These look pretty normal to

These look pretty normal to me as well. If usg < 1020 and UCCR is elevated then early pdh possible and about 10% of darenals are normal in pdh. Its importnt to runt he steps though and ensure there is repetitive pupd and not periodic or episodic pupd or even dysuria.

Here is how I woork through cushings cases to ensure I dont give trilostane to a false + dynamic function test.

The following suggested protocol is based on current available literature on Cushings disease and extensive clinical-sonographic experience evaluation + Cushings and False + LDDST & ACTH stim. cases in order to maximize the efficiency of a Cushing’s workup in practice.

Screen first, workup second

1) UA: Repeatable (2-3 urine samples) Urine specific gravity & urine cortisol/creatinine ratio (UCCR): If repeatable USG< 10.20 and  +  UCCR move to next step 2. UA is inexpensive and easy to obtain and if UA criteria is not met for Cushings then resources can be spent into other more pertinent diagnostics or left on hold until the UA criteria is met in emerging Cushings cases.

2) Sonogram: Does the patient have concurrent disease clinically or sonographically as these will influence the potential false + LDDST or even ACTH stim and gives a global perspective of the internal health of the patient to be considered in the Cushings workup as an assessment of concurrent disease. Is there a concurrent neoplastic process, UTI pancreatitis, mucocele….? Are the adrenals enlarged (Cushings-PDH, stress, age related or breed variant), or atrophied (Iatrogenic Cushings or adrenal burnout), have asymmetric enlargement ( Adrenal tumor, hyperplasia, adenoma, age related variant), or is there vascular invasion (Invasive pheo with false + UA criteria or adenocarcinoma or phrenic thrombosis)?

3) LDDST (0.01 D-Sodium phosphate mg/kg IV) (Better screening test but plagued with false +) if potential early Cushings or if adrenal asymmetry present on sonogram suspecting tumor. Use LDDST in cats higher dose (0.1 mg/kg IV).

OR

4) ACTH stim. (Better confirming test but can have false +) if the patient “looks” Cushingoid or if bilateral adrenal enlargement is present, or high normal width on sonogram, or if iatrogenic Cushings suspected (Cortisone tx in past).

5) If diabetic then run both LDDST & ACTH stim.

5) Run a serial blood pressure in BP friendly non “white coat effect” atmosphere, Run at least 3 at different times over a few hours or when eating as the patient tends to be calm when eating or give Torbutrol when entering the facility.

6) Perform CT of the pituitary to identify macroadenoma expansion if any lethargy or dullness or other central clinical CNS signs are minimally present.

Suggested reading:

Behrend EN, Kooistra HS, Nelson R, et al. Diagnosis of Spontaneous Canine Hyperadrenocorticism: 2012 ACVIM Consensus Statement (Small Animal). J Vet Intern Med 2013;27:1292–1304 .