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Haematology and biochemistry

Practical guide for analytical interpretation and differential diagnosis in small animals

HAEMATOLOGY AND BIOCHEMISTRY

AuthorS: Ignacio López Villalba,

Ignacio Mesa Sánchez.

Format: 15 x 21 cm. Number of pages: 168. Binding: Hardcover.

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This is a technical-scientific manual describing the main algorithms

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used for differential diagnosis in the field of haematology and biochemistry in the small animal clinic. The objective of this book is to optimize the work of clinical veterinarians by providing them with the necessary tools to guide and facilitate the diagnosis of the main haematology- and biochemistry-related diseases of small animals and to establish aetiology based on specific clinical signs. The authors, experts in the field of small animal haematology and biochemistry, include additional resources (tables, images, etc.) that make this manual an essential reference for veterinarians working with cats and dogs.

Presentation of the book Given the continually evolving nature of clinical veterinary medicine and the large number of daily consultations to veterinary practices, there is a growing need for clinicians to optimise the time spent on each clinical case. Establishing the appropriate treatment and the relevant preventive and control measures in each case will minimise the impacts of specific diseases and ensure good quality of life for the animal. Accordingly, it is crucial that the veterinarian has the necessary tools at hand, as this directly affects the likelihood of success in solving a given case. Algorithms used for differential diagnosis consist of a series of steps, based mainly on scientific and statistical evidence, that guide the clinician in the diagnosis of a given disease based on the symptoms presented by the patient, or enable them to establish a specific aetiology based on the results of a diagnostic test. The use of these algorithms also enables the classification and staging of diseases in many cases, thus aiding the selection of the most appropriate treatment for a given patient. This book describes the main differential diagnosis algorithms used in various areas of veterinary haematology and biochemistry in small animals (haematology, haemostasis, transfusion medicine, electrolyte and acid-base disturbances, alterations in serum biochemistry...), and provides a range of complementary resources (tables, figures, etc.). This practical information is clearly presented in an interactive and accessible format, making this book an essential reference work in the field of clinical veterinary medicine.

Practical guide for analytical interpretation and differential diagnosis in small animals Haematology and biochemistry

Authors Ignacio López Villalba Ignacio López Villalba received his PhD in Veterinary Medicine in 2002 from the Universidad de Córdoba, where he is Professor of Internal Medicine and Propaedeutics at the Faculty of Veterinary Medicine. Since 2003 he has worked in clinical practice at the Hospital Clínico Veterinario of the Universidad de Córdoba, where he currently heads the Department of Small Animal Internal Medicine. He is a member of the Veterinary Internal Medicine research group (PAIDI CTS-179) at the Universidad de Córdoba and the Calcium Metabolism and Vascular Calcification research group at the Maimonides Institute for Biomedical Research, Córdoba (IMIBIC). He is a member of the Spanish Society of Veterinary Internal Medicine (SEMIV) and the European Society of Veterinary Oncology (ESVONC), and is a founding member of the Veterinary Oncology Group of AVEPA (GEVONC). He has worked as a visiting veterinarian in several prestigious veterinary hospitals in the UK (University of Bristol and the Queen Mother Hospital of the Royal Veterinary College, London), Germany (Veterinary Hospital of the University of Hannover and Veterinary Hospital of the University of Berlin), USA (Veterinary Hospital of Ohio State University) and South America (Institute of Feline Medicine, Santiago de Chile). He has authored over 60 scientific publications in international journals in the fields of veterinary science, endocrinology, metabolism, urology and nephrology, and has spoken at over 100 national and international congresses and events. He has received numerous awards for his research in the fields of nephrology and mineral metabolism, including awards presented by the Spanish Nephrology Society in 2009 and 2013. He works exclusively in small animal practice with a special focus on oncology,

Practical guide for analytical interpretation and differential diagnosis in small animals Haematology and biochemistry

Ignacio Mesa Sánchez Ignacio Mesa Sánchez was awarded his bachelor´s degree and Masters in Veterinary Medicine and Animal Health Improvement by the Universidad de Córdoba in 2008 and 2009, respectively. He worked as a clinician at the Hospital Cínico Veterinario of the Universidad de Córdoba (2009) and the Hospital Veterinario San Marco (Padova, Italy) (2010). During the years 2011-2014 he held the residency in Internal Medicine (ECVIM-CA) at the Hospital Clínic Veterinari of the Universitat Autònoma de Barcelona (UAB). Later, he joined the Department of Internal Medicine at the Hospital Ars Veterinaria. Currently, he is working on Internal Medicine at the Hospital Valencia Sur and he is the Clinical Director of Animal Blood Bank. He is a member of the teaching staff in the Department of Animal Medicine and Surgery at UAB and an honorary staff member of the Department of Animal Medicine and Surgery at the Universidad de Córdoba. He has published in many national and international journals, and works exclusively in small animal practice with a special emphasis on internal medicine.

