Sheltie early stage CKF

[FawnT]

My Sheltie, Sadie was DX'd with early stage CKF in Sept.  She is a rescue  dog, so I am unsure of her age.  Likely, she is between 11 and 12. at this time,  we had a mass that developed very quickly, removed from her toe, which ended up being a toe amputation due to getting margins to close it.  It was then that we found the kidney function was abnormal in her pre-op bloodwork.  Her bloodwork had been checked 10 months before in a senior screen, where it was in the upper level of normal.  The mass turned out to be benign.  She had fluids before and after the surgery.  Her numbers were creatinine 2.0 and BUN 50.  I think her SDMA was 22.  She did not fast prior to bloodwork since we just went in to evaluate the mass, when our Vet decided to remove it and wanted to do the bloodwork.  Her urinalysis showed no protein and she was still concentrating, though at the low end of the values.  She was put on the kidney diet, which I was worried about since she is all about food, but she adjusted well. She also is taking Azodyl.  I give her an egg white every other day at breakfast and fresh veggies with her dinner, and on occasion, boiled chicken breast or lean hamburger, which my vet Ok'd.  Her bloodwork was repeated in Nov (2 months after DX), with good results, Creatinine came down to 1.6 and BUN 31.  SDMA 25.  All other values remained in normal level, except trace of protein in urine.  Set for re-check again in 2 months--Jan.  Jan bloodwork showed stable creatinine at 1.6 and BUN at 39, urinalysis showed protein of 1+ and still concentrating.  3 days after bloodwork, had an episode of vomiting upon waking, with the food from dinner (12 hours before) still intact, which was odd since it should have digested.  She was not interested in eating and began shaking, very lethargic.  I had read about shaking in late kidney disease, but her values were fine 3 days before.  Trip to emergency vet where she received fluids, and 2 injections for nausea and Pepcid.   Vet said possible gastritis, not necessarily related to the kidney disease, but possibly.  She ate a bland diet for a few days and back to the kidney diet.  6 days later we had another episode of the shaking, but this time she was swaying while standing.  No vomiting and she had eaten fine.  This was in the middle of the blizzard on the East Coast of the US and there was no way to get to the emergency Vet!  I was a nervous wreck.  This lasted about 30 minutes, 2 separate times.  Spoke to my Vet 2 days later and we decided to re-run the bloodwork that week.  It showed again, stable creatinine at 1.6 and BUN down to 33.  Her potassium was a little high and sodium a little low, just outside of the norm range.  ( I cut out any veggie or fruit high in potassium).  Urine protein was negative.  Otherwise, he had no explanation of the shaking and swaying.  It has been 3 weeks (praying it remains) since this incident. After all this background, my questions are: Is there anything else I should be doing for her and any thoughts on the shaking swaying?

Thanks in advance for any thoughts  or comments,
--Fawn

[FawnT]

Hi Tony, I sent you a private message, in the group's email.  Thanks, Fawn

[FawnT]

Hi Tony, I am in need of your advice.  I'm sorry to say, Hi Tony, Just wanted to update--Sadie is not doing great.  Over the last couple weeks she has become somewhat picky with her food and then refused her breakfast last Thursday, along with having one episode of diarrhea. Talked to my Vet via phone and he said to try to feed her lunch, which I did and she ate (gave bland food) and her dinner, though still seemingly reluctant. I did not give her any canned KD due to the high fat content..  Friday her stools firmed up and she ate (bland boiled chicken and rice), though still picky.  Saturday evening I reintroduced the canned KD and she again had diarrhea.  No vomiting at all on any day.  Spoke to my Vet and he overbooked her for first thing Monday (yesterday).  She is walking around and her mood is generally bright.  I don't see any lip-licking indicating nausea.  I asked that he run pancreatitis test be in-house and it came back positive. He said he would confirm with Spec cpL test sent to the lab with the rest of the blood testing sent out too.  Lab results just came back and he called.   He also just emailed to me.  We talked about the kidney values, the pancreatic values--confirming pancreatitis (which he believes is low grade).  He talked about and he  briefly explained Anisocytosis.  But, it wasn't until after we spoke that I opened the emailed results and see all the low values for RBC.  Could this be from the pancreatitis?  He mentioned possible urinary tract infection/stone.  Possible Internist consult, possible abdominal ultrasound, possible IV fluids--on hold for now since she ate well this morning and had a firm stool, by then by head was spinning.  I'm not sure I heard much more.  All up to me, he is just throwing out possibilities and honestly I will have to pick and chose since if I had unlimited funds, I would do everything and anything, unfortunately this is not the case.  I would really value your thoughts and apologize in advance for the length of my post.  

TEST RESULT REFERENCE VALUE
          9/25/17                          8/25/17  7/11/17
RBC 4.69   5.39 - 8.7 M/µL L   6.12   5.94
Hematocrit 32.5   38.3 - 56.5 % L   37.3   35.3
Hemoglobin 10.1   13.4 - 20.7 g/dL L   12.8   12.5
MCV 69   59 - 76 fL   60.9   59.4
MCH 21.5   21.9 - 26.1 pg L   20.9   21.0
MCHC 31.1   32.6 - 39.2 g/dL L   34.3   35.4
% Reticulocyte 4.1 % 1.0 0.5
Reticulocyte 192 10 - 110 K/µL H 58.1 30.3

A reticulocyte count of greater than 110 K/uL of blood is considered
evidence of bone marrow response to an increased peripheral demand.
Depending on the degree of anemia, a reticulocyte count 300

WBC 14.4   4.9 - 17.6 K/µL   12.11   11.27
% Neutrophil 78.5 % 78.5 80.2
% Lymphocyte 11.7 % 14.1 11.8
% Monocyte 7.0 % 5.1 4.3
% Eosinophil 2.8 % 2.1 3.5
% Basophil 0.0 % 0.2 0.2
Neutrophil 11.304   2.94 - 12.67 K/µL   9.5   9.03
Lymphocyte 1.685   1.06 - 4.95 K/µL   1.71   1.33
Monocyte 1.008   0.13 - 1.15 K/µL   0.62   0.49
Eosinophil 0.403   0.07 - 1.49 K/µL   0.26   0.4
Basophil 0   0 - 0.1 K/µL   0.02   0.02

Platelet 160 143 - 448 K/µL 171  287
Polychromasia SLIGHT
Anisocytosis SLIGHT
Remarks SLIDE REVIEWED MICROSCOPICALLY.
NO PARASITES SEE

Glucose 84 63 - 114 mg/dL 109
IDEXX SDMA a 38   0 - 14 µg/dL H
Creatinine 2.4   0.5 - 1.5 mg/dL H   2.3
BUN 45   9 - 31 mg/dL H   31
BUN:Creatinine
Ratio
18.8 13
Phosphorus 4.6   2.5 - 6.1 mg/dL  5.1
Calcium 9.9   8.4 - 11.8 mg/dL  10.6
Sodium 149  142 - 152 mmol/L  153
Potassium 4.9  4.0 - 5.4 mmol/L  4.5
Na:K Ratio 30  28 - 37  34
Chloride 121  108 - 119 mmol/L H  117
TCO2
(Bicarbonate)12  13 - 27 mmol/L L
Anion Gap 21  11 - 26 mmol/L
Total Protein 6.3  5.5 - 7.5 g/dL  7.0
Albumin 3.0   2.7 - 3.9 g/dL   3.1
Globulin 3.3   2.4 - 4.0 g/dL   3.9
Alb:Glob Ratio 0.9   0.7 - 1.5   0.8
ALT 25  18 - 121 U/L  55
AST 27  16 - 55 U/L
ALP 163   5 - 160 U/L H   282
GGT 3   0 - 13 U/L  0
Bilirubin - Total 0.1   0.0 - 0.3 mg/dL  0.2
Bilirubin -
Unconjugated
0.0 0.0 - 0.2 mg/dL
Bilirubin - <0.1
Conjugated
0.0 - 0.1 mg/dL
Cholesterol 268   131 - 345 mg/dL  267
Amylase 1,965   337 - 1,469 U/L H
Lipase 486   138 - 755 U/L
Creatine Kinase 157   10 - 200 U/L
Hemolysis Index N
b
Lipemia Index N
c
Spec cPL d
550   0 - 200 ug/L H
Urine
Protein:Creatinine
Ratio If Indicated
A urine p... A urine protein-to-creatinine ratio (UPC) has been ordered to
evaluate renal damage, as indicated by a positive SSA protein result

Urine Creatinine 90.4 mg/dL 102.3
Urine Protein 135.9 mg/dL 97.0
Urine
Protein:Creatinine
Ratio
1.5 0.9
Color STRAW  YELLOW
Collection FREE-CATCH FREE-CAT... FREE-CAT...
Color STRAW YELLOW YELLOW
Clarity CLEAR CLEAR CLEAR
Specific Gravity 1.016 1.018 1.017
pH 6.0 5.5 6.0
Urine Protein 2+ (200-300 mg/dL)
a
1+ (100-20... 1+ (100-20...
Glucose NEGATIVE NEGATIVE NEGATIVE
Ketones NEGATIVE NEGATIVE NEGATIVE
Blood / 1+
Hemoglobin
NEGATIVE NEGATIVE
Bilirubin NEGATIVE NEGATIVE NEGATIVE
Urobilinogen NORMAL NORMAL NORMAL
White Blood NONE SEEN
Cells
0 - 5 HPF  0-2  0-2
Red Blood Cells 0-2 HPF NONE SEEN NONE SEEN
Bacteria NONE SEEN NONE SEEN NONE SEEN
Epithelial Cells NONE SEEN 1+ (1-2)/HPF NONE SEEN
Mucus NONE SEEN NONE SEEN NONE SEEN
Casts NONE SEEN OCC FINE... OCC HYALI...
Crystals NONE SEEN NONE SEEN NONE SEEN
Other NON-CRYSTALLINE DEBRIS PRESENT

Total T4 a
1.1 1 - 4 µg/dL 1.1 1.3
Free T4 (ng/dL) 0.5 0.6 - 3.7 ng/dL L 0.9 1.2
Free T4
(pmol/L)
b
6.4 7.7 - 47.6 pmol/L L 11.6 15.4

Many thanks Tony,
--Fawn and Sadie

[tonyb286]

Hi. It must have taken forever to copy all the results out. Well done on that. In the Fb Group you can actually just scan and post, which is probably an easier way of doing things in the future. So, pancreatitis is fairly obviously indicated - and you're right to be cautious of fat content in food for now, until it subsides. There's not a huge amount you can do about pancreatitis, other than rest the pancreas by withholding fatty foods, until the inflammation goes down. In severe cases, antiinflammatories can help. If you are giving omega-3 supplements, that's good, because it helps things. If not, then that's something to consider doing. My preference has always been pure organic salmon oil with a canine formulated Vit E capsule.

Yes, a culture and sensitivity urine test is crucial right now. That would help identify if there is a UTI - and point out the right antibiotic to treat it.

Phosphorous is under good control, which is a real positive.

