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Chronic Kidney Failure in Dogs Community
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Avatar universal

Stage 2 chronic kidney disease in 18 year old rescue terrier

Hello--thank you for providing some of the most comprehensive information on managing chronic kidney failure in dogs that I’ve been able to find.  I have an ~18 year old terrier mix rescue dog who developed chronic kidney disease--stage 2, about 2 weeks after an episode of acute pancreatitis—now about 7 weeks ago.  He had been on metacam for degenerative joint disease (elbow, spine, hips) for about 2 years, so we have been monitoring his blood work at least every 6 months.  His creatinine had been creeping up slowly, but entered the abnormal zone at 1.8 after (but not during) the pancreatitis, BUN was 76 (BUN/Creatinine ratio 42), potassium 5.6, sodium normal (148), phosphorus not tested.  Urine was tested only for infection (no protein other analyses done).  Blood pressure not tested. Radiographs revealed an enlarged liver (present for several years) and kidneys at lower limit of normal size (new finding).  Prior to the pancreatitis, he sporadically leaked urine at night, but about a week before his pancreatitis emerged, it progressed significantly to every night, and during the day during long periods of sleep.  This has naturally persisted, along with classical symptoms of increased water intake.  To address his pancreatitis, he was placed on a low fat prescription GI diet (Royal Canin), which I have maintained, but I supplement with canned food (fat < 5%, protein 5-10%) and home cooked food (chicken/sweet potato/pumpkin/green beans/mixed vegetables/rice/flaxseed meal).  Although he seems to have recovered from the pancreatitis--he is active, enjoying his daily short walks, OK appetite (this fluctuates—I rotate his food to avoid associations with feeling sick), he has also developed sporadic episodes of trembling that seems to be increasing in frequency over the last week or so, which I assume will worsen as his disease advances.  My vet has discounted the trembling in spite of the high potassium at diagnosis, but I have made an appointment for 2 days from now for blood work and re-evaluation (hate to subject him to another urine test, which my vet does by cystocentesis).  He was prescribed subcutaneous lactated ringers solution 3 x week at home, but is not tolerating this well—it stresses him out.  Once the new blood tests are done, I will definitely follow the advice in this forum to deal with the issues with diet (and will post again), but I am struggling with the stress he experiences with administration of subQ fluids.  I know it is supposed to delay progression, but it is difficult to balance the stress against the suffering caused by kidney malfunction, and I do believe that he suffers with it.  He has also developed extreme restlessness in the evening before settling down to sleep (perhaps driven by hunger, but he often won’t eat additional food after his evening meal—I feed him a small meal in the morning/larger meal in the evening), and sensitivity to sudden exposure to light (such as when we walk into the sun).  His musculoskeletal pain seems controlled with 25mg tramadol twice a day.  By the way, he has too numerous to count skin tumors—mostly sebaceous adenomas—but had a malignant melanoma removed about 3 years ago—it doesn’t appear to have spread, unless his enlarged liver is an indication.  I would like to limit any procedures/trips to the vet to only that necessary to reduce his discomfort.  I am very afraid of him dying without me in the vet’s office—I prefer home euthanasia when the time comes.  Like others in this forum, I struggle with not knowing how long he will last in this state, and with identification of when the bad days outnumber the good.  Do you have a sense of what I might expect from my description? Any advice about management (I know this is a long thread) would be greatly appreciated. Thank you for reading through all of this!  
19 Responses
1916673 tn?1420236870
Hi. I can empathise with your concerns. It really is a balancing act trying to work out what is the best management/treatment for an older dog's group of health concerns. Often, helping one condition simply antagonises another, so all you can do is work on priorities and quality of life.

You may already know that the pain meds will cause some deterioration of the kidney disease and increase the toxin build-up in the blood stream. But, if giving the meds seems to reduce any pain your dog is experiencing, then it's a valid choice to make.

I am amazed your vet has not undertaken phosphorus testing - or taken a blood pressure reading - or checked urine for protein leakage. These are fairly critical tests and should be performed. Without them, you and your vet are working blind and not getting all the information you need to help your dog.

The other thing I would mention is about feeding. If you can arrange it, try to feed smaller meals more frequently - the ideal is every 2 to 3 hours - but with each meal being a tiny portion (so total daily intake meets guidelines for the breed and size of your dog). These smaller but more frequent meals reduces the workload and stress placed on the kidneys and helps to minimise any nausea. It also reduces toxin build-up and encourages appetite and eating.

