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Pomeranian, 10 year old, recently diagnosed Chronic Kidney Failure
Our dog, Bebe (pronounced bay-bay), was a rescue we found on the street 4 years ago. We're guessing he is about 10 years old or so. He weighs about 2.2 kg. / 4.8 lb.
Existing problems:
--Toothless when we found him; guessing from periodontal disease.
(Once every 4 weeks or more, will give a pulse therapy dose of Clindamycin antibiotic for about a week; we wait until he starts pawing his face/mouth; his lower jaw is dissolved and rubbery.)
--Enlarged heart with a slight heart murmur.
(No medication)
--Used to have honking cough; thought it was collapsed trachea;
(Used to give 25 mg of Theophylline once a week at least and this eliminated cough and eased breathing; but upon moving from polluted China and to USA the breathing and coughing problems stopped; now once every 4 weeks or so, we may give 25 mg of Theophylline to ease breathing.)
--Rear leg popped out of joint twice soon after we got him.
(Been taking a Hip + Joint supplement of Glucosamine, MSM, Chondroitin for years, and greatly improved his joints)
Blood tests were taken on December 19, 2016, and we were told Chronic Kidney Failure
Creatinine: 2.4
BUN: 46
Phosphorus: 6.3
Sodium: 147
Potassium: 5.2
Amylase: 1593
RBC: 6.0
Calcium: 11.8
WBC: 13.4
Our vet has prescribed Royal Canin Renal Support F diet, and we give him the dry kibble. He completes his portion in about 3 or 4 times during the day. It's only been a week, but he likes this dog food. Often, we'll add a small apple which we chew up and share with him.
3 days ago our vet prescribed Levothyroxine to help his low thyroid, hypothyroid. The initial dose appears to be too strong (.1 mg per day) and he became very aggressive and wild, like on caffeine, and trembling started. .1 mg is for a 4.5 kg / 10 lb dog, and our dog is half that weight. So, I stopped the Levothyroxine after day 1, and am observing. He still shows signs of trembling which didn't happen prior to medication. Eventually, I will restart Levothyroxine at .025 mg per day and observe.
No Phosphate Binder has been prescribed.
Our vet prescribed Omeprazole (generic Prilosec?), but our dog vomited after taking it 1st time. We haven't tried it again, and no vomiting since that one instance.
After the previous vomiting, our vet prescribed Cerenia anti-nausea, but we haven't given it yet. We were told to give after vomiting if it occurs again.
Our vet recommended against future SubQ fluids due to his enlarged heart and murmur - saying our dog might not be able to handle this process in the future. Our dog is a fighter, and doesn't take needles well.
Otherwise, Bebe showed no signs of Kidney Failure. He's active, walks a lot, eats well every day, and we didn't see increased urination. So, the CKF diagnosis was a complete shock.
Going forward, our basic approach is feeding Renal Support Diet, and re-introducing the Levothyroxine to help his hypothyroid.... and learning about CKF.
Is there anything we're missing, or should reconsider?
Existing problems:
--Toothless when we found him; guessing from periodontal disease.
(Once every 4 weeks or more, will give a pulse therapy dose of Clindamycin antibiotic for about a week; we wait until he starts pawing his face/mouth; his lower jaw is dissolved and rubbery.)
--Enlarged heart with a slight heart murmur.
(No medication)
--Used to have honking cough; thought it was collapsed trachea;
(Used to give 25 mg of Theophylline once a week at least and this eliminated cough and eased breathing; but upon moving from polluted China and to USA the breathing and coughing problems stopped; now once every 4 weeks or so, we may give 25 mg of Theophylline to ease breathing.)
--Rear leg popped out of joint twice soon after we got him.
(Been taking a Hip + Joint supplement of Glucosamine, MSM, Chondroitin for years, and greatly improved his joints)
Blood tests were taken on December 19, 2016, and we were told Chronic Kidney Failure
Creatinine: 2.4
BUN: 46
Phosphorus: 6.3
Sodium: 147
Potassium: 5.2
Amylase: 1593
RBC: 6.0
Calcium: 11.8
WBC: 13.4
Our vet has prescribed Royal Canin Renal Support F diet, and we give him the dry kibble. He completes his portion in about 3 or 4 times during the day. It's only been a week, but he likes this dog food. Often, we'll add a small apple which we chew up and share with him.
