May 21, 2021

Ureteral stones. Yes - it's a thing! With Dr Dave Collins.

Ureteral stones. Yes - it's a thing! With Dr Dave Collins.
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Season 1

Welcome back to another one of our clinical episodes. I decided to share this one today because of a case I dealt with just this morning. We had a cat in hospital with what was thought to be acute renal failure, but what turned out to be a ureteral obstruction. That's ureTEral, not urethral. Seeing this case reminded me how dangerous this disease is, and how easily it can be missed. So I thought I'd share this episode that we recently did on the topic with our resident medicine specialist, Dr Dave Collins. The thing is - until we did this interview with Dave, ureteral obstructions just wasn’t on my radar, but we're learning that it's apparently more common than we think it is. Probably because we’ve been missing them. 

If this comes as a surprise to you then I recommend you plug in and let Dave tell you everything you need to know about ureteral obstructions: from spotting them, to diagnosing them, and all the way to how to fix them. 

Enjoy!

 

Go to https://thevetvault.com/podcasts/  for the show notes about everything we talk about in the show.

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You might smell a rat.When you've got a painful cat that straining to urinate and think that ha urethral obstruction and then you feel an empty bladder, okay?And then the plot thickens.Hi, I'm Hubert, this is Gerardo.
Hi.I'm Dave Collins.I'm a small animal medicine specialist who works in the north of Sydney.And you are listening to the vet Bob Medical Park.Hello.Vit vaulters and welcome back to another one of our clinical episodes.
I decided to share this one with the wider world because of a case, we dealt with just this morning, we had a cat in a hospital, who'd gone into what was initially thought to be acute, renal failure.But that turned out to be a urethral obstruction.That's ureteral not urethral.
And seeing this case reminded me of how dangerous this disease is, but also how easily it can be missed with.Stating consequences.This made me think that I really should share this episode.We recorded with dr.Dave Collins, our resident medicine specialist a couple of weeks ago because up until I did this interview with Dave ureteral obstructions just wasn't really on my radar for acute, kidney disease.
But it's apparently more common than we think, probably, because we've been missing them.If this is a surprise to you, then I recommend you plug in.And let Dave tell you everything you need to know about your ritual, obstructions from spotting them.Diagnosing them.And all the way to how they can be fixed.
And if you enjoyed this episode and you feel like you could use more of these updates to sharpen your skills, and become the smartest vet in your clinic, then you should check out our clinical podcast series.If you haven't already, it's 3, 20 to 30 minute episodes, every week, backed up by summarized show notes.
So you can refer back to all the goodness at a later stage when you need to refresh your memory, our goal with these clinical episodes is to give you a handful of practical.Takeaways with every episode that you can go and apply in your workplace.Straight away in an easy to digest.Hopefully enjoyable medium that you can consume while you get on with your life.
I had a lovely email from a member this week to thank us for the clinical podcasts and she told us that it way more useful than any other CPD that she's ever tried.That's a quote which of course made my day go and try it for yourself at the vet volts.com.Just click on the clinical button on the top right hand of our homepage.
Okay, back to Dave and urethral obstructions.Whether welcome back, I hear that crowd to be back.Now, we've got an interesting topic today when I asked you, what should we talk about?
You kind of blindsided me with this one purely because I had no idea that it was a thing but that makes me wonder if I'm missing them.You said, let's talk about.You Rachel abstractions, but not urethra.I'm even rated wrong.
So obstructionism Europe that yeah, I miss them.Yeah.I think it's become particularly the ultrasound.It's become more and more recognized, and we've worked out.The prevalence is increasing, and I guess also many years ago, when science determine distribute through a big cause of obstructions and mostly urethral at that point, the diet change components to minimize magnesium, ammonium and phosphate the struvite components.
