Kidney Disease? (Was Incontinence)

[greyhead]

A month ago we were struggling with Shane's year-long incontinence and months-long UTI (E. coli). Here's that thread: UTI & frustration Went to an internist, got another week's worth of Orbax and did a cystocentesis -- twice! because the lab messed up the first sample. The UTI appears to have cleared, though he wants to test again in two weeks. He seems to think stabbing my puppy in the bladder with a needle three times in one month is a trivial thing, like a blood draw. Shane begs to differ!

But the worst part is -- well, there are two worst parts. First, Shane's always 2.1 - 2.2 creatinine is now 2.5, BUN is 33, and his specific gravity went from 1.015 to 1.014 during the week between the two cystos. Oddly, his phosphorus, which has been a tad low for the past year, is still a tad low. The recommendation is to put Shane on prescription renal food, and this doc doesn't buy the early stage and late stage distinction in feeding protein. This makes me nervous cuz I do buy it, but my experience is limited to two previous cats with CRF. Moreover, he wants to put him on enalapril, 20 mg twice a day, to reduce glomerular pressure in the kidneys.

 

Second, he thinks Shane is incontinent and that this may have caused the UTI. (His report is vague enough to allow the possibility that the UTI caused the incontinence.) And he guesses the kidneys are related to all that somehow. (He emailed me his report but we only spoke briefly because of bad cell phone connections.) SO, he wants Shane to take Proin. I asked if he'd taken Shane's BP when he saw him. He said no, that they would check it in two weeks. EESH! He considers remote the possibility that anything bad could happen, like a stroke, before then. Does that seem a bit casual to you? (He's an internist, but he's young and he works in an ER environment, so he hasn't seen the world, so to speak.)

 

Okay, here's what I think, and I want to know what you think too, please. I'm not giving the Proin, because his overnight pad only weighs 2 oz. or less in the a.m.! We're home all day and let him out frequently. I'm not bothered by the drippage, so I'm not taking the risk of that medicine. The kidney values do concern me. I will give him the enalapril starting tomorrow (because we'll be out this afternoon and can't watch him), and we'll see how he does. I've already started him on Royal Canin MP, which has 14 grams of protein. (He had been on Wellness Core at 33% and then First Mate at 24%.) We had been giving him a little milk every day this past year to raise his phosphorus, but I've stopped that. We'll recheck all his values in two weeks and see where we are. Meanwhile, his acupuncture vet will be ordering him some herbal pills; she's trained in Chinese medicine, and I trust it.

 

I also think his urinary tract could use a tune-up of some kind after all this time of infection and antibiotics. I just don't want it to be Proin. Have any of you tried testosterone in this or any other circumstance, or do you know of anyhow who has? Any literature you can point me toward? I know our regular vet doesn't like the potential of aggression, but I'm less concerned about that than stroke with this dog.

 

Also, I've seen Shane's kidney, SG, and liver values fluctuate up and down, though within a narrow range, since I've known him! That's almost five years. He was dx'd and tx'd for Babesia last year, after which the "incontinence" started. He had been "incontinent" once before, two years earlier, but that went away when the vet threw an antibiotic at it (without a culture). So is there any hope that this situation could also rectify itself, like when his bladder and everything have recovered more fully from his extended UTI? The only other relevant fact to consider here is that he has been supported by acupuncture and the herb rehmannia (on and off) all these years too, and of course his acupuncture vet would say that's why he has done so well up until now.

 

Sorry for another long post. Please address any or all of these questions to the extent that you can. I welcome both experience and speculation and will be *very* thankful for your shared thoughts. I've been going crazy with this situation for months, have gained 15 pounds, and feel like I have a lot to learn to be a proper advocate for Shane in this situation.

[gracegirl]

I'm going to start with just offering hugs, because as you know we are going through a similar thing here. I'm planning on getting Fenway's ultrasound report and taking him to an internal specialist in the next few weeks. I want to recheck blood and urine (free catch, first of day).

 

Fenway's only "off" value is the specific gravity of his urine. His only symptom is peeing more often.

 

The ultrasound finally gave us the answer to his kidney problems.

