Stage 2 chronic kidney disease in 18 year old rescue terrier

Question

Hello--thank you for providing some of the most comprehensive information on managing chronic kidney failure in dogs that I’ve been able to find.  I have an ~18 year old terrier mix rescue dog who developed chronic kidney disease--stage 2, about 2 weeks after an episode of acute pancreatitis—now about 7 weeks ago.  He had been on metacam for degenerative joint disease (elbow, spine, hips) for about 2 years, so we have been monitoring his blood work at least every 6 months.  His creatinine had been creeping up slowly, but entered the abnormal zone at 1.8 after (but not during) the pancreatitis, BUN was 76 (BUN/Creatinine ratio 42), potassium 5.6, sodium normal (148), phosphorus not tested.  Urine was tested only for infection (no protein other analyses done).  Blood pressure not tested. Radiographs revealed an enlarged liver (present for several years) and kidneys at lower limit of normal size (new finding).  Prior to the pancreatitis, he sporadically leaked urine at night, but about a week before his pancreatitis emerged, it progressed significantly to every night, and during the day during long periods of sleep.  This has naturally persisted, along with classical symptoms of increased water intake.  To address his pancreatitis, he was placed on a low fat prescription GI diet (Royal Canin), which I have maintained, but I supplement with canned food (fat < 5%, protein 5-10%) and home cooked food (chicken/sweet potato/pumpkin/green beans/mixed vegetables/rice/flaxseed meal).  Although he seems to have recovered from the pancreatitis--he is active, enjoying his daily short walks, OK appetite (this fluctuates—I rotate his food to avoid associations with feeling sick), he has also developed sporadic episodes of trembling that seems to be increasing in frequency over the last week or so, which I assume will worsen as his disease advances.  My vet has discounted the trembling in spite of the high potassium at diagnosis, but I have made an appointment for 2 days from now for blood work and re-evaluation (hate to subject him to another urine test, which my vet does by cystocentesis).  He was prescribed subcutaneous lactated ringers solution 3 x week at home, but is not tolerating this well—it stresses him out.  Once the new blood tests are done, I will definitely follow the advice in this forum to deal with the issues with diet (and will post again), but I am struggling with the stress he experiences with administration of subQ fluids.  I know it is supposed to delay progression, but it is difficult to balance the stress against the suffering caused by kidney malfunction, and I do believe that he suffers with it.  He has also developed extreme restlessness in the evening before settling down to sleep (perhaps driven by hunger, but he often won’t eat additional food after his evening meal—I feed him a small meal in the morning/larger meal in the evening), and sensitivity to sudden exposure to light (such as when we walk into the sun).  His musculoskeletal pain seems controlled with 25mg tramadol twice a day.  By the way, he has too numerous to count skin tumors—mostly sebaceous adenomas—but had a malignant melanoma removed about 3 years ago—it doesn’t appear to have spread, unless his enlarged liver is an indication.  I would like to limit any procedures/trips to the vet to only that necessary to reduce his discomfort.  I am very afraid of him dying without me in the vet’s office—I prefer home euthanasia when the time comes.  Like others in this forum, I struggle with not knowing how long he will last in this state, and with identification of when the bad days outnumber the good.  Do you have a sense of what I might expect from my description? Any advice about management (I know this is a long thread) would be greatly appreciated. Thank you for reading through all of this!

tonyb286 · Answer

Hi Wendy. Thanks for the hug. It took me a while to figure out what was staring me in the face while grieving ... those last few horrible periods of life were but a moment in the long life shared. And slowly I started to remember the happy times, the wonderful times, the times I had happy tears rolling down my face because of what she had done or the expression she had given me, and the love, the warmth, the loyalty ... the sheer fact that almost every waking moment of her life had been a shared experience. The Christmas Days, the impromptu walks, the holidays, the times she welcomed our guests to the home and their dogs too. The point being, those were the important times, not the last short phase of life.

I hope, in time, you can remember those days with Hank, because if Hank was able to, those are the times he would remember fondly.

Tony

RunawayHank · Answer

Hello Tony--

I know--the automatic routines will indeed take time to fade--I'm still waking up several times during the night to check up on him and like you, I have to remember not to prepare his food.  