And the flip side was a massive increase in calcium oxalate year or less.So I think Batman.The science is just getting on top of what kind of balance of minerals and pH and whatnot, is right for minimizing Stone formation generally.But yeah, the incidents of calcium oxalate is massively increased in the last 20 or 30 years, and most of the big problems we Face are in the upper urinary tract.
So Nefra this in Eurasia and let's so the foods that say they just anti stone for stone preventing, is that false advertising?I know.Technology has caught up, you know the big companies of found the optimum pH and precipitation factor or whatever they call it to minimize both oxalate and struvite formation.
But I guess to the immediate reaction to struvite a year in the tharsis was to acidify diets and of course calcium oxalate loves forming and acidic urine.Okay cool.And and dogs and cats or well cat awaits.
We see it a lot in cats, and not so much in dogs.In fact, I've rarely seen the ritual obstructions generally in dogs.When I have, it's usually secondary to transitional cell, carcinoma of struck me, at the level of the try, go and the ladder, whereas cats, I think we share your racial obstruction, every few weeks, some of the big centers, see one or two a week, hasn't been a lot of Australian data or seasonality done, but I get a feeling that springtime when things are warming up and cats are Further behind on the high trash and seems to be a bit of a pecan set for us, but that's more the polluted syndrome of diseases that causes those because when that in emergency, that's a regular thing times of year, we see lots of block ads.
Yeah.But the lower urinary tract.So it is this, are we talking about the same sort of stuff a fake higher up as well?Yeah, absolutely.So most common lower urinary tract you race from obstructions is going to be struvite.Yeah, and I guess the population I see He's going to be pretty biased.
You know lot of practitioners, see the race for obstructions pretty commonly and deal with them.Sort them out brilliantly in, we don't get involved whereas some of the more alcohol generic sick cats.You know, vomiting lethargic in a patent, may be Pirates.
If it's a can be a bit hard to determine, but I think if you boiled down to it and do some blood's and imaging a lot of these, I guess, what previously might have been assumed as being acute kidney injury, the main differentials of Go to be Lily toxicity pyelonephritis, for example, various other infections.
But I guess with the Advent of the Imaging and recognizing the significance of a dilated renal pelvis means that we're diagnosing.Your racial obstructions a lot more commonly.So what do they present?Okay.What if they're coming through the yeah, that's a good question.
I mean like any cat that they never give you much help in making the diagnosis with their disease but they are often quite Quite painful and off that vomiting, and a portent abdominal pains.Sometimes her XE and sometimes it's an incidental finding for not incidental, but sometimes there's a syndrome called Big kidney.
Little kidney.Okay.There's a few differentials of that, such, as cystic kidney disease, or even lymphoma, which is probably more often bilateral.However, sometimes we discover these cats have a urethral obstruction when the second key, This will the kidney or years, your is obstructed.
And the first kidney may have been obstructed and shut down a year or years ago.And so, that kidney is then shrunken and a chronic kidney or even a dysfunctional kidney and the it's been living on one kidney which is hypertrophy and particularly when it's in, obstructed, it presents as an acute emergency with an enlarged.
Painful kidney.Okay.So he could have the big candy little kidney.Hmm, that is there's two scenarios that are either, it's a chronic thing and the little kid is that they give me.Yep.Oh.Is it all so cute when you have an acute obstruction that the big one is an abnormally small?
Yeah.Well, it's been about.Yeah, I think I can hypertrophy when there's a solitary kidney or more acutely secondary to a urethral obstruction.Okay?So now it's just feeling on specifically sick, get better, absolutely downtown.
Sidestep abdominal pain, either always painful, you think they would be most times, not only painful, but angry and I guess that kind of comes down to Breeze.We see a lot of Maine Coons.And it's not a lot of data in Australia about breeds, but some of the breeds that have been mentioned in the US and Maine Coons in Siamese course, we see a lot of domestic shorthairs but some of them are going to be painful and just just plain angry.