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Practical guide for analytical interpretation and differential diagnosis in small animals Haematology and biochemistry

Table of contents 1. Haematology Blood sample collection: additives Blood smear evaluation Rating scales of blood smears Platelet concentration

Multiple myeloma Systemic lupus erythematosus (in dogs) Most common immunodeficiencies Hypersensitivity reactions

Alterations of the lymphoid organs and spleen

Erythrocyte abnormalities

Lymphadenopathy

Leukocyte abnormalities

Fever of unknown origin

Systematic evaluation of blood smears Alterations in blood smear Blood smear evaluation: template

Interpretation of CBC Anaemia Types of anaemia Based on degree of regeneration Regenerative anaemia Semi-regenerative anaemia Non-regenerative anaemia Based on aetiology

Splenomegaly

2. Haemostasis Diagnostic techniques Diagnostic approach Rapid assessment tests Definitive tests Diagnostic investigation in patients with haemorrhage

Alterations in haemostasis

Haemolytic anaemia

Petechiae and ecchymosis

Anaemia in chronic kidney disease

Thrombocytopaenia

Infectious anaemias

Hereditary coagulopathies

Iron-deficiency anaemia

Acquired coagulopathies

Anaemia of chronic disease

Disseminated intravascular coagulation (DIC)

Diagnostic process to differentiate iron-deficiency anaemia and anaemia of chronic disease

Erythrocytosis Alterations in the leukogram Leukogram patterns

3. Transfusion medicine: transfusion of blood and blood derivatives

Neutropaenia

Donor selection

Neutrophilia

Blood groups

Lymphocytosis

Dogs

Lymphopaenia

Cats

Monocytosis Eosinophilia

Leukocyte alterations

Compatibility testing Blood derivatives

Classification of leukaemias

Transfusion technique

Lymphoma

Transfusion reactions

Practical guide for analytical interpretation and differential diagnosis in small animals Haematology and biochemistry

4. Electrolyte disturbances Potassium Hyperkalaemia Hypokalaemia

Sodium Hypernatraemia Fluid type and Na concentration Hyponatraemia

Chlorine Hyperchloraemia Hypochloraemia

Calcium

Interpretation of urine test strips Interpretation of urinary sediment

Liver disease Jaundice Increased transaminases Increased alkaline phosphatase Increased bile acids Increased ammonium Summary: clinical and laboratory interpretation in liver disease Summary: extrahepatic conditions that increase liver enzymes

Gastrointestinal disease

Hypercalcaemia

Pancreatic disease

Hypocalcaemia

Alterations in glucose metabolism

Phosphorous Hyperphosphataemia Hypophosphataemia

Magnesium Hypomagnesaemia

5. Acid-base disturbances

Hyperglycaemia Hypoglycaemia

Alterations in lipid metabolism Hyperlipidaemia

Alterations in blood proteins Hypoalbuminaemia Hyperglobulinaemia

Acidaemia: aetiology and treatment

Proteinogram

Alkalaemia: aetiology and treatment

Creatine kinase

Normal blood gases and acid-base parameters Compensatory responses expected to primary acid-base disturbances

6. Alterations in serum biochemistry Kidney disease Polyuria and polydipsia syndrome Acute azotaemia (ARD) Chronic azotaemia (CKD) Proteinuria Haematuria

7. Body effusions Analysis of body effusions Joint disease

8. References

Haematology

Practical guide for analytical interpretation and differential diagnosis in small animals

Alterations of red blood cells in blood smear Name

Mechanism

Association

Microcytosis

Cytoplasmic maturation defects

• Iron deficiency

Macrocytosis

Defects in nuclear maturation

• Folic acid deficiency

anaemia • Pb poisoning • Vitamin B6 deficiency

• FeLV infection • Common in poodles • Regeneration

Elliptocytes

Dacrocytes

Spherocytes

Alterations in red blood cell development in the bone marrow

• Medullary neoplasms

Alteration in red blood cell development in the bone marrow

• Medullary neoplasms

Plasma membrane loss

• Immune-mediated

• Hepatic lipidosis

and liver shunt

• Hereditary diseases

• Glomerulonephritis

and hypersplenism • Iron deficit (ruminants)

haemolytic anaemia

• Hereditary diseases • Snake venom

Ghost cells

Intravascular cell lysis

Haemolytic anaemias: immune-mediated, caused by oxidizing agents etc.

