Always Being Surprised

One of the nice things about being a veterinarian is that you constantly are learning and seeing new things.  Just recently, I saw a new client whose dog was having a problem after urinating.  The owner reported that after her male dog urinated he would continue to dribble urine and get it on himself.  He was four years old and the problem had probably been going on for a couple of years.  The previous veterinarian prior to the owner moving to our area had run a few diagnostic tests on the urine, but did not find anything conclusive.

After hearing the history I started out with a physical exam and pretty soon felt like I had found the possible culprit.  Male dogs have a skin fold called the prepuce (similar to foreskin in humans) that covers and protects the penis.  In this case, the opening of the prepuce was very narrow and there was a large amount of extra skin.  I thought that the narrow opening was leading to the urine pooling in the extra skin and then dribbling out after the dog was done urinating.  I suggested that we perform surgery to remove the extra skin and make the opening wider.

The owners agreed and we performed the surgery the next week.  I called for an update a couple days later and the owners reported that the problem was resolved and no more dribbling was happening.  If you would have told me in vet school that I would essentially circumcise a dog I would have laughed, but like I said earlier, I am always surprised at what I get to see and do as a veterinarian.

Cold Weather Precautions

It was -11 degrees this morning when heading to work, so I thought it would be prudent to discuss cold weather considerations for pets.  Most of the recommendations are fairly straight forward, but I thought I would review them anyway:

1.) Make sure your pet has adequate shelter.  If your pet isn't going to be indoors with you, then make sure they have an place to stay warm.  This should mean an insulated and draft free shelter.  In cases where the temperature is dangerously low (such as today) I would strongly suggest allowing your pet inside where there is heat.

2.) Have adequate water and food available.  Also, make sure that the water isn't frozen.  When temperatures are cold pets have a higher metabolic rate, so will need more calories.  Make sure that enough food is available to them.

3.) Protect pets feet.  Many people will put out salt to help with the ice on driveways.  This can be irritating to pet's paws, so make sure to wipe down pets feet after being outside.  Also make sure that pets are not running over sharp areas of ice or snow that could cut their paws.  Booties are available for dogs and many dogs are surprisingly tolerant of them.

4.) Watch for ice.  Dogs tend to have a better footing than people, but they can still take a tumble on the ice.  Especially with older pets, make sure that the walking routes you are taking are clear and ice-free.

5.) Lastly, make sure that any antifreeze is stored up and out of the way of pets.  A very small amount of antifreeze ingested by pets can put them into kidney failure.  For those do-it-yourselfers, make sure to keep this liquid away from your pets.

Hope everyone stays warm and safe during the current cold streak.  Happy New Year!!!

Some Fun Quotes

With the holidays, I thought I would do a little lighter topic.  Here are some fun pet related quotes:

“Don’t accept your dog’s admiration as conclusive evidence that you are wonderful.”-Ann Landers

“Did you ever walk into a room and forget why you walked in? I think that’s how dogs spend their lives.”

-Sue Murphy

"Dogs are not our whole life, but they make our lives whole." -Roger Caras

"A cat is a puzzle for which there is no solution." -Hazel Nicholson

"Animals are such agreeable friends - they ask no questions, they pass no criticisms." -George Elliot

“Dogs are the leaders of the planet. If you see two life forms, one of them's making a poop, the other one's carrying it for him, who would you assume is in charge.” -Jerry Seinfeld

"I like pigs. Dogs look up to us. Cats look down on us. Pigs treat us as equals." -Sir Winston Churchill

Hope everyone has a happy holiday.

Silly dog, You ate what???

Now that I have discussed hazards among cats, lets talk about problems that dogs may encounter.

1.) Tinsel, ribbons, and ornaments:  Although these decorations are not toxic, they can definitely cause problems with your pets.  In particular, longer, thin decorations can cause major problems as they tend to turn into linear foreign bodies.  Unlike a ball, corn cob, etc that may be eaten and removed fairly easily, longer string like objects tend to get hooked higher up in the stomach and intestine and then continue to move down the intestinal tract.  This leads to a large amount of damage that tends to make it more difficult to remove and heal from.

2.) Holiday lights and candles: The constant flickering of lights or bright colors can be very attractive to pets.  The problem with this is the electricity running through the lights.  You may not get the reaction like in "National Lampoon's Christmas Vacation," but biting into a cord can cause significant mouth burns and possibly death.  Make sure lights are out of the way of your pet.