Do stresses the importance of doing Bloods.Sometimes it's a big Financial commitment.When When the kind of vague nonspecific signs, but if you've got a pretty decent as a team are I'm talking three, four, five, hundred plus creatinine, then we may be dealing with your racial obstruction.
Of course, you've got to be very careful in the history to talk about potential Lily exposure leptospirosis is pretty rare in cats, but I guess you're going to have a chat about their their environment and their background indoor/outdoor cats, for example.So nonspecific ad comes in painful abdomen, You're on Bloods and you go.
Okay, as a team, we have decent as a team.We are, as you say, mostly you, I didn't immediately think of toxicities or pyelonephritis.Is there anything there?Before you put a probe on it?That's going to make you think of it.Or is the next step?
Just okay, this something I think it is.Let's go scanner.Yeah I guess him.I will be guess if it's a sort of chronic and they're not always completely obstructed so they might take a little while to become as a team before or you.Remy.So might be losing weight or vocalizing from the pain.
They might have signs of more chronic kidney dysfunction such as PPD, or the weight loss or anemia.Hello, well, be lower urinary tract science.Like if some of the stones have gotten down into the lower urinary tract and the bladder and course cystitis or UT Island.
And there may well be a Plucky.Urea dysuria straining area.Etc.Ok.Ok.So we can present like a fairly typical your yeah, absolutely, yeah.And I guess, What you might smell a rat?When you've got a painful cat that straining to urinate and they think they're ha urethral obstruction and then you feel an empty bladder, okay?
And then the plot thickens and if you do, if you are lucky enough to have access to an ultrasound and just checking the bladder and the kidneys might give you your answer or alright, geography is not without use, you know, they calcium oxalate, thankfully a mostly radio opaque so it is worth getting ready grass to try and confirm.
Firm your suspicions, okay?Before we get to Imaging.Hmm.Just a few questions about your analysis that that spring to mind.Hmm.So if it's one kidney that switched off because it's blocked, there's a g or does the other one just take over and concentrate?
It's a good question.But often you will find that they can perfectly adequately concentrated urine with the one kidney and not be as a tunic.And it's not until that Remaining kidney starts to dysfunction that they'll go through the progressive phases, of nephron loss, which will be losing the ability to concentrate urine, become PPD.
And then eventually, when 75% of that kidneys nephrons are lost, they may become as a teeming, okay?Okay?So if the other kidney is not going to help you, then they're not necessarily in kidney failure.Yeah, it's actually in humans.They can then easily assess GF ours and determine which kidneys are working with Envy but we can't really do that.
So it's pretty hard for us to assess what's going on in the second kidney.It's not until that one's obstructed and failing that they're gonna develop the signs of renal failure.So, I've ever most the eyes of T because the same logic can go there and can that other kidney function well enough to prevent as a tibia.
Yes, yes.Oh, about 15 percent of cases are bilateral and abstraction but sometimes you can pick up a unilateral obstruction and the other kid Fine.So in which case they may not be as a teeming but it's only a small amount of cases, okay?
And they made us present as being really painful and it's not until the Imaging that that you can detect them and they may not be as a team.Okay, cool.And and other stuff on your analysis that do they do, they are other hematuria core.What else?Yes.So it depends I suppose on the degree of lower urinary tract securely tharsis, but in sometimes you An, have an F release, or you're actually sitting up, in the upper urinary tract, not even causing an infection yet.
Sometimes you might have a raging pyelonephritis and the UTI.So the amount find neutrophils you might find bacteria May well find calcium oxalate, you release and complicated factors.If you've got secondary infections, you might find struvite, crystals developing as well and yeah, it's changes but let's not get too comfortable, okay?
They say that it becomes very conversation, got a calcium oxalate, you could have a calcium oxalate crystals stuck in there.You're at the exactly Yang us through like, well, you probably got a riding UTI and the fraud Us by the time he got struvite.So, but you may well, find well stones in the bladder and you see eyes and oxalate crystals urea on on urinalysis Pre-K, and then you said right in the beginning, when they present their laughing present with the pyrexia, Is that there's bit sad because of secondary infection probably.
