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Chronic Kidney Failure in Dogs Community
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14801663 tn?1436788166

Help! CKD diagnosed yesterday and Ishka in crisis

Hello

We got Ishka's blood test results yesterday afternoon and were told over the phone that she has CKD. I don't know the actual blood test levels yet (because in the UK they don't give you a copy of the results, although I will be asking for a copy).

I'm really worried about her today because she isn't eating OR DRINKING. I have read a lot on the internet since getting the diagnosis (including Tony's article on InfoBarrel) and I think she is in uremic crisis. As well as refusing food and water, she also has sickness and diarrhoea.

She has been off her food for almost 6 weeks and has lost weight dramatically in the last week or so. (We thought she was just being fussy and now I feel terrible about not taking her to the vet sooner.)

While we were waiting for the blood results, the vet advised us to starve her (because she had been sick and the vet thought she might have a bug).  Having been starved on Thursday, she ate a small amount of white fish and white rice for both lunch and dinner yesterday and seemed to be much better in the evening. Because she'd eaten so little, we gave her some Royal Canin renal diet canned food at about 9pm last night but immediately afterwards she was sick (a clear watery slime - no food).

This morning she had diarrhoea at 8 am. We tried her with the white fish and rice again at 11 am but she wouldn't eat it (I understand she will probably have gone off it already). She did however take some processed chicken from my hand along with her antacid pill. Immediately after this she had more clear watery sickness (though I think the pill stayed down).

Most worrying, is that she is very reluctant to drink. She has only had a small amount of water since last night.  

I'm hoping the group members can help us get her through this crisis... what should I be doing for her?

Some questions:

- is it important to take the antacid *before* food or * food? (if before then how long before?)

- should I be asking the vet to put her on an IV?

- alternatively, should I be asking for anti-nausea medication to get her eating again? (or will the antacid help the nausea?)

Many thanks
Laura
12 Responses
1916673 tn?1420233270
Hi. Welcome to our family of friends. The blood results are really important, as they will suggest the stage things are at, so do ask for them. They should also show if there is a gastric infection going on, which is possible. Starving is not really the answer, though I understand why your vet said it (it is normal practice to starve a dog for 24hrs if there's a stomach upset), but in this case, I think it's more to do with the kidney disease. Yes, ask about anti-nausea meds - and try whatever is advised for 3 days - if it doesn't work in that time, get your vet to prescribe an alternative ... and so on, until the right one is found.

Antacid's should always be taken with food, but can be taken up to an hour afterwards. Anti-nausea meds are usually taken once a day, often early in the day, so the medication lasts through meal times. Some anti-nausea medications are however required to be taken immediately before or with a meal, and some immediately afterwards - so check with your vet over the directions for any specific med.

IV Fluids are a must - now, not later - unless the bloods show something different. I have just finished a drafted article on the 10-Point Plan for Canine Kidney Failure, but it isn't published yet. I think it would be really useful to you. If you send me a private message with your email address in it, I'll send direct from my computer.

Hope this helps

Tony
1916673 tn?1420233270
Just a footnote ... one of the problems with metabolic acidosis is ensuring vets treat it with the right medication. Treatment involves administering an alkalinizing salt, usually sodium bicarbonate or potassium citrate, in an amount sufficient to increase the blood bicarbonate concentration into the normal range. If Ishka has metabolic acidosis (your vet should know this by now), then they should also know the right form of treatment. Much depends on the potassium and calcium levels, to work out which of the two forms of medication above are more appropriate. It's worth checking (politely).

Antiemetics for the nausea and vomiting should be in the form of metoclopramide, 5-HT3 receptor antagonists such as ondansetron hydrochloride or dolasetron mesylate, or the neurokinin-1 receptor antagonist maropitant [Cerenia—Pfizer] or low doses of phenothiazine tranquilizers (prochlorperazine). If your vet is inexperienced, you might pass this information on to them.

Tony
14801663 tn?1436788166
Hi Tony

Thank-you so much for the in-depth reply. I'm so sorry I didn't acknowledge it earlier - I thought I'd get an email notification but I guess I didn't tick the right group setting.

Everything you say makes sense and we are armed with more info for our next vet visit now. The vet had only given us a few antacid pills in a paper bag so we didn't have the advice leaflet - we'd been feeding the pill (Omprazole) first thing in the morning with only a tiny amount of food so I'm really glad to know that we need to change this and try to get some more food into her first.  

