Doozer - 6yr old male shih tzu with familial nephropathy requiring dental work

[Sophie238]

Hello,

I've just come across this wonderful group and am wondering if you can help me.

My dog was diagnosed with familial nephropathy 2 years ago when he was 4 yrs old following a pre dental work blood test (the dental never went ahead as we began investigations in to his kidney health). At the point of diagnosis he was in the latter stage 2 on the Iris scale. He has remained fairly stable since with occasional bouts of tummy trouble (which Shih Tzu's are prone to anyway).

He had a recent bout of sickness and not eating and went off his chews together with a really foul breath. I took him to my local vet who gave him injections of non-steroidal anti-inflammatories, anti-emetic and antibiotics to treat the tummy and mouth infection. At this point I didn't really push the dental issue with my vet but when I examined him at home I realised it was actually a lot worse than I first thought, with the gum clearly infected and coming away from the teeth at the front of his mouth. I suspect the vet missed this on previous examinations as he tends to only look at the back of his mouth and he has never entertained the idea of putting him under anesthesia to treat the teeth (but I don't think he ever realised how bad it was).

A couple of days later I felt it necessary to take him back to the vet so I could show him exactly what I had seen and he agreed that he needs the teeth removed and his whole mouth cleaned up. If he were a healthy dog, it would be a straightforward procedure. My vet has limited experience working with dogs with kidney disease but has said he would anaesthetise Doozer and perform the dental procedure on him however I really think he should be anaesthetised by a specialist. I discussed this with him and he takes on board all of my thoughts however does not know of anywhere that he can refer me where there is a specialist anaesthetist willing to work on a dental case.

From my research, there are quite a few specialist veterinary practices that have specialist anaesthetists for a whole ream of procedures however none seem to have this in conjunction with offering dental procedures. I think this is because dentals are usually just done routinely by local vets and so there is no need to offer them at a specialist hospital that also has anaesthetists.

To add another layer of complexity to this situation;
I asked my vet to also take bloods (when I took him in for the second time to talk about his teeth specifically). He then called me later that night to give me the bad news that the bloods had deteriorated significantly. So whilst I had been researching all sorts of dog dentists, anaesthetists etc. he then drops the bomb that these are the worst bloods he has had... BUN 60, Creatinine 468. For reference, previous blood test in Oct 2016 BUN 26.7, Creatinine 299.

So at this point I do not even know if he will be well enough for anaesthesia at all. The vet said he needs to come in to be put on a drip overnight immediately. We then agreed that the drip would commence the next morning as he had no clinical symptoms and had eaten well and was very bouncy and happy that day. Whilst I know he isn't going to get better, it alarms me how dramatically his bloods had deteriorated. He has never had a blood test quite so soon after being administered injections of the anti inflammatory etc. so I do wonder if this played a role.

After being on the drip for a day, his bloods came down slightly; BUN 48, creatinine 446, still with no clinical symptoms. He is on the drip again at the moment and he will have some more bloods taken on Wednesday. Provided that they go down a bit more, I will press on with research in to the anaesthesia and dental work but what I would like to know is - does anybody have any experience of having a dog with kidney disease anaesthetised and if so, how did this go? I really don't want to damage him any further by putting him under but I worry the disease in his gums will be poisoning him and damaging his kidneys moreso. Secondly, does anybody know of any place in the UK that has a specialist with an interest in kidneys as well as anaesthetists?

I do need general advice on coping with his damaged kidneys but will hold fire on that until I get his bloods on Wednesday. I really really hope they will come down by then. It is so upsetting to think he might be closer to the end than I had thought. His bloods has been quite consistent for the past 2 years and I thought we were managing ok just with his diet.

Sorry if this has been a bit 'all over the place', it's really hard to manage to get all of the relevant details out and I'm sure I've missed something. Thanking you in advance x

[tonyb286]

Hi Sophie.

It is recommended not to treat dogs in kidney failure with Prilosec for longer than 8 weeks, so it would certainly be worth making a diary note of the start date and then reassess at say 6 weeks to see if it is still needed.

The dosing regime for animals is 0.5-1mg/kg. Always start at the lower dose.

The best type of fluid for kidney disease is usually Lactated RingerSolution (LRS), unless additional sodium is required due to low sodium levels in the blood (seen in recent tests), in which case saline can be used.

