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intake exceeds output (Buffington, 1994). Metabolic acidosis can be very harmful and lead to diseases such as renal insufficiency. Additives to acidify urine can also be toxic as well as possibly cause calcium oxalate crystals. Depletion of potassium is caused by urine acidification. Hypokalemia can lead to renal insufficiency.Urine volume and output can also affect urolith production. If urine output is decreased, urine can become more concentrated in turn possibly creating more urinary calculi. Increasing certain additives in food such as sodium can motivate a cat to consume more water. Increased water intake promotes higher and more dilute urine output.In addition to effects of components of the diet, the way cats eat could play a role in the etiology of struvite urolithiasis (Buffington, 1994). When a cat eats large meals urine becomes more alkaline creating a hospitable environment for struvite crystals.In the article Buffington goes on to discuss that struvite urolithiasis may no longer be a common cause of lower urinary tract disease in cats. Of 141 cats presented to the University of Minnesota veterinary hospital between 1980 to 1985 with signs of lower urinary tract disease, only 23% had struvite calculi (Buffington, 1994). Incidences of struvite calculi in felines have been on a steady decline.There are cases of feline lower urinary tract disease with no obvious cause. This issue is considered idiopathic and similar to women with interstitial cystitis. Establishing a diagnosis of idiopathic cystitis is made when a cat has feline lower urinary tract disease symptoms with no obvious cause. Cats with feline idiopathic cystitis commonly show signs of pain like head turning in the direction of their hind end and excessive grooming. Cats with feline idiopathic cystitis can also become fractious due to pain. Polyuria is also seen. Many times owners will think that their cat is constipated when the cat is experiencing symptoms of feline lower urinary tract disease, such as urethral obstruction. Cats will make frequent trips to the litter box. They will strain to urinate without producing any urine. Owners usually contact a veterinarian complaining that their pet may be constipated. Urine volume production during these episodes is usually less than 2 mL (Buffington, 1994). Cats with feline lower urinary tract disease or feline idiopathic cystitis will also urinate outside the litter box. The term for this is inappropriate urination. Amitriptyline is commonly used to treat idiopathic cystitis, but its effectiveness is not entirely understood. Amitriptyline can inhibit histamine release from (rat peritoneal) mast cells in vitro, inhibits segmental transmission of wide dynamic range, and nociceptive neurons in the cat trigeminal nucleus, and increase synaptic serotonin content by inhibiting axon reputation (Buffington, 1994). Buffington states that the amitriptyline also has anti-cholergenic effects and increases bladder capacity. There are a few different diagnostic procedures used to diagnose feline lower urinary tract disease or idiopathic feline cystitis. A sample of urine is needed to perform a urinalysis to determine the cause of feline lower urinary tract disease. One sample collection method used is a cystocentesis. A downside to this method is blood in the urine. Hematuria has been reported when reading at urine cytology but may be due to the urine collection via cystocentesis. Another form of diagnosis for a feline lower urinary tract disease and idiopathic feline cystitis is advanced imaging such as ultrasound or digital radiography when diagnosing feline idiopathic cystitis. Cystoscopy is required for the diagnosis of idiopathic cystitis, although typically cystitis shows prominent vascularity and submucosal petechial hemorrhages (glomerulations) after a second distention are shared with other bladder diseases (Buffington, 1994). It seems to be that any similarity between feline lower urinary tract disease and idiopathic cystitis are merely a coincidence at this time. Further research is needed to prove otherwise. An example of these similarities is histopathological findings indicative of mast cells from bladder biopsies.Next, the article takes a look at the presence or absence of substance P. Substance P is a peptide mainly secreted by neurons and is involved in many biological processes, including nociception and inflammation (Mashaghi, Et Al., 2016). Substance P is seen in cats with feline lower urinary tract disease because the bladder becomes distended from a urethral obstruction that prevents the cat from urinating. This bladder distention inflammation causes the release of substance P. There is more research needed to comprehend substance P’s role in disorders or diseases of the bladder.The most consistent finding in some patients with idiopathic cystitis is a functional defect of the urethral glycosaminoglycan (GAG) layer (Buffington, 1994). It has been discovered that cats with idiopathic cystitis have a lower number of GAG and increase substance P which increases bladder permeability. Studies have shown