Pancreatitis is a common problem and you are right to reduce fat intake to help guard against it happening again. To do this, you will need to ensure the normal fat content is replaced with viable carbohydrates. Sticky white rice, sweet potato and couscous are useful ingredients you can use in rotation.

At stage 2, protein isn't a huge issue (though more recent bloodwork results will be helpful to confirm it). You can provide up to 15% protein content in the food you provide, although low-fat protein sources would be advantageous. The protein you give should be high quality (human grade meats and poultry). Once the kidney disease moves into stage 3, then protein restriction becomes more important. However, what IS important right now is to restrict phosphorus. Phosphorus build-up causes huge problems in kidney disease. If phosphorus shows abnormally high in blood work results, then a phosphorus binder will be necessary.

Hope this helps.

Tony
3 Comments
Thank you Tony--you are really quite amazing!  He resists eating more frequently, though he will eat spoonfuls of his favorite foods (mostly chicken--always human grade, though I'm not sure how good any of our meat is anymore--I do my best to select reputable organic sources--I'm a vegetarian myself). There seems to be a volume threshold for nausea upon eating, and he is highly sensitive to pain or discomfort under the best circumstances.  Your answers on this forum have really helped me identify the information/practices needed from my vet--I will be requesting a complete blood panel when I take him in tomorrow, along with more complete advice for treatment based on the results.  It has bothered me too that we don't have the information needed to make the best decisions, and I'm really worried about his trembling--he wakes up during the night with it, and seems uncomfortable.  It's great to know that up to 15% protein is OK at this stage, and I'll be working to fill in with carbs.  Is there a maximum amount of phosphorus I should feed, or should I just try to keep it as low as possible, with guidance from blood levels?  I do think the tramadol is necessary, since we stopped the metacam as soon as he developed pancreatitis.  It's a real culprit for the kidney.  Finally, do you think that stopping or reducing the frequency of the subQ fluids is really not advisable?  It is tough on him, especially because of the need to maintain healthy skin around his skin tumors.  He sleeps about 21-22 hours a day but is mostly engaged and alert otherwise, so I don't think we are looking at letting him go yet.  Thank you again.
Thank you Tony--you are really quite amazing!  He resists eating more frequently, though he will eat spoonfuls of his favorite foods (mostly chicken--always human grade, though I'm not sure how good any of our meat is anymore--I do my best to select reputable organic sources--I'm a vegetarian myself). There seems to be a volume threshold for nausea upon eating, and he is highly sensitive to pain or discomfort under the best circumstances.  Your answers on this forum have really helped me identify the information/practices needed from my vet--I will be requesting a complete blood panel when I take him in tomorrow, along with more complete advice for treatment based on the results.  It has bothered me too that we don't have the information needed to make the best decisions, and I'm really worried about his trembling--he wakes up during the night with it, and seems uncomfortable.  It's great to know that up to 15% protein is OK at this stage, and I'll be working to fill in with carbs.  Is there a maximum amount of phosphorus I should feed, or should I just try to keep it as low as possible, with guidance from blood levels?  I do think the tramadol is necessary, since we stopped the metacam as soon as he developed pancreatitis.  It's a real culprit for the kidney.  Finally, do you think that stopping or reducing the frequency of the subQ fluids is really not advisable?  It is tough on him, especially because of the need to maintain healthy skin around his skin tumors.  He sleeps about 21-22 hours a day but is mostly engaged and alert otherwise, so I don't think we are looking at letting him go yet.  Thank you again.
Hello Tony--Again, I appreciate your help.  Just to let you know, I just returned from my vet, who was very receptive to all of my questions and concerns.  Hank's blood pressure is slightly elevated, but not to a threshold that triggers treatment.  Phosphorus, potassium, calcium, sodium levels all within normal limits.  We don't have an explanation for his trembling, but I'll keep an eye on it.  In spite of his age,  he's doing remarkably well, and since his disease is in the early stages, I can concentrate on his diet as treatment, with a goal of delaying progress and keeping him comfortable and as stress free as possible.  I really appreciate your advice.  I'll be following this user group regularly and will post what we experience.  Hopefully it will be helpful to others too.  Take care--
1916673 tn?1420236870
Hi. There isn't a marker for phosphorus reduction and it would actually be really hard to achieve one, even if one existed. Phosphorus is in all foods, so it's just important to try and restrict the intake by choosing the appropriate foods. There comes a point in kidney failure when diet restriction of phosphorus doesn't work and a binder is then required, in addition to diet restriction. The blood tests you are having done should prove interesting, so please post them once you have a copy of the results.

