Monday, February 8, 2010

Canine Kidney Disease

Mike and I moved back to Overland Park, Kansas in the summer of 2007 and when our veterinarian retired, we decided it was a good time to find a vet closer to our new apartment. Finding a new vet was not as easy as I thought. I researched a number of veterinarians, complied a list of eight and set-up interviews with each one. You would be surprised at the number of veterinarians I met with that had dirty offices and inflated egos. Marketplace Animal Hospital was last on my list and by the time I arrived for my appointment, I was tired, hungry and grumpy.

I dreaded walking into Marketplace Animal Hospital’s lobby. I couldn’t stand the thought of one more dirty office—but to my relief it was clean and nice. The office had wood paneling, large windows and a friendly staff. I met with one of the owners, Dr. Phil Radakovich. He was mild mannered, soft spoken, intelligent, personable and he had a very calming aura about him—but what I liked most about Dr. Radakovich was his philosophy on the role of a veterinarian.

Dr. Radakovich told me he feels it is a veterinarian’s job to provide his patients with the best care possible while providing the owners will all the information necessary to make intelligent, informed decisions. He also thinks it’s important to help guide the owners in making their decisions but to respect the decisions of the owners. Eureka! I struck gold! And if we felt lucky to find Dr. R., imagine our delight when we met his business partner, Dr. Jerry Immethun. He was just as professional, competent and caring as Dr. R.

There’s nothing better than knowing you have a great veterinarian staff to care for your pet’s health.

Since Molly died from an irreversible kidney disease, I wanted to include a post on canine kidney disease. Dr. R was kind enough to meet with me and share his knowledge of Chronic Renal Kidney Failure (CRF).

Dr. Radakovich explained that his desire to become a veterinarian was a culmination of many different factors: his love of animals, his exposure to science, his father being a science teacher, his desire to stay close to home while in college, his reading the James Herriot book All Creatures Great and Small and his experience working for veterinarians during high school and college. Dr. R said all these events led to the natural progression of attending vet school.

After earning his Doctor of Veterinary Medicine, Dr. R. moved to Chicago where he met his current business partner, Dr. Immethun. After several years of practicing veterinarian medicine in Chicago, the pair decided to open a practice in Lenexa, Kansas, as it was a halfway point between Dr. Radakovich’s family in Des Moines and Dr. Immethun’s family in St. Louis. So, in 1989 they moved their families from Chicago to Lenexa and opened Marketplace Animal Hospital.

Below is my interview with Dr. R. The information provided in this post should not be used to determine whether or not your dog suffers from kidney disease or kidney failure. If you suspect your dog is ill, please make an appointment with your veterinarian.

The kidney’s basic function is to filter out toxins from the body through the urine. What other purposes do the kidneys serve?

That’s probably most of it. They detoxify the blood, they concentrate urine, they have a compound called erythropoietin that is put out by the kidneys that stimulates red blood cell production. So, I would say those three things are probably the biggest. That’s why lots of times with kidney disease, dogs will be come anemic too and you wouldn’t necessarily think that but without erythropoietin, red blood cells aren’t stimulated in the bone marrow.

There are basically two types of kidney disease: Acute Kidney Failure and Chronic Renal Kidney Failure (CRF). If we’re talking about Acute Kidney Failure, which is normally the result of poisoning or external toxins, what products are particularly dangerous?

Probably the most common—and one of the most toxic—is antifreeze. That’s the one they get into the most. It’s because it’s sweet and sweet tasting and so once they start drinking it, they have no reason to stop; but the other reason is because it’s so readily available. I mean everybody has it. Everybody. It’s in the radiator and if you have a leak and it’s sitting in the garage or if you’re doing your own maintenance at home and you’ve got the bottle, I mean it’s just so common place.

The amount for when it becomes deadly, I’m sure depends on the size of your dog?