significant differences between normal cats without feline lower urinary tract disease and those with feline lower urinary tract disease or feline idiopathic cystitis. In summary, the connecting of the dots that states struvite formation leading to feline lower urinary tract disease may not be correct. It is possible that with pet food quality becoming better that there has been a noticeable decline in struvite urolithiasis related obstruction in cats. It is also relevant that research points to the acidification of urine possibly being excessive and resolving urolithiasis. Instead of acidifying urine removing alkalizing substances may be more beneficial. The decreased incidences of struvite urolithiasis over the recent decades have led to the acknowledgment of “feline urologic syndrome" or idiopathic cystitis.Methodology Research DesignFor this research paper, I decided to use two different research methods. The first being qualitative research using a single case study. The case study involves my cat who developed feline lower urinary tract disease. I decided to use my cat as a case study because his case was very unique. It is relevant to this paper and extremely informative on the treatment of feline lower urinary tract disease. It helps to lead to the conclusion that prescription diets work in the dissolution of stones as well as prevention and reoccurrence of feline lower urinary tract disease.Tommy, a nine-year-old neutered male domestic longhair, presented with lethargy and anorexia. He had no history of any medical issues before this presentation. Based on his physical exam there was no obvious disease process. His vitals were normal aside from an increased heart rate seeming to be indicative of pain. His CBC and comprehensive chemistry panel were within normal limits. Based on these findings radiographic imaging and ultrasonography were recommended by the on- call emergency veterinarian. A lateral and ventral- dorsal view abdominal radiographs showed the presence of bladder stones and kidney stones in Tommy. According to the Antech radiology report, his serosal detail was normal. The liver was normal. The spleen was mildly enlarged. The right kidney was mildly enlarged. The left kidney was slightly irregular and contained a small foci of mineralization. There were multiple small opaque cystic calculi within the urinary bladder. Differentials for the mildly enlarged spleen included a variant of normal, benign extramedullary hematopoiesis or lymphoid hyperplasia, or neoplasia. There were small foci of mineralization left kidney. The left kidney was slightly irregular, most likely secondary to chronic renal changes. Differentials for the mildly enlarged right kidney include compensatory hypertrophy, hydronephrosis, pyelonephritis, or infiltrated disease. There were multiple opaque cystic calculi present. A full abdominal ultrasound was recommended by the radiologist. Ultrasonography of his abdomen and bladder confirmed evidence of feline lower urinary tract disease. A Cystocentesis of the bladder was performed to collect a urine sample. The sample would be sent to a lab for a complete urinalysis and urine culture prior to the start of antibiotic therapy. His right kidney also seemed enlarged. At this time he did not show any signs of urinary obstruction. An intravenous catheter was placed in his right cephalic vein to deliver maintenance fluids to prevent dehydration. He was given buprenorphine 0.6 mg/ml and Cerenia 10mg/ml. An in-house urinalysis was also performed to visualize any urinary calculi present at this time. Calcium oxalate crystals were seen on this urinalysis. The veterinarian placed Tommy on Hill’s Prescription diet C/d multi-care. He was scheduled for a cystotomy for the following morning to remove any bladder stones.Tommy was induced with 4.0 mL of Propofol and 0.4ml of diazepam intravenous for intubation. He was maintained on isoflurane at 1.5% for the duration of the surgical procedure. Multiple stones were removed from Tommy’s bladder. They were sent to the urolithiasis laboratory in Houston Texas. According to the urolithiasis laboratory report, it was discovered that the stones were composed of 5% calcium oxalate monohydrate and 95% ammonium acid urate. The shell was 65% calcium oxalate monohydrate and 35% ammonium acid urate. Ammonium acid urate is considered a rare find in cats. Ammonium urate urinary calculi are usually observed in humans and Dalmatians. According to the Minnesota Urolith Center at the University of Minnesota College of Veterinary Medicine, although uncommon, porto vascular anomalies have been documented in association with urate uroliths in few cats. The University Minnesota Urolith lab also states that ammonium urate uroliths represent approximately 5% of all feline uroliths submitted to their center. Ammonium urate uroliths make up a very small number of uroliths presented to their lab. Uroliths they observe are struvite and or calcium oxalate crystals. This urolith discovery made Tommy’s case difficult to treat but in turn more interesting. The protocol for feline lower urinary tract disease would be to place the cat on