3.) Holiday food: With the holidays comes baking and cooking, so be cognizant of what you leave out.  Chocolate is a big concern in dogs.  Although all chocolate is bad, baking chocolate contains the most methylxanthines, which can cause heart arrhythmia and death in large enough doses.  Other fatty foods and trimmings can also cause issues.  High fat foods can trigger pancreatitis in your pet leading to vomiting, pain, dehydration, and in severe cases, death.

4.) Antifreeze: Although not really a holiday problem, antifreeze becomes more readily available during colder months.  In the past antifreeze has been enticing to pets due to its sweet taste.  Fortunately, legislation passed last year that requires manufacturers of antifreeze to add a bittering agent to the liquid that will make it less tempting to pets.  Pets only need to be exposed to a small amount of the liquid to cause a problem.  Pets typically succumb to renal failure if they are not treating early and aggressively.

5.) Holiday plants: The good news is that most plants will only produce mild gastrointestinal upset if your pet is exposed to them.  Poinsettias, holly, and mistletoe typically fall under this category, but with large exposures there can be other problems, so always contact your veterinarian.

The best way to avoid a problem with your pet this holiday season is to keep anything that could be a hazard out of their reach.  Have a safe and happy holiday season.

Holiday Hazards

With the holidays quickly approaching I wanted to take time to discuss some holiday hazards to try to avoid.  The first post will deal mostly with cats and is taken from Dr. Tina Wismer's handout from a talk she gave for a rounds discussion in 2010.  Listed below are some common items that a cat might encounter during the holidays along with descriptions of possible problems.

1.) Silica Gel Packs

Desiccant packs are included as moisture absorbents. They are found in shoeboxes, electronics, medications and food. Silica gel comes in paper packets or plastic cylinders. Packages of silica gel are attractive to pets because of the rustling noise, and the packages are easy to bat around. Most ingestions will not cause clinical signs, although a mild gastrointestinal upset may occur. If a large amount is ingested, there is potential for diarrhea occurring. In most cases, the packet will be ruptured and the contents eaten. Ingestion of the intact packet may cause an intestinal obstruction.

2.) Christmas tree preservative

Christmas tree preservatives primarily contain dextrose and NPK fertilizers. The concentration of metals (copper, iron, zinc, magnesium) is usually small in commercial products. Most cats that drink water containing Christmas tree preservative develop no signs. Occasionally we can see mild GI signs, rarely, bacterial/fungal contamination of the water may lead to more severe signs.

3.) Christmas trees

Christmas trees may be one of several species. The most common are: Douglas fir (Pseudotsuga menziesii), Balsam fir (Abies balsamea), Black spruce (Picea mariana), Blue spruce (Picea pungens), White spruce (Picea glauca), Scotch pine (Pinus sylvestris), Norway spruce (Picea excelsa), Red Pine (Pinus resinosa), and Red spruce (Picea rubens). The most common clinical signs after ingestion of the needles are vomiting, anorexia, abdominal pain and depression.

4.) Poinsettias

The toxicity of poinsettias is generally overrated. The plants do contain diterpene esters, but large quantities must be ingested for signs to develop. Most cats just experience mild, self-limiting vomiting that resolves with little to no treatment.

5.) Mistletoe

Most ingestions involve American mistletoe (Phoradendron spp.). Mistletoe contains lectins, but ingestion of a few leaves or berries will generally cause just a mild gastritis. If purchased in a store, the berries frequently have been removed and replaced with plastic "berries" which can be a foreign body. Large ingestions may require decontamination and cardiovascular monitoring.

6.) American Holly

American holly (Ilex opaca)is a member of the Aquifoliaceae family. All parts of the holly plant are considered to contain potentially toxic compounds, including methylxanthines, saponins, and ilicin. True toxicoses not generally expected in cats. Most ingestions cause gastrointestinal irritation and depression. Recent ingestions can usually be managed with dilution and monitoring at home.

7.) Lily

Members of the Lilium and Hemerocallis genera (Easter lilies, tiger lilies, day lilies, etc.) cause acute kidney failure in cats. The water soluble toxic principle is unknown. Even minor exposures (bite on a leaf, ingestion of pollen) may result in toxicosis, so all feline exposures to lilies should be considered potentially life-threatening. It should be noted that not all plants with “lily” in the name are members of Liliaceae.

Affected cats often vomit within a few hours after exposure. Within 24 to 72 hours of ingestion, kidney failure develops, accompanied by vomiting, depression, anorexia, and dehydration. Elevations in BUN, creatinine, phosphorus and potassium are detectable as early as 12 hours post ingestion. Creatinine elevations may be especially high.