[Guest 2dogs4cats]

Hmmm...I am a little confused by the lab results. The urine isn't concentrating, but the Phosphorus is low. I am so glad you are not giving Proin. I wouldn't either and it wouldn't work anyway if the incontinence is due to kidney disease. I also wonder why the vet is wanting you to give a low protein diet when the phosphorus is low? I feel like I am missing a piece of this puzzle, but not sure what it is yet. Was there protein in the urine? How much does he drink and pee? Is the incontinence just dribbles or full pees? How old is Shane? Sorry for all the questions. In my opinion, the low protein diet is to keep the phosphorus level low, but this has been debated on the board before about renal diets. The old school thinking is that the protein will harm the kidneys by making them work harder. I have had my pup on Chinese herbs also and that has really seemed to help her kidneys, so YAY that you have also gone that route. If I were you, I might get a second opinion. Send the labs to another vet and see what they say. Good luck and hugs.

[greyhead]

Oh, I'm with ya on that confusion thing! Shane is 8, there's no protein in his urine. He had a couple full-on peeing accidents, and his leakage used to be significant. But since treating the UTI the leakage is negligible. He is also not drinking and peeing as much as he did when he had the infection, and I'd say his consumption and output are almost normal.

 

Gotta run cuz we're out doing stuff in the world and just checking in here for a second. Thanks for thinking about this. I'll be back in a couple hours!

 

ETA: Back to the phosphorus thing... Shane has been having gigantic poops for a year or so too, which is why I switched him from Natural Balance and put him on Wellness Core, on which he had done well in the past. Well, poops still huge, same on First Mate, and same now on the kidney food. So that fact combined with the low phorphorus suggests to me that he's not getting the most out of his food! How this relates to his kidneys, if it does at all, I'm not sure, but the internist isn't addressing it whatsoever. It's weird!

Edited April 6, 2011 by greyhead

[tbhounds]

Forgive me-- must admit I just skimmed your post as I'm running out the door in a minute but, a few things come to mind. I would get a blood pressure- is there protein in the urine? Was the urine submitted a first a.m. sample? That's a pretty high dose of enalapril-- 20mgs bid?? If your vet feels your pup may be dealing with GN and is fearful of your pup throwing a clot you might want to talk to him about starting a low dose (like 20mgs) aspirin daily.

Finally, you might want to consider home cooking for your pup if your vet feels strongly about a diet change.

Oh- one more thing-- personally I am fearful of proin-- I know many have their hounds on it but, you won't find if in my house-- ask about DES instead. Side effects are very

very rare but, you do need to monitor CBC's.

Edited April 6, 2011 by tbhounds

[greyhead]

Isn't DES for girls, though? I thought testosterone was what you give to boys to accomplish the same ends.

[tbhounds]

Isn't DES for girls, though? I thought testosterone was what you give to boys to accomplish the same ends.

Oops-- I didn't realize we were talking about a boy pupper-- I truly did just skim. Had to run out quickly to deliever a hound I have been pupsitting!

[Batmom]

Anything else abnormal (or close to abnormal) in his bloodwork?

 

Has he had an x-ray / ultrasound of the bladder?

[JJNg]

I believe there are different schools of thought on this, but in general, enalapril usually isn't used in kidney disease unless/until there is protein in the urine and/or if blood pressure is high. Why does your internist feel Shane's glomerular pressure is high? If it was high, there should be protein in the urine.

[greyhead]

Anything else abnormal (or close to abnormal) in his bloodwork?

 

Has he had an x-ray / ultrasound of the bladder?

His regular vet x-rayed the bladder some weeks ago and saw nothing abnormal. (The urinary system was somewhat visible on his spinal MRI in December, and nothing jumped out as problematic. Ultrasound is the next thing I'd want to do, of the kidneys on down, if things don't improve. Nothing else in his blood work was abnormal or close (exept his platelets are kind of high for a GH at 261, aren't they?).