Hill’s Prescription C/d multi-care. This was diet the Tommy was placed on prior to the results from the urolith lab. There has not been much research on ammonium urate crystals in cats. Recommendation of the urolith lab to prevent ammonium urate formation was to keep Tommy’s urine pH around 6.6. This is accomplished by putting Tommy on Hill’s Prescription diet K/d which is formulated to produce urine with the pH of 6.6 to 6.9. This diet minimizes purines because there are lower levels of high-quality protein in these diets. A direct quote from the Minnesota Urolith Center at the University of Minnesota college of veterinary medicine states that we have successfully dissolved ammonium urate uroliths in two cats with a combination of allopurinol (15 mg/kg per os every 12 hours and one cat, 15mg/kg per os every 24 hour in the other) and canned prescription diet K/d. Even though limited information was available I chose this route to treat Tommy’s ammonium urate crystals and existing kidney stones. Tommy was started on the allopurinol 15mg/kg and Hill’s Prescription K/d diet canned formula. The doctor recommended a urinalysis in one month and then every 3 to 6 months thereafter. The doctor also recommended medical imaging such as radiology or ultrasonography every six months or sooner if there are recurrent urinary signs. Within two weeks it was noticed that Tommy’s attitude seemed to decline. He became depressed, listless, and again anorexic. He returned to the clinic for a repeat kidney profile. Tommy’s kidney profile was indicative of acute renal failure. Due to the fact that his blood work was within normal limits prior to surgery and after surgery pointed to the allopurinol as the offender in damaging Tommy’s kidneys. There is no evidence of any new urinary calculi in his bladder only the existing kidney stones. The fact that there is limited information on the use of allopurinol in cats pointed even further that this medication may have damaged Tommy’s kidneys. At this point the veterinarian chose to place Tommy on subcutaneous fluids and for him to remain on the Hill’s prescription K/d diet. Tommy’s bloodwork was checked monthly as long as he was eating. If he became anorexic his bloodwork was checked sooner. Tommy to this day is still maintained and doing well on subcutaneous fluids and Hill’s prescription diet K/d. The second methodology I used for this research paper was a small survey that the veterinarians at VCA Oso Creek Animal Hospital and Emergency Center participated in.Sample populationThe sample population for this research experiment consisted of one subject for qualitative case study and nine veterinarians for quantitative survey rmed consentDue to the fact that this case study was my on pet no, informed consent was needed. As for the quantitative part of my research survey permission was received by each participating veterinarian to include the survey results in this paper. Geographic limitationsGeographic limitations were not observed in the study.Data collection and InstrumentationFor the case study on Tommy, data collection was done by maintaining records consisting of diagnostics such as blood work and radiology. Instrumentation used was an in-house chemistry analyzer, in-house digital radiology, and in-house ultrasonography. Next, listed is the survey. This information includes the survey questions and answers given and received by nine veterinarians at VCA Oso Creek Animal Hospital and Emergency in Corpus Christi, Texas. What is the most common symptom owners describe in their cat is experiencing feline lower urinary tract disease? What they think is constipationvocalizingvomitingfrequent trips litter box 5/9 veterinarians chose this answerall of the above 4/9 veterinarians chose this answerAre most of the cats you diagnosed with feline lower urinary tract disease neutered?Yes 9/9 veterinarians chose this answerNoWhat are the most common uroliths you see at a urinalysis for cats experiencing feline lower urinary tract disease? Struvite 4/9 veterinarians chose this answercalcium oxalateammonium uratecombination 5/9 veterinarians chose this answerWhat prescription diet do you recommend to treat feline lower urinary tract disease?Hill’s Prescription C/d multicare 9/9 veterinarians chose this answerHill’s Prescription S/dRoyal Canin S/onone of the aboveWhen you recommend a PU surgery for a cat with recurring feline lower urinary tract disease?After one – two times obstructingAfter three – four times obstructing 9/9 veterinarians chose this answerAfter five – six times obstructingAre the majority of the cats that you diagnosed with feline lower urinary tract disease obese?Yes 2/9 veterinarians chose this answerNo 5/9 veterinarians chose this answernot sure 2/9 veterinarians chose this answerDo you place feline lower urinary tract disease patients on prazosin after treating a urethral obstruction?Yes 9/9 veterinarians chose this answerNoDoes a cat living in a multi-cat household create any issues for pets with a history of feline lower urinary tract disease?Yes 9/9 veterinarians chose this answerNoHave you observed struvite uroliths dissolution with Hill’s