RBCs are moderately low, which could certainly indicate some anemia. I would discuss with your vet about whether this is regenerative anemia (which I think it is), and in which case some iron supplementation may help. Anisocytosis (the differing sizes of red blood cells seen) can be caused by many things, but in this case it's very likely to be that they are being released too soon (before they have properly developed in the bone marrow). That might be due to another group of things, but also possibly because the demand for them outstrips the body allowing them to properly develop. It is for that reason iron supplementation may help, as it will support the body's production of new red cells - hopefully attaining the demand.

Getting the anemia under control will hopefully improve red cell production.

Your vet might also consider prescribing Aranesp (darbepoetin alfa) , which may be very helpful.

Creatinine is creeping up, and your vet is right to say that might be unavoidable as the kidney disease progresses. But, nothing ventured nothing gained, so moderate fluid therapy may help bring it down a little - or just stabilise it - or not do anything at all. It's certainly worth doing

Hope some of this helps.

Tony

[FawnT]

Yes it does!  You may not fully know how your kindness has effected me (and certainly Sadie too!) in dealing with CKD over the last almost 2 years!!  I was really upset by all the red numbers, since we have never had blood work results like this before.  
I will follow up with my Vet.  I did take her off the salmon oil when all this started, well she took herself off when she wasn't interested in it, but I was just trying to eliminate anything that might have been causing the appetite issues.  My Vet mentioned Welactin as a omega supplement, any thoughts?  Especially if she is turning her nose up at the salmon oil.  
Many Thanks,
Fawn  

[FawnT]

Hi Tony, we found it necessary to go to the Vet due to some issues with Sadie where she seemed to be uncoordinated, leaning to the right with some weakness.  This happened for a few minutes but it is very concerning to me.  This was much like the episode we had 1.5 years ago, which prompted my original post to you, but then it was magified in intensity and time it lasted greatly.  This seemed like a little snipet of that experience.  My Vet could find no neurological deficits upon extensive exam.  He did in-house blood work to see if any issues with her kidneys could be causing this.  There was no explanation.  However, her creatinine was reading 2.3 (he said it would not match up with sending it out to the IDEXX lab exactly and his reference for normal was up to 1.8, not 1.5 when sending out), so while some increase, hard to know exactly how much in comparing to last blood sent to lab and she was fasted for only 6 hours not 12 like we normally do.  We dropped a first catch urine sample the next day and it came back with more protein since 2 months ago in June.  Her urine ratio was 0.9 now.  Vet gave me a prescription for Benazepril 5mg to address the protein.  I took a look online at it and it says it treats high BP.  I am now concerned about giving this to her since she is already taking Amlodipine Besylate 1 and 1/4 tabs (10mg tabs), so 12.5 mg daily.  My Vet left for vacation yesterday, so I was wondering if you have any thoughts on this?  

As always thank you,
Fawn and Sadie

[tonyb286]

Benazepril does indeed lower blood pressure, but it also helps improve blood flow through the kidneys - and also increases blood volume. It has been shown to assist in reducing protein leakage into urine. So, the thought process is appropriate.

However, as she is already taking Amlodipine Besylate it is VERY important that your vet keeps a very close eye on what is happening to blood pressure. When you went in and he prescribed the Benazapril, did he also do a pre-check of blood pressure as a control reference for comparison?

If not, that was very bad.

Given the weakness you mention ... which could either be due to an imbalance of electrolytes (though you did say everything was within normal range, so doubtful this is the problem), it could be the result of the blood pressure medications. If BP falls low, and into hypotension, then that would certainly explain the weakness and falling over like symptoms.

I would suggest having a BP check done by your own or another vet as soon as you possibly can, to be on the safe side.

Tony

[FawnT]

Yes, he did take BP measurements, actually 4 readings which were averaged. (BP/Arterialmean/Heart rate).  Her PB was a normal reading.  The weakness is what I went in for, so it occurred before adding the Benazapril.  I was just unsure about dosing the Amlodipine with the new Benazapril at the same time or if I should do one in the am and one in the pm to split it up some.  I did speak with the vet on duty in my vets absence and he said it was ok to give together and we went in today for another BP reading which was good, but she has only been taking the new med for a couple days.  My regular Vet mentioned a neuro consult as a possibilty, but I am not sure what we will gain by this.   Thanks!
Fawn

[tonyb286]

Hi. I can't really answer this one. If electrolytes and minerals in blood testing are within normal range - and BP is also within normal range, then either it's some associated neurological issue (which you can get with kidney disease), or it's another condition that has yet to be diagnosed.

The neuro specialist may have more success finding the reason for it, or might at least be able to discount certain things.

Tony

[FawnT]

Hi Tony, Hope all is good with you!

My Vet called the manufacturer of Galiprant and they do not have enough data to determine its affects on kidney disease, so of course, my Vet is doesn't feel comfortable prescribing it for Sadie for her mobility issues/arthritis.  We have had several accupunture appts and this is definitely been helpful, she is much more steady/stronger--not tripping or falling or scuffling on hard floor surfaces as much.  However, she is still having difficulty rising sometimes, but mainly with laying down, so he is suggesting Gabapentin in a reduced dosage to start to see how she responds.  I noticed it was not one of the ones you responded with a few posts up.  Was wondering if you are familiar with it?  He said he has had mixed reactions with adaquan and thought we should try the gabapentin first and if not working consider the adaquan.  I appreciate any thoughts you may have on the interaction with Sadie's KD.  While, I don't want to mess with the KD bloodwork, since we have worked so hard to keep the numbers good, I can't stand see her in pain either.  I'm just not sure how to balance it all.

Thanks for any thoughts you may have,
--Fawn

[tonyb286]

Unfortunately, Gabapentin is exclusively eliminated through the kidneys, so sadly not a great choice. Even low doses are going to cause "issues" of toxicity and will probably cause creatinine to rise. Adaquan is a peculiar "medication" usually given by injection. I say peculiar because it isn't really a drug as such, but it is known to be eliminated also through the kidneys and "issues" of altered kidney function have been reported. That said, I have a good friend who swears by Adaquan for her kidney dog, in lower doses than normally given. She also actually likes Metacam, because she can control how much is given and when as it's in liquid form (and doesn't give it as a matter of routine, but only when absolutely required).

The real problem is just about all pain relief drugs have a similar effect in terms of affecting the kidneys, and there's no easy way around it. Lower doses are certainly advised - and follow-up blood test to see how the drug of choice may be affecting kidney function (primarily creatinine levels).

I'm assuming by now you are giving salmon-oil as a supplement, together with a Vitamin E capsule? The omega-3 in salmon oil is excellent for kidney dogs, and its anti-inflammatory effects will almost certainly be helpful to the joint pain.

I would also suggest giving turmeric a try too. Although I am not a great advocate of herbs and herbal remedies, The curcumin in turmeric is also anti-inflammatory. It also tops the list for natural remedies for treating dogs with stiff joints.

Hope some of this helps.

Tony

[FawnT]

Thanks it does!  I'm giving the salmon oil you recommended  & I only recently heard of the turmeric, so will incorporate that too. We gave the gabapentin a try yesterday and it was NOT good.  Sadie was very lethargic, which in itself is not bad, especially if she was just adjusting to the drug.  I gave 100 mg (per my Vet, lower than regular dose) in the morning.  She basically slept most of the day.  When she woke, she was unsteady on her feet and her hind legs seemed weak, she ate her lunch and dinner.  I spoke to my Vet's office and they said it was normal to have a sedating effect--this was before she got up. I gave the 2nd dose in the evening and it just magnified the unsteadiness from earlier and she was leaning to the right.  She could barely stand, was falling--which is never good, when you already have joint issues and I was so worried.  I called my Vet's office this morning and he is off, but I will not give another dose until we can get this sorted out.  Today she is fine and we went to acupunture.
I actually called the manfacturer of Galliprant since they advertise it doesn't affect the kidneys/liver and spoke to a Vet.  They have completed a 9 month study with a large # of dogs and gave up to15X the standard dosage with no changes in kidney/liver functions.  However, the study was done in healthy dogs, not ones with kidney impairments.  It's never easy.  Thanks again for your suggetions!  

[tonyb286]

There are lots of dog owners (and vets) hopeful about Galliprant, but as it's so new (2016) there really haven't been any reliable independent studies undertaken yet.

Tony

[FawnT]

Hi Tony, I was reading some of the other posts and wanted to find out the best salmon/fish oil to use for Sadie and the dosing.  My Vet gave me some fish oil tablets some time ago and I ran out.  They were expensive, so I thought I may look for something on line.  Sadie weighs 47 pounds.  Thanks!

[tonyb286]

I buy Nutrivet's wild salmon oil. It's got a handy pump action and my medium sized dogs get one pump on their food every 2nd day (importantly with a Vit E capsule). In mls it's:
4 ml for 0-26lbs dogs
8ml for 26-53lbs dogs
12ml for 53-106lbs dogs
16ml for dog 106lbs and over

Whatever you buy, it should have dosing regimes on the label.

Tony

[FawnT]

Thank you

[tonyb286]

Hi. The blood numbers are really good. Well done on getting them to fall. Urine results are still displaying the evidence of the disease and, in some ways, track progression in a more predictable way. Urine testing is actually the best method of catching early kidney disease. My own dogs have their urine tested at least once a year, just in case.

Although the urine is showing some deterioration in kidney function, you are certainly getting some good control of her blood values, and that's a big positive. Bear in mind the kidney organs will have tissue damage that cannot be improved, so maintaining diet control continues to be very important.

It's also useful to remember that specific gravity in healthy dogs can vary considerably from 1.015 to 1.045. It is possible therefore that her specific gravity is within "her" normal range, albeit on the low end of the range. Personally, I don't think I would be worried about it at this stage. The result suggests there is a moderate concentration of urine, which is good, but that fluids (good water intake) remains important to prevent any dehydration (which would inhibit the kidneys being able to do their job).

The urine protein/creatinine ratio is literally on the low-end border of being normal. I don't think you could ask for much better than that.

SDMA result is almost back to where it was mid-February. Further improvement may be possible over time, but of course it does depend on how damaged the kidney organs might be.

For now, just keep doing what you're doing.

In terms of pain medications, you are right, most of them are filtered through the kidneys, and that can be a big problem. I would be very interested to find out the "new" one the vet mentioned. Maybe you could ask them? Either Tramadol or Gabapentin are the standard anti-pain medications for dogs with kidney disease - BUT there remains a risk in taking them, as they need good renal function to eliminate the by-product toxins. Consequently, it is always better to give very low doses (much lower than for a healthy dog) to try and prevent problems occurring.

Some owners have reported positive results from acupuncture. This may be something worth considering as an alternative. I have no experience of using it for my own dogs, but I do have a fairly open mind to it ... given the anecdotal evidence.

Tony

[tonyb286]

A good friend of mine suggests Low Level Laser therapy, hydrotherapy, acupuncture, Adequan injections, GlycoFlex Stage 3 Supplement ... are all useful for arthritis (when accompanied with kidney disease).

