Urinary dilemmas in feline hyperthyroidism (Proceedings)


Urinary dilemmas in feline hyperthyroidism (Proceedings)

Nov 01, 2009

Key points

     • Older cats with hyperthyroidism frequently have concurrent renal disease or UTI.
     • Concurrent diseases can suppress total thyroid hormone measurements in cats and confuse the diagnosis of hyperthyroidism.
     • GFR is increased by the hyperthyroid state and declines over the first month after treatment.
     • Hyperthyroid cats with concurrent renal disease require a trial treatment period with reversible anti-thyroid medications in order to determine the likely effects of definitive treatment on renal function.
     • Systemic hypertension and proteinuria may resolve after treatment of hyperthyroidism.
     • Hyperthyroid cats with concurrent chronic kidney disease, persistent systemic hypertension or proteinuria require specific management of these disorders in addition to management of hyperthyroidism.
     • UTI in hyperthyroid cats should be managed as complicated UTI.

Polyuria/polydipsia in cats

Although cats may not demonstrate polyuria/polydipsia in as dramatic a fashion as dogs, a change in water intake or increase in urine in the litter box warrants further investigation. Owners will readily notice a change in habits if a cat begins to empty the water bowl or seeks water from other sources, such as a dog bowl, sink, faucet or shower. Polyuria is confirmed by documenting dilute urine in several random samples. Recall that normal cats usually concentrate urine to a specific gravity much greater than 1.035.

The most common causes of PU/PD in cats include chronic kidney disease, hyperthyroidism and diabetes mellitus, all diseases of geriatric cats that can co-exist in an individual cat. In hyperthyroidism, it is thought that changes in medullary blood flow alter distal concentrating mechanisms. Psychogenic polydipsia may result from thyrotoxicosis in some cats as well. A data base including biochemical data, thyroid hormone measurement and urinalysis is usually adequate for diagnosis of pu/pd in cats.

Hyperthyroidism and renal function

High circulating thyroid hormone directly impacts renal blood flow and the hemodynamic forces favoring glomerular filtration. Filtration forces and tubular functions are increased. In the short term, hyperfiltration will preserve total GFR even if the kidneys have lost functional nephrons. In cats with marginal renal function, treatment of hyperthyroidism may remove these positive forces and reveal ("unmask") the biochemical or clinical effects of the underlying renal dysfunction. On the other hand, sustained glomerular hypertension is a known mechanism perpetuating renal disease in many species. Systemic hypertension associated with untreated hyperthyroidism also is damaging to renal and other capillary beds and is a risk factor for progressive dysfunction.

Concurrent hyperthyroidism and chronic kidney disease

Chronic kidney disease is usually discovered by finding alterations in renal structure, urine concentrating ability, biochemical indicators (BUN, creatinine) or persistent proteinuria. In a hyperthyroid cat, however, urine specific gravity is a unreliable indicator of renal function; BUN and creatinine can be affected by dehydration (or conversely, decreased by muscle wasting and malnutrition). Likewise the stage or degree of renal disease cannot be determined by the level of azotemia in a CKD cat with concurrent hyperthyroidism. Other clues become important in determining the relative contribution of renal disease to the cat's illness: patient history, prior laboratory findings, kidney size or architecture. Measures of GFR can provide more objective information, although GFR is affected by thyroid hormone levels. GFR measurements lower than 2.25 ml/min/kg as measured by DTPA scintigraphy are associated with worsening of renal parameters after radioiodine treatment in hyperthyroid cats. Plasma clearance methods are becoming more practical for veterinary practice and can be used to provide some objective measure of renal function in questionable cases. GFR can be expected to decline to some degree in all cats after definitive treatment of hyperthyroidism (radioiodine, surgical thyroidectomy), but the decline appears to stabilize at about 4 weeks post-treatment.

Hyperthyroidism, hypertension and proteinuria

Because older cats often suffer from hypertensive disorders (hyperthyroidism, diabetes mellitus, chronic kidney disease, or idiopathic hypertension), serial monitoring of blood pressure, fundic examination and urine protein:creatinine ratio should be part of the management strategy. UPC serves as a key marker for the risk of, and progression of CKD in cats. Specific management of proteinuria may be required in cats with persistent, significant proteinuria (UPC > 0.4) despite control of underlying hyperthyroidism or hypertension.