3 days ago our vet prescribed Levothyroxine to help his low thyroid, hypothyroid. The initial dose appears to be too strong (.1 mg per day) and he became very aggressive and wild, like on caffeine, and trembling started. .1 mg is for a 4.5 kg / 10 lb dog, and our dog is half that weight. So, I stopped the Levothyroxine after day 1, and am observing. He still shows signs of trembling which didn't happen prior to medication. Eventually, I will restart Levothyroxine at .025 mg per day and observe.
No Phosphate Binder has been prescribed.
Our vet prescribed Omeprazole (generic Prilosec?), but our dog vomited after taking it 1st time. We haven't tried it again, and no vomiting since that one instance.
After the previous vomiting, our vet prescribed Cerenia anti-nausea, but we haven't given it yet. We were told to give after vomiting if it occurs again.
Our vet recommended against future SubQ fluids due to his enlarged heart and murmur - saying our dog might not be able to handle this process in the future. Our dog is a fighter, and doesn't take needles well.
Otherwise, Bebe showed no signs of Kidney Failure. He's active, walks a lot, eats well every day, and we didn't see increased urination. So, the CKF diagnosis was a complete shock.
Going forward, our basic approach is feeding Renal Support Diet, and re-introducing the Levothyroxine to help his hypothyroid.... and learning about CKF.
Is there anything we're missing, or should reconsider?
My little Yorkie also has kidney failure and enlarged heart. He takes pimobendan, enalypril, and phos binder. I too was told he would not be able to handle subq fluids. In May he got extremely dehydrated and the vet gave him 75 ml of subq fluid and I continued it for one week, then 50 ml every other day for one more week (if I recall correctly). Once we stopped the fluids, he got dehydrated again. So with vet permission we continued the 50 ml every other day. It has been over 6 months and he is handling it very well. Ask your vet if a low amount can be administered and have them monitor him. It gave my dog a few months of quality. I thought I was going to loose him when he got dehydrated.
Hi. Okay, there's a lot to talk about here, so bare with me.
Firstly, thank you for rescuing him. And that's on behalf of all dog lovers throughout the world ... and Bebe herself. By coincidence, my own rescued lurcher, named BB (yes honestly) is why I started to learn about canine kidney disease many years ago. Sadly, BB is no longer with me, but her legacy lives on in every message I make, which is now scores every day on so many websites.
I think your vet has got some things right - and some things wrong. But do remember I am not a vet, so it's up to you who you listen to and what actions you take.
I think he could be right about fluid therapy. This can be extremely tricky when a dog has a heart problem, but it is more risky with dogs that have congestive heart failure, which I am not so sure is the diagnosis here. Fluid therapy is the first line of treatment for most dogs in severe creatinine abnormality, so it's definitely something you should discuss further with your vet (or preferably a vet with good heart condition knowledge and experience), because it will become a much more important consideration in due course as the kidney disease deteriorates (but see below).
The original dental issues are potentially a reason why the kidney disease began. Dental disease is the most common cause of canine kidney failure. The infection and bacteria from bad gums and teeth over a prolonged time period goes down the gut and eventually to the kidneys. As the immune system becomes affected, the kidneys cannot cope with all this bacteria and start to shut down - and that starts a process that leads to chronic kidney disease.
While the Clindamycin no doubt helps, unfortunately all antibiotics add stress to the compromised kidneys, which have to try and deal with the by-products of the drug while it is being metabolised. This added stress can make the kidney disease deteriorate that much faster, but it's a difficult decision whether to give or not, because there are both pros and cons involved.
Theophylline is metabolized extensively in the liver (up to 70%). The remainder is metabolized by the kidneys. That's quite good, because the liver is probably more able to deal with things than the kidneys (many drugs are metabolized only by the kidneys). However, like all drugs, there will still be some added stress to the kidneys. In addition, as the liver is required to take over some of the functions of the deteriorating kidneys, this also puts a strain on the liver. At the very least, you need to start giving Bebe some supplemental protection, such as Milk Thistle.
Glucosamine is another problem. It can cause kidney failure and/or cause a rapid deterioration of any existing kidney failure. On the other hand, it no doubt eases the painful joints, so hard decision to give or not give. This really is a quality of life decision only you and your vet can assess.
