A Big Dog With a Big Problem

Kodi was a BIG dog-a gorgeous 120-pound Malamute- who had a very big problem-his kidneys weren't working like they should. For him, this meant the waste products of every day metabolism that build up in the bloodstream just kept rising, unable to be filtered by those failing kidneys. Now, Kodi wasn't an old dog as you would have expected. Older patients get things like organ failures-they just wear out after years and years of use. Sometimes they get cancer in those organs. This just wasn't the case for Kodi-he was only 4 years old. As we attempted to treat Kodi for the obvious problems resulting from his kidneys not working, we also had to go on a hunt for possible causes of their failure-or we might not be able to stop it from happening again.

Since kidneys are a filtering organ, anything that travels in the blood stream and accumulates in the kidneys could potentially casue those organs problems. Drugs like non-steroidal anti-inflammatory medications can do this, especially ibuprofen, a drug really meant for human, NOT canine use. Other medications humans routinely take could have renal toxicity problems in dogs, but Kodi's owners were fairly certain he didn't have access to anything like that. They hadn't given him anything as some people do, "just to make them feel better" before resorting to a veterinary visit. We couldn't think of any plants or yard products/chemicals he could have eaten, and they hadn't changed their anti-freeze in their cars recently. Anti-freeze is a well known kidney toxin.

There are, of course, primary diseases of the kidneys themselves-infections like pyelonephritis which can develop from bacteria that travels up the urinary tract from the bladder to the kidneys when a pet has a bladder infection, often unnoticed by owners. The blood work we did on Kodi did not indicate any infection in his body right then, but it was still a slight possibility.

Leptospirosis is a bacterial disease that can affect the kidneys of dogs, as well as humans. Wild critters such as possums, racoons and rats can be the carriers, spreading the organism through their infected urine. The disease can be serious for both humans and animals. In people, the symptoms are often like the flu, but sometimes leptospirosis can develop into a more severe, life-threatening illness with infections in the kidney, liver, brain, lung, and heart. Because we had put many of the other possibilities for Kodi's kidney problems lower on the differential or "rule-out" list, leptospirosis worked its way higher up the list. Testing for the disease is done via a blood sample, but results often take 10 days to get back. Since the treatment for the leptospirosis bacteria itself is done with antibiotics, we decided to start Kodi on these right away rather than wait for the test results to come in.

Leptospirosis is one of the "big" diseases we usually vaccinate at-risk dogs for every year, but unfortunately the vaccine does not provide 100% protection. This is because there are many strains (types) of this bacteria, and the vaccine does not provide immunity against all strains. It is important to get your pet vaccinated again even if it gets leptospirosis because it can still get infected with a different strain of leptospirosis. Kodi was vaccinated each year for 4 different strains of lepto, but his test came back positive for another strain, one for which a vaccine is not available. It was a good thing we had started him on antibiotics when we did. when we got the test results back, we also started his house mate, Kiona, on a prophylactic course of antibiotics. She wasn't showing any symptoms of the disease, and we certainly wanted to keep it that way.

As mentioned, treatment for the leptospirosis bacterial infection is antibiotics, specifically those in the penicillin family. These will arrest the on-going infection, but dogs can remain carriers of the disease unless a second antibiotic from the tetracycline family is used, often for 6 weeks, to break that carrier state. Kodi was initially put on injectable ampicillin since he was so nauseated and anorectic from the kidney disease that resulted from the infection. And this was the big problem: we had a handle on the disease and could get it treated, no problem. But the damage it had already done to Kodi's kidneys was severe-he was hospitalized multiple times, once for 4 days in a row for 24 hour a day IV fluid therapy in a attempt to diurese his blood and get those kidneys working again. It never worked. His owners were terrific. They did everything we asked of them, bringing him in for testing, for hospitalization and treatment despite the considerable time they had to take off work and expenses they incurred. He spent a lot of time with us and in the emergency hospital when we weren't available.

We really expected such a young, big, strong, dog to turn the corner any time and make a full recovery, but it was not to be. Kodi's initial bloodwork showed just how poorly the kidneys were doing, and his first retesting of their values showed good improvement. Kodi was given very aggressive care, including those antibiotics, fluids, anti-vomiting medications, prescription renal diets to require less work on the kidneys while providing good nutrition for healing, antacids, appetite stimulants, phosphate binders (phosphorus levels go sky-high in kidney failure patients, making these patients very weak and wobbly, and Kodi was no exception)-you name a drug in our pharmacy and he probably was on it at one time or another! Subsequent testing showed no changes in those kidney values, and his phosphorus levels worsened, making him even weaker. His owners were reaching their limits of what they wanted to put him through, and frankly, what they could afford to spend. When Kodi finally became painful-his kidneys evidently swollen and tender-he was crying out as only a 120-pound Malamute can-his loving owners made the choice to end his suffering and said goodbye. It was a terrible tradgedy-his owners did everything right, loved him, fed him right, provided him with good preventive health care-and it just wasn't enough. They unselfishly did the right thing for him that weekend, as hard as it was on everyone involved.

Kiona is still symptom-free, and we fully expect her to stay that way. We had a little scare when one of out veterinary technicians became ill this week and made sure to alert her physician about her exposure to leptospirosis. In fact, we were required to report Kodi's case to the state veterinarian, that's how serious this disease is.

Definitely get your pet vaccinated for leptospirosis (the "L" part of a typical DHLPP vaccine) if he or she is at risk, and do your best to control the rodent/small animal population to minimize their urine in your pet's environment. Leptospirosis is out there, but is not a very common disease, thank goodness. If your pet has been confirmed by your veterinarian as having leptospirosis, don't despair. Early, aggressive treatment usually brings about good results. Kodi's case was rare and tragic.