prescription C/d multi-care?Yes 9/9 veterinarians chose this answerNoThe results of the case study showed that maintaining Tommy on subcutaneous fluids and Hill’s Prescription K/d will result in closer to normal kidney parameters. He is still in renal failure at this time but maintaining well. It seems as though the Hill’s Prescription K/d has resulted in the dissolution of kidney stones based on ultrasonography. .The results of the survey have shown the veterinarians consistently choose Hill’s Prescription diet C/d multi-care due to the result of urolith dissolution.Data analysisData analysis was performed by collecting Tommy’s bloodwork results over the next few months and determining whether or not his therapy was treating the underlying disease process. Attached in the appendices will be is Tommy’s bloodwork results, urolith lab results, and radiology results. FindingsExperimental and clinical investigations have confirmed the importance of dietary modifications and medical protocols designed to treat and prevent feline lower urinary tract disease (Kerr, 2014). Based on the individual case study and the survey it has been shown that feline lower urinary tract disease can be treated by dietary modification. The control of urine acidity by diet seems to help prevent reoccurrence of feline lower urinary tract disease. Prevention should be based specifically on crystalline types found within a given urolith; however, care should be taken not to increase the risk of other urinary stones (Kerr, 2014). Another finding related to the case study was the fact that limited research of allopurinol treatment in cats is detrimental to their overall health. There needs to be more research done on this medication use in cats before it is recommended for therapy. In the survey attached veterinarians agree that modification of diets are important in the treatment of feline lower urinary tract disease. Summary and ConclusionEvidence suggests that certain nutrients in the feline diet may cause urinary calculi leading to feline lower urinary tract disease. Feline lower urinary tract disease is a set of clinical conditions with similar symptoms related to inappropriate urine elimination due to a combination of genetics, stress and frustration reactions, environment and medical condition or conditions, for example, idiopathic cystitis, urolithiasis, urethral obstruction, and urinary tract infection (Kerr, 2014). It is shown through multiple studies that diet plays a major role in the prevention and reoccurrence of feline lower urinary tract disease. Based on diagnostic findings these cats would be placed on a prescription diet to treat their feline lower urinary tract disease. These diagnostics consist of a complete urinalysis and sometimes a urine culture. Other diagnostics recommended are radiology and ultrasonography. Once the offending urinary calculi are determined the cat is placed on the appropriate diet and medications to treat feline lower urinary tract disease. There is an abundance of research indicating the role diet plays in the treatment and prevention of feline lower urinary tract disease, but most of this research focuses on urinary calculi such as calcium oxalate or struvite uroliths in cats. Research is needed in the field of ammonium urate calculi cats. Due to the fact that this is an unusual crystal or stone seen in cats, the treatment protocol is limited. According to the University of Minnesota, it is possible that portovascular anomalies may lead to ammonium urate uroliths in cats. At this time specific protocols have not been designed to dissolve these uroliths. Surgery seems to be the most reliable method of removal. In a 2007 study at the University of Minnesota, only two of six cats had uroliths sufficiently radiopaque enough to be detected by survey radiography. Contrast ultrasonography is necessary to consistently visualize urate uroliths in the urinary tract according to the University of Minnesota Urolith center. Further research has shown that dilution of urine is also important when preventing reoccurrence of feline lower urinary tract disease. To promote the production of large volumes of dilute urine a potentially limit stagnation, dietary moisture concentration should be over 70% (Kerr, 2014). The more dilute a cat’s urine, the less likely the potential for feline lower urinary tract disease recurrent to exist. If the urine is less concentrated, crystals shouldn’t form.Another important fact in relation to feline lower urinary tract disease is the acidification of urine through diet modification. Dietary ingredients the act as urinary acidifiers (e.g., phosphoric acid, methionine, magnesium chloride) and alkalinizing agents (e.g., potassium citrate) should be used to target the appropriate urinary pH (6.2 to 6.5) as this can also impact urine saturation (Kerr, 2014).Implication of findingsThis research suggests that feline lower urinary tract disease is treatable with prescription diets. Main goals of dietary modifications to prevent feline lower urinary tract disease are to promote large dilute volumes of urine, decrease the relative super saturation of urine