 

WBC 6.8 K/uL 6.0-17.0

RBC 9.13 H M/uL 5.50-8.50

HGB 22.2 H g/dl 12.0-18.0

HCT 64.5 H % 37.0-55.0

MCV 70.6 fL 60.0-77.0

MCH 24.3 pg 19.0-25.0

MCHC 34.4 % 32.0-36.0

Platelet count 261 K/uL 200-500

Differential

Count: % ABS

Polys 78.3 5350 /ul 3600-11500

Lymph 15.3 1050 /ul 1000-4800

Monos 2.8 190 /ul 150-1350

Eos 1.9 130 /ul 0-1250

Baso 1.7 120 /ul 0-500

COMMENTS: Slight acanthocytosis

Spun hematocrit = 61

CBC

Glucose, Serum 121 mg/dl 65-130

BUN 33 H mg/dl 6-29

Creatinine 2.5 H mg/dl 0.6-1.6

Sodium 151 meq/l 140-158

Potassium 4.3 meq/l 4.0-5.7

Na/K Ratio 35 27-40

Chloride 113 meq/l 100-118

Carbon Dioxide 21 meq/l 18-26

Anion Gap 21 13-25

Calcium 10.0 mg/dl 8.0-12.0

Phosphorus 2.5 L mg/dl 3.0-7.0

Osm, Calc 307 270-310

Total Protein 6.5 g/dl 5.4-7.6

Albumin 3.5 g/dl 2.3-4.0

Globulin 3.0 g/dl 2.4-4.4

Alb/Glob Ratio 1.2 0.6-1.2

Bilirubin, Total 0.1 mg/dl 0.0-0.5

ALP 57 U/L 10-84

GGT 0 U/L 0-10

ALT 54 U/L 5-65

AST 40 U/L 16-60

CK 130 U/L 50-300

Cholesterol 176 mg/dl 150-275

Amylase 759 U/L 300-1500

Lipase 187 U/L 0-425

Edited April 7, 2011 by greyhead

[greyhead]

I believe there are different schools of thought on this, but in general, enalapril usually isn't used in kidney disease unless/until there is protein in the urine and/or if blood pressure is high. Why does your internist feel Shane's glomerular pressure is high? If it was high, there should be protein in the urine.

Thanks for pointing this out. What he said to me is that IF the glomerular pressure is high, the enalapril will reduce it. So you see why I'm confused. The way it appears to me is that he doesn't have a lot of experience with this, and he clearly doesn't have much greyhound experience because he wasn't aware of the fact that a slightly elevated creatinine is not unusual in the breed. I went ahead and bought the enalapril at the drugstore, but I haven't administered it, and I don't think I will for now.

 

Do you know of greys or other canines who have been treated with testosterone instead of Proin to tune up the urinary tract? And do dogs ever take these meds temporarily and then get off of them after improving? Many thanks for your expertise; I was hoping you'd show up here!

[JJNg]

Hmm...I guess since you were seeing an internist (I'm assuming board certified, DACVIM?), I kind of assumed an abdominal ultrasound had already been done. Every time I refer a patient to our local internist for kidney disease or chronic urinary tract issues, they almost always do a complete abdominal ultrasound, which gives you more detailed info than an x-ray. With a male with chronic UTIs, I would want to have a good look at the prostate - while unusual in a neutered boy, wouldn't hurt to make sure that's not the source of the infection. And there are also some types of bladder stones that don't show up on x-rays and would be seen on ultrasound. Maybe the MRI in Dec already included these areas? Or if they've been doing ultrasound-guided cystos, maybe they got a look already?

 

Regarding testosterone...I only have experience with 1 dog. Older labrador who was incontinent and and didn't respond to Proin. We ended up using a combination of Proin and monthly injections of testosterone cypionate, which improved the incontinence to a point that was more manageable but still didn't completely resolve it. This dog didn't have any side effects, no change in behavior, and the owner even mentioned that he was aggressive toward other male dogs before he was neutered.

 

However, it's not something I would recommend unless you are fairly sure it's truly incontinence and all other possibilities have been ruled out. If it's really incontinence due to poor sphincter tone, it's unlikely that you can stop the meds, especially with a male where incontinence usually isn't seen until there are other complicating factors that increase urine production. In treating females with Proin, I have found that a number of dogs can be weaned down or off the medication and be fine for a period. But most end up showing signs again after a while.