Using the smallest needle possible helps reduce scar tissue and keep dogs comfortable. However, this also makes it more difficult to push fluids in, so the time the process takes is longer. Dogs often react differently, some happily stay still while the fluids are administered - whereas others squirm and struggle - in time you will work out whether a faster flow (bigger needle) is better than a slower delivery (smaller but more comfortable needle).

http://www.zzcat.com/CRF/supplies/AboutNeedles.htm

And there are loads of good instruction videos online ... this is just by way of an introduction:

https://youtu.be/04xfMYP85Yw

Tony

[Sophie238]

Hello Tony,

Thank you for the info.

I gave Doozer his first Sub Q this morning and it went in very well. I had to adapt the technique slightly and give as an injection from a syringe instead of a drip as my vets did not have small bags of Hartmanns, only large 500ml bags with no measuring lines on them so I wouldn't have known how to ensure he got 50ml. After injecting, the fluid was gone within about 10 minutes so he must have been very dehydrated so I'm very glad I did it.

We are having problems with getting him to eat anything at all so in addition to the omeprazole and cerenia we have today added in mirtazapine. I feel like everything else we are doing will be in vain if he won't eat a thing and even his favourite treat (sausage) won't temp him now. He simply turns around whenever he is near food. I suspect as well as a physical sickness he now has a mental issue with eating so am hoping the antidepressant will help this.

Thanks for your help so far - I'm sure I'll be needing more advice soon!

Sophie

[tonyb286]

Hi. Your vet said: "He drinks a lot of water and the clinician did mention that this isn't really any different from giving Sub Q's ...".

This is not true. KD dogs drink a lot of water, but they don't employ it - because they cannot create concentrated urine. The water they drink, they simply pee out. So, SubQ fluids are quite different, as they go straight into the cellular structure of the canine body and have more chance of getting into the bloodstream, which is where they are needed, as it's from there the fluid is transported around the body.

It is of course completely impossible for me to say whether SubQs will truly help longer term, but they will almost certainly help short term. As to administering them ... if you do go down this route, let me know and we can talk about needle sizes and options for administering.

Omeprazole also comes in an oral suspension in 2 mg/ml. I'm not sure why your vet hasn't supplied that (as Prilosec), as it would be easier for you.

Tony

[Sophie238]

Thanks so much Tony. As I thought, your advice is much more practical.

I would like to know about how to administer Sub Q's as I will need to source the equipment required and understand the procedure of administering. I don't want to leave it until it's really urgent and I am not prepared. Any guidance or tips would be really appreciated.

Re the Omeprazole, I did wonder about this and also the dosage for his body weight. My dad takes 10mg Omeprazole as a maintenance dose for his acid reflux and he is a 6ft man! I'm concerned this is too high a dose for Doozer. From researching the web, it looks like he should be on 5mg. I will ask for the oral suspension as splitting the capsules is ridiculous!

Thanks,
Sophie

[tonyb286]

Hello. I am so sorry. This must all be a dreadful shock for you and I can empathise with how much stress this is putting you under.

The priority at the moment is the kidney disease, because unless the creatinine can be brought down, then things are looking fairly grim. The IV fluids are the best route to getting the creatinine down - and at least 3 days of IVs will be needed to help achieve it. When IV fluid therapy has finished, you will need to continue giving SubQ fluids at home. Your vet will need to prescribe the fluids for you and teach you how to administer them The fluids should be Lactated Ringer Solution (LRS).

Next, there's the dental assessment. That's a big and difficult decision. It carries a 50/50 risk of making the kidney disease worse - or maybe not even surviving the anesthetic. I think you are absolutely right to seek veterinary specialists. One route that may help is to contact veterinary teaching establishments (universities) and ask for their advice. I don't expect such assessments are going to be cheap though.

Diet and other changes will become necessary ... please follow these links to access articles of mine that will help you become more familiar with the disease and start a management plan ...

http://www.infobarrel.com/5_of_the_Best_Things_You_Can_Do_for_Your_Dog

http://www.infobarrel.com/How_Diet_Affects_Dogs_with_Chronic_Kidney_Disease

http://www.infobarrel.com/Changing_Diet_During_Canine_Kidney_Disease

Okay. That's probably enough for now. Let me know how you get on and please ask questions if you have any after reading the articles.