for specific stone types, and promote healthy bacterial populations in the gastrointestinal and urogenital tracks (Kerr, 2014). The impact of dietary composition, including dietary moisture, protein concentration and digestibility, mineral concentrations (i.e., sodium, chloride, calcium, phosphorus, and magnesium), inclusion of acidifiers and alkalinizing agents, and dietary guidelines for cats are important in the treatment of feline lower urinary tract disease (Kerr, 2014).RecommendationsIt is important to monitor a patient with feline lower urinary tract disease closely. These cats should be maintained on the appropriate prescription diet determined by the urinary calculi discovered. Based on the research above including my own cat’s diagnostics, a dietary modification can result in the prevention of reoccurrence of feline lower urinary tract disease. Maintaining a certain pH of the urine can prevent urinary calculi. Based on repeat ultrasound results of my cat, dissolution of urinary calculi and stones are possible utilizing prescription diets. On Hill’s Prescription diet K/d, Tommy’s existing stones had dissolved. At this time there is no further evidence of stones and Tommy’s bladder or kidneys. This means that the prescription diet is successful in the prevention of new stones forming in the dissolution of existing stones. It is recommended by the veterinarians in a survey that Hill’s Prescription diet C/D multi-care be utilized in the treatment, prevention, and reoccurrence of struvite uroliths and calcium oxalate uroliths. Hill’s prescription diet C/d multi-care both wet and dry formulas contain high levels of Omega -3 fatty acids from fish oil and antioxidants to help break the cycle of inflammation in patients with feline idiopathic cystitis (Hill’s). These diets are formulated with no excess sodium and ideal for long-term feeding and multi-cat households (Hill’s). Being able to feed multiple cats in a single household the same prescription diet is extremely important to owners in direct relation to compliance. This prescription diet reduces the risk of both calcium oxalate struvite uroliths, maintains urine saturation levels that minimize the risk of calcium oxalate growth, and dissolve struvite uroliths in less than 14 days according to Hill’s. The last recommendation that I feel is necessary to mention is the use of allopurinol in the treatment of ammonium urate uroliths in cats. Until further research has been performed, I believe that allopurinol should not be prescribed for use in cats. This recommendation is based on my first-hand experience with my cat in the iatrogenic renal failure. I believe that the allopurinol caused this renal failure which has become chronic. Tommy’s now chronic renal insufficiency is currently controlled with Hill’s Prescription diet K/d. In conclusion, when treating a cat with feline lower urinary tract disease dietary modification with prescription diets seems to be the most important key aspect of medical therapy for these cats. The likelihood of reoccurrence is decreased when fed solely a prescription diet targeting the feline urinary tract system. The main diet recommended is Hill’s Prescription diet C/d multi-care in the treatment and dissolution of struvite and calcium oxalate uroliths. References 1.Bassert, J. M., & McCurnin, D. M. (2010). McCurnin's Clinical textbook for veterinary technicians (7th ed.). St. Louis, MO: Saunders Elsevier. 2. College of Veterinary Medicine - Cornell University. (2006). Retrieved November 06, 2016, from . Hendrix, C. M., & Sirois, M. (2007). Laboratory procedures for veterinary technicians (5th ed.). St. Louis, MO: Mosby Elsevier.4. Houston, D. M., Moore, A. E. P., Favrin, M. G., & Hoff, B. (2003). Feline urethral plugs and bladder uroliths: A review of 5484 submissions 1998–2003. The Canadian Veterinary Journal, 44(12), 974–977.5. Houston, D. M., & Moore, A. E. P. (2009). Canine and feline urolithiasis: Examination of over 50 000 urolith submissions to the Canadian Veterinary Urolith Centre from 1998 to 2008. The Canadian Veterinary Journal, 50(12), 1263–1268.6. . Kerr, K. R. (2014, November 25). Companion Animals Symposium: Dietary management of feline lower urinary tract symptoms. Retrieved November 19, 2016, from . Key to Clinical Nutrition. (n.d.). Hill's.9. Lulich, J., Kruger, J., McCleay, J., Merills, J. M., Pateau-Robinson, I., & Osborne, C. A. (n.d.). Feline Lower Urinary Tract Disease - Clinician's Brief. Retrieved November 12, 2016, from . Norkus, C. L. (2012). Veterinary technician's manual for small animal emergency and critical Care. Chichester, West Sussex, UK: Wiley-Blackwell.11. Osborne, C. A. (n.d.). University of Minnesota Urolith Center [Pamphlet]. St. Paul, MN: University of Minnesota College of Veterinary Medicine. 12. Ruda, L., & Heiene, R. (2012, November 20). Short- and long-term outcome after perineal urethrostomy in 86 cats with feline lower urinary tract disease. Retrieved November 06, 2016, from . Summers, A. (2014). Common Diseases of Companion Animals (3rd ed.). Philadephia, PA: Elsevier/Mosby. ................
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