azotaemia –Potassium –Calcium Urinalysis –Retained concentrating ability –Leucocyte dipstick response –Crystaluria significance What’s different about cats?

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Feline Chronic Renal Disease Mild Moderate Marked Mild Moderate Marked Azotaemia Urea mmol/l Urea mmol/l Creatinine umol/l Creatinine umol/l

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Feline Chronic Renal Disease High renal tubular flow promotes potassium loss Potassium depletion is only poorly reflected in serum concentration Hypokalaemia exacerbates renal insufficiency Anorexia, vomiting, depression, muscle weakness can all reflect hypokalaemia Hyperkalaemia in CRF is a poor prognostic sign High renal tubular flow promotes potassium loss Potassium depletion is only poorly reflected in serum concentration Hypokalaemia exacerbates renal insufficiency Anorexia, vomiting, depression, muscle weakness can all reflect hypokalaemia Hyperkalaemia in CRF is a poor prognostic sign Potassium

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Feline Chronic Renal Disease Total calcium comprises 3 components Usually serum calcium is normal in CRF 10% of cats have increased total calcium in CRF Phosphate restricted diets may increase calcium Total calcium comprises 3 components Usually serum calcium is normal in CRF 10% of cats have increased total calcium in CRF Phosphate restricted diets may increase calcium Calcium

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Urine Specific Gravity In Cats Concentrating ability is retained later in cats USG need not exclude renal disease Concentrating ability is retained later in cats USG need not exclude renal disease Measure on cat USG scale Dipstick SG scale is useless Measure on cat USG scale Dipstick SG scale is useless

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Urinary Tract Infection In Cats Increasingly common with age Need not be associated with leuconuria Leucocyte dipstick gives false positive Increasingly common with age Need not be associated with leuconuria Leucocyte dipstick gives false positive

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Boric Acid Tubes

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Crystaluria In Cats Alkaline urine Cooled urine Concentrated urine May dissolve in boric acid Alkaline urine Cooled urine Concentrated urine May dissolve in boric acid Acidic urine Cooled urine Concentrated urine Acidic urine Cooled urine Concentrated urine StruviteOxalate

Nick Carmichael  2005 Feline Liver and Renal Clinical Pathology Making The Diagnosis In Feline Renal Disease Need blood and urinalysis Complete the renal profile Urine best examined/prepared whilst still fresh Sediment and culture required Serial measurements are valuable for monitoring progression/response to treatment Need blood and urinalysis Complete the renal profile Urine best examined/prepared whilst still fresh Sediment and culture required Serial measurements are valuable for monitoring progression/response to treatment