Peace,
DrReneigh

When Organs Go Bad

Hi all, Remember me? I haven't been able to blog for quite awhile-we have been busy at the hospital and extra-curricular "stuff" has just left me tired and uninspired for writing. I hope those times are behind me now!

We had a very sick patient the past couple of days that everyone on the staff worked very hard for. Jericho was a sweet, older dog who could barely walk in to the hospital yesterday-he was just way too weak and disoriented. He was constantly vomiting and had severe vomiting. Worst of all, these symptoms had likely been going on for 10 or more days with no treatment! He was beginning to show signs something was wrong almost 2 weeks ago, but then the owners had to leave town for vacation. Their dog sitter didn't provide any care for Jericho while they were gone, so he just continued vomiting, not eating, and got weaker and weaker. The dog we saw just wasn't the same dog they knew and loved.

Of course we wanted to know if he could have gotten into anything, eaten poisonous plants, swallowed a rock or bone or some other foreign object, causing an obstruction in his GI system and thus the signs we were seeing. Other possibilities were eating a toxin of some kind, antifreeze for instance, or being fed a poison by a disgruntled neighbor. You hate to think that way, but it sure can happen. He was an older dog but not geriatric, so we didn't really think organ failure was high on the list of rule-outs, but we put them on the list any way-kidney and liver insufficiency, pancreatitis, enteritis. Jericho was not current on his vaccinations, so parvovirus was possible. No matter the cause, this boy was SICK. He was dehydrated from the loss of so much fluids and inability to keep anything down, and the weakness and disorientation could have been from electrolyte imbalances or toxin build up in his blood stream. His prognosis or ability to recover from this problem wouldn't be able to be determined until we identified a cause.

We gave Jericho's worried owner a treatment/diagnosis plan, starting with a parvo test-it was negative, thank goodness. We then did a complete blood count and general blood profile and there we learned the source of his symptoms. Blood Urea Nitrogen or BUN and creatinine are two blood values that are normal by-products of metabolism and excreted by the kidneys. Our "normal" values for BUN are 7 - 27 mg/dl-Jericho's value was over 130! It was so elevated that the machine couldn't give an accurate value. The creatinine was similarly increased. The two values being elevated together is called azotemia-a strong indication that Jericho's kidneys had failed. The other major problem was the phosphorous level, a product usually eliminated from what we eat, again by the kidneys. When they aren't functioning, it becomes elevated and makes the patient weak and ataxic or wobbly, just like Jericho was. His phosphorous level was sky high.

Jericho's owners couldn't think of anything he could have gotten into that could have caused this to happen. They said they have good neighbors that love dogs-very unlikely to poison him. There are some diseases like leptospirosis as we have discussed in the past that can cause kidneys to fail. Of course, being an outdoor dog, he could easily have found something bad to eat, so we may never know what did this to him. The most important thing was-could he recover?

The answer to that question is never easy. Dogs are individuals, and sometimes those with very severe symptoms and lab values recover uneventfully and go on to live long lives. Some with minor changes will suddenly worsen and die despite aggressive treatment. Only time and treatment will tell. Often that means spending a lot of money, unfortunately without a guarantee of success. I felt Jericho's chances to survive were very poor, but his owners felt they owed him at least a chance. Our whole team came together for him and initiated an aggressive treatment plan. We sent in an ethelyne glycol test. This would tell us if he had been exposed to antifreeze or not. If he had, his chances would be next to zero and I told his owner this. In the mean time, we placed an IV catheter to administer fluids, gave him pain relief medications, anti-vomiting medications, and antacid medications-all by injection as he wasn't keeping anything down orally. He was so much more comfortable right away-just taking away the pain and vomiting reflexes was enough to allow him to sleep comfortably and allow his body to start to heal-or so we had hoped.

Jericho received IV fluids and medications throughout the day. We aren't a 24 hour hospital, so we could have sent him to one for round the clock observation if I had thought he needed that. His pain level seemed OK, his fluids were running well and all he was doing was sleeping so I thought he would be fine. I offered to check on him later that night and his owner agreed that should be fine. Around 10:30pm he was QAR (remember our abbreviations?-quiet, alert, responsive), he walked very slowly outside to urinate, but I had to carry him back in. He just got tuckered out. He hadn't vomited but his heart rate had increased and his pupils were dilated so I thought his pain level might be rising. I gave him another dose of a narcotic and made sure he was toasty warm and that his fluids were running well.

This morning Jericho was again QAR. The ethylene glycol test came back negative. I was considering running a test for leptospirosis, an infectious cause of kidney damage, and would discuss that with his owners later. We again gave him pain meds and some anti-vomiting medication as he had started to lick his lips and drool a bit. Today, though, his drool was quite bloody-I was very worried about gastritis from the uremia that had developed from the kidney failure. His owner came to visit him and spent about half an hour with him. He seemed to perk up a bit while she was here which was good for both of them. Literally a few minutes after she left, Jericho stopped breathing. The nurses called me back to see him, but it was usesless. He had made the decision about whether or not to fight this horrible disease. At least we know he wasn't in pain and his owner and he got to spend some nice time together right at the end.

I feel so bad for the family-I know they will hurt over Jericho's loss for a long time to come. It was great, though-his younger owner came right back into the hospital holding on tightly to a very scared brown tabby cat she had seen running wild behind the strip mall where our hospital is. She was worried the cat was lost, not eating, and possibly reproducing out there on her own. We scanned the kitty for a microchip-none was found. We will notify her if anyone calls missing their cat and she will foster it until then. This kitty is redirecting some of her grief energy into something more positive. Animal lovers through and through. Rest in peace, Jericho.

Peace,
DrReneigh