 

Personally, if the incontinence is mild and manageable, I'd consider alternative options, like herbs and acupuncture before going to meds. Has your acupuncture vet specifically treated Shane for his incontinence issues?

[kudzu]

I'm curious about some things. Was Shane maybe a little dehydrated when this blood work was run? What is this vet's explanation of how Shane's incontinence may contribute or cause UTI? What is his rational for prescribing Proin to a dog with suspected renal dysfuntion/damage. Have you asked him what the impact may be of feeding a low phos diet to a dog displaying hypophosphatemia on at least the last two sets of blood work? (I'm not knowledgeable about this, just a question I would ask if it were my dog.) Did he comment on the acanthocytosis?

 

Here are a few thoughts that came to mind while looking at Shane's blood work. Yes, his platelets look high compared to the info I have on Greys. Also, his RBC, HGB & HCT look at the highest part of or maybe even slightly higher than average for a Greyhound. Not saying that's bad or good just eye catching to me when thinking of pets with renal probs who are usually low normal or below. His total protein might be high for a Grey. No idea if that is significant. How long has Shane had hypophosphatemia? What was his Ca:Phos ratio on prior lab work? The above shows it is currently 4.0. I went back through my own dogs' lab work results, one of whom had nephritis & later CRF. The results showed ratios ranging from 1.79 to 2.34 with their individual average ca:phos ratio between 1.90 & 2.07. Have no idea what that means or if it matters that Shane's is marked different. Would feeding a low phos diet to a dog with hypophosphatemia be detrimental? Not saying it would, just pondering possible effect if any.

 

This item was in my files. (Cannot remember why, perhaps related to rhabdomyolysis.) Anyway, here it is from Hypophosphatemia: Clinical Consequences of Hypophosphatemia by J Amanzadeh, RF Reilly:

 

Rhabdomyolysis

The effect of chronic hypophosphatemia on muscle function and composition in dogs fed a low phosphorus diet for 4 weeks has been examined. Average resting transmembrane electrical potential difference fell, and muscle Na+, Cl- and water content rose. After 4 weeks of phosphorus repletion, all of these variables returned toward control values. The authors concluded that moderate phosphorus depletion can induce reversible changes in the composition of skeletal muscle and transmembrane potential in the dog.[42] In hypophosphatemic dogs a subclinical myopathy might set the stage for rhabdomyolysis if acute, severe hypophosphatemia is superimposed.[43]

 

Those are all just things that I would wonder about if it was my dog but I tend to get a little lab work obsessed at times. Do you keep a spreadsheet on Shane's blood work to keep a running comparison? It's helped me on occasion.

 

[side note: Charting lab work helped me notice a trend my little foster dog's blood work. Researching what those changes might mean alerted me to possible Cushing's disease instead of just skin allergies for a foster dog. (Umtil then I knew nothing of Cushing's.) This dog was scheduled for an appt with a new vet, the fourth to see this little dog. Vet was examining her & commenting on seasonal allergies causing her skin infections, possible treatments, meds, shampoos, etc. I brought the change in blood chem to the vet's attention. She then stopped, stood back & stared at the dog. Said something like, "Hmmm, I wonder..." Then she went into the back & brought out a text book pointing to a picture of a stereotypical Cushingnoid dog. That dog & my foster were nearly identical. She did indeed have Cushing's.]

[greyhead]

Jjng, I checked the ACVIM site, and he doesn't appear to be board certified. Is that something it takes a while to accomplish or something that can be done right out of school? But I do think we won't be going forward with him because I don't trust his expertise at this point. We haven't gotten to speak much since the test results. When we did I felt he was defensive in the way that very new practitioners often are. So I'm not holding out hope that discussion with him will resolve anything. He did want to do an ultrasound but then checked with the neurologist who did the MRI, who told him that the prostate was tiny. He said the prostate was the main thing he wanted to know about at that point, so we held off, awaiting urine culture results. I don't know if he asked the neurologist about the stones that x-ray wouldn't have shown. His regular vet was comfortable from paplpation, behavior, and the x-rays that stones weren't the problem. Do you think I should have an ultrasound done even if the urine leakage remains as small as it is (i.e., 1 oz. overnight)?