Yeah, I guess if they're acutely painful enough.They might have a mild Parks you.But you could have got decent / X here at 40 plus.That's usually going to indicate at least two, UTI, or maybe pyelonephritis.So think this is if I've missed them.
It's probably very where I go.Yeah, I've Got a Boner fried, as job, done.So with them out.Treat them.Yeah.And then they might go under the radar.Like that potentially.Yeah.And if you're lucky enough to sort, In fiction, the racial abstract, the stone might actually pass eventually.
Okay, only about 10% of them are thought to do that.But if you've got a really small Stone, why it's a millimeter diameter.It may eventually passed down the ureter.Cool.Dear chap behaves a bit like the referendum.If there's a stone or a rough painful stone passing down at spasms.
So once that settles then it might lead to passing of the stone and I guess we'll we can talk about medical therapy in a minute.But There are strategies we can do to try and support cats through your visual obstructions that may avoid expensive interventions.
Cool.So it sounds like diagnosing, it's kind of come down to just can Yeah.Called standard.Yes I think if you've got clinical suspicion, you know signal that's important, the breeze.We talked about this usually middle, okay?So now the clue is that often kind of middle-aged cats.
So kind of 528 is a typical age.One study, reported the median age of eight whereas a lot of our chronic kidney disease cats or acutely decompensated chronic kidney cats geriatrics you know 12 or 13 on average.
So if you've got a kind of young Cat in an otherwise, pretty good body condition.That might be a clue that you've got a Ki acute kidney injury, secondary to your Edgeville obstruction, and if the astute clinician sees that and season as a team here and can even shoot a radiograph then maybe a uh well obstruction should be on the radar awesome.
And then what do you see on a scan that you are hopefully going to see this Stone but and and I presume you're going to see some distillation of the renal pelvis and the yeah.So I guess for a novice ultrasonographer, really subtle.Rental public relations are tricky and I can usually the renal pelvis is collapsed.
You usually don't see anything if a patient's on fluids or if they're PPD, if the Diaries and you might get them distended to 2 or 3, mm pyelonephritis, the fluid might be distended to that or even for a 5.
Mm.And the fluid may become more academic.As opposed to pretty normal urine, which is anechoic or dark there.So that may mean, you've got some pus going on there and I think there's no doubt that if you're above 8 to 10, mm and certainly 13.
Mm.Don't even mm 100%.The ureters obstructed 8 to 10.Mm it's pretty certainly obstructed and I guess between 4 and 5 and 8 millimeters then that's tricky but you certainly want to get you good longitudinal section of the kidney and just Again, through the see what's going on in the renal pelvis, if you can turn the probe 90 degrees, you might get a transverse section of the pelvis.
And what you might even see is a distended ureter, extending from the renal pelvis extent.The standard a few millimeters across.You got to remember a normal cat ureters about 0.4.Mm diameter.Because why stenting of them is so difficult whereas humans are about 6.
Mm.So, you know, human nature, human neurologists have got it.It easy isn't that?So funny and as soon as you try and intervene with the ureter, the your to gets really cranky and strictures and spasm.So it's it's a really tricky area.
So yeah.So you might see the distended ureter.You might even be able to follow that most of the weight of the bladder.It gets tricky, because you've got: and gas, there, alone all of the time and you might even see a hyper echoic shadowing Stone.Either in the proximal ureter or or further distal towards the try going to the bladder.
Okay, how long does it take for the for the pelvis to start to standing?So you get obstruct them day one.When you start seeing those changes, you know?Yeah, that's a good question.I think, within 48 Hours of a colossal start to spending and they progressively distend and also Progressive nephron lost the longer.
They're obstructed as well.So within if two weeks of obstruction is there's 80 percent nephron loss in the kidney.So, the sooner you get in there and try and unobstructed, then the happier the Kidneys going to be okay.So do you have a bit of time?So it's not.