Image

Haematology

Name Echinocytes (crenation)

Mechanism Alterations in membrane phospholipids of red blood cells

Association

Image

• Artefact • Snake venom • Uraemia • Pyruvate kinase

deficiency

Echinoelliptocytes

Alterations in membrane phospholipids of red blood cells

Renal impairment (glomerulonephritis)

Acanthocytes

Alterations in lipid composition of plasma membrane

• Liver disorders

Schistocytes

Red blood cell fragmentation

Microangiopathic haemolytic anaemia: DIC, haemangiosarcoma, dirofilariosis

Keratocytes

Alterations of the plasma membrane

• Iron deficiency

Oxidative phenomena that induce fusion of the plasma membrane

• Ketoacidotic diabetes

Alterations of the plasma membrane

• Low number

Eccentrocytes

• Target cells • Codocytes

• Glomerulonephritis • Haemangiosarcoma

and DIC

• Liver disease • Doxorubicin in cats

• Intoxication with

oxidizing substances: onions, paracetamol, NSAIDs, etc.

(physiological)

• Iron deficiency • Regenerative

anaemias

Haematology

Practical guide for analytical interpretation and differential diagnosis in small animals

Anaemia Differential diagnosis of anaemias signs of regeneration? Yes

Hypoproteinaemia?

Hyposideraemia?

Yes

Acute haemorrhage

Haemolysis

Iron deposition?

Myelopathy

Low

Normal or high

Iron deficiency

Chronic inflammation

signs of regeneration • subjective: macrocytosis, polychromasia, anisocytosis, nucleated red blood cells, etc. • objective: RPI ›1%

% Reticulocytes x observed Ht RPI = normal Ht

Haematology

Types of anaemia Depending on the degree of regeneration Regenerative anaemias

Regenerative anaemia IR >3%

• Normocytic • Normochromic

• Macrocytic • Hypochromic

Haemolysis

Haemorrhage

Intravascular

extravascular

• Ghost cells • Drugs and poisons • Immune-mediated (IgM) haemolytic anaemia • Mechanical damage • Bacterial lysines • Babesia

• spherocytosis • Heinz bodies • Immune-mediated (IgM) haemolytic anaemia • Abnormal red blood cells • enzymatic defects • Mycoplasma haemofelis

Figure 1. Immune-mediated haemolytic anaemia. Autoagglutination.

Internal

external • Hypoproteinaemia • Loss of iron

Figure 2. Immune-mediated haemolytic anaemia. Spherocytes. 7

Haematology

Practical guide for analytical interpretation and differential diagnosis in small animals

Erythrocytosis Increase in RBC, Hb concentration and Ht value.

Aetiology Polycythaemia vera Primary Congenital erythrocytosis

Right-to-left cardiovascular shunt

Relative (dehydration)

Chronic lung disease

erythrocytosis Appropriate

Absolute

Airway obstruction Altitude Carbon monoxide

secondary

Methemoglobinaemia

Renal neoplasm Renal amyloidosis Inappropriate

Pyelonephritis Paraneoplastic syndrome

Haematology

Diagnostic approach  RBC,  Hb,  Ht erythrocytosis Dehydration? Yes

skinfold CRT, dry mucosa, PT, prerenal azotaemia

Absolute • Blood gas values • Pulse oximetry • Chest x-ray • echocardiography • eCG

Normalization of haematocrit with fluid therapy Relative • Hypoxia • Cardiopulmonary abnormalities

No abnormalities

Appropriate secondary erythrocytosis

• Abdominal ultrasound • Abdominal x-ray

Renal tumour

Non-renal neoplasm

Inappropriate secondary erythrocytosis

No abnormalities ePo? Increased secondary erythrocytosis Re-evaluate the patient

• Normal/Low • No other aetiology Primary erythrocytosis

Haematology

Practical guide for analytical interpretation and differential diagnosis in small animals

Diagnostic techniques Alteration of reference value

Parameter Primary haemostasis

Secondary haemostasis

Fibrinolysis

Platelet count

Interpretation

<175,000/µl

Thrombocytopaenia (FIV, FeLV, Ehrlichia spp., bleeding, DIC, bone marrow disorders, autoimmune destruction, sequestration)

<30,000/µl

Severe thrombocytopenia with risk of bleeding (usually with primary or secondary immunemediated component)

Mean platelet volume (in combination with thrombocytopenia)

<12 fl

No bone marrow response

>12 fl

Adequate bone marrow response

BMBT

>1.5 min

Thrombocytopenia, platelet dysfunction, von Willebrand disease

Antiplatelet antibodies

Present

Primary or secondary immunemediated thrombocytopenia (vaccines, drugs, infection or neoplasia)

vWF

<50%

Von Willebrand disease

PIVKA

Present

Presence of proteins associated with vitamin K deficiency

>10 seconds

Alteration of factors V, VII, X, prothrombin or fibrinogen

APTT

>18 seconds

Alterations in factors V, VIII, IX, X, XI, XII, prothrombin or fibrinogen (haemophilia)

<85%

Hypercoagulable state (DIC, protein-losing nephropathy, protein losing enteropathy, systemic inflammation, neoplasia)

FDPs

>10 ug/ml

Increased fibrinolysis (DIC)

D dimers

>250 ng/ml

Thromboembolism, DIC

haemostasis

Diagnostic approach Rapid evaluation tests Platelets

ACT

BMBT

CRT

N/I

Thrombopathy

D/N

Liver disease

Haemophilias

Von Willebrand disease

DIC

N/I

Angiopathy

N = normal; I = increased; D = decreased.

