EQUINE VETERINARY EDUCATION / AE / MAY 2019
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Outcome
Further diagnostic tests were discussed, including evaluation of coagulation (prothrombin time, partial thromboplastin time, D-dimers and thromboelastography) to more comprehensively evaluate haemostasis, angiography for renal vascular anomalies, indirect measurement of blood pressure (Doppler using a tail cuff) to evaluate for hypertension, scintigraphy and renal biopsy to rule out pyelonephritis and neoplasia. In addition to further diagnostic testing, hospitalisation for medical or surgical treatment was offered and discussed but, due to the stallion’s age, concerns regarding future haemorrhagic crisis, and financial considerations, the stallion was subjected to euthanasia.
Post-mortem findings
Fig 1: Caudal facing cystoscopic image shows active haemorrhage from the left ureteral orifice (white arrowhead; consistent with abnormalities identified during ultrasonographic examination of the left kidney). The right ureteral orifice is apparently normal (black arrowhead). Urine within the bladder is red-brown.
renal cortex exhibited normal echogenicity and had normal parenchymal blood flow. The left kidney was enlarged (22 9 10.1 cm, normal is 15 9 10–11 cm [Kidd et al. 2014]). No other sonographic abnormalities were identified. The marked increase in echogenicity and size of the left
renal medulla was attributed to the presence of a large blood clot, accumulation of exudate or neoplasia affecting the renal pelvis. The lack of acoustic shadowing ruled out renal pelvic calculus (nephrolith) formation. Ultrasonographic findings were supportive of the clinical diagnosis of idiopathic renal haematuria affecting the left kidney, although a definitive locus of haemorrhage was not identified. Other differential diagnoses for unilateral renal haemorrhage included renal or vascular neoplasia, pyelonephritis (although pyuria was not evident on urinalysis, a well-encapsulated abscess might have been present), glomerulonephritis, verminous nephritis, vascular malformations, haemorrhagic diathesis or renal trauma.
Findings at gross necropsy were consistent with the clinical findings. There were no pathological abnormalities in the right kidney or ureter. Significant pathological abnormalities were confirmed in the left kidney and ureter. The left kidney weighed 1950 g (normal is 600 g [Toribio 2007]) while the right kidney weighed 950 g (normal is 650 g [Toribio 2007]) (Fig 4). The renal pelvis of the left kidney was dilated with coagulated blood, and the associated cortical parenchyma was red-tan and thinned (Fig 5). The left ureter and ureteral orifice were enlarged (Fig 6). The urinary bladder contained serosanguineous fluid with blood clots. Histopathology of the left kidney revealed haemorrhage, neutrophilic infiltrates, eosinophilic debris in the renal tubules and occasional eosinophilic tubular casts. Areas of extensive haemorrhage were present throughout the renal interstitium. In this case, a primary aetiology for renal haematuria was not identified and the clinical diagnosis of idiopathic (essential) renal haematuria was confirmed.
Discussion
The term idiopathic (or essential) renal haematuria stems from failure to identify a primary aetiological explanation for renal haemorrhage and similar conditions have been reported in both human subjects and dogs (Hitt et al. 1985; Holt et al.
a)
b)
Fig 2: Longitudinal (a) and transverse (b) ultrasonographic images of the right kidney of a 17-year-old Egyptian Arabian stallion with a 4-day history of haematuria and blood clots in the urine. There is a mild decrease in the cortico-medullary ratio. The size and echogenicity of the right kidney was determined to be within normal limits. The right dorsal colon is seen ventral to the right kidney. Blood flow (via Color flow Doppler) was appropriate (not shown). C5-1 MHz transducer; depth of field 17 cm (a) and 18 cm (b).
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