 

I guess we'll reculture the urine in a week or so to see where infection stands. Do you think we should do another cysto for that? I hate putting Shane through it when I'm perfectly capable of running a plastic container through the sterilizing cycle on my dishwasher! Thanks much for sharing your experience on the testosterone and proin. I don't know what to think about whether it's incontinence truly. As I mentioned somewhere before, he had this problem about three years ago, the vet considered it incontinence, I said he's only 5-1/2, and she said that didn't matter. Without culturing, she gave him an antibiotic to humor me, and the "incontinence" stopped, never to reappear until last year after his TBD treatments. And it continued for months (March to August) until Shane got floppy and refused food, at which point I requested a culture, the E. coli turned up, and the antibiotics were started -- and stopped and started and stopped and started -- until they were stopped finally 2 or 3 weeks ago. (Whenever they were stopped, the leakage increased, and then lessened when the med started again. It stopped entirely for two weeks in late December!) I can't help but feel that the way the infection was (not) treated affected Shane adversely. Not looking to sue anyone, just trying to understand what happened so Shane can be helped appropriately.

 

But whatever the cause, it sounds as though sphincter tone, once truly gone, can't be regained. It can only be imitated through medication. Did I get that right? And the last time Shane had it, sphincter tone, was December.

Edited April 7, 2011 by greyhead

[greyhead]

Kudzu, I knew I liked you! You have the same questions I have and a few more! YES, he was dehydrated I'm sure, as he had been panting intensely for a half-hour! I even asked if they could get him some water but I don't think they did. So which values do you think would be most suspect as a result? No, he didn't comment on the acanthocytosis, and I wonder about that too. When I Googled it, it sounded scary. What do you think about it, could it be a transient thing?

 

I had a list of questions for him yesterday, the implications of the phosphorus being one of them. But as I wrote in my last post above, we didn't really talk. (He was calling cell phone to cell phone, I asked him to call back on the land line, he redialed the cell phone, it required yelling to be heard, I had a migraine, and I could tell he was going to be defensive by his answer to my question about why we were giving enalapril! So I said: Ya know what, I'll email my questions to you, and he said fine. I haven't done that yet cuz I'm listening to my GT peeps first! (And I may not even bother, I may just change vets. At the very least, I'll talk to the acupuncture vet about all this, since she made the referral in the first place. My sense is that she won't entirely approve of his treatment plan.)

 

I haven't kept a spread sheet but will probably start. The hypophosphatemia popped up a year ago, around the time of his TBD treatment; I'm not sure if it was before or after the treatment, but I can check. It was borderline like it is now, and the recommendation was to give him a bit (1/4 to 1/2 C) of skim milk daily. We've done that, using 2%, but not religiously -- more like a whole cup every 2-3 days. I know there are medicinal interventions, and perhaps its time to ask for one since the milk hasn't changed it. Shane has lost his beautiful thigh muscles over this last year, now that you mention it.

 

His protein might be high for a grey because before the renal food, he was on high-protein food. Wellness Core Low Fat has protein of 33%. I'm thinking I'm going to have the blood work redone locally and when he's not dehydrated. (The internist is 45 mostly-high-speed minutes away, giving Shane plenty of chance to stress.) Meanwhile, I'm taking him off the renal food and not giving him either proin or enalapril. What I *really* wonder about is this: Why is a dog on first-rate food producing gigantic amounts of poop? He has been doing that for a year too, although they are elegantly formed logs of which we've been inordinately -- and perhaps inappropriately -- proud. He was eating Natural Balance venison and sweet potato along with Spencer. So I changed him to Wellness to see if the poop quantity would decrease. It didn't. Nor has it decreased on First Mate (24% protein and also grain free) or on the Royal Canin renal. So between the poop quantity and the low phosphorus, I have to wonder about how Shane is processing his food. Any thoughts on that? (It'd be so much easier if the poops were loose, I know.)

 

Many, many thanks for all this help, to both you and jjng this morning!!! I've been a bit of a mess with all this, and it really helps to know it's not "just me" having these concerns.

Edited April 7, 2011 by greyhead

[Guest Swifthounds]

Forgive me if I've lost track, but did you have an abdominal ultrasound done?