I'm surprised that Hank hasn't visited me in a dream, but it might be because I'm still on what I call emergency emotion--a state of emotional distance that allows me to remain calm enough to act constructively when challenged by tough circumstances.  Although it does protect me from a lot of the immediate impact of shock, clarity of thought in the moment is affected.  Otherwise, I'm sure I would have done better for Hank on that day.  

As I write this, I'm so aware of how tough we humans can be on ourselves--I'm sure Hank would have long moved on to enjoy the here and now!  That's one of the many lessons from him that I would be wise to incorporate into my daily life. 

I will try.

Take care,

Wendy

RunawayHank · Answer

Hank had "projects" along the trails we walked close by-- one involved digging a hole underneath a specific bunch of bushes--he worked on it every day that we took that route, until he had a hole at least one foot deep and a few feet wide.  Leaves would fill the hole in between his work days, and he matched the vigor of his excavation to the amount of leaves he found. I think he was after rodents in the beginning, being a typical terrier--an earth dog--but perhaps there were other scents to chase.  When he was done, he would emerge from the bushes with a wild and wonderful expression of joy on his face and then let out a satisfied "ha!" as he turned his attention back to the walk.  But the last few times we hiked the trail, a few months before I made the fateful decision, it seemed as if he was digging to bury his pain, circling as if he planned to lie down, like he did when he made a bed for himself out of blankets.  Then he would become aware of me, aware that I was watchful, and he would stop, and join me, still somehow satisfied.  

I returned to this project a few days after he died, and took a look at the hole, almost totally concealed by a new collection of leaves.  Oddly enough, I was trying to live a little in his world, as you described.  I'd love to know a bit more than 10%, but I did indeed learn so much from him--and what a world he occupied.

It will get better--

Thank you,

Take care,

Wendy

RunawayHank · Answer

Thank you Tony!

Twenty years!  That's amazing--you must have provided such good care, and a happy comfortable home.  I can see that you put a great deal of thought into relieving Meg's suffering, until, and after the end.  Although the final decision is excruciatingly difficult, it is honorable and kind.  I feel for you, for the image that lingers.  I know that you are right, that we didn't fail Hank or Meg, and that Hank would forgive me, not only because dogs live in the moment and because of the merciful passage of time, but also because of the close bond we had. 

I love her name--Meg--it brings an image of friendship to mind.

It's interesting that you mentioned loss of muscle as a factor -- I suspect that this contributed to Hank's response.  I also think that a lipoma he had on his hip may have been compressing his sciatic nerve, unfortunately on the side that was injected.  So many factors!  

Your response brings me great comfort -- thank you!  I am thinking of you, and the experiences you've had that have led you to offer such sensitive support.

Take care,

Wendy

tonyb286 · Answer

Hi Wendy

It is so hard for us, when things in the end don't go how we had planned or hoped. I empathise completely.

One of my dogs many years ago now, had to be euthanised. Meg was a lurcher and the most extraordinary dog I have ever owned. Incredibly intelligent, intuitive, always at my side and a lover of getting into mischief. She lived to the ripe old age of 20, but by that time she had gone completely blind and deaf - and her quality of life had been swept away. It was only when her back legs started to give way due to arthritis (meaning she could no longer enjoy her daily walks) that I decided that time had come, even though it was impossible for me to even contemplate.

I decided to have our great and compassionate vet come to the house, so Meg could die peacefully in her own home. Sadly, the injection for muscle relaxation and the sedative made her yelp - she had lost so much muscle tissue. Although her passing came swiftly after that, I cannot help but remember that yelp and it haunts me to this day. The last thing I wanted was to inflict any more pain.

So, what am I saying ... well, the end is just a few seconds in a long life of happiness and contentment. You were doing all you could to the best of your ability and by the end time, things were really out of your control. You certainly have absolutely nothing to feel bad about (yeah, easy said, right).

You did not fail him. You gave him all you had and more, you helped him take his final journey and you brought him peace. If Hank could, he would be saying thank you ... right now.

Run free Hank.

Take good care of yourself Wendy. Come back and chat any time.

Tony

RunawayHank · Answer

Thank you Tony,

My belief is that non-verbal communication and the dependence on subtle cues to guide our interactions with our pets (and humans, for that matter) create a much more powerful bond than those that require words (though as a writer, I'm sure you know how powerful words are).  The loss of that kind of relationship is truly profound.  Most of the people in my life recognized the bond Hank and I had, and didn't think of him as "just a dog" for me.  I'm grateful for that.  