The trembling is almost certainly associated with muscle wastage - but it could also include some neurological changes. Again, the blood test results are crucial, because they will show if some of the essential nerve transmitting minerals are abnormally low or (more usual) abnormally high. These will include sodium, potassium, magnesium, calcium and others. When the blood numbers become askew, the kidney disease deteriorates, and the trembling can develop into small seizures. It's therefore worth getting things under control as much as possible, as this will help reduce the symptoms.

SubQ fluids are useful in helping get the blood levels under control, so I would try to keep going with it, at least for the time being. The blood test results will tell you whether it remains necessary. SubQ fluids also help deal with any dehydration, which is very common in kidney failure dogs and causes lots of problems - and can even by life threatening if not dealt with.

Tony

I have just caught up with your 2nd message, so some of what I have said above may no longer be relevant. What were the creatinine and BUN levels like? I am posting you a link about tremors and shaking in canine kidney failure. This is one of my own articles and I think it will be of value to you. http://www.infobarrel.com/Tremors_and_Shaking_in_Dogs_with_Kidney_Failure
Avatar universal
Thank you again Tony.  Sorry for the delay in my response--I am discovering that this forum isn't optimized for Mac/iPad/Safari users, so I am now using different devices and browsers.  

Anyway, the vet did not repeat the BUN and creatinine, and didn't believe that they would change much in such a short period of time.  Exam included blood pressure and ocular pressure measurements, along with testing electrolytes/minerals.  She didn't think that the trembling was due to kidney issues, since he only recently converted to a 1.8 creatinine level after several years of monitoring every 6 months.  In addition, his trembling appears to occur primarily during sleep at night, and continues after waking for several hours.  He is unsteady upon waking, but that resolves during the day.  I read your article (thank you) and it focuses a bit on trembling in later stage kidney disease, so she may be right.  However, I will be monitoring and documenting to see if the trembling is associated with something specific, or has a trigger of some sort.

I read the other articles you've posted on infobarrel and find them very helpful--you distill information to the most essential points in a kind way.  I feel that I now have the information I need to move forward with my little Runaway Hank--especially with your recipes.  I will focus on limiting both phosphorus and sodium, and will try to balance high quality protein with vegetables with his low-fat food for his pancreatitis.  

I expect to be back to the forum on a regular basis.  Thank you again, and take care--
Avatar universal
Oh, and I meant to indicate that I will be requesting follow-up blood and urine testing on a regular basis to make sure I'm on track.  It will help me cope with the relative unpredictability of his kidney disease, and as you say, will make me less blind!  Take care--
1916673 tn?1420236870
Hi. I'm very pleased you found the articles of some value ... I try my very best to give all the info necessary, but in a fairly straightforward and easy-to-digest manner.

I am a little surprised your vet doesn;'t think creatinine (even more than BUN) is a necessary test to be included. To be honest, I find it extraordinary. Creatinine is THE key test for degenerating kidney disease. It can also change dramatically and very quickly over a very short period of time. Without this test being done, you nor your vet cannot gauge whether the disease is under control or deteriorating. Personally, I would absolutely insist on the test being done.

Feel free to come back any time ... ask questions, contribute to others that post and need support or just keep us updated with any changes that may occur.

Regards

Tony
Avatar universal
Sigh--I know, it was surprising to me again.  Apparently they run some blood panels in house and some are sent out, and it doesn't appear that any one of them has all the measurements we need.  By the time I figured out that they didn't add the phosphorus, sodium, potassium etc to an existing panel that also included creatinine and BUN, they were already finished with him.  Next time I will ask to go over all the panels available (I would think that they would have a kidney specific panel, with such a high prevalance of kidney disease in older dogs) and make sure all the right measurements are done in the future.  

I have access to scientific journals and found a trend toward the use of serum SDMA to detect kidney disease prior to elevation of creatinine.  It doesn't look like it will be useful for monitoring progression though.  In addition there are some recent studies of commercial kidney diets, typically limited in scope, but they basically confirm the benefit you've indicated.  If you'd like, or you don't have access to journals yourself, I'll be happy to either provide pdf copies of papers or a list results from a search. Not sure I can do that in this forum.  

Hank woke up very sore from his arthritis this morning, mostly in his right elbow--it's been most affected these last 6 months. I'll probably need to give him an extra dose of pain meds, but I'll know more after we are up and moving. He had a subQ LRS treatment Thursday, so he is feeling better from the kidney point of view.  

Just another day in the life of a geriatric dog. It's a roller coaster.

Thank you again--

Wendy
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