Kidney Disease? (Was Incontinence)

[JJNg]

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?

Here's the FAQ page on the ACVIM site that explains what's involved in getting board certified. In general, for any vet to be advertising and practicing as a specialist, they should be board certified. When I hear "internist," I assume board certified internal medicine specialist. What are your vet's credentials as an internist and how long has he been practicing as such? Were you referred there by your regular vet, and is he working at a referral/specialty center?

 

The only situation I can think of that a practicing internist might not be board certified yet, is if they've completed their residency, has been hired and is working with other internists and is just waiting take take board exams to make it official. Our local specialty center hired their new oncologist last year, and she started seeing cases (including one of my dogs) several months before she officially received her oncology board certification. Although I'm sure there are exceptions, all of the specialists I've worked with, even if they had just finished their residency, were very knowledgeable and confident in their field.

 

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)?

How crucial the ultrasound is at this point probably depends on how Shane is doing overall. With the questions about his kidney function as well as the chronic UTIs, I think it would be a good idea to do, even if it's just for peace of mind.

 

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!

Cysto is the 'gold standard' for getting a sample for culture, and I always prefer to get it that way if possible. It's not a matter of having a sterile container (although I doubt your dishwasher is truly 'sterilizing' like an autoclave for surgical instruments would sterilize). When you catch a voided sample, the urine can be contaminated by contact with the skin and hair on the way out.

 

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.

I may have missed this in your previous posts, but how long was Shane on antibiotics continuously? In your original thread, I think you mentioned 20 days...was that how long every course was? Did you ever go longer than that? Some chronic infections need at least 4-6 weeks of antibiotics.

 

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.

If Shane is only leaking an ounce overnight, he still has sphincter tone - it's just decreased from normal. A dog with absolutely no sphincter tone would be dribbling urine continuously and not be able to hold it at all. Because males have a longer urethra, they usually only leak urine with the combination of decrease sphincter tone and increased urine volume. If it's an infection causing Shane's increased urine volume, getting that cleared up may also resolve the incontinence, like it did before. If it's renal insufficiency causing the increased urine volume, that usually can't be reversed.

 

Also, about his hypophosphatemia...has it stayed stable over the past year, or is there a trend of it getting higher or lower? You mentioned that he was panting intensely at his last vet visit. Was this when the blood was drawn? Panting can cause phosphorus to be lower on bloodwork, a normal change that doesn't have any clinical significance. Is he always anxious and panting at vet visits, or prior to/during blood draws? Dehydration can cause the hematocrit, total protein, BUN, and creatinine to be slightly higher than if he was well hydrated.

[SkipSailors]

Thank you all for helping our woof.

[greyhead]

I'll be back in a few hours with a precise answer to jjng's question about the duration of the antibiotics. Have to go to the doctor first and then go through Shane's records. Just didn't want anybody to think I'd suddenly lost interest.

[greyhead]

Cysto is the 'gold standard' for getting a sample for culture, and I always prefer to get it that way if possible. It's not a matter of having a sterile container (although I doubt your dishwasher is truly 'sterilizing' like an autoclave for surgical instruments would sterilize). When you catch a voided sample, the urine can be contaminated by contact with the skin and hair on the way out.

...

I may have missed this in your previous posts, but how long was Shane on antibiotics continuously? In your original thread, I think you mentioned 20 days...was that how long every course was? Did you ever go longer than that? Some chronic infections need at least 4-6 weeks of antibiotics.

........

Also, about his hypophosphatemia...has it stayed stable over the past year, or is there a trend of it getting higher or lower? You mentioned that he was panting intensely at his last vet visit. Was this when the blood was drawn? Panting can cause phosphorus to be lower on bloodwork, a normal change that doesn't have any clinical significance. Is he always anxious and panting at vet visits, or prior to/during blood draws? Dehydration can cause the hematocrit, total protein, BUN, and creatinine to be slightly higher than if he was well hydrated.

Pruned your answer to the above paragraphs. First, can't the skin and hair be cleaned with a sanitizing wipe the way people do before giving a sample?

 

Second, I'm driving my disorganized self crazy trying to answer the continuity question with records, but here's the best I can do. And the short answer is no, he was not on a continuous 4-week course of antibiotic at any time over all these months, until the very last course of Orbax.