But the home euthansia procedure went poorly--as required by law, the vets are required to ask about bite history, and when I made the appointment, I told the vet that Hank could be nippy if approached wrong, especially since he was in so much pain.  In spite of telling her that I knew how to deal with that, this disclosure led to him being labelled a "fractious" dog, and without my knowledge, the vet who came to the house chose a different protocol than was described over the phone (sedative was supposed to be given subcutaneously before the iv injection to stop his heart).  At the time, I didn't know what vets consider to be a fractious dog, or I could have prevented what the vet did without describing it to me--she chose to inject the sedative i.m. in a surprise, tentative approach, which, as you can imagine, did not go well--it required two injection attempts.  Once she finally got all the sedative in, he collapsed very rapidly, but not before we were both traumatized. I blame myself for not insisting that she go through the protocol with me, but the vet I spoke to on the phone was very clear, so I was taken by surprise.  Death can be quite the trickster, and in spite of all of my preparations for what I thought was going to be a good death, it found another way to fool me. 

I comfort myself with the knowledge that it was just a few minutes out of more than 8 years (I got him when he was 10) of a fantastic, loving partnership and excellent care, but my emotions have not caught up with that yet. At this time, I doubt they ever will, though I hope my sense of failing him in his last moments on this earth, will diminish with time.  

I know you understand, and I'm grateful for that.

Take care,

Wendy

RunawayHank · Answer

Thank you Tony,

I do have questions about the use of medications for separation anxiety--do you have any experience with them, and if some are less deleterious to the kidneys?  It's been recommended that I give them a try in an effort to alleviate Hank's suffering when I have to leave him alone.  I'm a little reluctant for obvious reasons, but also because he is only anxious when I leave him, and he doesn't always tolerate medications that act on the central nervous system very well.  Any insights would be greatly appreciated, though I know this is a tough subject.

Thank you,

Wendy

RunawayHank · Answer

Thank you Tony--I'll do that--I'm glad you are OK with the catch method.

Managing all of this can definitely be stressful, especially when my work commitments and deadlines loom-- the routine helps.  But the little guy had quite an adventurous, troubled (and often notorious) past before he landed on my doorstep at the age of 10, bringing a lifetime of stories with him--mostly entertaining, but some not so pleasant.  So I want to make the rest of his time on this earth as good as it can be for him.

Not too long ago I caught him on video (nanny cam set up) unplugging a lamp while I wasn't home, then looking up at it as if he knew he had turned it off.  Needless too say I immediately dog proofed all the outlets. So he is a handful.

All the best--Wendy

tonyb286 · Answer

Hi Wendy

Yes, fluid therapy, additional drinking and CKD all contribute to bladder issues. You seem to be coping extraordinarily well, although I'm sure it must be stressful for you. Frequent urinating can also actually be a significant symptom of bladder and/or urinary tract infection, so it's worth you trying to catch a sample (first one of the morning is best), and ask the vet to do a culture and sensitivity test on it. Any glass jar will do, just boil it in water to sanitise it, then dry it and allow to cool. It may be purely due to the CKD, but it's worth checking and could solve at least one problem if an infection is discovered.

Tony

RunawayHank · Answer

Thank you!  

In addition to managing the veterinary and diet issues, what I've mainly been dealing with is Hank's urinary issues.  He is not continuously incontinent (yet), but has significant leakage during sleep or rest.  If he finds himself wet, he will try to lick it clean, which I imagine can't be a good thing.  So in addition to getting him outside on a regular basis during the day (usually every 3 hours), I've purchased washable waterproof (whelping) pads and placed them in all the places he's chosen to rest (on his beds and under my beds) -- it's less expensive than disposables, which he hates anyway.  At night, I use disposable male wraps that usually need to be changed once (sometimes twice) during the night.  I don't like to use them much more than at night, as I worry that they may lead to bladder infections or skin issues, even with frequent changes.  

I try to make sure that my sleep conforms as much as possible to a normal human sleep cycle, which is on average about 1.5 hours.  This means that I try to get Hank up at night every 3.0 or 4.5 hours.  So far, this is working OK--it means I'm not as tired as I could be.  