I have a question about the metabolic acidosis: is the antacid another way of treating this? i.e. is the alkalinizing salt (which I assume is a fluid treatment) reserved for severe acidosis, or do the two treatments have distinct aims?  

Ishka had a bad two days over the weekend. The very small amount of food she ate on Saturday was regurgitated - completely undigested - at 11pm that night. We started trying to feed her again on Sunday morning only for the same thing to happen at 3pm. The vet agreed to see her after that (we had phoned twice on Saturday but he'd said that provided she was drinking and urinating he wasn't too concerned). He suggested on the phone that fluid treatment might be necessary but when he saw her - tail wagging and jumping from the car like the true fighter she is - he said he didn't want to traumatise her by keeping her in overnight. Instead, he gave her an anti-nausea injection, which he said would also help food to be digested, and a vitamin shot. She has had some food today (though only about the same amount she was eating over the weekend) and we're just hoping there will be no sickness this time. He's also given us Cerenia tablets - and we'll follow your advice there.

I will take all your info with me when we next go into the vets and check it all over with him (politely!)

Thank you so much for your help. My husband and I shed so many tears over the weekend that we were feeling rather worn out. Your information and advice is helping us to feel more positive and more in control and for that we can't thank you enough.

Best
Laura
1916673 tn?1420233270
Hi Laura

Omeprazole is used chiefly for acid reflux, stomach ulcers and acid. Strangely enough, I am myself on the human form of this medicine, so I do know a fair bit about it. While it is very effective, it also has some unwelcome side effects for kidney failure dogs, which is nausea. Obviously, if a dog already has nausea, giving Omeprazole (with the rare but possible side effect of nausea), will just exacerbate the problem. I think it's worth trying for a few days, but if it doesn't seem to be having the desired effect, it's best to go back to the vet and try something else.

Metabolic acidosis is the term vets use to describe a specific form of nausea caused by kidney disease, where the kidneys are not removing enough of the acid from the body. There are two fairly distinct forms of treatment needed:

1. Treatment of the acidosis with alkali administration. This can be in several different forms - tablet, injection and/or fluids - but fluid therapy on its own is certainly one of them. The fluid therapy doesn't just treat the acidosis but other elements involved in kidney failure too, depending on additives used to supplement the fluid bags (IV or SubQ).

2. Treatment of the nausea with anti-nausea medication. There are many different tablets suitable for this, and your vet will be able to advise on the best one for the job. Again, if after a few days, it doesn't seem to be working, you need to report it back to the vet so an alternative can be prescribed.

Cerenia is an antiemetic. This is intended purely to treat the vomiting, so should only be issued on a short-term basis.

Although IV fluids would probably be more beneficial right now, I can understand your vet saying this would be stressful, as dogs need to stay overnight and at least for one night. However, you could discuss with him the possibility of undertaking SubQ fluids at home.

I have also sent you by email my 10-Step article, which I hope will give much more info about the first steps you and your vet need to make, following the diagnosis of kidney failure.

Hope this all helps and I haven't overloaded you with too much to read all at once.

Let me know how things go.

Tony
14801663 tn?1436788166
Hi Tony

No, it's not too much information! It is all really appreciated.

I have one (hopefully) quick question:

Ishka still isn't eating. My husband and I prepared a homemade renal diet food as per your article on InfoBarrel but because she won't look at it we have resorted to trying various other things just to get her eating - but all she will eat is chicken leg meat. Should I be concerned that this is Ishka in the final stages of decline? I've read so much about them being picky eaters but this seems to be a complete refusal of everything - including things she used to love, and also various things she'd never had before (green tripe, cottage cheese). Or do you think this is partly due to her not having proper anti-nausea medication? (because as you say the Cerenia is an antiemetic)

If the complete lack of appetite is a sign that she's nearing the end then I'd like to be prepared. I was so hopeful after our vet visit yesterday but today she's just been much the same as yesterday.

She's still drinking and urinating, and she had a bowel movement today so she must be digesting her food which is good.

All the best
Laura
14801663 tn?1436788166
Tony

I just read the 10-step plan article you sent me and I think it answers my question above about the complete loss of appetite - it could indeed be her nausea and perhaps if we find the right anti-nausea medication, we will see an improvement.

I hope you find a publishing outlet for the article soon because I think it could help a lot of owners: we've been feeling so powerless but this sort of information allows one to feel that they can ensure the best is done for their pet .