In severe cases, death or euthanasia due to acute renal failure generally occurs within 3 to 6 days of ingestion. When initiated within 18 hours of ingestion, decontamination (emesis, oral activated charcoal, and cathartic) and fluid diuresis for 48 hours have been effective in preventing lily-induced acute renal failure. Conversely, delaying treatment beyond 18 hours frequently results in death or euthanasia. Baseline renal values should be obtained upon presentation and then repeated at 24 and 48 hours. Because the tubular injury from lily ingestion spares the renal tubular basement membrane, regeneration of damaged tubules may be possible. In severe cases, peritoneal dialysis may aid in managing renal failure until tubular regeneration occurs (10-14 days or longer).

8.) Ice Melts

Many brands of sidewalk ice melts are on the market. The most common ingredients in these ice melts are sodium chloride, potassium chloride, magnesium chloride, calcium carbonate, and calcium magnesium acetate. A few ice melts contain urea. Cats may be exposed by walking on the ice melts themselves or by ingesting granules brought inside on the shoes of the owner’s.

Ingestion of urea is not a toxicity issue in non-ruminants. Ingestion of sodium, potassium, calcium and magnesium salts can lead to vomiting and electrolyte abnormalities. Monitor electrolyte levels and treat with appropriate fluid therapy.

9.) Liquid Potpourri

Liquid potpourri is commonly used during the holiday season. Cats are often exposed to liquid potpourri by direct ingestion from simmer pots or spills, or by rubbing against leaky bottles or simmer pots containing the potpourri, or from spilling the containers upon themselves. Oral exposures result following grooming. 

Exposure of cats to some types of liquid potpourris can result in severe oral, dermal and ocular damage.

Liquid potpourri is a combination of cationic detergents and essential oils. Cationic detergents can cause extensive systemic and local effects at concentrations as low as 2%. Local tissue injury caused by cationic detergents resembles that seen with exposure to other corrosives. In addition, cationic detergents can cause systemic toxicity including CNS depression, coma, seizures, hypotension, muscular weakness and fasciculations, collapse, pulmonary edema, and metabolic acidosis; the mechanism of these signs is not known. 

Treatment of local exposure includes dilution with milk or water, pain control (opioids), GI protection (sucralfate slurries) and supportive care (antibiotics, feeding tube). Systemic signs should be treated symptomatically (i.e. fluids for hypotension, diazepam for seizures, etc.).

10.) Alcohol

Due to their small size, cats are far more sensitive to alcohol than humans are. Even ingesting a small amount of a product containing alcohol can cause significant intoxication. Cats are attracted to mixed drinks that contain milk, cream or ice cream (e.g. White Russian, alcoholic eggnog, Brandy Alexander). Ethanol is rapidly absorbed orally and signs can develop within 30-60 minutes. Alcohol intoxication commonly causes vomiting, loss of coordination, disorientation and stupor. In severe cases, coma, seizures and death may occur. Cats who are inebriated should be monitored by a veterinarian until they recover.

 Hope everyone has a safe and happy holiday season!

Stomach Tacking

I have seen a few Great Danes come through the office lately, so I thought I would discuss stomach tacking (gastropexy).  Large breed dogs with deep chests (Great Danes, Irish Setters, Saint Bernands, etc) have a lot more room in the front part of their abdomen that allows for more movement in the stomach and ultimately makes them prone to gastric dilatation and volvulus (GDV or bloat).  

The exact cause of GDV is unknown, but many things can predispose to the condition including

1.) rapid eating

2.) eating one large meal daily

3.) overeating and overdrinking

4.) heavy exercise after eating

5.) conformation of the dog

A dog who has GDV will typically be anxious, may be drooling, have a distended abdomen, and are retching without producing anything.  The condition quickly becomes an emergency as the twisting of the stomach compromises blood return to the heart leading to shock.  The treatment involves immediate treatment of the shock (with fluids and pain medications) and then de-rotating the stomach.  Measures can be taken without surgery including passing a tube to deflate the stomach or passing a needle into the stomach through the body wall, but in most cases surgery will eventually be needed.  Even with surgery it is not guaranteed that the pet will pull through because if blood flow is compromised long enough you may get tissues that die and become infected.