Hank is also a very restless sleeper--he gets up and moves from bed to bed, place to place, all night.  I think it indicates pain (arthritis), but it may also be due to other forms of discomfort. It's funny, he woke up this morning acting like a puppy--very happy and animated.  Some days it seems as if he's immortal, but other days, I worry that he won't be with me long.

I think that Hank's breath may be a good indicator of worsening--it was absolutely terrible when he had pancreatitis.  It is mostly OK now, but I noticed that when he has a subQ LRS treatment, it improves.  So I'm hoping I can use it as an indicator of the need to treat, or the need to make another trip to the vet (absent other signs).

I hope this information will be helpful.  

Take care--

RunawayHank · Answer

Thank you Tony--I did read them and have found them very useful -- I believe that they contain the most comprehensive, up to date and user friendly information one can find.  I will continue to use them to manage Hank's kidney issues as well as my emotional reactions as we face this stage of his life.  I am greatly relieved to have a better understanding of what I can and can't control, and to have clear guidance for what needs to be monitored as he progresses.  The rest is up to Hank and mother nature!  

Have a lovely day--

Wendy

RunawayHank · Answer

I figured you had access!  I have only begun to sift through the literature, but I am now acutely aware of the need to monitor the factors you've indicated.  It will be interesting to see how long we can keep Hank going . . .

Take care, and thank you--

tonyb286 · Answer

Hi. Yes, SDMA was invented about 3 years ago and it was rolled out across most of the USA and UK last year. It's a good test for diagnostic purposes, but panel testing of creatinine, BUN and other elements remain crucial. Blood pressure and urine testing are also fragments of the diagnostic testing for kidney failure. It take all of these tests to make a valid diagnosis.

I do have access to most journals, but thanks for the offer. In fact, I read hundreds of journal entries each week, from universities and researchers all over the world, just to keep up to date.

Tony

RunawayHank · Answer

Sigh--I know, it was surprising to me again.  Apparently they run some blood panels in house and some are sent out, and it doesn't appear that any one of them has all the measurements we need.  By the time I figured out that they didn't add the phosphorus, sodium, potassium etc to an existing panel that also included creatinine and BUN, they were already finished with him.  Next time I will ask to go over all the panels available (I would think that they would have a kidney specific panel, with such a high prevalance of kidney disease in older dogs) and make sure all the right measurements are done in the future.  

I have access to scientific journals and found a trend toward the use of serum SDMA to detect kidney disease prior to elevation of creatinine.  It doesn't look like it will be useful for monitoring progression though.  In addition there are some recent studies of commercial kidney diets, typically limited in scope, but they basically confirm the benefit you've indicated.  If you'd like, or you don't have access to journals yourself, I'll be happy to either provide pdf copies of papers or a list results from a search. Not sure I can do that in this forum.  

Hank woke up very sore from his arthritis this morning, mostly in his right elbow--it's been most affected these last 6 months. I'll probably need to give him an extra dose of pain meds, but I'll know more after we are up and moving. He had a subQ LRS treatment Thursday, so he is feeling better from the kidney point of view.  

Just another day in the life of a geriatric dog. It's a roller coaster.

Thank you again--

Wendy

tonyb286 · Answer

Hi. I'm very pleased you found the articles of some value ... I try my very best to give all the info necessary, but in a fairly straightforward and easy-to-digest manner.

I am a little surprised your vet doesn;'t think creatinine (even more than BUN) is a necessary test to be included. To be honest, I find it extraordinary. Creatinine is THE key test for degenerating kidney disease. It can also change dramatically and very quickly over a very short period of time. Without this test being done, you nor your vet cannot gauge whether the disease is under control or deteriorating. Personally, I would absolutely insist on the test being done.

Feel free to come back any time ... ask questions, contribute to others that post and need support or just keep us updated with any changes that may occur.

Regards

Tony

RunawayHank · Answer

Oh, and I meant to indicate that I will be requesting follow-up blood and urine testing on a regular basis to make sure I'm on track.  It will help me cope with the relative unpredictability of his kidney disease, and as you say, will make me less blind!  Take care--

RunawayHank · Answer

Thank you again Tony.  Sorry for the delay in my response--I am discovering that this forum isn't optimized for Mac/iPad/Safari users, so I am now using different devices and browsers.  