I diagnose one tonight at work and I have to go jump in there and do do some sort of emergency.Well, I guess the complication there is and they may not be 100% of structure, that might be a little bit of you urine coming out, but you've got to be really careful that if they're essentially and nurick and become hyper claiming.
It's an emergency you need to decompress that area immediately.Okay.So are we at a treatment or is this something we're missing?Well so, you know, I guess diagnosis is important.So we talked about the ultrasound and the other team, Mia really important things.
And if you're lucky enough to have acid base, to see how bad the acidosis is, how bad the hyperkalemia is, you know, met in my experience, I haven't seen a lot of acute hyperkalemia is life.I used to see with urethral obstructions, but same principles.
Calcium gluconate Try and stabilize the heart, some interim glucose to try and get that potassium down, but then that's only going to buy a time to try and get rid of the the urine somehow.Okay.So it's in terms of stabilization it's going to be depending on what you see on your Bloods.
Basically you can see some electrolyte disturbances and bacteria.So initial medical therapy just to keep them stable.It's going to depend on your blood cells.That's a drag.Yeah.So if you've got a particular, got a neutrophil.If you don't know You sediment and can you hear my dog something?
I can't.I can see.He looks like an old dog.He won't like it all dug.The fuck's, the floor boards and nails.And so yeah, if you got a neutrophil earlier and active sediment, then you know urine sample even from the bladder can be very helpful to try and diagnose a UTI because you may well want to introduce antibiotics analgesia antiemetics IV.
Fluids hot may be necessary for A drone.However, like any acute kidney injury ever be really careful and volume overload.A lot of these cats present volume overloaded, which can be detrimental to return of kidney function.
So if will do whatever you can to try and monitor the urine output, if you've got some, your it output, then you could even try some fluid and Mannitol to try and Diaries the stone out.Particularly, if you've got an idea that there's a small Stone and it's in the Year to that might help at past.
However, if you have got access to a referral center, who can sort out the renal pelvis with a sub or a ritual bypass, and that would be the ideal management, but it's pretty expensive stuff.We're talking 12 to 15 thousand four Sub in one kidney up to 20,000 for a couple of kidney.
So it's a huge money.So once it's done, talk me through.What do you do, at the Sub?Sub is a Device developed by some vets in New York.She can Alison who worked with Norfolk bit to develop this.Subcutaneous ureteral by-paths Norfolk.
That I've got a really good website as YouTube videos on them, but basically it's a, an artificial ureter.So there's an F trust in You Tube going into the renal pelvis.There's a little subcutaneous Port sitting under the skin, where connect the nephron system, YouTube.
And in the other end is assist ostomy.So it essentially drains the urine from the distended raynal kovas via the port, and then into the next ostomy tube and hence into the bladder.So, the pretty cool little things.I'll make sure I get some information and some pictures for you, for you.
Yeah, show notes.Cool.And we've put a hell of a lot in some centers of and the US and Europe and Australia put in hundreds of them with great results.Is that a surgical thing?If you've At the luxury of fluoroscopy putting it in and it's brilliant to actually see in real time, the placement of the device, but you probably the trickiest part is placing the defrosting YouTube, which doesn't need surgery.
A so got to go into the abdomen and in the early days, people were using ultrasound guidance to place the net frostini tube in the kidney and then surgically connecting that to the sub and to the cysts ostomy chew.So yeah, so definitely need to get some surgeons involved but yeah certainly needs some Medical Imaging in Put to do it as successful as possible.
And as that permanently I could, do they have that?Yeah.Yes.Look how its complications but it's about an 80% success rate in most studies and in my experience.So, and I can last for up to three years, I think the latest study had, you know, median, three years.
Sometimes, they need to be replaced, main complications are infection, which is usually an issue if there's already infection there.I think the figures are about eight to ten percent of them get.Chronic UTIs and of course, being a prosthesis.They developer biofilm, which makes them a real bugger to treat these and only Confections.
