Xanthine Urolithiasis in Cats
Xanthine is a natural by-product of purine metabolism, which is normally converted to uric acid (the waste product of proteins found in the blood) by the enzyme xanthine oxidase. Because xanthine is the least soluble of the purines excreted in urine, excessive amounts of xanthines in the urine may be associated with formation of xanthine uroliths (stones). Impairment of xanthine oxidase ultimately results in xanthines in the blood (hyperxanthinemia) and xanthines spilling over into the urine (xanthinuria). It may be naturally occurring, as with enzyme deficiency, or drug-induced (allopurinol). Xanthinuria can be a congenital or an acquired disease.
A breed predisposition has not been identified in cats, but in naturally occurring xanthinuria, a familial or congenital defect in xanthine oxidase activity is likely. Consumption of high purine diets (high protein) increases the risk of xanthinuria in patients being treated with allopurinol.
Symptoms and Types
Although some cats may not display any clinical symptoms (asymptomatic), most will exhibit such signs as:
- Mustard colored urine
- Bladder stones:
- Stones in the urethra:
- Frequent urination
- Difficulty urinating
- Bloody urine
- Urethra may be blocked
- Kidney stones (nephroliths):
- Asymptomatic
- Hydronephrosis – kidney is swollen with urine due to a blocked ureter (the tube leading to the bladder from the kidney)
- Kidney disease
Causes
- Xanthines in the urine can lead to formation of stones
- May recur in cats not given preventative therapy
- Excessive allopurinol medication in combination with high purine diet
- Relation to urine chemistry:
- Acid urine pH
- Highly concentrated urine
- Incomplete and infrequent urination
Diagnosis
Your veterinarian will perform a thorough physical exam on your cat, taking into account the background history of symptoms and possible prior conditions that might have led to this condition. A complete blood profile will be conducted, including a chemical blood profile, a complete blood count, a urinalysis and an electrolyte panel. The urinalysis will show xanthine crystals in the urine sediment.
These crystals cannot be distinguished by light microscopy alone. For a precise diagnosis, the urine should be sent for infrared spectroscopy, which can be used to differentiate xanthine uroliths (urinary tract stones) from other types of uroliths. Also, high-pressure liquid chromatography of urine can be done to detect xanthine, hypoxanthine, and other purine metabolites.
Ultrasonography, double-contrast cystography, and intravenous urography are some additonal diagnostic tools that can aid in detecting uroliths and the location they are originating from. Uroliths generally do not show up on normal X-rays.
Xanthine uroliths in the urethra and bladder stones near the urethra may be detected by urethrocystoscopy, which uses a small flexible tube that is equipped with a camera and can be inserted into small spaces, in this case, the urethral passage. Small uroliths may be retrieved for analysis by removing fluid using a transurethral catheter, or using a method called voiding urohydropulsion. This latter method involves filling the bladder completely while the patient is anesthetized, and then emptying the bladder, after attempting to shake stones into the urethra, so that the stones can be collected.
Treatment
Voiding urohydropulsion is effective for removing the smaller xanthine uroliths that will easily pass through the urethra, but surgery is still the best way to remove larger uroliths from the lower urinary tract. Perineal urethrostomy surgery may minimize recurrent urethral obstruction in male cats, but this condition is known for recurring in many cats that have been affected.
Urine pH may be increased to prevent xanthine uroliths, and a low-purine diet may be fed along with plenty of water to increase urine output. Depending on your cat's overall health and the severity of this condition, your veterinarian may also recommend a diet that is designed for cats suffering renal failure. The goal is to reduce the amount of ingested purine, along with reducing the formation of acid urine, in addition to increasing the amount of urine that is voided from the bladder so that the passages remain clear of stone forming chemicals.
Living and Management
Your veterinarian will schedule monthly follow-up appointments for your cat in order to conduct urinalysis, contrast X-rays, or ultrasonography exams. Your cat's treatment may be adjusted to how well its health is progressing since the initial treatment. Xanthine uroliths often recur in cats.