Tony

[Sophie238]

Hello Tony,

Thank you so much for your response. I really appreciate your input and have read your articles.

After being on the drip for a second day his bloods have come down a bit further; BUN 40.8 and Creatinine 414. He is back on the drip again today so hoping for them to drop further. The fluid he is on at the vet is Hartmanns - is this the usual?

We spoke to our vet about SubQ fluids and he said that given the size of our dog (5.4kgs and is bony with no body fat), he feels that it would not be humane to put him through that procedure because he feels the swelling from the fluid would be painful. I hasten to add that his experience with this situation is limited so I am still considering it. I have asked that we continue to put him on the drip at the vet until his bloods stop dropping any further.

We asked for a referral to a specialist that we found at the Royal Veterinary College as we would like a second opinion on the kidney situation before going forward with the dental. The vet is a lecturer in Small Animal Internal Medicine with a special interest in feline and canine nephrology and urology. Happy to say we have an appointment next Tuesday. She has also recommended an RVC dental specialist but unfortunately despite many phone calls to many practices, it seems that specialist anaesthetists don't work alongside on dental cases! Following the advice of the specialist, we will reassess whether to go forward or not.  

With regards to diet, we have been home cooking meals for the last 2 yrs. Am now trying to source green tripe without much luck so far. Can you advise on where I can get it from? Most distributors say it is for a raw diet so am I ok to buy that and then cook it?

Following reading the articles I am going to ask the specialist about the idexx SDMA test and the phosphate binder which I will be looking to incorporate. Also the salmon oil although I am struggling to work out how much I should give to him.

I am crossing my fingers that more fluids can help. At the same time I can't wait to pick him up and bring him home as he is such a nervous little thing.

Sophie

[Sophie238]

Sorry I forgot to add. Since diagnosis 2 yrs ago, we have been monitoring his bloods fairly regularly and prior to this dramatic deterioration, although overall the bloods were deteriorating, the progression was slow(ish). I'm concerned that the non-steroidal anti inflammatory that the vet gave for his mouth infection a few days before could have contributed to a sudden deterioration in his bloods - could you let me know your opinion on this?

Below is a table of his recent bloods:
Date        BUN     Creatinine
28/06/2015 15.5        209
27/08/2015 22.7   216
18/09/2015 22.9 256
29/09/2015 25         380
17/11/2015 29.3 263
12/04/2016 34.4         325
14/10/2016 26.7         299
13/01/2017 60         468
16/01/2017 48         446

[tonyb286]

Hi. Hartmanns solution is the same as Lactated Ringer Solution. Only the name is different.

Great that you found a vet from the Royal Veterinary College specialised in kidney issues. I would be very interested in what they suggest, so do keep me posted on how the consultation goes on Tuesday.

I buy the Green Tripe from Natures Menu. My local pet store sells it in the frozen section. You can call them on [phone] and ask about local stockists. Yes it is for a raw diet primarily, but I actually do cook it (there's no good reason for it, I just always have done).

Once you have the salmon oil, just contact me again and give the weight of your dog so I can work out dosing for you.

It is indeed possible for the steroid to have caused a worsening of the kidney disease values. The fluids should correct this - fingers crossed. While anabolic steroids can be used to stimulate appetite, they are not recommended, due to their potentially life-threatening side effects.

Hope things settle down and you have a productive consultation on Tuesday.

Tony

[Sophie238]

Hi Tony,

Just come back from vets and really upset - Doozers blood test this morning showed a further deterioration in the creatinine to around 480 despite having had 3 drips over the past 6 days. I can't understand this as it came down after the first 2 drips and has now come up again to higher than the first 'bad' blood test!

He is back on the drip for the day but I am concerned if this is the right thing to do for him.

It seems my hope that the injections he was given accounted for some of the deterioration is probably not correct :( I now have the names of the meds - the non-steroidal anti inflammatory was 0.50 x Carprieve injection and the antiemetic was 0.55 x Cerenia injection 10m.

At this point I'm not really sure what to do next but will press on with his appointment next week. He is still pretty much asymptomatic.
        

[tonyb286]

As a class, cyclooxygenase inhibitory NSAIDs may be associated with gastrointestinal, renal and hepatic toxicity. All dogs should undergo a thorough history and physical examination before initiation of NSAID therapy. Appropriate laboratory tests to establish hematological and serum biochemical baseline data prior to, and periodically during, administration of any NSAID should be considered. Owners should be advised to observe for signs of potential drug toxicity (see Adverse Reactions, Animal Safety and Post-Approval Experience).

