Need some guidance to dog's condition for CRF

[shibainu1234]

Hi, I'm new to this forum and would like to seek some guidance to my dog's condition. I've a 16 year old shiba inu that was diagnosed with CRF and heart murmur on Jul 2017. He had two seizures this year, once on July and another in Sep. He is on daily subQ, azodyl, sAME, vetmedin and phenomav for the past six months. He has access to a Vet with reviews done about once a month. He eats twice daily of homecooked meals of rice, some chicken/fish and cabbage. However, recently he has been getting more tired and  takes much effort to stand up. After a meal, he pants heavily for an hour before sleeping. His last blood test results suggests non-regenerative anemia. I'm worried his condition is starting to turn for the worse. Is this the last stage for his condition? Should i start to prepare for the worst? Is there anything I can do to help him better manage his current condition? Appreciate any advice and kind words. Thank you very much.

RBC 6.56 x 10^12/L
HCT 36.4%
HCB 12.9g/dL
MCV 55.5fL
MCH 19.7pg
MCHC 35.4 g/dL
RDW 17.2%
%RETIC 0.5%
WBC 10.90 x 10^9/L
%NEU 59%
%LYM 21.7%
%MONO 9.1%
%EOS 10.1%
%BASO 0.1%
NEU 6.44 x 10^9/L
LYM 2.36 x 10^9/L
MONO 0.99 x 10^9/L
EOS 1.10 x 10^9/L
BASO 0.01 x 10^9/L
PLT 433 K/uL
MPV 10.7 fL
PDW 13.5 fL
PCT 0.46%

GLU 4.7mmol/L
CREA 102umol/L
UREA 10 mmo/L
BUN/CREA 24
TP 85g/L
ALB 27g/L
GLOB 59g/L
ALB/GLOB 0.5
ALT 97 U/L
ALKP 376 U/L

[tonyb286]

Hi. The creatinine is really very good, so it seems as if this is either very early kidney disease or kidney disease that is actually under good control. There's no indication of infection (very unusual), which is also good. Red blood cell count is actually okay and mid-normal range. HCT (packed cell volume) is on the lowest edge of normal, but not yet into anaemia. It is not yet low enough for active treatment (with EPO), but that may be needed if the anaemia worsens.

I think it is worth asking your vet to perform two distinct tests - one for iron levels in the blood, as that would determine if you can give iron supplementation and maybe help boost the production of red blood cells, thus thwarting the anaemia development. And also test for serum phosphorous - which would assess whether current phosphorous restriction management is okay, or whether it's time to start using a phosphate binder.

In short, I certainly don't think it's time to consider eutrhanasia. The laboured breathing could be due to SubQ fluid administration, which at the present time may not be necessary. Can you let me know what your dog weighs, how much fluid your are giving and how often you are giving it, and how long you have been giving SubQs.

Hope this helps.

Tony B

[shibainu1234]

Hi Tony, thank you so much for your response. He's about 10.3kg and fluid is 200ml each time that it is administered. From Jul to Sep, he was given twice a week as we were still getting used to it. In Oct, three times a week. Recently since Nov, the SubQ has been given every day. The vet did mention to me about this EPO thing which she said if the levels drop again in the next review we might have to consider it. His next review is in three weeks. The thing i'm unsure about is if EPO is needed, how much will it help?  

[tonyb286]

Hello again. Anaemia commonly occurs in dogs with kidney disease because of the interaction of the kidneys on other systems. The kidneys produce a hormone called EPO, and EPO is needed by the bone marrow to produce red blood cells. If damaged kidneys cannot produce the hormone, then red blood cells cannot be replenished (they only live for about 120 days). Anaemia therefore gradually occurs, and worsens.

Aranesp is a relatively new form of synthetic EPO that can be given, quite successfully, to dogs with this type of non-regenerative anaemia. I am absolutely certain it will prove very beneficial. Unfortunately, it cannot be given until the anaemia reaches a certain stage (when HCT in blood testing reaches 20% or below).

So, in short, EPO will be helpful. It may however be needed for some time and there will be a cost associated with this treatment.

350ml of fluid daily is the maximum amount needed to control creatinine and BUN for a dog weighing 10.3Kg. The 200ml you are giving is a moderate dose and clearly enough to keep the creatinine down to almost normal levels. However, while creatinine is now at CREA 102umol/L (102 umol/L of Creatinine converts to 1.15 mg/dL) I don't believe fluid therapy is needed at all. I would stop fluids - reserving it for the future when it may be needed again.

Phenomav is an anti-seizure (anticonvulsant) medication. The real question is why seizures have occurred. Has your vet considered this? There are seizures related to chronic kidney disease when electrolytes become imbalanced, and there are seizures associated with neuropathy (akin to epilepsy). Depending on the reason for the seizures, it may be that this drug can be slowly withdrawn - for example, if the problems that started them are no longer apparent.

Stopping the drug may help de-stress the kidneys. All drugs cause stress on the kidneys, because they have to be metabolized and the kidneys are responsible for eliminating waste by-products (toxins) during this process. Damaged kidneys find this action difficult, and it can add to the kidney damage. I would certainly hope your vet would consider reducing the Phenomav to see if it is still needed.

Vetmedin is for the heart disease/murmer and so cannot be stopped.One point worth mentioning is that excessive fluid therapy can make the heart condition worse (fluid can build up in the lungs), so this is another good reason for considering a withdrawal of fluid therapy at this stage - unless there are clear signs of dehydration, which I am assuming there is not.

Hope this helps

Tony