Tony

[tonyb286]

Just thought, your vet may be talking about Galliprant. This is an interesting recent new NSAID drug. Normally NSAIDs are ill-advised in kidney failure, but this one is said to have a different route for metabolising. As it's a very new drug (with insufficient testing so far despite approval by the FDA), I would be hesitant about it. Suggest thorough reading-up so you know the full story.

Tony

[FawnT]

Hi Tony!  Hope you are well, I'm so sorry I did not see your further comments.  We went back to the vet today for our 3 month blood work.  I had a long discussion with my Vet addressing the mobility issues and asked about acupuncture, as I had searched out animal acupuncture online and wanted to get his take on it.  He was all for it, gave me a referral and I have an appointment set up for tomorrow.  I experienced acupuncture myself several years ago and I had very good results with a bonus of feeling of being balanced-- it is hard to describe.  But given my experience, I am willing to try for Sadie.  You are right on--I did ask my Vet today about the new med he mentioned last time and it is Galliprant.  For now, we will hold off and see how the acupuncture goes, but certainly leave it open as an option.  Crossing fingers for good blood results.  Thanks for your advice, you have been so so helpful in my management of the KD over the last year and 1/2.  I so appreciate it!!!
Fawn

[FawnT]

P.S. My Vet did say he would need to study the Galliprant more on how it effects the kidneys before he would give it to Sadie, but he said he has had some good results with dogs suffering from OA on it.  I believe he said it was approved in 2016 and he has just been using it a few months.

[FawnT]

https://bothellveterinarian.wordpress.com/2017/04/02/galliprant-new-arthritis-medication-for-dogs/

[tonyb286]

I am all for trying acupuncture as well. Of course, in humans there is the psychological aspect of it (if someone tells you it's good for you, then it will work if you believe it enough). While this isn't the same with dogs, I have heard some amazingly positive results gained from acupuncture. Do let us know how you get on.

Tony

[FawnT]

Hi Tony, I am in need of some advice.  But first, the acupuncture has gone well.  In fact, Sadie was scuffling on the hardwood flooring when getting up from a laying position and has been able to stand directly up without scuffling the majority of time.  She seems more steady and stronger. We have had 2 appts.  So very pleased.  The acupuncturist I'm using has been practicing for 19 years and in addition to treating her mobility issues,she is also addressing her KD and pancreas as well.  I also got the results of bloodwork and overall my Vet is very pleased.  All KD bloods are close to the same as in March.  However, her amylase is high as is her lipase.  My Vet felt she may have been coming off a bit of pancreatitis, as 2 days before bloodwork she had some loose stools and was not interested in eating some favorite treats, but ate 3 meals that same day, no vomiting.  She is really not very interested in the Royal Canin canned KD so much anymore..she has been on it for almost 2 years and I really think she is just tired of it.  She is picky to begin with.  I had recently added a bit more lean protein, as she is still in stage 2 and I was worried her mobility may be affected by lack of protein with muscle issues and the protein is so controversial to begin with.  Even though our results are basically good, I am discouraged.  I don't know where to go from here.  I feel I should cut back or out the Royal Canin KD since it is high fat, but is her source of energy and that may be affecting her pancreas numbers, but I don't know what to do and if no dog good what to supplement since I have to watch phosphorus, fat, potassium-- (which was great this time).  I will post the results.  Also, I am a bit concerned with the urine results, do you think this could be making her feel bad? Her urine protein/creatinine ratio is now 0.7.  

6/28/17 (Order Received) 3/10/17 11/22/16 6/29/17 TEST RESULT REFERENCE VALUE
      6-28-17   REF  3-10  11/22/16
RBC 6.65   5.39 - 8.7 M/µL   6.89   7
Hematocrit 41.3 38.3 - 56.5 % 42.8 42.1
Hemoglobin 14.2 13.4 - 20.7 g/dL 14.7 14.8
MCV 62     59 - 76 fL    62    60
MCH 21.4  21.9 - 26.1 pg L 21.3 21.1
MCHC 34.4 32.6 - 39.2 g/dL 34.3 35.2
% Reticulocyte 1.3 % 1.2 1.1
Reticulocyte 86   10 - 110 K/µL 83  77
WBC 11.5   4.9 - 17.6 K/µL  11.2   10
% Neutrophil 76.0 % 77.7 76.4
% Lymphocyte 14.5 % 15.0 15.3
% Monocyte 5.4 % 3.0 3.8
% Eosinophil 4.1 % 4.3 4.5
% Basophil 0.0 % 0.0 0.0
Neutrophil 8.74   2.94 - 12.67 K/µL 8.702   7.64
Lymphocyte 1.668   1.06 - 4.95 K/µL 1.68   1.53
Monocyte 0.621     0.13 - 1.15 K/µL 0.336   0.38
Eosinophil 0.471   0.07 - 1.49 K/µL 0.482   0.45
Basophil 0 0 - 0.1 K/µL 0 0
Platelet 324  143 - 448 K/µL 352  350
Remarks SLIDE REV... SLIDE REV... SLIDE REVIEWED MICROSCOPICALLY. NO PARASITES SEEN
6/29/17                                 3/10/17
Glucose 103   63 - 114 mg/dL  100
IDEXX SDMA
28   0 - 14 µg/dL H    23
Creatinine 1.8  0.5 - 1.5 mg/dL H  1.7
BUN 35   9 - 31 mg/dL H   34
BUN:Creatinine Ratio19.4    20.0
Phosphorus 4.3  2.5 - 6.1 mg/dL  3.8
Calcium 10.5   8.4 - 11.8 mg/dL  10.7
Sodium 146   142 - 152 mmol/L   145
Potassium 4.9   4.0 - 5.4 mmol/L  5.5
Na:K Ratio 30   28 - 37   26
Chloride 112   108 - 119 mmol/L 111
TCO2 (Bicarbonate)
17   13 - 27 mmol/L   18
Anion Gap 22   11 - 26 mmol/L   22
Total Protein 6.7   5.5 - 7.5 g/dL  6.8
Albumin 3.3   2.7 - 3.9 g/dL   3.4
Globulin 3.4   2.4 - 4.0 g/dL   3.4
Alb:Glob Ratio 1.0   0.7 - 1.5   1.0
ALT 52   18 - 121 U/L   49
AST 24   16 - 55 U/L   21
ALP 339   5 - 160 U/L H   244
GGT 3   0 - 13 U/L   6
<0.1Bilirubin - Total 0.0 - 0.3 mg/dL <0.1
Bilirubin Unconjugated
0.0 0.0 - 0.2 mg/dL 0.0
<0.1Bilirubin Conjugated
0.0 - 0.1 mg/dL <0.1
Cholesterol 313 131 - 345 mg/dL 296
Amylase 1,774   337 - 1,469 U/L H 1,246
Lipase 1,305  138 - 755 U/L H  570
Creatine Kinase 142 10 - 200 U/L 155

Chemistry (continued)
TEST RESULT REFERENCE VALUE NHemolysis Index b
1+
NLipemia Index c
N
Urine Protein:Creatinine Ratio If Indicated
A urine protein-to-creatinine ratio (UPC) has been ordered to evaluate renal damage, as indicated by a positive SSA protein result and inactive urine sediment.
Urine Creatinine 97.6 mg/dL   96.0
Urine Protein 66.7 mg/dL   46.4
Urine Protein:Creatinine Ratio
0.7   0.5
YELLOWColor d
YELLOW
Urinalysis
6/28/17 3/18/17 11/22/16
TEST RESULT REFERENCE VALUE FREE-CATCHCollection FREE-CAT... FREE-CAT...
YELLOWColor YELLOW YELLOW
CLEARClarity CLEAR CLEAR
Specific Gravity 1.017 1.018 1.018
pH 6.0  6.0  6.0
1+ (100-200 mg/dL)Urine Protein a
TRACE  NEGATIVE
NEGATIVEGlucose NEGATIVE NEGATIVE
NEGATIVEKetones NEGATIVE NEGATIVE
NEGATIVEBlood / Hemoglobin
NEGATIVE NEGATIVE
NEGATIVEBilirubin NEGATIVE NEGATIVE
NORMALUrobilinogen NORMAL NORMAL
0-2White Blood Cells
0 - 5 HPF 0-2 2-5
NONE SEENRed Blood Cells HPF NONE SEEN NONE SEEN
NONE SEENBacteria NONE SEEN NONE SEEN
NONE SEENEpithelial Cells 1+ (1-2)/HPF 1+ (1-2)/HPF
NONE SEENMucus NONE SEEN NONE SEEN
Casts NONE SEEN NONE SEEN OCC HYALINE (0-1)/LPF
NONE SEENCrystals NONE SEEN NONE SEEN
Other AMORPHOUS...
a Protein test is performed and confirmed by the sulfosalicylic acid test.
Endocrinology
TEST RESULT REFERENCE VALUE
Total T4
a
1.1 1 - 4 µg/dL 1.3 1.3
Free T4 (ng/dL) 0.9 0.6 - 3.7 ng/dL 1.2 1.0
TEST RESULT REFERENCE VALUE
Free T4 (pmol/L)
b
11.6 7.7 - 47.6 pmol/L 15.4 12.9

Appreciate any thoughts you have.

Many thanks!
Fawn and Sadie

[tonyb286]

Hi. The protein/creatinine ratio now at 0.7 is a marker to keep a close eye on. It isn't hugely abnormal as yet, but it may deteriorate as time goes on. While it remains under 0.9, I wouldn't get overly concerned.

The SDMA is very specific at identifying kidney disease and at 28, it is indicative of a deteriorating condition. All it is really telling you is that kidney disease is progressive and this will continue to deteriorate as time marches on.

Creatinine at 1.8 indicates Stage 2 of kidney disease. This also suggests protein restriction is not necessary just yet, but high quality (human grade) meats, poultry and fish remain essential, rather than low quality proteins. Most kd specific dog foods usually have high quality proteins, but it is always worth checking with the supplier/manufacturer if uncertain.

Serum alkaline phosphatase (ALP) is high. This might be suggesting some liver concerns, but the test is very sensitive, so it's always worth repeating this specific test again and compare. If you are not using Milk Thistle as a supplement right now, I would add it, as it will help protect the liver from further damage. The liver needs to take over some of the functions of the compromised kidneys, so it's little wonder it may be under some stress - assuming the test reading is accurate.

The high amylase and lipase are definitely suggesting some inflammation of the pancreas (pancreatitis), and lowering fat content will certainly help things settle down. One way to achieve this is to reduce the amount of kd tinned food by half of the daily amount, and replace the lost fat element with some additional carbohydrate (sticky white rice, couscous or tapioca would be the better low phosphorous ideas).

Hope this helps a little.