It doesn’t take much. It does not take much. If you catch it early enough I think it’s reversible. And it’s reversible by, sometimes they’ll use a chemical to bind the antifreeze, but it’s a lot of fluids as well just run through those kidneys to keep those kidneys from shutting down. Once they shut down, then you’re really—your back is against the wall.

Chronic Renal Kidney Failure happens because the kidneys aren’t able to remove the toxins?

There are a lot of reasons you’ll have chronic renal failure, and a lot of those reasons are unknown. But there are different parts of the kidneys that can be affected by different chronic conditions. The glomerulus, the nephrons—those things have different parts and different functions. One is for concentrating the urine. One is for sodium and potassium balance but chronic renal failure can affect different parts of that kidney; for example, amyloid.

Amyloid is a protein we don’t know very much about. Amyloid is a protein that they thought was going to be real diagnostic for people with Alzheimer’s too because they would find amyloid in the brain.

Amyloid can go to a lot of places. It can go to the brain, it can go to the heart, it can go to the kidney, and they really don’t know why that happens in some people but when it does go to those places it really screws things up.

Immune-mediated complexes are another reason that you can get these antibody antigen complexes that go and they set up house keeping in the kidney and that can be a reason for kidney failure.

Bacterial diseases, just aging, and loss of the glomerulus to do its job and the nephrons to do its job lead to that renal failure where you get azotemia and uremia—that’s where you’ll get the toxins that will start to build up in the blood stream. And the two proteins that are usually building up are BUN and creatinine. Basically, what those are is they’re by-products of metabolism in the body. You should have some in there, I mean they’re by-products and they’re going to have to be eliminated, and if they’re not eliminated and they start to become too high that’s when it becomes a toxic effect.

Why is kidney disease more prevalent in older dogs? I read that seven or eight years of age are about the average age for a dog to suffer from kidney failure.

Yeah. I think that kind of depends on the breed because you know the life expectancy of a Rottweiler, per say, is ten and the life expectancy of a Cocker is 16, and so you can see it certainly in younger dogs and you can see it in juvenile dogs. We had a dog in here one time that came in just for a routine neuter, just six months old, was a schnauzer, we did the preoperative blood tests and the BUN and the creatinine were off the scale. It had an inherited congenital problem with the kidneys, so I mean these types—chronic renal kidney disease, the bacteria, amyloid, the immune-mediated complexes, cancer, congenital problems—those are all things that can lead to a not very well-functioning kidney.

I’ve read that signs of kidney failure don’t normally show up until 70 to 75% of the kidney function has been lost. Why does it take so long to show up?

That’s a good question and it’s just the ability of the body to compensate. What would be a great discovery is if you could earlier predict kidney disease. That’s where it really needs to go. You’re monitoring BUN and creatinine values to do that, and for whatever reason you really have to have less than 25% of a functioning kidney for the BUN and creatinine values to go up. So you can be sitting there, theoretically, at 30% of a functioning kidney, and the dog would not only be acting normally but the blood work would be normal as well.

So you can start to maybe get some indication that the kidneys are not working maybe before that time by checking urine samples, and depending on the part of the kidney that might be damaged, there are clues in the urine that can indicate that. Too much protein being leaked out in the urine can be from kidneys, doesn’t necessarily need to be, can be. The inability of the kidneys to concentrate urine. So if you always have dilute urine versus concentrated urine, can be a sign of kidney problems although lots of other things can cause that as well.

The first signs of kidney disease are increases in thirst and urination. Other symptoms included vomiting, diarrhea, or loss of appetite. Every dog owner will eventually have a dog that has diarrhea or vomits or loses its appetite. What are you looking for? Are you looking for a combination of symptoms or symptoms that persist over a certain period of time?

I think you’re looking at combination of those things. You know if I’ve got a two-year-old dog that walks in with a history of eating barbeque off the grill that’s vomiting versus a 13-year-old dog that’s not feeling well, no history of eating table food, and vomiting, I’m a lot more concerned about that 13-year-old. So I think it’s a combination of those things. You’re taking in history, you’re taking in the age and what has happened in the dog’s life and is… kidney disease a common problem for a dog of that age?