I think this is a wait and see - fingers crossed - situation. Fluids can take a while to have the desired effect. So, maybe, just maybe, there will be some improvement over the next 2 to 3 days. The difficulty here is not knowing just how much damage there is to the kidney organs themselves and the filtering nephrons, because that is going to determine whether an improvement or recovery is possible.

Do keep me informed and try not to stress too much. Easier said than done, I know.

Tony

[Sophie238]

Update on Doozer

It's been a couple of weeks since I posted as it has been an extremely stressful time.

We went to the RVC for some advice and a plan and decided to go ahead with a dental under anaesthetic with a specialist I had found. The clinician at the RVC felt it would be in Doozer's best interests to take the risk as the tooth decay may be contributing to his numbers. She was happy that his numbers seemed to be 'holding their own' despite being off the drip for a few days and so we made the arrangement to have the dental.

Doozer seemed very lethargic on Saturday so we took him to our local vet for another blood test (as he was due to have his dental a few days later). The results were bad - the worst they had been - BUN 54 and Crea 648 and PHOS 3.3. Hence the dental was cancelled and we feared the worst over the weekend. As there were multiple specialists and clinicians involved with his care at the RVC as well as the practice where he was going to have his dental and my local practice, I got some conflicting advice. The general consensus was that he needed a drip immediately but my local vet felt that this would be futile. I also felt like I didn't want to put him on a drip as he gets so stressed at the vets and consequently won't eat or pee and holds and folds up his little paw that has been cannulated . If he is nearing the end, I really don't want to make him any more stressed and there seemed to be more negatives than positives associated with the drip at this point. Over the course of the weekend he seemed to rally and by Sunday afternoon he was behaving normally. We decided to give one more shot at the RVC for some advice, however this time asking for advice of a more palliative nature.

He has been behaving dare I say 'normally' this week. At our visit to the RVC yesterday he had another blood test and his numbers have come down slightly - BUN 53 creatinine 546 and PHOS 3.14. The clinician exclaimed that whilst he is definitely in stage 4 according to his bloods, his clinical symptoms are more like stage 2. This might be due to the fact his kidney failure is genetic and hence his kidneys have been deteriorating his whole life and he has become tolerant of this. If he had rapidly developed kidney disease, his body would probably find that harder to process hence would be more symptomatic.

Anyway, I asked the clinician about Sub q's and he gave a demonstration however I am really undecided about them. Firstly, he brought in sodium chloride and not LRS which I didn't think was the right solution but the clinician said this was just for demonstrative purposes.... secondly, he didn't demonstrate on Doozer, just put the set together whilst I watched... thirdly he didn't explain how I am supposed to keep a needle in my dog for 10-15 mins for all the fluid to infuse!? Before this demo, I was under the impression that sub q's were an injection, not an infusion. He didn't give me any specifics on the giving set he used, or needle size. There is also the question of if this will be too uncomfortable for Doozer (he is only 5.4kgs and really bony) but as he didn't actually demonstrate on Doozer, I don't know how he will react.

So I just wondered what your advice is with Sub Q's. As I mentioned, I am really mindful that everything I do is in Doozer's best interests and I don't want to do anything that upsets him as this has a knock on effect with his eating etc. I just want to make sure his days are as comfortable as possible. He drinks a lot of water and the clinician did mention that this isn't really any different from giving Sub Q's so do you think this is necessary?

I get the distinct feeling that advice we have been getting is rather hit and miss and sometimes I feel I am directing the vets instead of vice versa, even at the RVC (they are all such busy people).  I asked for a medication for acid as i can hear his stomach gurgling and burping regularly and they gave me omeprazole 10mg (1/2 a capsule morning and 1/2 evening), so this morning I found myself splitting the capsule open and counting out theses minute little balls of the actual drug into the 2 doses.  i've ordered vegetarian capsules online and am going to count out into doses - do you have any tips on administering omeprazole?

I feel like I am getting much more practical advice and help from this group than the vets but I do of course need them as well - it is such an uphill battle! My Doozer still has his bounce and I just want him to feel comfortable and safe.