Tony

[FawnT]

Thanks for your input.  The SDMA seems to bounce back and forth.  It was 23 last time, but 33 the time before, which was higher than 28 this time.  For now I have backed off the canned Royal Canin KD food.  I am going to give her a little break and concentrate a bit more on high quality protein and carbs--white noodles/rice.  I haven't tried couscous or tapioca, so we'll give that a try too.  I have only been giving her one can of the canned KD, split into 3 meals (about 1/2 cup each feeding = 1 can)and supplementing with chicken breast, ground turkey and rice/noodles/low potassium veggies and egg whites.  I have added a couple tablespoons of low fat cottage cheese and peaches which she is liking.  And she loves the organic honey you suggested before with her rice.  I don't want to mess with the #'s, but I also want her to like what she is eating.  It's a fine balance. We will be 2 years in with the KD next month, I hope we can continue to manage, but her mobility issues are worrisome.  Thanks for all you do!

--Fawn

[tonyb286]

That's great Fawn. Keep up the good work.

Tony

[FawnT]

Hi Tony, I was reading some of the other posts and wanted to find out the best salmon/fish oil to use for Sadie and the dosing.  My Vet gave me some fish oil tablets some time ago and I ran out.  They were expensive, so I thought I may look for something on line.  Sadie weighs 47 pounds.  Thanks!

Fawn

[FawnT]

Hi Tony, it has been some time since I posted and I thought an update was due.  Sadie continues to do well with her KD.  We had routine blood work done in March.  We're having it tested about every 3 months. I won't bore you with all the details, but the key values are:  creatinine came down again to 1.7 from 1.9 in DEC and 2.2 in AUG.  As well as her BUN, now at 34, was 37 in DEC/AUG.  Her phosphorus came down too to 3.8, it was 4.4 in DEC. (She has been on a phosphate binder since June when she had her crisis).  Even her potassium, which had been high is at just above norm of 5.4 at 5.5.  I continue to work hard on her diet.  However, she always seems hungry and I am afraid to increase the protein, which is probably the only way to satisfy her.  In addition, she is having issues with her mobility and it is getting difficult for her to lay straight down from a standing position in her back legs.  I don't want her to be in pain, so I am wondering what the best meds would be for her to take.  I know anti-inflammatories are bad for the kidneys.  Are there alternatives?  My Vet mentioned a new med out (but not the name) at our March apt that doesn't effect the kidneys/gastro as much, but I told him I wanted to wait, as I wasn't quite there that she needed it.  I think we may be near the point she could use a medication, it is hard to watch her struggle to get down.  She is ok getting up and still runs a little outside, so I don't think its a pain once she is up and moving.  Maybe stiffness, I wish she could tell me... I want to balance the kidney disease, but also don't want her to be in pain.  Any thoughts are greatly appreciated.  I also have all the blood values, should you have any questions.  
Many thanks!
--Fawn
  

[FawnT]

I forgot to mention her SDMA came down too from 33 to 23.  But given all these good bloodnumbers, her urinalysis showed a trace of protein, neg. blood and 1.018 gravity.  How can the blood #'s be so good and urine with urine protein/creatinine ratio of 0.5?

[tonyb286]

No problem. And the same to you, Sadie and your family.

Tony

[tonyb286]

Hi. First things first ... the extensive testing of blood and urine is fabulously comprehensive. A credit to you and your vet.

There are a few things that I will go on to mention, but overall the results are great, very positive and much improved on previous testing. Whatever you are doing, just keep doing it, because it's having a very beneficial impact.

MCH is slightly low, but not alarmingly low. This particular test is for the amount of hemoglobin in the red blood cells, and can be a pointer towards anaemia. However, as RBC is within normal range, anaemia is not currently an issue. The low MCH is a worthwhile warning that anaemia could occur, so it may help to add some canine iron supplements to boost red cell production and hopefully improve the volume of hemoglobin.

BUN is at 37 and stable (it was 37 last time too). This confirms the kidney disease - but also helps confirm things are static (not getting worse).

Creatinine is 1.9, which is a great improvement on both prior blood tests. This places your dog at Stage 2 of the disease, bordering on Stage 3. Earlier results were showing Stage 3.

The SDMA result at 33 simply confirm renal disease, but significantly it has dropped from a prior high of 37. Anything above 20 indicates renal disease.

Phosphorous is brilliant - bang on normal, from a previous high. It is rising, so just keep restricting it in the diet. If you are using a phosphate binder, keep using it.

Potassium is just in the abnormally high range. It's not alarming, but it may be worth analysing the diet and any regular treats to see if you are giving any high potassium content foods, and then adapt to reduce them slightly.

ALP (alkaline phosphatase) is high. This suggests there is some liver damage. This is not uncommon in kidney disease, because the liver has to take over some of the functions the kidneys would ordinarily perform, so the organ becomes stressed. If you aren't already giving it, I would add some Milk Thistle as a supplement which will help protect it from further damage.

The normal amylase confirms there is no pancreatitis, which is excellent.

Lipase is slightly high, but greatly improved from previous testing. This result suggests your dog cannot absorb or utilise fats as well as healthy dogs, and this can lead to an inflamed pancreas as a result. But, so far at least, the pancreas is not suffering - but keep an eye on the amount of fatty foods given and try to cut it down very slightly to prevent problems occurring.

And that's it. All other results are good.

Tony

[FawnT]

Thanks Tony--Yes, we are very much in better shape than in June with creatinine of 4 then, with it now being 1.9 and BUN was at 50.  She is on a phosphate binder, as her phosphate was up to 7 when she got sick in June (it was always in the 4's before her sickness in June) and went down to 3.8 initially after starting it.  I still think the crisis in June was first related to an issue with her stomach or pancreatitis and not her kidneys.  My Vet said after the crisis passed and she bounced back that he thinks she got dehydrated with all the loose stools.  Thankfully that has passed.  

Thank you for continuing to take a look at Sadie's results.  I truly appreciate it and hope you have a wonderful holiday season!  

--Fawn

[tonyb286]

Aha ... wasn't notified to your post (MedHelp is sometimes technically challenged) but found it after a bit of searching. Let me check the results and I'll get back to you later.

Tony

[FawnT]

Hi Tony!  It has been awhile, which I guess can be a good thing =).  Sadie went for follow-up blood work and appointment yesterday.  She had really good results, her creatinine came down from 2.2 to 1.9, her BUN is holding steady at 37 and while still high, her SDMA came down too from 37 to 33.  I am posting results, in case anything stands out, but my Vet is very pleased overall.  Oh, her potassium is back to on the above normal side again, but I am not feeding any high potassium foods that I am aware of.  (The last 3 visits are reported with most recent being on the left side).  (The June values were when she was very sick/ hospitalized after 2 days of IV fluids).  Thanks for taking a look!

11/22/16 (Order Received) 8/3/16 6/25/16
11/23/16 6:45 AM (Last Updated) 8:12 AM
TEST RESULT REFERENCE VALUE
RBC 7    5.39 - 8.7 M/μL    6.59    5.67
Hematocrit 42.1    38.3 - 56.5 %    41.2    32.4
Hemoglobin 14.8    13.4 - 20.7 g/dL    13.9    11.1
MCV 60    59 - 76 fL    63    57.1
MCH 21.1    21.9 - 26.1 pg L    21.1    19.6
MCHC 35.2    32.6 - 39.2 g/dL    33.7    34.3
% Reticulocyte 1.1 %    1.0    0.9
Reticulocyte 77    10 - 110 K/μL    66    51
WBC 10    4.9 - 17.6 K/μL    11.1    17.87
% Neutrophil 76.4 %    77.2    88.2
% Lymphocyte 15.3 %    14.2    6.5
% Monocyte 3.8 %    4.2    3.4
% Eosinophil 4.5 %    4.4     1.7
% Basophil 0.0 %    0.0    0.2
Neutrophil 7.64    2.94 - 12.67 K/μL    8.569    15.78
Lymphocyte 1.53    1.06 - 4.95 K/μL    1.576    1.16
Monocyte 0.38    0.13 - 1.15 K/μL    0.466    0.6
Eosinophil 0.45    0.07 - 1.49 K/μL    0.488    0.3
Basophil 0 0 - 0.1 K/μL    0    0.03
Platelet 350    143 - 448 K/μL    380    323
Remarks SLIDE REVIEWED MICROSCOPICALLY. SLIDE REV...
NO PARASITES SEEN

Chemistry

TEST RESULT REFERENCE VALUE
Glucose 112    63 - 114 mg/dL    122
BUN 37    9 - 31 mg/dL H    37    44
Creatinine 1.9    0.5 - 1.5 mg/dL H    2.2    3.4
IDEXX SDMA a 33    0 - 14 μg/dL H    37
BUN:Creatinine
Ratio
19.5    16.8    13
Phosphorus 4.4    2.5 - 6.1 mg/dL    3.8    6.0
Calcium 11.1   8.4 - 11.8 mg/dL 1   1.4
Sodium 145    142 - 152 mmol/L    146    158
Potassium 5.7    4.0 - 5.4 mmol/L H    5.3    4.2
Na:K Ratio    25    28 - 37 L    28    38
Chloride 112    108 - 119 mmol/L    111    123
TCO2
(Bicarbonate)
14    13 - 27 mmol/L    12
Anion Gap 25    11 - 26 mmol/L    28
Total Protein 6.7    5.5 - 7.5 g/dL    6.5    6.3
Albumin 3.3    2.7 - 3.9 g/dL    3.2    3.2
Globulin 3.4    2.4 - 4.0 g/dL    3.3    3.1
Alb:Glob Ratio 1.0    0.7 - 1.5    1.0    1.0
ALT 35    18 - 121 U/L    32
AST 24    16 - 55 U/L    18
ALP 195    5 - 160 U/L H    174
GGT 4    0 - 13 U/L    3
Bilirubin - Total <0.1 0.0 - 0.3 mg/dL <0.1
Bilirubin -
Unconjugated
0.0 0.0 - 0.2 mg/dL 0.0
Bilirubin - <0.1
Conjugated
0.0 - 0.1 mg/dL <0.1
Cholesterol 316    131 - 345 mg/dL    300
Amylase 1,338    337 - 1,469 U/L    1,435
Lipase 796    138 - 755 U/L H    877
Creatine Kinase 170   10 - 200 U/L    91

Hemolysis Index N b N
Lipemia Index N c N

Urinalysis
11/22/16 (Order Received) 8/3/16    6/11/16
11/23/16 6:45 AM (Last Updated)
TEST RESULT REFERENCE VALUE
Collection FREE-CATCH   FREE-CAT...   CYSTOCE...
Color YELLOW    YELLOW    YELLOW
Clarity CLEAR    CLEAR    HAZY
Specific Gravity 1.018    1.015    1.021
pH 6.0    7.0 5.   5
Protein NEGATIVE   NEGATIVE    TRACE
Glucose NEGATIVE    NEGATIVE    NEGATIVE
Ketones NEGATIVE    NEGATIVE    NEGATIVE
Blood / NEGATIVE
Hemoglobin
NEGATIVE  NEGATIVE
Bilirubin NEGATIVE    NEGATIVE    NEGATIVE
Urobilinogen NORMAL NORMAL    NORMAL
White Blood 2-5
Cells
0 - 5 HPF 2-5 0-2
Red Blood Cells NONE SEEN    HPF 0-2   NONE SEEN
Bacteria NONE SEEN    NONE SEEN   NONE SEEN
Epithelial Cells 1+ (1-2)/HPF 2+ (3-5)/HPF 1+ (1-2)/HPF
Mucus NONE SEEN NONE SEEN NONE SEEN
Casts NONE SEEN NONE SEEN NONE SEEN
Crystals NONE SEEN NONE SEEN NONE SEEN
Other NON-CRYST... NON-CRYST...
a Protein test is performed and confirmed by the sulfosalicylic acid
test.