Okay.The other complication is because these cats are Stone formers, they can mineralize into the device and obstruct.So there's techniques these days to manage them with a solution called Tetra EDTA which sort of breaks down the calcium oxalate stones and trans prevents mineralization and can also help with But if they managed properly, then we've got a number of cats that have had them in for three years or more and some with some within both kidneys.
Sometimes you find by the time, the suburb structs, the natural EuroTrip becomes patient.Again, that's the best-case scenario and we didn't actually talk a lot about the differentials so we can have strictures.We can have neoplasia usually at the level of the Trigon.
Can also just get dsbs or dried solidified blood clots forming And sometimes in combination with a stone, the other anatomical abnormalities some cats, get her a circum Carville ureter, where the ureter actually goes dorsal to the court or vena cava, all right?
And that corner causes the kink in the ureter and predisposes it to obstruction and structure, okay?So it's not, it's a predisposition, but they won't necessarily present as kittens.They could they could be saddled.Would add a yeah?Coming later.
Yeah, it's sort of a race.FIFA disaster.If you've got the circum car with your share and then you get a stone because it's going to have a real problem.Getting around that corner.I want to go back to the little blood clots.Where are they?So the blood transformed in the kidney.Yeah, so in the kidney, are the secondary to trauma or an effortless, something like that, and they passed down the ureter and form a clot, which then dries, and then close an abstraction and obstruction to the Erica.
Well, they result like a probably not so you think that there'd be a lot more harmless than a stone but then in fact, causes bad and instruction is a stone so.So they need some kind of bypass and not saying Subs of the only way if you facilities no Davis and the state's prefers to extents in the in the feline ureters but very fiddly and tricky.
And I think you definitely need a specialist surgeon and think the results are quite as good as the So is the sub pretty much stick the domain of Specialists?Like it's not something that you could hear somebody's Keen to learn.And in GT, there are very change surgeon.
That's got a high caseloads and throughput and says a few of these, does some training, the AMC in New York where cheap price analysis and Brent work, they do training courses on this subs and other Urological procedures.
You know, in general it is a surgical thing.Thing and you'd probably need to do a bit of training and work with some Specialists, but I think if you can do that and get some some practice doing it with getting the higher case numbers and you know, I think a handy surgeon would be able to achieve it.And what about zapping them with lasers or sound?
Whatever, I know Newman's their race down the yeah that's certainly the treatment of choice in humans and probably you know he's been going some will University or research institutions in the state.Sure, if anyone's using lies of nephal Astoria racialist in Australia, but that may change in the future, as people get more training and experience, but you're not really a viable option at this stage.
What I did want to go back on is if in very understandably, if a sub or referral is not an option.So you can try medical management.So said about 10% of them May respond.Grant as I said, very careful with fluid.
It's definitely need to be have them on analgesia.It gets my ideally 24-hour facility.With a fentanyl CR is my choice.I think even buprenorphine is probably not strong enough analgesia.You've got to be really careful with NSAIDs in these cats because of the kidney dysfunction.
And that at all.I think you need to be cautious of that particularly, if the stones unlikely to pass, but there's some support for drugs called prazosin and amitriptyline is smooth, muscle relaxants try, Minimize the urethral spasm and consequently, the pain and maybe help us the stone is, so the Mannitol is that you trying to flush it through that, it has, so as an osmotic diuretic so you know, guess it's an aggressive way of trying to combat these and hope that you might pull enough fluid into the table Kobe's and through the ureters to try and flush the stone.
Probably not something I'd recommend and and okay, you're not going to I was going to So we why specifically Mannitol and not prove my at all or another lady?Yeah, it's a good point.How I think the Mannitol has an osmotic diuretic tends to draw fluid without altering electrolytes.