Anyway, the vet did not repeat the BUN and creatinine, and didn't believe that they would change much in such a short period of time.  Exam included blood pressure and ocular pressure measurements, along with testing electrolytes/minerals.  She didn't think that the trembling was due to kidney issues, since he only recently converted to a 1.8 creatinine level after several years of monitoring every 6 months.  In addition, his trembling appears to occur primarily during sleep at night, and continues after waking for several hours.  He is unsteady upon waking, but that resolves during the day.  I read your article (thank you) and it focuses a bit on trembling in later stage kidney disease, so she may be right.  However, I will be monitoring and documenting to see if the trembling is associated with something specific, or has a trigger of some sort.

I read the other articles you've posted on infobarrel and find them very helpful--you distill information to the most essential points in a kind way.  I feel that I now have the information I need to move forward with my little Runaway Hank--especially with your recipes.  I will focus on limiting both phosphorus and sodium, and will try to balance high quality protein with vegetables with his low-fat food for his pancreatitis.  

I expect to be back to the forum on a regular basis.  Thank you again, and take care--

tonyb286 · Answer

Hi. There isn't a marker for phosphorus reduction and it would actually be really hard to achieve one, even if one existed. Phosphorus is in all foods, so it's just important to try and restrict the intake by choosing the appropriate foods. There comes a point in kidney failure when diet restriction of phosphorus doesn't work and a binder is then required, in addition to diet restriction. The blood tests you are having done should prove interesting, so please post them once you have a copy of the results.

The trembling is almost certainly associated with muscle wastage - but it could also include some neurological changes. Again, the blood test results are crucial, because they will show if some of the essential nerve transmitting minerals are abnormally low or (more usual) abnormally high. These will include sodium, potassium, magnesium, calcium and others. When the blood numbers become askew, the kidney disease deteriorates, and the trembling can develop into small seizures. It's therefore worth getting things under control as much as possible, as this will help reduce the symptoms.

SubQ fluids are useful in helping get the blood levels under control, so I would try to keep going with it, at least for the time being. The blood test results will tell you whether it remains necessary. SubQ fluids also help deal with any dehydration, which is very common in kidney failure dogs and causes lots of problems - and can even by life threatening if not dealt with.

Tony

I have just caught up with your 2nd message, so some of what I have said above may no longer be relevant. What were the creatinine and BUN levels like? I am posting you a link about tremors and shaking in canine kidney failure. This is one of my own articles and I think it will be of value to you. http://www.infobarrel.com/Tremors_and_Shaking_in_Dogs_with_Kidney_Failure

tonyb286 · Answer

Hi. I can empathise with your concerns. It really is a balancing act trying to work out what is the best management/treatment for an older dog's group of health concerns. Often, helping one condition simply antagonises another, so all you can do is work on priorities and quality of life.

You may already know that the pain meds will cause some deterioration of the kidney disease and increase the toxin build-up in the blood stream. But, if giving the meds seems to reduce any pain your dog is experiencing, then it's a valid choice to make.

I am amazed your vet has not undertaken phosphorus testing - or taken a blood pressure reading - or checked urine for protein leakage. These are fairly critical tests and should be performed. Without them, you and your vet are working blind and not getting all the information you need to help your dog.

The other thing I would mention is about feeding. If you can arrange it, try to feed smaller meals more frequently - the ideal is every 2 to 3 hours - but with each meal being a tiny portion (so total daily intake meets guidelines for the breed and size of your dog). These smaller but more frequent meals reduces the workload and stress placed on the kidneys and helps to minimise any nausea. It also reduces toxin build-up and encourages appetite and eating.

Pancreatitis is a common problem and you are right to reduce fat intake to help guard against it happening again. To do this, you will need to ensure the normal fat content is replaced with viable carbohydrates. Sticky white rice, sweet potato and couscous are useful ingredients you can use in rotation.

At stage 2, protein isn't a huge issue (though more recent bloodwork results will be helpful to confirm it). You can provide up to 15% protein content in the food you provide, although low-fat protein sources would be advantageous. The protein you give should be high quality (human grade meats and poultry). Once the kidney disease moves into stage 3, then protein restriction becomes more important. However, what IS important right now is to restrict phosphorus. Phosphorus build-up causes huge problems in kidney disease. If phosphorus shows abnormally high in blood work results, then a phosphorus binder will be necessary.

Hope this helps.

Tony

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