Thank you, Fawn

[FawnT]

Hi Tony, I'm not sure if my posts are coming thru.  I know this was an issue before, or maybe I've posted so many I've reached my limit.  I hope you are well.

[tonyb286]

Hi Fawn

Yes, the pancreatitis might have been an issue in June, but glad things have settled down. Wet food does indeed tend to have higher fat content. It's worth just seeing what the next set of blood values say, and then if need be, we can have a re-think, but for now I would pretty much continue as you are doing.

Fat is an important element for dogs with kd, because it gives them the nourishment so much needed along with the energy they gain from it. The only alternative is to swap some fat for carbohydrates, but dogs don't metabolise carbs nearly as well, so it's a second-best option. For now, as long as the pancreatitis is under control, everything's fine. The amylase at 1124 is right on the border of normal to high, so if it can be kept there, that's okay.

You're doing great, just keep going.

Tony

[FawnT]

Hi Tony, posting the last blood/urine values for Sadie which I received today.  The first is most recent visit 8/3/16, with the emergency visit in house values now referenced to the right (something new on the report, great for reference I guess).  

Looks like WBC has come down to normal from being at the Vet and from what I can tell RBC is ok now?  Noticed glucose was a little high, could this be from carbs?  She doesn't eat anything high in sugar.

Hematology
8/3/16 (Order Received)      6/25/16       6/24/16
8/3/16 8:38 PM (Last Updated) 8:12 AM 9:53 AM
TEST RESULT (REFERENCE VALUE)
RBC 6.59    (5.39 - 8.7 M/μL)              5.67     5.81
Hematocrit 41.2   (38.3 - 56.5 %)      32.4   33.4
Hemoglobin 13.9   (13.4 - 20.7 g/dL)   11.1  11.5
MCV 63    (59 - 76 fL)    57.1    57.5
MCH 21.1    (21.9 - 26.1 pg) Low      19.6   19.8
MCHC 33.7    (32.6 - 39.2 g/dL)    34.3    34.4
% Reticulocyte 1.0 %   (0.9  1.6)
Reticulocyte 66    (10 - 110 K/μL)     51   95.3
WBC 11.1     (4.9 - 17.6 K/μL)        17.87    11.03
% Neutrophil 77.2 %     (88.2 81.6)
% Lymphocyte 14.2 %   (6.5 10.5)
% Monocyte 4.2 %   (3.4- 4.3)
% Eosinophil 4.4 %   (1.7-3.4)
% Basophil 0.0 %      (0.2 0.2)
Neutrophil 8.569    (2.94 - 12.67 K/μL)  15.78    9
Lymphocyte 1.576 1(.06 - 4.95 K/μL )   1.16   1.16
Monocyte 0.466    (0.13 - 1.15 K/μL )    0.6     0.47
Eosinophil 0.488    (0.07 - 1.49 K/μL)    0.3     0.38
Basophil 0      (0 - 0.1 K/μL)                  0.03    0.02
Platelet 380    (143 - 448 K/μL)     323 * 364

TEST RESULT REFERENCE VALUE
Glucose 122    (63 - 114 mg/dL)    H
BUN 37    (9 - 31 mg/dL )  H       44    59
Creatinine 2.2    (0.5 - 1.5 mg/dL)  H    3.4    4.0
IDEXX SDMA a 37    (0 - 14 μg/dL) H
BUN:Creatinine Ratio  16.8    13    15
Phosphorus 3.8   (2.5 - 6.1 mg/dL)   6.0    7.5
Calcium 11.4    (8.4 - 11.8 mg/dL)
Sodium 146    (142 - 152 mmol/L)  158    156
Potassium 5.3    (4.0 - 5.4 mmol/L)    4.2   4.6
Na:K Ratio 28    (28 - 37)    38    34
Chloride 111    (108 - 119 mmol/L)    123    120
TCO2 (Bicarbonate)  12    (13 - 27 mmol/L L)
Anion Gap 28    (11 - 26 mmol/L) H
Total Protein 6.5   (5.5 - 7.5 g/dL)    6.3    6.8
Albumin 3.2    (2.7 - 3.9 g/dL)    3.2    3.6
Globulin 3.3   (2.4 - 4.0 g/dL)    3.1    3.2
Alb:Glob Ratio 1.0    (0.7 - 1.5)    1.0    1.1
ALT 32    (18 - 121 U/L)
AST 18    (16 - 55 U/L)
ALP 174    (5 - 160 U/L H)
GGT 3    (0 - 13 U/L)
Bilirubin - Total <0.1    (0.0 - 0.3 mg/dL)
Bilirubin -Unconjugated  0.0    (0.0 - 0.2 mg/dL)
Bilirubin - <0.1 Conjugated (0.0 - 0.1 mg/dL)
Cholesterol 300    (131 - 345 mg/dL)
Amylase 1,435    (337 - 1,469 U/L)
Lipase 877    (138 - 755 U/L)  H
Creatine Kinase 91 (10 - 200 U/L)

Urinalysis
Dates 8/3/16            6 /11/16           6/1/16
Collection FREE-CATCH CYSTOCE... FREE-CAT...
Color YELLOW YELLOW  YELLOW
Clarity CLEAR HAZY HAZY
Specific Gravity 1.015   1.021   1.023
pH 7.0   5.5   5.5
Protein NEGATIVE   TRACE   TRACE
Glucose NEGATIVE   NEGATIVE   NEGATIVE
Ketones NEGATIVE   NEGATIVE   NEGATIVE
Blood /Hemoglobin NEGATIVE     NEGATIVE   TRACE
Bilirubin NEGATIVE    NEGATIVE    NEGATIVE
Urobilinogen NORMAL    NORMAL    NORMAL
White Blood Cells  2-5   0- 5 HPF    0-2     6-10
Red Blood Cells 0-2 HPF   NONE SEEN    2-5
Bacteria NONE SEEN    NONE SEEN    NONE SEEN
Epithelial Cells 2+ (3-5)/HPF   1+ (1-2)/HPF   2+ (3-5)/HPF
Mucus NONE SEEN    NONE SEEN    PRESENT
Casts NONE SEEN    NONE SEEN    2+ HYALIN...
Crystals NONE SEEN    NONE SEEN    NONE SEEN

Thanks, Fawn

[tonyb286]

Hi. Great results and thank you for sharing them. What a difference. You should be really happy.

A couple of things worth mentioning. Eosinophil is a white blood cell, released in higher quantities when there's an infection present. This may be a residue effect of a recent infection, but it's worth keeping an eye on. If it remains higher than normal or starts to increase, it means the infection either wasn't fully treated or that a new infection is starting. Culture and Sensitivity test of the urine in a week or so would answer the question.

In terms of treating UTIs ... it's first important to have the C&S test done as that will identify the type of infection and the best antibiotics to cure it. Second, dogs with kidney disease need lower doses of antibiotic or an extended period, as otherwise the infection won't be cured and the higher dose will adversely affect the kidneys.

The other thing I noticed is Amylase. This is raised when there is pancreatitis. The value isn't in the high zone yet, but it's not far off. One of the things that increases the risk of pancreatitis is a high fat diet. This is tricky with kd dogs, because fat content is useful to supply energy. It may be worth assessing your feeding regime, looking at what might be considered higher in fat and swapping two-thirds of it for something less fatty for a few weeks. This should help prevent pancreatitis occurring and bring the amylase back down (in theory). Once it's ck in the mid-normal range, you can go back to the original diet - and then re-check amylase again after another couple of weeks or so, to see whether it is creeping up again.

The reason I'm saying that is to prevent something from becoming another problem before it has chance to. It's always easier to prevent something than try to cure it afterwards.

Yes, carbs have a fair amount of sugar in them and the increased use of carbs may very well be raising the glucose level. I don't feel it's terribly significant though, as glucose can go up and down, depending on how close to the test food was eaten and what amount of excitement/exercise was taken recently. It's worth remembering for the next routine test but not something I would be concerned about right now.

The SDMA puts Sadie pretty much on the border of stage 2 to 3. This means the kidney disease is being well managed, although it would be wonderful to get it comfortably within stage 2. This may not be possible, depending on how much organ tissue remains - and I don't think you can do much more than what you're doing right now. Personally, I think you've achieved a lot, so well done you.

Give Sadie a congratulatory hug from me.

Tony

[FawnT]

Thanks Tony, I appreciate your input and very interesting about the Amylase.   In the beginning of June
I weaned Sadie totally off her KD dry food--which was no easy task.  I wonder if the wet KD is higher in fat than KD dry.  Her Amylase was 1124 on June 1 (routine 2 month Blood work).  The only thing I have changed is adding more (all) wet.  The things I add on to it are all low fat/lean.  I wonder now if she had  pancreatitis, which was causing the diarrhea during that long period in June.    I'm glad you pointed this out as I was thinking of switching the things I add to the canned KD food, such a boiled chicken breast, 93% lean ground beef to less lean beef and dark meat chicken, since these are lower in phosphorus, but think I should stick to lean in consideration of the amylase.  I am feeding about 75-80% canned KD to 25-20% human grade--white sticky rice, white noodles, green beans, egg white, cauliflower, cabbage, yellow squash, boiled chicken, lean ground beef.  Rotating primarily between either noodles, rice, egg white and veggies/meats mixed in to these.  I am also using the organic honey.  I am also being careful with potassium since we had that issue too!  I feel trying to figure out the food is my biggest issue (now anyway).  She seems always hungry.  THANK YOU for looking out for us and your kind reply and I will see to it that Sadie gets her hug too!

--Fawn      

[FawnT]

The WBC was normal when she went in on 6/24 and then high the next day.  WBC 11.03(norm) / 17.87(high).  I was thinking maybe it was the stress of kenneling her overnight for the IV fluids, not sure if it would reflect that quickly.  We just re-ran all the bloods on 8/3, including a CBC and urinalysis.  When my Vet called, he was just looking at them and we discussed the key renal values.  I will request a copy and post the other results--thanks!

[tonyb286]

Hi Fawn. Yes, WBC can increase with stress. It can cause an acute episode of increased cells to be released into the bloodstream, as an auto-immune response. So, you're right to question if stress was an influencing factor.

Tony

[tonyb286]

Hi Fawn

No problem. I do sometimes have to rely on others to intervene and reply to posts, and sometimes they just happen to be as busy as me during that particular week I guess.