 

Details: He was on Cephalexin 250 mg for 2 weeks and then 500 mg for 2 weeks last March. The leakage was 95% stopped but resumed definitively the day after the antibiotics ran out in early April. So that was four weeks. No C&S ever done.

 

---- Then tried Proin and didn't like his reaction -- he just didn't seem right -- so took him off after 2 days. Started with belly bands instead. Took doxy in varying doses for four weeks in August, on the theory that he might have a TBD or something that doxy might treat. Leakage improved over what it had been before the doxy, but the leakage did continue at that reduced level.

 

---- After C&S confirmed E. coli in late November, he started on Amoxi Clav Pot for two weeks, and the leakage stopped completely for two weeks afterward. Leakage resumed early January, another C&S showed E. coli, and he took the same antibiotic for 30 days total, with breaks of a day or two after each week! Each time the med would stop, the leakage would increase, and I'd call and request a refill. (The vet was getting perceptibly impatient with me because she believed that incontinence is the basic problem.) We waited a week after the last refill, repeated the C&S, and it came back with E. coli again, to the vet's amazement.

 

---- Started Orbax on 2/22 and continued until 3/14, at which point I thought he needed more but couldn't face asking the vet for it because there was some chance that either or both of us would explode during the conversation. So we went to the internist and got another week's worth of Orbax, giving Shane about 4 weeks worth of that, uninterrupted. The next C&S showed no infection.

 

So I think (hope) the infection is beaten finally. I think the short courses (7 to 10 days) of antibiotics, with anywhere from 2 to 10 day breaks in between, made it take a lot longer than it needed to be. But whatever, we're left with this rather tiny amount of leakage now -- and elevated kidney numbers.

 

I don't think the potassium has only been low when he has been panting, but I'll have to check further. It does seem to show a decreasing trend over the past two years, correlating with the time he has been eating venison. Rest assured that the next blood draw will be done under conditions of minimum stress and normal hydration, which I'll accomplish by having it done nearby instead of miles away. Thanks *very* much for your thoughtful attention. I would have recorded things more precisely if I'd ever suspected how much trouble a UTI could entail.

[Batmom]

First, can't the skin and hair be cleaned with a sanitizing wipe the way people do before giving a sample?

 

It sure could be. Remind me to tell you about the time I snoogled my vet into sending off a Zema urine sample for culture. No sanitizing wipe, non-sterile (tho properly cleaned) container, just a plain old midstream clean catch.

 

Nothing grew. Not "normal flora only." Nothing. One clean petri dish.

 

Cysto / catheter samples *are* undoubtedly cleaner. At the same time ... we don't do that with people, nor do we supervise their use of sanitizing wipes, technique, etc. And yet, most of the time, on a human urine culture it's pretty easy to sort out normal human skin flora from stuff that shouldn't be there.

 

 

For your other matter, my angel Zema had an odd pattern of excessive drinking and urinary leakage when eating commercial food. Any commercial food -- low-sodium prescription stuff, kidney diet, you name it. On a limited homeprepped diet, no problem at all. I think I already posted the details about that. If I didn't, holler and I'll PM you.

[greyhead]

Thanks Jey, if you wouldn't mind PMing me about the homecooked diet, I'd appreciate it. Or just point me to the right thread if you remember it.

 

As to the supplements, he hasn't been on anything but Rehmannia 6, which is for the kidneys. But his acupuncture vet thinks she can do better with things she's going to order, so I'll let her. Other than that, someone PM'd me the suggestion to give B vitamins, omega fish oils, and vitamin C, so I just started some of that this week. And you know what, his leakage is down to a half-ounce now! So did you mean that I should discontinue this kind of thing? I'm thinking that he has been through a lot the last few months, and the resupplying the B's and C will help repair anything that could have been hurt by a stress-induced shortage of them. (I did give him a few days of probiotics, but he's off those now too.)

[JJNg]

Thanks for the additional details. Sounds like the last course with Orbax did the trick, and I'm glad to hear the incontinence seems to be improving. When will you be getting bloodwork checked again? I wouldn't worry too much about the kidney values until you know if the elevations are consistent.