X-ray image of stomach with GDV

The surgery involves deflating the stomach, placing the stomach back into normal anatomical position, and then permanently tacking the stomach to the body wall (which prevents recurrence of GDV).  There are many different procedures to tack the stomach; however, I typically perform a simple incisional gastropexy.  This involves making an incision into the outer portions of the stomach and then making a corresponding incision into the body wall.  The incision is then sutured together using two parallel lines of suture material.  The suture material will initially hold the stomach and body wall together, but eventually scar tissue will form and permanently hold the surgery site together.  If caught early enough, many dogs can do well; however some dogs may need more aggressive surgery (removal of a portion of the stomach, accompanying splenectomy) if the condition goes on long enough.

Tacking stomach to body wall

Because of deep chested breeds risk for GDV later in life, some owners may consider performing a preventative gastropexy.  This involves performing the gastropexy before a GDV occurs (typically done during a spay or neuter procedure).  There are some minimally-invasive techniques involving laproscopy, but not all veterinarians can perform these and the cost will likely be more.  A conversation about this procedure with your veterinarian should be made when the puppy is young, so a plan can be made for performing the gastropexy.

Kidney Disease

What are the functions of the kidneys?

The kidneys play a vital role in the body, participating in a number of processes including removing waste products from the body, regulating water balance in the body, regulating calcium and phosphorus levels, and producing certain hormones for the body.  Blood that passes into the kidney is filtered through thousands of small structures called nephrons where waste products are removed and excessive water is released. 

What is chronic kidney disease?

Chronic kidney disease (CKD) is not a singular disease, but more a catch all term for kidneys that are not functioning at full capacity.  The underlying cause for this could include a number of different conditions including:

• Congenital malformation of the kidneys
• Chronic bacterial infection of the kidney (pyelonephritis)
• High blood pressure (hypertension)
• Diseases of the immune system (i.e. Lupus)
• Recovery from acute kidney disease (toxin, infection, etc) leading to chronic disease

In many cases we do not figure out the exact cause of kidney insufficiency, but treat the end result.

Signs of chronic kidney disease:

Pets with chronic kidney disease can manifest many different clinical signs including:

• drinking too much (polydipsia) and urinating large volumes of urine (polyuria)
• vomiting and/or diarrhea
• lack of appetite and weight loss
• general depression related to the elevation of waste products in the blood (uremia)
• anemia resulting in pale gums and weakness due to a low blood count
• overall weakness from low blood potassium         

How is chronic kidney disease diagnosed?

If a pet is having clinical signs consistent with kidney disease, then some tests will be recommended to evaluate kidney function.  A combination of blood work and urine evaluation is used to give a good indication of kidney function.  Two blood values are of particular concern when evaluating kidney function (Creatinine and Blood Urea Nitrogen (BUN)).  Elevations in these values could indicate that the kidneys are not functioning well. 

If creatinine elevations are seen, then the urine is also evaluated.  In particular, we are looking at the concentration of the urine.  Normally, the kidneys try to maintain proper water balance in the body.  They do this by reabsorbing water and maintaining it in the body.  When the kidneys are functioning properly they will make more concentrated urine.  If the creatinine or BUN is elevated and there is dilute urine, then this indicates that the kidneys are not functioning properly and may have chronic kidney disease.  There is also a staging system (stage 1-4) to help indicate the degree of damage to the kidneys

STAGES	CLINICAL SIGNS	FASTED PLASMA CREATININE mg/dl (umol/l)assessed on at least 2 occasions in the stable patient		EVIDENCE FOR RENAL DISEASE
		DOG	CAT
I	Absent but patients should be substaged with urine protein creatinine ratio and blood pressure measurements	< 1.4 (<125)	< 1.6 (< 140)	Inadequate urine concentration, renal proteinuria, or abnormal renal architecture based on palpation, imaging, or histopathology
II	Usually mild or absent but substage as noted above	1.4-2.0 (125-179)	1.6-2.8 (140-249)	As for stage I
III	Usually present and may be related only to kidneys. Substage as noted above	2.1-5.0 (180-439)	2.9-5.0 (250-439)	As for stage I in addition to clinical signs
IV	Present, but may have extra-renal signs. Substage as noted above	>5.0 (>440)	>5.0 (>440)	As for stage I in addition to clinical signs

Other changes on blood work and urine could include:

• Non- regenerative anemia
• Increased phosphorus
• Low potassium levels
• Calcium is often normal but can be elevated in some pets with CKD and rarely is decreased
• Protein or bacteria in the urine

Other tests may also be recommended including:

1. Abdominal radiographs (x-rays) or ultrasound to evaluate kidney size
   What might this test show?  The kidneys in pets with CRD are usually small reflecting the death of a large number of nephrons. If the kidneys are large then certain causes for the CKD should be considered such as lymphoma (cancer) of the kidneys, or an uncommon disease called amyloidosis. Some pets with signs of kidney disease who have large or normal sized kidneys may have acute kidney failure rather than CKD. The treatment and prognosis for pets with acute kidney disease differs from the treatment and prognosis of pets with CKD.
2. Bacterial culture
   What might this test show?  Bacterial infection is not a common cause of CKD but pets with CKD may develop a bacterial infection as several aspects of the pet's immune system may be less functional when the kidneys are failing.  If white blood cells are observed on microscopic examination of the pet's urine, a bacterial culture of the urine should be obtained.
3. Urine protein/creatinine ratio
4. Blood pressure

What are the treatment options for my pet?

Unfortunately, chronic kidney disease is a progressive disease and is not curable.  However, there are many options available to help treat symptoms and signs associated with kidney disease.  There is no treatment combination that is standard for every pet and many times incremental addition to medications is needed as the disease process progresses.  In some cases, pets may need to be hospitalized for a period of time to replenish fluids and in other cases pets are sent home with conservative treatments.  I will list treatment options available, but remember that an individual pet may not need all these treatments.

• Diet modification:  Studies have shown that pets switched to a protein restricted (high quality protein), phosphorus restricted diet have a higher quality of life, fewer uremic crises, and may live longer than pets fed a regular maintenance diet.  There are many commercially available, prescription diets that meet these standards. 
• Phosphorus binders: Even with phosphorus restricted diets some pets still have elevated phosphorus levels.  In these cases, supplements can be added to the food that help bind more phosphorus and restrict levels even more
• Hypertension medications: High blood pressure often accompanies kidney disease and can lead to further damage to the kidneys.  Monitoring for hypertension and adding anti-hypertensive medications (amlodipine, ACE inhibitors) when present may be warranted in some pets.
• Stomach protectors: Build-up of uremic toxins can lead to stomach upset and inappetence.  Protecting the stomach lining with medications that lower the acidity of stomach contents can be helpful.  Medications can include antacids (famotidine or ranitidine), protein pump inhibitors (omeprazole), or stomach lining medications (sucralfate).
• Anti-nausea medication: Pets may also be inappetent because of nausea.  Cerenia or metoclopramide are examples of anti-nausea medications.
• Omega 3 fatty acids: Supplementing with fatty acids has been shown in some studies to improve survival in pets
• Anemia medications: The kidneys produce a hormone called erythropoietin that signals the bone marrow to make more red blood cells.  With kidney disease, this hormone may be depleted, so anemia develops in patients.  There are commercially available erythropoietin supplements that can be given to increase red blood cell counts.  Pros and cons of this medication should be discussed prior to starting the medication.
• Fluid supplementation: Since diseased kidneys are unable to concentrate urine properly, a pet will lose an excessive amount of water in the urine.  Making sure that water is always available and promoting water consumption is important.  In cases where a pet is not keeping up with fluid loses, either periodic subcutaneous fluids (can be done at home) or intravenous fluids may be necessary.
• Potassium supplementation: Excessive potassium is lost with diseased kidneys, which can lead to loss of energy.  Adding a potassium supplement may be needed.
• Calcitriol: Calcitriol is the active form of vitamin D and helps with regulation of calcium and phosphorus.  It is produced in the kidney, so may be decreased in patients with chronic kidney disease.  To help combat renal secondary hyperparathyroidism, calcitriol may be instituted.  Careful and periodic monitoring of calcium and phosphorus levels is recommended. 

As discussed earlier, not every pet needs every treatment and your veterinarian will evaluate blood work and clinical signs before recommending certain treatments.  Also, some pets are more amenable to treatment (especially in the case of cats) as multiple medications may be needed in a day.  Individual owner circumstances can also dictate how aggressive treatment might be.  With cats, combining multiple medications into a single gel cap may be easier than administering multiple medications at a time.

Goal of therapy:

As chronic kidney disease is not curable, our goal is to provide a good quality of life as long as we can.  Some owners may elect to only change the diet in response to diagnosis, whereas others may add as many medications as reasonable and possible to help their pet.  The goal is to find the right balance for both the owner and the patient.  With proper care some pets with early kidney disease can still live a great quality of life for years.

For more information from the perspective of an owner please visit http://www.felinecrf.com.