Creatinine at 2.4 would put Bebe in Stage 3 of kidney failure. This is the appropriate time to start fluid therapy in most dogs, which would help reduce the creatinine maybe bringing the kidney disease back to stage 2. As outlined earlier, it would be appropriate to undertake a careful risk assessment preferably with a specialist vet.
Phosphorous at 6.3 means it is just in the abnormally high region - and NOW is the time to start an effective phosphorous binder. My advice is to use aluminium hydroxide gel powder (you can actually buy this from places online such as ThrivingPets, which will be way cheaper than through your vet - but you may need a vet's prescription for it - some countries need it, others don't). This is the most effective of all the binders available and is best started early rather than late. It must be given with food and the dosage is dependent on weight of dog (ask if you need advice on dosing).
In addition to the binder, the diet needs assessing, so that phosphorous content in food is reduced as much as is possible.
Amylase is high, which means your dog has pancreatitis. Did your vet mention this? An inflamed pancreas can be very painful and is made worse by fatty dog foods - so reduce all fat in food as much as possible until the pancreatitis is resolved. Antiemetic medication is useful to prevent vomiting - particularly important with kidney disease dogs, as that can lead to further dehydration. It would be useful to get lipase checked in a new blood test.
WBC is within normal range, but at the higher end. This would be indicative of an infection being resolved - or one starting up. Did the vet do a Culture and Sensitivity urine test? If not, I would have it done (you can catch a mid-stream specimen yourself and take it in, so Bebe isn't stressed by having to go to the vet). The result will disclose whether there is a urinary tract infection (UTI) and if there is then the C&S test will also provide the best antibiotic to solve it.
Omeprazole will help against acid-reflux, which is a major cause of nausea in kidney disease dogs (and why many turn their noses up at all food). The Cerenia is a good choice, and this helps deal with other nausea issues. Both the Omeprazole and Cerenia should continue to be given.
Very important ... has your dog been checked for tick-borne infections/viruses? This can be the start of an acute episode of kidney failure. If Bebe has not been checked, make sure your vet undertakes it asap.
I assume your vet also checked blood pressure? If not, again, this is extremely important. 90% of kidney failure dogs have high blood pressure, which makes the disease progress significantly faster.
Dry dog food (of any kind) is the very worst dog food you can give a kidney failure dog. To cut a long story short, it is less nutritional, has masses of chemicals and preservatives, and more importantly, it does the reverse of what's actually needed by dehydrating the gut and gastric tract - thus making the kidneys even more stressed. It has been proved beyond doubt that long-term use of dry foods (without enough pre-watering) actually causes canine kidney failure.
The best food (other than home cooking) is a suitable kidney specific canned dog food. I tend to suggest Hills kd canned, only because I am more familiar with it. It contains 80% water, has restricted protein and low phosphorous - all the qualities your dog needs right now.
There are a couple of supplments you might want to start, which will also help ... CoQ10 and Pure Organic Salmon Oil (salmon oil must always be given with a Vitamin E supplment, as it depletes this vitamin in the dog's body). All supplements should be canine formulated, not human varieties.
Okay, well, there's a lot to take in there I guess. So, have a think, adapt diet, discuss things with your vet, get the additional tesing done and get back to me when you can.
Tony
Firstly, thank you for rescuing him. And that's on behalf of all dog lovers throughout the world ... and Bebe herself. By coincidence, my own rescued lurcher, named BB (yes honestly) is why I started to learn about canine kidney disease many years ago. Sadly, BB is no longer with me, but her legacy lives on in every message I make, which is now scores every day on so many websites.
I think your vet has got some things right - and some things wrong. But do remember I am not a vet, so it's up to you who you listen to and what actions you take.
I think he could be right about fluid therapy. This can be extremely tricky when a dog has a heart problem, but it is more risky with dogs that have congestive heart failure, which I am not so sure is the diagnosis here. Fluid therapy is the first line of treatment for most dogs in severe creatinine abnormality, so it's definitely something you should discuss further with your vet (or preferably a vet with good heart condition knowledge and experience), because it will become a much more important consideration in due course as the kidney disease deteriorates (but see below).
The original dental issues are potentially a reason why the kidney disease began. Dental disease is the most common cause of canine kidney failure. The infection and bacteria from bad gums and teeth over a prolonged time period goes down the gut and eventually to the kidneys. As the immune system becomes affected, the kidneys cannot cope with all this bacteria and start to shut down - and that starts a process that leads to chronic kidney disease.