One quick thing ... if the WBC count remains high on the next test, it may be worth dropping a morning collected urine sample to your vet and asking them to do a Culture & Sensitivity test on it. This will disclose any UTIs and suggest the best antibiotic to get rid of it.

Tony

[FawnT]

Hi Tony, No worries about not getting notified.  I know there are others with much more dire need for information on this forum, as well as you are volunteering your time to help us all.  A big thank you!

--Fawn

[tonyb286]

Hi again. Well, kind of good news that your vet is getting on board with things, but a few pointers ...

First, the Alum Hydroxide is great - and really very important. The liquid form isn't the best as it has a taste that dogs don't like. Forget getting it from your vet at no doubt huge cost, go to another supplier and buy the gel powder form. Once you have it let me know and I'll work out dosing for you. Keep up with the liquid for the time being (note it must be given with food). You can get online from thrivingpets.com

Next, start feeding your dog in tiny amounts more often, if that's possible. So the ideal would be 6 times a day every 2 to 3 hours. This helps remove a lot of the stress placed on the kidneys from one or two larger meals.

Potassium at 4.7 is good. It would be interesting to see what calcium is doing and calcium to potassium ratio. These two minerals along with phosphorus are closely linked in canine kd.

She definitely needs a kd diet, as that's the only way to keep the blood numbers stable (in addition to the phosphorus binder). Even though phosphorus levels may be seemingly in control, they will start climbing again if you don't maintain a low phosphorus diet AND give the binder every day with food. So, eating is important, as without it she won't be able to have the binder.

Talk to your vet about prescribing Mirtazapine. This helps on several levels, and importantly will encourage her to eat the kd diet. It doesn't work on all dogs, but it's worth a try.

The best way with food is a canned kd dog food such as Hills kd, for now. You can also try home cooking. Things like human grade chicken are good, which you can mix with sticky white rice as a filler. Check out my kd recipes, which will give you a good idea of the kinds of things you can use. This article is on my website. tonyboothwriter.com

To help protect the liver a little more, start giving Milk Thistle as a supplement.

This will all take time to have beneficial effects, so be patient.

Tony

[FawnT]

Thanks for your comments Tony.  I requested a copy of the blood values yesterday from the office.  She has been on the KD since last September.  I have been rotating her thru the 3 choices of Royal Canin KD--initially dry and wet, to eliminating dry & only wet.  I have always given her something on top and since the CKF DX, only low phosphorus items.  Typically I was giving her an egg white with the Royal Canin in the am.  Royal Canin in the pm with fresh veggies (which became more difficult with the increased potassium reading) and the next day either chicken breast or lean ground beef in place of the egg white and either rice or noodles for variety.  I think that is why her phosphorus always remained in the normal range until we went last Friday on a more emergency basis.  Her appetite has returned, albeit still a little picky.  She actually ate some of the canned KD last night and this morning.  I leached out the potassium of a sweet potato and gave her a quarter mashed with a tiny bit of butter/cinnamon--she loved it, along with shredded chicken breast and some canned wet which I left separate in the bowl.  I will check out the recipes you have as well.  She is definitely feeling better, has more energy.  I will post the blood results as soon as I get them.  My vet did mention getting a compound form of phosphate binder (maybe even from the people pharmacy) but I guess he gave me the liquid he had to see if she would eat.  My question is, if she is eating smaller meals, does she just get it twice still?  (bottle dosing reads twice a day with meals).  I am giving it to her as soon as she finishes her food in her bowl.  She is doing pretty well with it, after I learned how to control the syringe so it doesn't pour out the side of her mouth.  But finding something less expensive would be ideal as financially this last visit/hospitalization was very expensive. My other question is do you think the stress of her Vet visit on June 1, causing the diarrhea and stomach issues, possible dehydration, caused the creatinine to spike?--Her numbers were good at 1.8 Creatinine, Bun 37, Calcium 11, Phos 4.4, Potassium 5.7, Sodium 145 on June 1st.

[tonyb286]

Hi. Great news. Yes, the numbers aren't that bad, which indicates you are on the right track. Calcium needs watching, but don't restrict it in food just yet. The huge problem with calcium is it can seemingly be high, when actually what's more often happening is the parathyroid hormone (PTH) starts drawing calcium out of bone, thereby giving blood readings a false higher level. This is often connected to phosphorus, so get phosphorus under good control and the calcium will ordinarily settle too.

Phosphate binders take about a month to have an effect, so just keep it going. The best way of sorting the amount out when dividing meals into 6 portions is to look at the total amount of food in a day and the total amount of alum hydroxide advised per day, then divide each by the number of meals being given - and give the portion of alum hydroxide with each meal portion.

I've gone the long way around saying that less food in one meal means less alum hydroxide is required for that meal.

Stress does play a part in kidney disease, so the various upsets are certainly possibly connected to it. As long s things have settled down, there's no need to be concerned. I often say to people, there will be bad days, but the goal is to try and achieve more good days than bad ones.

I meant to ask about the meat and poultry content of "additions" you sometimes use ... are these human grade ingredients (food you would buy for yourself to eat)? If yes, that's good, because the protein content will be high quality, which is what is needed.

Tony

[FawnT]

Hi Tony, unfortunately the numbers you referenced were from June 1, which was our last "regular" vet appt for routine 2 month blood work.  I am still waiting on getting the in-house results from 6/24-625--our emergency visit,  he went over the key values. I have requested twice from front office.   So the numbers are probably not as good.
Yes, my additions have been human grade--boiled chicken breast and lean ground beef--which I eliminated since I think it was adding to the loose stool.  So right now we are going with sticky rice --I drizzled with organic honey as you suggested and  she likes it!  Or white pasta, shredded chicken breast and canned Royal Canin KD--which she is eating a little bit more of.  I hold my breathe each time I put her bowl down.  I also am not mixing it.  I put 3 separate "piles", which she has done great with.  This morning I scrambled her an egg white with a tiny bit of the yolk and she ate that.  My main dilemma is not knowing how much to feed her total, since I was going by feeding guidelines per mfg.  Royal Canin.  She is 54 lbs.  I got the Alum. Hydrox. today at a pharmacy not too far away, they compounded it into capsules--dosing 300mg-- 3 caps 2X a day.  I now see how I can break up the dosage with the smaller meals--thanks so much, I appreciate all your advice!

[tonyb286]

Fingers crossed for the blood numbers. I know exactly what you mean about dreading to see what happens every time you put the bowl down. And then feeling so elated when your pup actually eats. Just watch the egg yolks, as they are very high in phosphorus. Try increasing the kd food and lessening others if you can, as this is the safest thing until you know what the bloods are doing.

I think you may be over doing the aluminium hydroxide. The recommended starting is 800mg per day for your dog's weight. However, it can go up (slowly titrated) to 100mg per lb of a dog's weight if phosphorus is over 8.00mg/dL and the binder isn't having the desired effect at the lower titrated doses. So, your current dosing is well within the guidelines, but we are assuming the phosphorus is still high.

Two monthly bloods are a bit cautious while getting levels under control, so it may be worth every month for a short time, which would give the dosing of the binder a chance to have an effect, and if the effect isn't as we would like, the dose can be increased then tested a month later. Hope that kind of makes sense.

Tony

[FawnT]

Yes, I sent my Vet an email yesterday asking what the plan is.  He called me last Tuesday to check on her and said he wanted to give her a rest from the stress of coming to the Vet for a little while.  Since she was a breeder dog in a puppy mill and was kenneled for 24/7 for who knows how many years, I wonder if having to be in a cage at the vets office, brings on an association of that time and wondering if I'm coming back.  When they took her back, she stopped and turned her head around twice to look at me--like to say--aren't you coming with me?!  It was heartbreaking to leave her, but knew it had to be done.  
She seems to be doing very well in most aspects.  She is constantly in the kitchen with me now when I'm there, on crumb patrol and waiting/looking to eat.  She stays awake longer and looks brighter.   I am still dealing with loose stools though.  He has her on diphenoxylate-atrop (lomotil) for the time being trying to get past the stool issue.  She has been to the Vet 3X in June, which of course, stresses her.  They are mostly normal in frequency, but semi-firm or runny--I definitely don't want her to get dehydrated.   He did tell me that her phosphorus was, I believe 7.9 at arrival 6/24 and after 2 days of fluids--normal, but I'm Still waiting on the paperwork from front office staff to see actual numbers.  I will try to increase KD.  Yes, what you said does make sense.  Thanks for reading my rambling long posts!
--Fawn  

[tonyb286]

Hi Fawn. Longer posts are better than short ones, so don't worry on that score. From your description of her behaviour, it sounds very positive. Do keep me informed how things progress.

Tony

[FawnT]

Thanks Tony =).  You have been so supportive!  She is doing so well--I am almost afraid to enjoy it, but know I need to.  She is eating well, I have increased the amt of KD and backed off the additions, but still need to add something to entice the KD--otherwise she eats a few bites of the KD and walks away once she figures out there is not anything "good" in her bowl.  She is going out in our yard, exploring more and for the first time today since the craziness started, she put her front paws down in the grass and butt up and the air and scratched her face in the grass--she had not done this in weeks.  The things that make us happy =)

[FawnT]

Hi Tony, we are going along nicely.  Eating well and even had a little run/gallop a few times lately!

I went to the Vet today to pick up  renal canned food and got a copy of the blood values from June 24/25, during our emergency visit.  They are likely moot now, as it has been over 3 weeks.  I spoke with my Vet while there and he wants her back for blood work the 1st wk of Aug or so.  He is in agreement with me that the stress of her visits is playing a hand in her kidney values spiking, especially since her values were good on June 1st at her routine blood work and spiraled out of control on the next two visits all within 3 weeks with the gastro symptoms starting and the fact that it seems like things have settled down.

The values are in clinic IDEXX, so they look a bit different.  I don't see Calcium listed.  There's Hematology and Chemistry sections.  I will post anyway in case something stands out to you (posting low or high values only:
June 24 / June 25**
HCT 33.4% / 32.4% (low)
HGB 11.5 / 11.1 (low)
RBC 5.81 / 5.67(low end of norm)
WBC 11.03(norm) / 17.87(high)
NEUT 9.00k/ul / 15.78 (high)
MCV 57.5 / 57.1 (low)
MCH 19.8 / 19.6 (low)
RDW 22.2% / 22.6% (high)

Chemistry
June 24 / June 25**
ALB 3.6 / 3.2 (normal)
BUN 59 / 44 (7 - 27 normal range)
CREA 4.0 / 3.4  (0.5-1.8 norm range)
PHOS 7.5 / 6.0  (2.5-6.8 norm range)
TP 6.8 / 6.3
GLOB 3.2 / 3.1
Chloride 120 / 123
Potassium 4.6 /4.2
Sodium 156 / 158
BUN/CREA 15 / 13
Na/K 34 / 38

**the blood work was taken early morning on 6/25 and she continued fluids for the rest of the day until I picked her up at 3pm.