 

Regarding collecting samples for urine culture, as Batmom explained, yes, clean samples can be submitted and that seems to be standard for people. However, without getting too graphic, I have to wonder if certain differences in, um...anatomical details and positioning may make it harder to get a truly clean sample in pets even after cleaning the skin and hair.

 

Sometimes a relatively clean voided sample is the best we can do, and can still be used for culture. If you get no growth, or a fairly obvious bacteria (like E coli), then great. But if you get a questionable result, like certain Staph species, then you're left with wondering if it was really from the bladder. I prefer to avoid this possible ambiguity if possible.

 

However, I did have one patient, a Siamese cat, who we never could cysto because she would urinate before we ever got a chance to get near her with a needle. Sometimes she'd pee in the car on the way to the clinic, sometimes when she was picked to get her out of the carrier, sometimes when we went to position her for the cysto. LOL Her owner finally figured out a system - she kept a clean dish in the car, cleaned kitty's private parts before getting in the car, drove to the clinic with kitty in her lap, and if she started to urinate, she'd catch the sample in the dish while driving! I was always impressed... And yes, we did get some usable culture results with this method, along with some questionable ones.

[Guest 2dogs4cats]

It sort of sounds like Glomerulonephritis. I am perplexed that no protein was found in the urine or it's possible the urine was too dilute. It also sound like they never ran the antibiotic long enough. With chronic cases, I think it is recommended 4-6 weeks of antibiotics continuously. Low specific gravity means either diabetes or kidney troubles. If the incontinence is related to the kidney problem, incontinence meds won't help. If the Rehmannia 6 isn't working, you may want to try Rehmannia 8. You may not be seeing the classic signs of kidney disease due to the use of Rehmannia. I'm not sure what your vet is thinking with the proin, but I would consider getting another vet's opinion and making sure that the infection is really gone. Good luck. I know it's so hard when your pupper is sick and you don't know what is going on.

[greyhead]

However we get the sample, I'm pretty sure it won't be like that cat. Toward the end of this coming week seems like a good point to repeat the blood work and reculture, or early the week after? That should give things time to settle, yes? This is assuming, of course, that he continues to do well enough.

 

2dogs, his acupuncture vet specifically forbade Rehmannia 8 because he is a "hot" guy, and that has cinnamon in it, which is heat-producing. But yes, we may have been forestalling kidney problems for the last two years with the Rehmannia 6 and acupuncture. What makes you think of glomerulonephritis precisely?

 

Thanks again, both of you!

 

ETA: It's Saturday morning now and the belly band had just two small yellow spots. Like yesterday, it wasn't even enough to register as a fraction of an ounce! I'm so hopeful that the drippage since the antibiotic just represents his urinary apparatus healing slowly from its ordeal. And I can only think the added B vitamins (50 mg) and C (500 mg) have helped with that, as stress just wipes those two out.

Edited April 9, 2011 by greyhead

[kudzu]

...YES, he was dehydrated I'm sure, ... 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?

 

jjing covered the dehydration effects. I had not even heard of acanthocytosis & like you found a search on it disturbing. My attitude to these things when they first show up & to pretend it is a mistake or just resolve not to worry until the next lab work. (Though it might cause me to contrive to have the lab work done sooner rather than later.)

 

Shane has lost his beautiful thigh muscles over this last year, now that you mention it.

 

Oh, now I am a bit sorry I mentioned it.

 

What I *really* wonder about is this: Why is a dog on first-rate food producing gigantic amounts of poop?

 

Yes, that's a curious thing. There are a few things that make me wonder if he's not digesting things properly. I've no idea what might be going on though. When my Daniel D. was going through all his gastroparesis, dysmotility, SIBO, etc. they kept asking me about big D (a term I find funny now since one of Dan's nicknames was Big D.) & I kept saying he had normal stools. "Are you sure?" Well, heck I was following him around in the yard collecting & measuring his urine output. You'd think I would also notice the quality of his stools. Yet, I don't think they ever believed me.

 

B-vitamins & especially injectable fortified B-complex was a great boon to Daniel & later my senior Grey, Luke. It also didn't upset their stomach as oral b-vits sometimes can. However, oral is still good & if it works for Shane then stick with it. You may also want to add extra B-12. Hope things continue to improve. Let's not seeing any funny shaped blood cells or other oddities on our next lab work, OK Shane? Please?!