I'll let you know how we get on.

Many thanks
Laura
1916673 tn?1420233270
Hi Laura

Without the blood numbers, it's hard to say how far the kidney disease might have progressed. If you can get them from your vet, it would certainly help to say what stage things are at. It's equally tough to answer your question about whether the lack of eating is due to the kidney disease having progressed or due to nausea alone, though nausea will certainly discourage her from eating either way. I'm pleased you found the article helpful.

Chicken is fine, but ideally use human grade chicken (chicken you would buy and eat yourself) - and cook it leaving the skin on. The skin contains useful fat, which is both tasty to dogs and provides energy. Chicken is high in protein, but human grade chicken has high quality protein, so not nearly as problematic. Obviously, this needs to be a relatively short-term fix as far as eating is concerned, as getting her to eat a proper renal diet would be preferable.

Keep me posted on how things go.

Tony
14801663 tn?1436788166
Hi Tony

I requested a copy of the blood results yesterday so I'll let you know when I get them through.

The chicken was human grade dark meat (thigh) with the skin on, removed from the bone. Phew, at least I've done something right!

Thanks again for all your help, Tony - it feels like this forum is the only place I can get answers - though I'm phoning for another vet appointment today.

Laura
1916673 tn?1420233270
Hi Laura

Don't worry. you've done everything right - and you are continuing to work so hard to improve things. This is a horrible illness that often confounds us, annoys us, saddens us and leaves us feeling confused, helpless and isolated. I'm pleased you have found your experience (so far) on this forum beneficial. In the end, we can only do the best we can do, but when we do them together ... sometimes what seems like miracles happen. We are here for you.

Tony
14801663 tn?1436788166
Hi Tony

Thanks again for there kind words - the good wishes we have received from friends have been incredibly important to us.

At our last vet appointment, we ran through most of the points in your 10-step plan. (The vet was incredibly patient with us.) And we also got a copy of Ishka's blood results. I'll detail the vet's response to each of our questions for you because I know you add to your knowledge of the disease, and to vets' approaches, by gathering this sort of info. I hope it's helpful, and if you have any comments, please let me know.

With regard to blood pressure, and the need for treatment in order to reduce stress on the kidneys, the vet answered that the heart disease medication Ishka is taking will address this, by increasing blood to the kidneys. The medication is called Fortekor.

I asked whether we needed to confirm the diagnoses with further tests but she answered that due to the blood levels they are already quite certain it is CKD. I asked whether a Newfoundland's bone density might affect the results (like a Greyhound's muscle mass) but she said no.

I said that, from everything I'd read, fluid therapy sounds essential. The vet answered that they do this a lot with cats, who are prone to CKD, but not so much with dogs. (I wasn't happy with this answer, but she was the third of her colleagues I had put this question to and none of them seem keen - is it simply that they're inexperienced in IV therapy in dogs??) She was more positive about my husband administering SubQ fluids at home, and said we could talk about that going forward. (We're concerned though that without the IV therapy, the SubQs will be less effective.) Another thing she said was that administering SubQs in giant breeds such as Newfies requires a lot of fluid and that there's a danger this will sit in pockets under the skin and make them feel uncomfortable. I have to say that I am skeptical of this because surely the amount of fluid given to a giant breed is *proportional* to the amount given to a small breed....

The vet told us that the Cerenia is both an antiemetic and anti-nausea drug, and that it works on the brain, rather than the gut. I have to say that Ishka seems less nauseous this week so hopefully it is indeed working.

Sadly, Ishka is still experiencing acid reflux - and had a little even while still taking the Omeprazole, her course of which we finished yesterday morning. I'm now wondering whether we need to ask for something else. The vet said that both the nausea and the reflux would pass and that she hopefully wouldn't need medication for them longterm but so far with the reflux that isn't the case.

We asked about new drugs that were proving useful for improved kidney function (Calcitriol, Benazepril, etc) but the vet said she hadn't heard of them and suspected that weren't being used for dogs yet.

The vet wasn't sure about the use of a phosphate binder and said she'd refer the question to the Edinburgh School of Vets (we're in Scotland), who are usually up-to-date with the most recent developments in treatment.

We also asked about vitamin supplements but it turns out the injection Ishka got for her anaemia is a B vitamin injection (B12 treats anaemia in dogs) and she shouldn't require any more B vitamins.