We are continuing with the head tremor thing, so I don't think it is related to being hypertensive.  He said we would likely need to do a neuro-consult if it starts happening more frequently or in intensity.  It comes and goes and can be gone for days and then occur several times in a day, lasting a split second each time.  It is very perplexing, as I cannot relate it to anything in particular and I have gone over everything I can think of from particular food to time of day.  

I have posted in awhile, so I think I am making up for it now =).  Hope all is well with you!

--Fawn
  

[FawnT]

Hi Tony, we have a follow-up Vet appointment tomorrow.  Very nervous and hoping we don't have a bad stress reaction to contend with again.  I posted the blood values (above) from her emergency visit.  Wondering if there is anything you think I should be asking Sadie's Vet tomorrow?  Should I ask about decreasing the Alum Hydrox based on new bloodwork (prescription started at 300mg 3 capsules 2X a day).  Thank you!
--Fawn

[FawnT]

**that is if new bloodwork taken tomorrow shows a decrease in phosphorus?

[FawnT]

So Tony, I have some really good news to post and I'm so happy to report it!  We went to the Vet on Aug 3rd for bloodwork and I just spoke to my Vet.  I will request a copy of the entire blood values, but  her just went over the key values: her BUN has come down to 37--it was 59 when we went in on June 24th.  Her creatinine was 4.0 and then 3.4 the next day after 1 day of IV fluids--it is now down to 2.2!, Her phosphorus was 7.5 when we went in, came down to 6 the next day and is now 3.8.  Her potassium is 5.3 Even her liver ALP was 600 and it is now 174.  I know you get lots of bad news, so I thought I would share some good for a change.  Any thoughts on getting the creatinine down a bit?  Also, I asked about reducing the Alum Hydrox and he felt like the numbers were so good across the board we should just keep doing what we are doing.  

[tonyb286]

Hi. I have no idea why I didn't get notified by MedHelp about your posts ... I think they are doing some tech stuff with it, and it's gone a bit haywire.

Anyway, having read all your posts, the news is fabulous. You couldn't really ask for more. Your vet sounds like one of the good ones - so hang on to them. I completely agree that it's best to keep with the phosphate binder ... there is no advantage to stopping or reducing it and everything to be gained by keeping with it.

The creatinine may not come down any more, because it's directly influenced by organ damage. So, if the kidneys are compromised, the creatinine will be high - but you can maintain the creatinine by doing what your doing right now. Phosphorus control is the main thing - along with dietary intake.

I noticed on the original blood tests the RBC was low, which suggests there may be some anaemia creeping in - worth keeping an eye on and seeing what it reads on the next test. WBC is high, and that suggests maybe an infection (UTIs are not unusual in kd dogs). Again, worth comparing with the next blood test results.

All in all, it's good news. Congratulations.

Tony

[FawnT]

She is having a good evening!  She ate some pasta and boiled chicken.  Her stool is still loose.  She has always had a sensitive stomach, in so far as how her stools go.  This is the first time it has had an impact on her appetite for an extended period.  I believe the whole shaking episode in January had some impact from her Vet appointment for bloodwork.  When we came home she had her "normal" after Vet diarrhea and it spiraled from there.  We had bloodwork on June 1st and this GI issue started right after.  She went  in for her head shake and 2 month bloodwork. Maybe it is an unfound correlation, but I think some must be related to stress.  This began when her Creatinine was 1.8 and BUN in the 30's, would she be feeling nausea with such numbers?

I have been giving her white bread toast.  It was the only thing she was really interested in eating.  Feeding several small meals, is not an option, as I work full time.  I may be able to work out 3 though, versus the 2 I am doing now.  

I hope we are on the road to recovery (for now) and I can get her back to the KD.  She came outside for a long while with me this evening and has been wagging her tail, hopefully all positive signs.  I am not sure about making a vet appointment next week for fear of another stress reaction.  It is a double edged sword, for sure.  

[FawnT]

Hi Tony, I have backed off the white bread--only a bite or 2 as a treat--mainly because I don't know what else to offer with her stool issue.  She is eating better overall.  I have been feeding her a bland diet 3X a day due to the stool issue.  She has had a couple normal stools, but they rotate between formed--but still watery ones.  I haven't seen anymore mucus in her stools for the last several days  I am feeding either white rice with a couple tablespoons of her KD canned food and some shredded boiled chicken or white pasta with the same.  I tried lean hamburger, but she had a loose stool after, so I'm back to chicken.  She is eating most of it--3 smaller portions.  I still see her licking her lips on occasion.  Is this nausea?  I have seen this before especially after waking up--is her mouth dry?  She does not do it all the time. I am driving myself crazy since she can't tell me--I would hate for her to feel nauseated all the time.  I pulled up her lip and it bounced back right away, her gums are wet and bright pink and when I pulled back the skin between her neck/shoulders it bounced back, so I don't think she is dehydrated.  She is having a normal # of stools, 1 to 2 a day, it's just the consistency.  She did vomit once yesterday.  It was after I gave her the 2 azodyl pills in the morning and her Pepcid and flagyl.  It was the water she drank and cream cheese from her pills.  She has to wait an hour after the azodyl to eat. She seemed fine after and went on to eat all her food later in the morning and no further issue.   I am afraid to try any of the home cooked recipes, for fear of changing her food and possible stool/tummy impact.  I spoke to my Vet's office yesterday and since she had a couple firm stools, they decided to have her come in next week to let her chill from her Vet visit.  I really don't know what is best for her anymore.

[FawnT]

Hi Tony, Sadie is at my Vet's office now (Friday).  She would not take her cream cheese with morning pills.  I made her a scrambled egg white with a tiny bit of the yolk, which she did eat (gave her 1/2) & drink water, only to vomit it up a little later.  I was dreading this visit, as intuition told me, it would not be good.  He ran a renal panel and her creatinine was 4 and BUN 57.  He was amazed and had no explanation that her potassium is now down to 4.7.  He didn't mention any other values, and while I knew it would not likely be good, I was in shock nonetheless, so I didn't ask.  He didn't do a CBC (yet), just the renal panel first.  She was admitted to receive IV fluids (instead of sub Q) this time.  He may keep her overnight (he said he will see how things go), and do the fluids through tomorrow or possibly let her come home for tonight and have me bring her back tomorrow to avoid the stress reaction of having her kenneled over night.  He is also going to have a new vet to the practice, who specializes in ultrasound do an abdominal ultrasound to rule out any other issues that might be going on.  Over the past few days, I've read  more of your writings/articles, you are an amazing writer and incredibly knowledgeable.  You would make a wonderful Vet.  Your BB sounds very much like my Sadie is to me.  These are tough times...

[tonyb286]

Hi. Firstly, thank you for your kind words. I think you are going along the right path with things, for now, so try not to fret. It's great that Sadie's having IV Fluids, as that should truly help get the creatinine down.

The creatinine level is really showing Sadie to be in final stage kidney failure - but if the numbers can be brought down, then she might just move back into stage 3, which would be much better. Of course, kidney disease is not curable, so time may not be on her side. The ultrasound will hopefully look at the size of the kidneys and try to see if there are any stones in the organs or along the urinary tract.

You really do need to ask your vet or the blood test results - all of them - do remember you own them, you paid for them, they are yours.

I can offer more help, but I need the bloodwork results to give the best info and advice.

Why the vet hasn't done a full panel blood test I really don't understand. It needs blood, but he was taking it for the renal test anyway.

My big concern at the moment is phosphorus level, which I think may be abnormal. If it is, then diet changes are crucial - and a phosphorus binder (my preference being aluminium hydroxide) absolutely essential sooner rather than later.

Tony

[FawnT]

Hi again.  Sadie is home.
She had a renal panel/CBC/Electrolytes-- (NaK+CI) done yesterday (6/24).  I guess he ran the renal while I was there to see if that was indicating the issue, then ran the rest once she was admitted.  He didn't mention anything with the CBC being abnormal. As you suspected, her phosphorus was 7.9--I believe (definitely 7 something). He also reported the potassium coming down to 4.7.
I definitely paid for the blood work analysis, so I will request a copy when I call him Monday.  I spoke with him early this morning while she was still there and he had just re-run her blood.  Her creatinine came down to 3.4 and he continued the fluids after the blood work there today until 2pm so hopefully it came down more.  He said her BUN came down as well and her phosphorus was normal.  Her ultrasound revealed smaller kidneys.  He said he did not know if it was hereditary or not and an enlarged liver.  (We went thru this with our first Sheltie--saw a specialist and had a liver biopsy, which was benign.  So I'm not sure if Shelties have a predisposition to this or not).  Her spleen normal, they didn't see any tumors on adrenal glands, though adrenal glands were not seen clearly.  He did send me home with Aluminum Hydroxide.  She was bright and doing well.  She ate some boiled chicken and small piece of toast--I checked with my Vet, he felt this was fine.  She is not interested in the KD and rice.  She is definitely exhausted.  She has had more to drink since arriving home, not sure if she had water with fluids.  They said to give her the Aluminum Hydroxide if she ate tonight.  It is liquid and I got some in, but not all.  Any ideas on what she may eat that is going to build her strength and not create issues for her kidneys, that she will eat?  Should she be feeling better right away, or should this take some time?  Thanks!!

[tonyb286]

Hi. I think one of the things you can do (if it's practical) is to change the feeding routine. One or two meals a day puts enormous stress on the kidneys and will almost definitely lead to nausea shortly afterwards - and dogs that become nauseous will then associate the sickly sensation with the last food they ate, so it becomes a vicious circle. Feeding very small (and I mean tiny) portions more often is the way to go. So, work out the appropriate volume of food for your dog (breed and weight appropriate) and divide this into 6 or more portions and then feed these smaller portions every 2 - 3 hours.

This is worth trying, I think. It may be very tempting to feed your dog more food when they are eager to eat something ... but this is counter-productive in the long run. The kidneys simply have to then try to deal with lots of by-product toxins, which they can't do successfully, so all those extra toxins end up in the stomach and blood stream - and make the dog sick, or feel sick.

Toast is not the best source of nourishment for a dog. I would try to stay clear of it if you can. It depends on the type of bread, but any yeast content will cause serious gastric issues - and bread given over several days will almost certainly lead to diarrhoea or constipation.

The next blood results will be interesting. Try to ensure you get the levels for creatinine, BUN, amylase, potassium, calcium, phosphorus and sodium. WBC and RBC would also be useful, as they can indicate if there is any infection elsewhere and/or any anaemia.

Tony

[FawnT]

I also forgot to mention, her urine was still concentrating at the low end of 1.021, he said he wasn't concerned-- this was not a first catch, but the sample from the vet's office.  It is Tuesday now and I offered her some white rice mixed with an egg white topped with 1/2 piece of toast (I cut it in bite size pieces).  She more or less picked out the toast and ate a some of the egg white.  When I offered the remaining egg white by hand she spit it out.  Is there anything you make of this?  She is walking around as I am preparing breakfast for my kids "asking" for food, I don't know what to offer her.  She looks bright this morning and has been wagging her tail.  She is drinking water at a normal rate.  Not sure if she is experiencing nausea.  I watch her and sometimes see her licking with her tongue.  Of course, she has done this before, but now I'm not sure if it's related to feeling sick to her stomach.  Thanks for any thoughts or suggestions you may have, I appreciate you!  