[greyhead]

What, you don't want to read my *tomes*?! No, no abdominal ultrasound done. Yet.

[Guest Swifthounds]

I write a novel to rival War & Peace in response to requests for advice, so I could hardly complain. I read the initial post, but not sure I haven't missed a post in the last day or so while my only Internet access has been my phone.

 

The ultrasound isn't cheap, but it will give you a lot of information about organs, kidneys, and the bladder.

[Guest Stripeyfan]

Only just seeing this! I am so sorry that Shane's problems are continuing. I'm afraid I have no advice re the kidney stuff, but I agree that your vet seems a little casual about BP checking. As you know our old vet was extremely dismissive when I suggested Kelly's problems were from worm damage and... well, you remember how THAT turned out. If you're willing to pay to have Shane's BP checked and it help, how on earth can that be a bad thing??

 

Sending lots more hugs to you and Shane. Kelly sends a greyt big wag too! We are thinking about you guys.

[greyhead]

Personally, if the incontinence is mild and manageable, I'd consider alternative options, like herbs and acupuncture before going to meds. Has your acupuncture vet specifically treated Shane for his incontinence issues?

Sorry, I forgot to address this. The acupuncturist has been focusing on his lameness for most of the time, but she has also given some attention to his kidneys (with creatinine around 2.1 for years) and incontinence. She only comes to town every two weeks, so Shane sees her once a month, as does Spencer for his LS and IBD. So I may have to start taking Shane in every two weeks to get more attention to this problem. And she was just waiting for the urine culture and blood work before ordering Shane's herbs. (She usually mixes her own concoctions from powders, but I'm skittish about contamination and prefer pills, which she understands.)

 

Stripeyfan, thanks for your good wishes and those of Kelly. Happy woofs to him from my boys! Yeah, Shane's not getting proin without a BP check, and he's probably not getting it anytime soon anyway! I like jjng's suggestions. In fairness to the vet, though, Shane was panting non-stop and clearly anxious, so the chance of getting a decent resting BP on him that day were nil, and we did touch on that. Problem is, suppose his resting BP is fine, and then he runs the intense zoomies he likes to do in the yard and has a stroke because of proin? Just not worth it!

 

Swifthounds, I'm so glad I'm not the only loquacious person on this board! We're still paying off Shane's MRI from December, so while we can manage an ultrasound too, we're not rushing to do it. Let's see how Shane does the next week or so and how his repeat urinalysis and blood work turn out. Then we'll decide on the ultrasound. And that income tax refund has to come eventually!

Edited April 7, 2011 by greyhead

[gracegirl]

The ultrasound isn't cheap, but it will give you a lot of information about organs, kidneys, and the bladder.

after spending my tax refund on an ultrasound rather than new shoes or a purse...I'd say that an ultrasound will probably tell you a whole heck of a lot of info about what's going on. I'm now quite glad I did it.

[greyhead]

Oh dear. Went back and found that we were supposed to be giving Shane TWO cups of milk per day for mild hypophosphatemia, not a half cup! No wonder he still has it.

 

I still don't understand, though, how he could have been on a high-protein food and still have low phosphorus. Where's he putting the phosphorus? Or is phosphorus maybe especially low in venison, I wonder... Sigh. Bad mom.

Edited April 7, 2011 by greyhead

[gracegirl]

From memory....I believe that vennison is a low phosphorus food. It's what Fenway is on now, has been for over a year...and if I recall correctly I decided a rapid change in diet was not needed because his phosphorus levels are within range.

[greyhead]

Thanks, Lauren, that's very helpful. Hope Fenway is doing well!

[Batmom]

Is he on any supplements or meds?

 

What I would do -- partly scientific and partly just my experience, YMMV:

 

1. Discontinue any supplements.

2. Start a homeprepped moderate* protein, limited-ingredient diet with no additives other than enough calcium to balance the phosphorus. No added salt, etc. One protein, one carb.

3. Get a blood pressure and the ultrasound soon.

 

 

*moderate protein = @ 2 grams per kilogram of dog's body weight per day from meat/eggs; ignore the protein amount in your chosen carb.