And decreased appetite is a big one as well. Usually when they start to show signs of kidney disease, they just really don’t want to eat all that well.

When you bring your dog in for a diagnosis, you said you’re looking at history, urine tests, blood tests; what else can you do?

That’s a pretty good start. You’re going to start with those things. You can on the physical examine, sometimes these chronic kidney cases will have really kind of hardened, smaller, knobby feeling kidneys… and you’re feeling through the abdominal wall obviously, but if you have a nice, smooth feeling kidney that’s not hard and it’s palpating about the right size, that’s the way you like them to feel. But with chronic problems you’ll get those changes. So that’s one of the things we’re looking for as well.

If you have a dog that is starting to show kidney disease and you want to test further, then there are other tests that you can do: ultrasound; you can do biopsies of the kidney.

When Mike and I were deciding whether or not to have a biopsy done of Molly’s kidneys, one of the things I read was that if they already have kidney disease and you go in and do the biopsy, it enflames the kidney and can make it even worse, is that true or is it one of those myths?

When you start to get those invasive diagnostic procedures, I think you have potential of making things worse. You have a small biopsy punch but on the other hand you’re going into an organ, and so yeah, I think the potential is there.

But say for example, about the only time in my opinion that I think you’d want to do a (biopsy), and maybe there’s others, but this is one I can think of right off the top of my head, where you’d want to do a biopsy is if you’re suspicious of an immune-mediated problem, because how are you going to treat an immune-mediated problems? You’re going to bomb them with cortisone is the way that you’re going to do that. Well, cortisone is not the greatest thing to be on, and now if you had a diagnosis of—yes this is an immune-mediate problem—okay great, you know you need to go with cortisone, but that’s a tough diagnosis to make without a biopsy. So then you’re kind of sitting there, okay, if you don’t do a biopsy then you’re trying to figure out, okay, is this an immune-mediated problem that cortisones may help or is it not?

If you go with the cortisones and it’s not an immune-mediated problem, does that make everything worse?

It can… and that’s why you don’t necessarily like to do that. And the other thing about the cortisones, is not only that it can make it worse for the patient if it’s not the case, but cortisones are going to cause the pet to drink more and urinate more too. Now you have the owner going through maybe a dog who’s not getting up to go to the bathroom and just making more messes around the house, and you’re really not quite sure whether you need to be on that high dose of cortisone or not. So there are other reasons to do it as well. But those, and of course if you have kidney disease, and I mentioned this before I think, where sometimes they’re bacterial in origin. Well then you try to find the bacteria so you can know whether you need to be on a specific antibiotic or not. So then there are serology testing and blood tests that you look for antibody titers. Usually, you typically have to start some medicine before that time, so a little bit it of it is guess work as well.

Since there is no cure for Chronic Renal Kidney Failure, early detection is important. Do the treatments options, fluid therapy, diet, medicines, only help to a certain point? Are we talking about just prolonging your dog’s life anywhere from a couple of months to a year?

And the answer to that question really could be determined more exactly with a kidney biopsy, because you’re going to find out how much of functioning kidney tissue you have left and without that it’s hard to know how much time to say. Some dogs will live for years with Chronic Renal Failure.

Any last thoughts or comments on kidney disease?

I really like the foods that are out now. The problem with those foods is sometimes the pets don’t want to eat them and then you’re really stuck between a rock and a hard place.

It’s a condition that we see so much of, but thankfully it usually doesn’t happen until they’re very old and then the body just kind of wears out. They start acting sicker as those toxins start to build up. It’s a tough, tough disease because there are so many different things that can cause it—so many different things and part of the treatment is based upon the cause, and sometimes you don’t know the cause exactly and without going through all the diagnostics, which it’s hard to take your dog for a kidney biopsy, when, like you said, there’s the potential for making things worse.

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