While the Clindamycin no doubt helps, unfortunately all antibiotics add stress to the compromised kidneys, which have to try and deal with the by-products of the drug while it is being metabolised. This added stress can make the kidney disease deteriorate that much faster, but it's a difficult decision whether to give or not, because there are both pros and cons involved.
Theophylline is metabolized extensively in the liver (up to 70%). The remainder is metabolized by the kidneys. That's quite good, because the liver is probably more able to deal with things than the kidneys (many drugs are metabolized only by the kidneys). However, like all drugs, there will still be some added stress to the kidneys. In addition, as the liver is required to take over some of the functions of the deteriorating kidneys, this also puts a strain on the liver. At the very least, you need to start giving Bebe some supplemental protection, such as Milk Thistle.
Glucosamine is another problem. It can cause kidney failure and/or cause a rapid deterioration of any existing kidney failure. On the other hand, it no doubt eases the painful joints, so hard decision to give or not give. This really is a quality of life decision only you and your vet can assess.
Creatinine at 2.4 would put Bebe in Stage 3 of kidney failure. This is the appropriate time to start fluid therapy in most dogs, which would help reduce the creatinine maybe bringing the kidney disease back to stage 2. As outlined earlier, it would be appropriate to undertake a careful risk assessment preferably with a specialist vet.
Phosphorous at 6.3 means it is just in the abnormally high region - and NOW is the time to start an effective phosphorous binder. My advice is to use aluminium hydroxide gel powder (you can actually buy this from places online such as ThrivingPets, which will be way cheaper than through your vet - but you may need a vet's prescription for it - some countries need it, others don't). This is the most effective of all the binders available and is best started early rather than late. It must be given with food and the dosage is dependent on weight of dog (ask if you need advice on dosing).
In addition to the binder, the diet needs assessing, so that phosphorous content in food is reduced as much as is possible.
Amylase is high, which means your dog has pancreatitis. Did your vet mention this? An inflamed pancreas can be very painful and is made worse by fatty dog foods - so reduce all fat in food as much as possible until the pancreatitis is resolved. Antiemetic medication is useful to prevent vomiting - particularly important with kidney disease dogs, as that can lead to further dehydration. It would be useful to get lipase checked in a new blood test.
WBC is within normal range, but at the higher end. This would be indicative of an infection being resolved - or one starting up. Did the vet do a Culture and Sensitivity urine test? If not, I would have it done (you can catch a mid-stream specimen yourself and take it in, so Bebe isn't stressed by having to go to the vet). The result will disclose whether there is a urinary tract infection (UTI) and if there is then the C&S test will also provide the best antibiotic to solve it.
Omeprazole will help against acid-reflux, which is a major cause of nausea in kidney disease dogs (and why many turn their noses up at all food). The Cerenia is a good choice, and this helps deal with other nausea issues. Both the Omeprazole and Cerenia should continue to be given.
Very important ... has your dog been checked for tick-borne infections/viruses? This can be the start of an acute episode of kidney failure. If Bebe has not been checked, make sure your vet undertakes it asap.
I assume your vet also checked blood pressure? If not, again, this is extremely important. 90% of kidney failure dogs have high blood pressure, which makes the disease progress significantly faster.
Dry dog food (of any kind) is the very worst dog food you can give a kidney failure dog. To cut a long story short, it is less nutritional, has masses of chemicals and preservatives, and more importantly, it does the reverse of what's actually needed by dehydrating the gut and gastric tract - thus making the kidneys even more stressed. It has been proved beyond doubt that long-term use of dry foods (without enough pre-watering) actually causes canine kidney failure.
The best food (other than home cooking) is a suitable kidney specific canned dog food. I tend to suggest Hills kd canned, only because I am more familiar with it. It contains 80% water, has restricted protein and low phosphorous - all the qualities your dog needs right now.
There are a couple of supplments you might want to start, which will also help ... CoQ10 and Pure Organic Salmon Oil (salmon oil must always be given with a Vitamin E supplment, as it depletes this vitamin in the dog's body). All supplements should be canine formulated, not human varieties.
Okay, well, there's a lot to take in there I guess. So, have a think, adapt diet, discuss things with your vet, get the additional tesing done and get back to me when you can.