[FawnT]

Hi Tony, I spoke to my Vet this morning.  He received the Urinalysis/Fecal results he sent out Friday back today and they were not indicating any infection.  The urine was taken by ultrasound guided cystocentesis and came back without any bacteria present or protein leakage.  (He didn't mention if the trace of blood was still present, like 10 days ago).  He still has the culture in house and was going to check that, but called with the lab results  He is now thinking this is more GI related.
She had a good appetite Friday evening after coming from the Vet, getting fluids, also got Diphenoxyl/atropine (don't know what this is) and Cerenia injection--for nausea (no vomiting).  I gave her a 1/2 can of KD with a small amt of noodles mixed in for dinner Friday.  She ate it all.  Repeated same meal Saturday morning and wouldn't touch it.  She had another loose stool shortly thereafter, even though she is taking Flagyl, which he wanted me to continue with until the stool firmed up.  Gave her a 1/2 piece of white bread toast, to not put anything heavy on her tummy and prevent further loose stools.  She was very interested in the toast, though she has taken a few bites here and there and I don't know what else to offer that wouldn't upset her stomach further, so we stuck with that.  Sunday she seemed to not feel well in the morning, but ate her toast, but was looking much brighter in the evening and ate an egg white with again toast.  No stool at all, loose or otherwise. This morning, I made her some sticky rice and topped with the gravy and morsels--a couple table spoons full of her canned KD since she had not had a loose stool since Sat. am.  She ate it all and I went to work.  Upon arriving home, she was looking like she wasn't feeling well AGAIN and had another loose stool.  I put a call into my Vet to see if I could give her the Flagyl a few hours before due (dosing once every 12 hrs), or if I should just let whatever was in her system the opportunity to get out--was the Flagyl preventing this from happening?  She was looking like she was feeling better and acting like she wanted to eat, but I didn't know if I should feed her right away or wait for the Flagyl to start working.  I put a call in to my Vet, but his technical called back to say he was slammed with appointments, which while I understand, I was somewhat disappointed.  I have been going there for 20 years and just spend over $500 US Friday. I mentioned this morning whether he thought the BP meds could be contributing to any of this and he said he didn't think so, or if we should switch with the creatinine rise.  He said this BP med doesn't usually cause an increase in creatinine and her BP was 120 on Friday, so he wanted to stick with it for now and felt the fluids would bring the creatinine down.  As of this morning, he wanted to give her a break from the stress of coming to the office this week, but wants to repeat renal panel next to check creatinine. I forgot to mention he did Sodium/Potassium on Friday with the renal in house and her Potassium was down to 5.1.  Nothing seems to add up with her.  Thank you for taking the time to read my post, I feel like I'm rambling on here.  

--Fawn

[tonyb286]

No problem. Let me know what they say.

Tony

[FawnT]

Thanks Tony, I appreciate your input and will follow up again with my Vet.

[FawnT]

Hi Tony, I have been absent from the internet and CKF research for awhile.  I felt I needed to take a break, as a lot of what I was reading was conflicting and spending endless hours online was only taking away from quality time with my 2 kids and Sadie.  Having said that, we had our 2 month follow up bloodwork on June 1st.  She had been stable, but had developed a sort of head shake (I would equate to a Parkinson's move).  It would occur randomly and for only a split second and go away, not to be seen for weeks, months (this was not like the full body shake during the snowstorm, but started then).  Given this I took her a few days early for blood work since I was seeing this head movement more frequently and it seemed to move into her body a couple times.  She also seemed like she wasn't as steady on her feet. She actually did the head movement at the Vet's office, so thankfully he was able to observe it. He did BP and it was high.  (Not uncommon as she is so so stressed there), but he can usually get normal readings in past.  He did 12 readings.  First 6 in back without me and then again when she was back with me since he saw that she calmed down a bit. Started her 10 days ago on Amlodipine Besylate 10mg once daily.  Head tremors went away, only saw it once last Sat. for a split second.  (I work, so I don't see her every move though). Blood work came back with slight change in creatinine from 1.6 (for 8 months) to 1.8.  BUN 37 from 32.  Calcium 11, Phosphorus 4.4.  Sodium 145.  Potassium came down from 6.3 to 5.7.  Urine Specific gravity 1.023, also trace of protein in  and trace of blood in Urine.  Over the last several days she has become more picky with her food, leaving some of the KD in her bowl, and looking up at me like is this the best you can do!  I would say she is eating 80 to 90% of it and all of the toppings. On Wednesday she had an accident (BM) in the house and very lose stools last night X 4.  I called and got her in today.  He wanted to recheck her blood pressure anyway. When I told him about the food pickiness, he decided to do a renal panel in house.  Her creatinine was 2.7 from 1.8 10 days ago.  He is thinking possibly because of the BP meds, or even a UTI--going to run culture in house.  In addition, she had another BM accident there in the exam room--this usually happens when we get home--stress diarrhea.  She is there now getting Sub Q fluids.  He mentioned colitis--listening to her stomach too.  I am devastated, while I know the "good" numbers can't last forever, and she would not beat the odds, so to speak, she was doing so well.  He mentioned the "AT SOME POINT quality of life thing...."  
Hoping to hear your input.

[tonyb286]

Hi. Even before you mentioned it, I was thinking a bladder or UTI infection was likely by the symptoms. Culture and sensitivity testing is crucial and hopefully they will identify the type of infection and get her on a suitable antibiotic to solve it.

Of course, that may take several days, so be patient until that gets sorted.

Amlodipine Besylate is a calcium channel blocker and widely used by vets for high blood pressure. Frankly, it wouldn't have been my first choice, but it is usually quite effective. I would have preferred to see an ACE Inhibitor drug, such as Benazepril (1st choice), and then a Calcium Blocker added if it didn't achieve the desired result on its own.

ACEIs are often used together with calcium-channel blockers (CCBs), partly because the latter can offset the adverse reactions of ACEIs while at the same time enhancing the anti-hypertensive action of such medications.

Blood in the urine could be from the infection, so don't worry too much about that. Once the infection is solved, the blood should stop discharging.

Tony

[tonyb286]

Hi Fawn.

Yes, Addison's is a possibility. Time is something that more often tells Addison's from Kidney Disease, as the kidney disease will deteriorate (slowly or faster depending on interventions). Of course, Addison's is equally serious, as it involves the destruction or loss of the cells that produce cortisol and aldosterone in the adrenal cortex - and it can also lead to Addison's Crisis, which is life threatening. Addison's is much less common than kidney disease, but with similar symptomology, which is why kidney disease is more often diagnosed. The ACTH stimulation test is what your vet needs to do to rule out Addison's.

Tony

[FawnT]

Hello, Sadie had her  bloodwork this week and I wanted to post results.  Everything was good, but Potassium remains on the high side (6.3).  My Vet talked to his Internist friend and she did not seem to think it was a big worry.  Apparently, he consulted with her last time too, which he never mentioned and she was also ok with the numbers.  Out of caution, he called the lab and they still had her blood work, so they ran a cortisol test.  It was not the ACTH test you mentioned and I read about since they had the blood already at the lab I guess.  The cortisol test came back negative, I got the results back from the receptionist as my Vet had gone out of town, so we haven't discussed yet.  But the receptionist said the results read negative for Addison's.  Her sodium came up a bit, into the normal range (146).  Her Creatinine remains good/stable at 1.6 and Bun good at 32.  Her ALKP came down significantly, but still running high, he was not concerned with this.  My concern is the potassium, especially since I cut out high potassium foods like sweet potato, bananas etc.   I think as you mentioned the KD may be too low in sodium and maybe that was what was causing the low sodium reading?  Is sodium damaging to the kidneys or is it a concern as a high blood pressure issue?    Any thoughts on the potassium?  I greatly appreciate your thoughts and advice!
Thanks, Fawn

[tonyb286]

Hi. Dogs are fortunate insofar as they do not respond to sodium in the same way humans do. Ordinarily even high sodium isn't a great concern in dogs (unlike humans, where it has known adverse issues with blood pressure and heart conditions). All that said, in kd dogs, sodium is more of a concern as it acts as one of the neurotransmitters, allowing both the brain and muscles to function correctly. High sodium and low sodium levels are best dealt with by alterations to the diet.

Potassium is another somewhat complex mineral. It has a whole range of functions, including a unique collaboration with both calcium and sodium. High or low calcium and high or low potassium can cause several problems in the canine body, and more so in the kd dog's body.  The point is, higher than normal levels of potassium are normally eliminated by the kidneys, but when the kidneys are impaired, the potassium levels just keep on rising. High potassium has an adverse effect on the heart, causing it to function abnormally.

Your vet needs to deal with this and if he/she seems reluctant, then get another vet. This is not something that should be left to its own devices as things will steadily get worse until it seriously affects the heart and blood circulation.

If sodium is low or "normal" in blood results, then SALINE IV fluids is the best treatment to get potassium back under control quickly. After that, diet control is the normal route to keeping potassium restricted along with monthly blood checks.

Low sodium is of a concern, because in itself (as a symptom) it can cause potassium levels to rise. KD dogs often have high sodium, rather than low sodium, but low sodium is also not that unusual in kd dogs. Many things can cause this including kidney disease, heart conditions and high levels of fat in the diet. In your dog's case, I'm fairly sure it will be the kidney disease.

The secondary underlying cause (after the kidney disease) may be low blood volume. It might be useful for your vet to look at adding a medication that will boost blood volume, thereby also helping the kidneys as a secondary consequence.

Regards,

Tony

[FawnT]

thanks for your comments.  Is 6.3 considered really high for potassium?  My Vet is out of town, so I will speak with him this week.  As, I mentioned he spoke to a Vet Internist, so I am perplexed by their response then.  I think the KD is high in fat--I wonder if that is having an effect.  Would low blood volume be something that shows up on bloodwork--she had a complete senior screen, in addition to the renal panel done.  I just don't know what to look for.  I also forgot to mention her SDMA came down from 27 or 29 to 24.  Her calcium is good at 10.8.
--Thanks, Fawn

[tonyb286]

Hi. The SDMA is still very high. Anything above normal is high, therefore it's best to think in terms of the potassium being abnormally high. It certainly needs to be dealt with by your vet, as leaving it in a high state can cause severe complications.

The high fat is unlikely to be the problem. High fat is more likely to cause pancreatitis, if anything. But most kd dogs need a higher fat diet, because the protein is being restricted - and they need to get the energy from something in the diet, fat being the most obvious first choice.

Low blood volume will show up on certain blood tests, particularly RBC, albumin and certain other levels. Low blood volume (and indeed high blood pressure) cause serious complications for a dog with kidney failure, and they need to be treated as a matter of some urgency.

Tony