Definitive tests aPTT

FDP

Liver disease

Vitamin K deficiency

Haemophilias

DIC

Excess heparin

Von Willebrand disease

I/N

N = normal; I = increased; D = decreased; F = fibrinogen.

10-20 ml/kg/ 8-12 hours

1 unit/10 kg

Rodenticide poisoning, hypoproteinaemia, hypovolaemia, pancreatitis Von Willebrand disease, haemophilia A, dysfibrinogenaemia Deficiency in factors II, VII, IX, anticoagulant poisoning, haemophilia B, hypoproteinaemia, AT II deficiency

Albumin, globulins, certain haemostatic proteins (deficiency in factor VIII and vWF), AT and protein C vWF, factor VIII and fibrinogen

Albumin, globulins, factors II, VII, IX, XI and XII, AT and protein C

FFP

Cryoprecipitate

Cryosupernatant

Thrombocytopenia

10 to 20 ml/ kg/ 8-12 hours

Coagulopathy, pancreatitis, hypovolaemia, hypoproteinaemias and AT III deficiency

Albumin, globulins, haemostatic proteins, AT and protein C

Red blood cell concentration

Platelets

5-10 ml/kg/ 24 hours

Normovolaemic anaemias (haemolysis and ineffective erythropoiesis)

Red blood cells

Stored blood

PRP

10-20 ml/kg/ 24 hours

Anaemia, DIC, pancytopenia, hypoproteinaemia

Erythrocytes, some haemostatic proteins (deficiency in factors V, VIII and vWF), albumin, globulins, AT

1 unit/10 kg

10-20 ml/kg/ 24 hours

Anaemia, DIC, coagulopathies, hypoproteinaemias

Erythrocytes, albumin, globulins, haemostatic proteins, platelets

Fresh blood

Volume

Indications

Composition

Blood product

5-10 ml/kg/hour

10-20 ml/kg/ hour

Rate

1 day

1 year/-18 °C

5 years/ -18 °C

1 year/ -18 °C

35 days/ 1-4 °C

Use in <6-8 hours

Storage

Haematology Practical guide for analytical interpretation and differential diagnosis in small animals

Transfusion Medicine

Transfusion practice Blood product indicated depending on the pathology Haemorrhage

Anaemia

Haemolysis Ineffective erythropoiesis

Whole blood other: erythrocyte concentrate erythrocyte concentrate other: whole blood erythrocyte concentrate other: whole blood Hepatic failure

FFP FFP

DIC

Deficiency in coagulation factors

Pathology

Haemophilia A

Haemophilia B Von Willebrand disease

Coagulopathy

Rodenticide poisoning Thrombocytopenia

Hypoproteinaemia

other: fresh blood, cryosupernatant Cryoprecipitate other: FFP, fresh blood Cryosupernatant other: FFP, PC Cryoprecipitate other: FFP Cryosupernatant other: FFP, PC, fresh blood

Platelet concentration PRP, fresh blood

Human albumin other: FFP, PC, cryosupernatant

Haematology

Practical guide for analytical interpretation and differential diagnosis in small animals

Transfusion reactions • Nonspecific signs: tremor, vocalization, dyspnoea, tachycardia, bradycardia, arrhythmias, hypotension, vomiting, diarrhoea, angioedema, urticaria. • General treatment: stop transfusion and monitor patient.

Immunological reactions

Specific signs

Reaction to erythrocytes

Haemolysis, haemoglobinuria, haemoglobin, acute renal failure, DIC

Reaction to plasma proteins

Urticaria, angioedema, hypotension

Leukocyte reaction

Fever, vomiting, noncardiogenic pulmonary oedema

Reaction to platelets

Thrombocytopenia

No immunological reactions

Treatment

Antihistamines, corticosteroids, fluid, oxygen, epinephrine, dopamine

Specific signs

Treatment

Volume overload

Dyspnoea, pulmonary oedema, pleural effusion, ascites

Furosemide, oxygen

Hypothermia

Drop in temperature, tremor, arrhythmias

Warming

Citrate poisoning (hypocalcaemia)

Tremors, convulsions, vomiting, arrhythmia

Calcium gluconate

Thrombosis

Dyspnoea

Heparin

Microbial contamination

Vomiting, dyspnoea, fever

Antibiotic

Hypophosphatemia

Haemolysis

Phosphate salts

Acidosis

Bicarbonate

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