It's also a bit of an antioxidant and it helps minimize some of the subsequent renal damage that occurs with, with the obstruction, okay?But do you say you avoided it around a little bit of what it?Yeah, I mean, I I think unless it's pass well I guess sadly parcel die for the patient and yeah I would probably be avoiding it and particularly for Farrell's adoption.
I've try and give it a miss and I tend to stick to just analgesia and prazosin and cautious IV.Fluids and one-off Dosa.Dexamethasone, you know may not do any harm settle down some inflammation in the area and some of these guys you know need regular checking with the ultrasound to see if things change.
In Bloods.And it may take up to a week to pass by which time you think you've already spent a hell of a lot of money.So mmm.So if there is option for decompression or referral then and that would be preferable.Okay?And a lot of sounds like a fair amount of prayer and goodness.
Good thoughts.I've had a few come good.But yeah.I think you've got a sadly, you know, prepare the owners that have got a sometime relatively Lovely young cat here than they may be a bad outcome.So why can't you get the kidney out?
Is it because they like to do throw one of the other side?Yeah, that's a good, good question.And, and yeah, that my will be a salvage procedure in some cases and yeah, yes, you hit the nail on the head.There.The big problem is you've got to be rude.
Really sure that the other kidneys working before you remove and you'd have to do an F rho U, Reacher Russia me.You know, which is a relatively challenging procedure for a lot of vets.I wouldn't I wouldn't be game for example, but you know, but you make sure there's no net for little you reach for this or dysfunction in the other kidney.
So, and even if you do, you know, do put a sub device in.If you can get them into both kidneys, you sort of never know how much function you're going to get.Even out of a kidney.That looks hopeless and shut down, sometimes you can save some residual nephron function.
So you know nephrectomy nephew retracting may be an option but I just want to be really careful that the other kidneys happy before you do that.Yeah, and I'm just trying to think because you said right in the beginning that sometimes you find them in sedately with a, with a shrunken little kidney, but sadly, it's actually, that's probably you don't want to say, what?
Sorry.Sorry.Get you kind of fur.You're gonna have to get over this and we wait for the kidney to dry off.That's, that's not an ethical option.Really is it?Because if, but, yeah, so we need to have the conversation with Yona that you're going to try everything to try and And save them and manage to keep cat comfortable and medical therapy.
While hoping that stone would pass.But it's not to say that that small kidneys completely dysfunctional.But yeah, it's a big surgery to pull that obstructed kidney.Are you have a cat with Stage for chronic kidney disease, and one kidney.So, you know, I don't think it's the right thing to do, no actually because edit there, we have it covered everything was there, is there anything we missing?
Well, you know, I guess we've talked about Smoke to the complications and things with the stub devices and I do need regular check-ups for flashing with this Tetra, PTO solution.And even then you can still get some mineralization or infections forming.
Sometimes the tubes, pull out, sometimes I Kink if they're not Place correctly, sometimes they can leak a little bit and you know certainly had one very committed owner that would we replaced the sub?And we just couldn't get rid of the pyelonephritis and we tried, for think 12 months the most happy.
And it had pretty much urinary tract signs the whole time.And I'm very scared of removing the outer kidney and then we have eventually removed the czaban that kidney, and now to cap 2 million bucks.So really, it was her.Yeah, it's about two years ago.
So that was a success story, but you will very, very nervous about pulling the kidney out for a while.That's if you say, regular check-ups to have flash to that hair regulars, regular how often is it going to the to the clinic?Yeah, so we ideally get them out of hospital as soon as possible.
The AMC New York, they get them out the next day, they routinely put a self adjusting me to Binford, to manage feeding and hydration and medication.Some, we tend to have them into a two or three days post-op and you sometimes see a dramatic reduction in the as a team, you know, sometimes it 12 or 15. 1800 creatinine, and they have overnight and well, Happy Days.
Inn cat, start eating and they're purring.We're so swearing and trying to kill you a day ago.So we tend to flush them at discharge and have him back in a week and month and three months for go.Get your not there's not like a weekly thing with it.Yeah.It sort of depends on the degree of residual, kidney damage you've got you know like any other CKD cat.