Tony
3 Comments
Tony, thank you so much for BB's legacy. I have been referring frequently to your reply, and it's really been helpful for our Bebe.
Update on Bebe's situation:
He's now taking an aluminum hydroxide powder phosphorus binder called "Phos-Bind". Twice a day he takes 1/8 tsp (.125 mg). Thank you for this. My vet wasn't on board, wanted to wait, and wanted to use calcium carbonate Epakitin instead. But Bebe already has elevated calcium, so I went ahead independently with the aluminum hydroxide, and it easily dissolves into his canned meals.
2/3's of his meals are canned, Royal Canin Renal Support D. He eats canned food at 5 AM and 5 PM.
1/3 is dry, Royal Canin Renal Support F. (The dry kibble is pre-soaked in water for about 2 minutes.) He eats this in two miny meals during middle of the day.
He's also been regularly eating skinless Granny Smith apples that I chew up for him. He gets some apple mid day, and after his late night walk around 9 PM, I give him an apple in an effort to help hydrate him throughout the night.
My big issue is encouraging him to DRINK WATER, especially throughout the night. He used to drink water as needed during the night - he'd get up and walk to his bowl for it, and then go back to sleep. He'd also used to wake me up after midnight to take him out to pee then, too. Now, doesn't want to pee at night.
Recently, probably around same time as starting the new, low-phosphorus Renal Support diet, he has totally STOPPED drinking ANY water during the NIGHT. Absolutely no water at night, and doesn't get up to pee.
By the morning his mouth feels dry to my fingers. Then he eats his canned food, and starts drinking water more normally during the day. During the day, he's perky and seems well hydrated. He still drinks water during the day.
Now, we're always encouraging him to drink more water, and especially trying to come up with ideas to get him to drink at night - so he's not so dried out by morning. That's why I give him a big, juicy apple before bed.
Medicine update:
He's taking the Thyroid medicine, Levothyroxine, .025 mg, once a day in morning. It seems to be the right small dosage for him.
Have not given the antibiotic Clindamycin since November 26, nor the asthma medicine Theophylline since December 6. This was all before we found out about his kidney failure on December 19.
Stopped taking the Glucosamine per your reply.
Have not needed to start or give Omeprazole or Cerenia yet.
(So, he's only on Phos-Bind and Levothyroxine. No additional supplements yet.)
His blood pressure was checked back around December 21, and even though he was worked up and fighting at the clinic, his blood pressure reading was good, and normal.
The vet tested the urine back on December 19, and it was diluted, and that was her first clue that he had kidney problems, and CKF was confirmed when the blood results came next day.
There're no ticks, but we didn't test for this.
Back in July 2016, while still living in China, Bebe had 1st instance of acute Pancreatitis. Not sure what caused it. Maybe, he licked some poisonous substance on the outside of a bag of construction waste that was near by. I stopped him immediately, but later that night and next morning, he had some bad diarrhea and normal vomit. Worried, we went to the vet, and vet hooked him up to I.V. for fours hours, and gave him some four injections in the back. After that, we took him home, and then he looked REALLY sick and he suffered acute pancreatitis, and so we headed back to vet. Four more days of some I.V. treatments, and then slowly over 3 weeks he got back to normal condition.
I have not researched Sub Q fluid therapy yet.
Cheers again for BB's legacy,
Rick
Update on Bebe's situation:
He's now taking an aluminum hydroxide powder phosphorus binder called "Phos-Bind". Twice a day he takes 1/8 tsp (.125 mg). Thank you for this. My vet wasn't on board, wanted to wait, and wanted to use calcium carbonate Epakitin instead. But Bebe already has elevated calcium, so I went ahead independently with the aluminum hydroxide, and it easily dissolves into his canned meals.
2/3's of his meals are canned, Royal Canin Renal Support D. He eats canned food at 5 AM and 5 PM.
1/3 is dry, Royal Canin Renal Support F. (The dry kibble is pre-soaked in water for about 2 minutes.) He eats this in two miny meals during middle of the day.
He's also been regularly eating skinless Granny Smith apples that I chew up for him. He gets some apple mid day, and after his late night walk around 9 PM, I give him an apple in an effort to help hydrate him throughout the night.
My big issue is encouraging him to DRINK WATER, especially throughout the night. He used to drink water as needed during the night - he'd get up and walk to his bowl for it, and then go back to sleep. He'd also used to wake me up after midnight to take him out to pee then, too. Now, doesn't want to pee at night.