Both the vitamin injection and the blood samples are to be repeated every three weeks.

Now here is the interesting bit that I know you'll like... The vet phoned us the day after the above and said she'd heard back from the Edinburgh School of Vets and their approach is that Ishka needs to have her blood pressure measured and a urine sample analysed before we go any further! So according to the vet school your 10-step plan is spot on! She's booked in to have this done on Monday.

Okay, now for her bloods. I'll put a star before the levels that are outside the normal range, although this is probably obvious to you. I assume that the "reference range" is the same for all dogs so I haven't included this here.

ALT 16 iu/l
Alkaline phosphatase 16 iu/l
* Urea 35.4 mmol/l
* Creatinine 441 umol/l
* Total protein 49 g/l
* Albumin 15 g/l
Globulins 34 g/l
* Red blood count 2.9
* Haemoglobin 88 g/l
* Packed cell volume 0.22 l/l
MCV 77 fl
* MCHC 396 g/l
Reticulocytes < 60
* Platelets 95
White Blood count 6.5

Unfortunately Ishka's appetite is still very bad, which is preventing us from moving forward with the renal diet. The only food she will take from us is meat. If we put the meat on top of vegetables, she will pick it off and leave the veg. And if we mix the veg and meat together then she simply refuses to eat it (and appetite-enhancing salmon oil doesn't help). However, her appetite is pitiful and the amount of meat she is willing to eat is a handful at a time. (She's normally a 48 kg dog).

Importantly, my husband is now managing to feed liquidised homemade renal food to Ishka using a syringe. We are not the only people doing this because we have since found a video diary of a dog owner on Youtube doing this too!

Any advice on the acid reflux problem would be appreciated. When we pressed the vet about using antacids, she said we could try Gavison. However I'm slightly concerned about this because Gaviscon's ingredients sodium alginate, sodium bicarbonate, and calcium carbonate... should all this sodium concern us?

Thanks for all your help and I hope the above was interesting for you
Laura
1916673 tn?1420233270
Hi Laura. Thank you for such a detailed reply. It's really helpful. And for the impressive amount of work you have done to pursue things with your vet(s). I think you have made an impact with them - and though they may not admit it, you've taught them a few things too.

All that said, I am still very disappointed in their somewhat hazy and clearly inexperienced approach. They are probably trying their hardest, but I feel their lack of experience and knowledge is hindering you. It's excellent that they have at least now made contact with the Edinburgh School of Vets. Let's hope they learn a few things from their good advice too.

You are absolutely right, Gaviscon is primarily a human medicine which can be used (cautiously) on dogs that are otherwise healthy - but not on renal disease or heart condition dogs. Gavison also contains magnesium, which kidney failure dogs should not have. Another point to make is that Omeprazole is not a short-term drug, but one that should be given for the duration of acid reflux. That means it is inappropriate at this stage to withdraw it, unless blood results suggest other issues with the drug.

Talk to your vet about using sodium bicarbonate (in a carefully assessed quantity). It is safe for dogs when properly prescribed and won't affect the blood pressure. It's often good at neutralizing an acidic system, so worth trying.

I am pleased they are agreeing to repeat the blood tests every 3 weeks - every 2 weeks at this stage would be better, but 3 weeks is okay.

I notice BUN, potassium, sodium and calcium are missing from the blood results. Ask about these as they are important elements in judging the stage things are at.

On the subject of fluids ... well, what can I say. The response they have given you is more about them being extremely cautious and probably not quite knowing how to proceed. In my opinion, IVs would be useful, but let's agree to their compromise and go ahead with SubQs ... anything is better than nothing, right?

Make sure they add appropriate things to the SubQs though, because it's a great way of getting any additional electrolytes in the system without causing further stress to your dog.

Food is going to continue to be a problem without a) the fluid treatment; and b) getting the nausea under control. Hopefully, while Ishka is eating meat, she's getting some nutrition (even if not quite enough just yet). I would (maybe every 3rd day) try a tinned renal diet, just to see if she'll take it. The syringing is great - and hopefully only necessary as a temporary measure.

You've done an amazing job so far, despite veterinary obstacles. Keep me informed how things progress.

Kind regards,

Tony
14801663 tn?1436788166
Thanks, Tony - helpful as always. I've taken note of the points you've made and will query them on Monday. I've phoned for a repeat prescription of the Omeprazole.

Will let you know how we get on

Best
Laura
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