But generally you know we want to minimize the time in the hospital for flushes.And some of them went to be doing three months without saving for another 6 or 12 months, but but it's a been individual after that.Yeah.Okay, we covered it all I think so.
Yeah, so yeah, like I was really Keen to kind of raise the profiles of the original Stone.There's sort of a minority group when it comes to acute kidney injury.So this wanted to make more of its of wherever and the, where are the options for management?Yeah, I love it.It's great to have something on the radar.
That that's really again I don't look for them really, it's a good.Thank you.That's I think that's going to be useful and I guess also for you Rachel or lower urinary tract obstructions, you know, I really like to get the ultrasound on the bladder, the see what the bladders doing.
A lot of it probably doing that already to see how many stones are in there and, you know, so good idea to check the kidneys and just make sure that the upper urinary tract is clear as well.That's maybe one of the key things because you have more and more.To sound in GP practice and GB B fully capable of looking at the periodic table.
So maybe it is the lesson that if you have urinary tract disease and it cats will scan them with their owners up where.And if you can do a check price for a year in real true sound and the more that that's can kidneys and bladder.So Northern going to get used to normals.
And once you see one of these bad loans, you know, you'll never get what they look like.Okay, cool, thanks Deb.That's awesome.Okay, no worries.See you next time.So you hit oil is Dave to tell us about two very excited conferences that is putting on for Australian and New Zealand bets.
I can't we can wait for these you got two trips coming up, cancelled in 2020 back on the cards with 22:31.Thank goodness after a long A desperate break from traveling.Yeah really looking forward to kicking off its on tour.This year, we've got two great conference.
Has lined up both sides of the the Tasman bubble butt.Hopefully we can travel to New Zealand as Aziz.So there's an event in thredbo, for the first time in the beginning of August.And we've got some world-class speakers, including Rachel Corman.Speaking on feline medicine and dr.
Alan lie on surgery and Keeley Wilson on anesthesia and analgesia.So, so I'm really looking forward to that Gilly on the podcast.Oh, you did.Did you, okay?So, listen is all be aware of how amazing she is and full of practical advice and help them here.
So I get to work with And she's revolutionized their pre-med and sedation protocol and anesthesia department.So she's awesome.So have you got specific topics always that to be confirmed it?Yeah, just working on the lecture program now but we've got a wide variety of topics that are going to be super useful to practitioners, so they can Implement them back in their practice the very next week or some.
And but that's left behind as there's a bit about the education.Or is it about ski gave?Well, look, it's world class education, and Happens to be in some pretty epic ski resorts.So we have a great day skiing and then get to sit back and learn in the evening with a great crowd of people, the veg V all about creating a balanced life.
Good vet, said to me, it fits perfectly, that's a very well-balanced conference and I implore anyone to give it a try mr.Danzig a day.So I got threadbare in the first week of August August, the first to the sixth and Wanaka thought we'd better over a couple of weeks between events.
Oh Veronica's on the 22nd, to the 22nd 7th of August at Edgewater where we've been traveling to since 2005.So, brilliant venue one of the most picturesque hotels on the lakes, with views of the mountains that you'll ever see.Are they just in case?
I wanted to do two conferences this?Yeah, the different topics different contents or eyes again.So we've got some some local talent speaking in New Zealand so that we won't have the awkward situation of speakers not being able to fly in.So Got a couple of Surgeons dr.
Work Bruce and Helen Milner.Were well-known to our kiwi audience and a few others based in Auckland, dr.Sarah healed and Jessica Romain apologies.If that names not pronounced, right?But some medical talks and some diagnostic imaging to round it off with Carol vandiver's.
So good five-day mix of five different speakers and I'm really looking forward to hopefully getting there and listening to what they've got to say after an epic day scheme.

Dr Dave Collins