Recently, probably around same time as starting the new, low-phosphorus Renal Support diet, he has totally STOPPED drinking ANY water during the NIGHT. Absolutely no water at night, and doesn't get up to pee.
By the morning his mouth feels dry to my fingers. Then he eats his canned food, and starts drinking water more normally during the day. During the day, he's perky and seems well hydrated. He still drinks water during the day.
Now, we're always encouraging him to drink more water, and especially trying to come up with ideas to get him to drink at night - so he's not so dried out by morning. That's why I give him a big, juicy apple before bed.
Medicine update:
He's taking the Thyroid medicine, Levothyroxine, .025 mg, once a day in morning. It seems to be the right small dosage for him.
Have not given the antibiotic Clindamycin since November 26, nor the asthma medicine Theophylline since December 6. This was all before we found out about his kidney failure on December 19.
Stopped taking the Glucosamine per your reply.
Have not needed to start or give Omeprazole or Cerenia yet.
(So, he's only on Phos-Bind and Levothyroxine. No additional supplements yet.)
His blood pressure was checked back around December 21, and even though he was worked up and fighting at the clinic, his blood pressure reading was good, and normal.
The vet tested the urine back on December 19, and it was diluted, and that was her first clue that he had kidney problems, and CKF was confirmed when the blood results came next day.
There're no ticks, but we didn't test for this.
Back in July 2016, while still living in China, Bebe had 1st instance of acute Pancreatitis. Not sure what caused it. Maybe, he licked some poisonous substance on the outside of a bag of construction waste that was near by. I stopped him immediately, but later that night and next morning, he had some bad diarrhea and normal vomit. Worried, we went to the vet, and vet hooked him up to I.V. for fours hours, and gave him some four injections in the back. After that, we took him home, and then he looked REALLY sick and he suffered acute pancreatitis, and so we headed back to vet. Four more days of some I.V. treatments, and then slowly over 3 weeks he got back to normal condition.
I have not researched Sub Q fluid therapy yet.
Cheers again for BB's legacy,
Rick
Hello Rick.
You can afford to hold back on the Omeprazole and Cerenia - until your dog stops or refuses food, then give to help combat nausea. Don't worry too much about drinking during the night - if he's drinking well during the day, that's great and the canned food will also add some hydration (being 80% or so water).
The alum hydroxide should have a very positive effect. But it may take a week or so to start bringing phosphorous down. I would plan for a re-check of bloods in 2 to 3 weeks time.
I would definitely have the culture and sensitivity (C&S) urine test done, as that will help determine if there is a UTI - and then how best to treat it.
I would personally want to have tick-borne viruses checked, because they can be very influential on kidney failure.
Tony
You can afford to hold back on the Omeprazole and Cerenia - until your dog stops or refuses food, then give to help combat nausea. Don't worry too much about drinking during the night - if he's drinking well during the day, that's great and the canned food will also add some hydration (being 80% or so water).
The alum hydroxide should have a very positive effect. But it may take a week or so to start bringing phosphorous down. I would plan for a re-check of bloods in 2 to 3 weeks time.
I would definitely have the culture and sensitivity (C&S) urine test done, as that will help determine if there is a UTI - and then how best to treat it.
I would personally want to have tick-borne viruses checked, because they can be very influential on kidney failure.
Tony
Hi Tony.
Bebe appears to be doing ok. Seems more active, alert and happy compared to one month ago.
We'll be taking him to the vet in four days to check his blood for his kidney and thyroid levels.
At that visit, Bebe is also due for his vaccinations, both leptospirosis and rabies.
He received lepto, rabies, and distemper vaccines one year ago.
I was wondering if you had any thoughts on any risk to giving lepto and rabies vaccines to dogs with stage 2 or 3 renal failure? Could it hurt his kidneys?
Rick
Bebe appears to be doing ok. Seems more active, alert and happy compared to one month ago.
We'll be taking him to the vet in four days to check his blood for his kidney and thyroid levels.
At that visit, Bebe is also due for his vaccinations, both leptospirosis and rabies.
He received lepto, rabies, and distemper vaccines one year ago.
I was wondering if you had any thoughts on any risk to giving lepto and rabies vaccines to dogs with stage 2 or 3 renal failure? Could it hurt his kidneys?
Rick
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