Excessive Water Drinking and Urination

In general, most vets and owners are concerned that the majority of pets don’t drink enough water to support good health, urinary system flushing and prevent dehydration. It is recommended that pets be supplied with fresh water TWICE DAILY after scrubbing the bowl free of natural bacterial and fungal contamination. The water source should be from a highly filtered source or DISTILLED WATER to insure that it is free of municipal water contaminants like asbestos (most of the older cement pipes that supply city or county water are reinforced with asbestos), fuel contaminants (winter gas additives have infiltrated most of the LA County soil around buried fuel tanks), agricultural chemical run off and heavy metals NOT COVERED BY CLEAN WATER REGULATIONS ON THE DATE THAT THE WATER FILTRATION FACILITY WAS COMPLETED AND PERMITTED. Most tap filters are inexpensive and inefficient (Britta® only filters out lead and chlorine). Bottled water is, by law, just that; water in a bottle from any available legal source. Spring water comes from a natural hole in the ground, regardless of content. Distilled water is the liquid product from a heat distillation process and is the same quality, regardless of retail source, by law.

However, some pets will begin to demonstrate an increased thirst, and concurrent increased amount of urination, especially as they age. In medical terms this is referred to as polydipsia and polyuria, aka “PU/PD” for short. Sometimes this phenomenon can be presented as a lapse in discipline with indoor accidents, or as a heavier cat box weighted down by extra urine volume. These patients are a mixed group of conditions and only have an increased thirst in common. They are separated by species into the most common causes. This list is not inclusive for all patients, but does address the great majority of pets presented for diagnostics and care. Cats and dogs are addressed separately below.

CATS:

1. Diabetes mellitus- These patients are often overweight, older (greater than 8 years old), have rough haircoats due to neglected grooming, may have recent weight loss, are often lethargic or act prematurely aged and are both drinking and urinating at obviously high volumes. Appetites may have been increased, but dropped with less activity recently. This is often the presenting complaint, despite the whole process has been ongoing for months. The uncontrolled sugar in the blood spills into the urine through the kidneys and “sucks’ the water out of the cat. This leads to an excess of urine lost and a need to replace the lost water by drinking. Type 2 diabetes is the most common cause and requires a blood glucose and fructosamine test to confirm it. In cats, this most frequently results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was formerlyreferred to as non-insulin-dependent diabetes mellitus (NIDDM for short) and aka adult-onset diabetes. This is the typical form of diabetes in cats. A quick blood glucose in-house analysis will help identify these patients. Full diagnostics include a blood screen, urinalysis, urine culture (half of the affected cats will have a bacterial infection of the urinary system). A low to zero carbohydrate diet with high fiber, insulin therapy and possibly, oral glucophagic drugs will be started to control the long term toxic affects of too much sugar in the blood stream. An alternative diet program is a fairly high fat and high protein food to reduce hunger, slow digestion and promote weight loss.

A more thorough assessment of this disease is presented in the obesity and diabetes document on this same webpage.

2. Kidney Disease- Chronic kidney disease (CKD) is the number one reason that indoor cats succumb after middle age (9 years old and up). The two kidneys provide each cat with 400% more function than is needed to survive. The cells are lost during normal wear and tear as they process the excess and potentially toxic nitrogen from protein breakdown generated by food processing and normal cell death and regeneration. Acute kidney disease usually has another diagnosis, such as infection, poisoning, car trauma or viral disease. CKD cats generally are presented for PU/PD plus or minus weight loss, vomiting, poor appetite and generally are dehydrated. Creatinine levels are analyzed by blood tests taken to evaluate the kidneys ability to eliminate waste products. Tubulointerstitial diseases (versus glomerular disease in dogs) are a common cause of CKD in cats. These are the cells of the deeper portions of the kidney that select filtration or retention of metabolites and electrolytes occurs. A specific relationship between this type of CKD and urinary tract infections, stones, obstructions and toxic drugs has been reported in humans. Other risk factors that predispose cats to CKD include: Genetics; - Polycystic kidney disease (PKD) in Persians

- Amyloidosis in Abyssinians, Siamese and Orientals

Glomerular disease does occur in cats and their predisposing factors include; - Infections – chronic urinary infections,

viruses, incl. Felv, FIV and FIP - Inflammatory diseases - pancreatitis, cholangiohepatitis,

systemic lupus erythematosus, other immune-mediated

diseases, chronic progressive polyarthritis - Cancers – leukemia, lymphosarcoma - Other clinical factors: secondary of acute renal failure,

urinary stones, obstruction of lower urinary tract, diabetes,

hypercalcemia, heart failure - High blood pressure - Drugs: antibiotics, such as aminoglycosides, sulfonamides,

polymyxin B, amphotericin and various chemotherapeutic drugs.

Diagnosis:

All cats suspected to have kidney disease should be diagnosed using- - standard blood panel, this includes creatinine and phosphorous - urinalysis - urine culture (infections rise from 20% in cats 8-10 years to up to 80%

in cats 16-18 years old) - blood pressure (often elevated in renal disease cats) - Abdominal X-rays for urinary stones and calcification of kidneys - ultrasound for kidney defects and stones invisible on X-rays - biopsy –may be indicated if cancers are suspected

There are two different forms according to the International Renal Interest Society (IRIS) that span the range of progressive kidney dysfunction scale of 1-4, renal insufficiency and chronic kidney disease;

Grade 1 -the first is renal insufficiency and includes cats with a creatinine level of less than 1.6 mg/dl (nonazotemic). The do not exhibit PU/PD unless other causes are present. They have some kidney abnormality, such as poor ability to concentrate urine minerals and salts, irregular anatomy on x-rays or ultrasound or by palpation and blood pressure. These cats are considered nonazotemic and are generally active and eating well. Their water intake may still be of a normal volume. These cats qualify as being renal insufficient.

Grade 2- creatinine levels are between 1.6-2.8 mg/dl with cat now entering the range of azotemia. Many of these patients, especially at the lower end, will appear normal with some having moderate PU/PD signs and/or mild indications, such as weight loss. Blood pressure may be elevated.

Grade 3 – creatinine levels are between 2.9-5.0 mg/dl. Clinical signs are mild to obvious for weight loss, poor appetite, and/or increased vomiting incidences, kidney changes on ultrasound or by palpation, elevated blood pressure and dilute urine with excess protein losses from kidneys.

Grade 4 – creatinine levels are above 5.0 mg/dl. Clinical signs are obvious but vary in severity. Some cats will be very this, refuse to eat and vomit several times each day, while others are more stable and have entered a state of “chronic maladaption”. This is more likely the longer the degenerative process has taken. Cats that reach level 3 or 4 quickly via acute renal disease (ARD) via toxins (lilly or antifreeze ingestion, clots or traumatic injury, etc) are severely ill in a very short number of hours.

Treatment:

Cats in grade 1 and 2 can be treated with a fairly good outlook using a veterinary prescription, low phosphorous diet, preferably canned or pouch with gravy type. The goal is to get the damaged cells to regenerate wherever possible in the kidney and to return the kidneys to normal function. SOVG can provide 3 or 4 different samples at

no charge to see what type your cats will accept. These are totally nutritious for healthy cats that will be eating along with the patient. Increased water consumption is crucial for stability; use what ever method the cat prefers such as filtered fountains, bowls scrubbed TWICE DAILY, ice cubes in hot weather to cool bowls, heavy drinking glasses that can not be turned over. Distilled water will typically double water intake over tap water for nearly all cats. Do not worry about mineral deficiency; there is plenty in one mouthful of food to cover any difference in the types of water. A few will continue to prefer tap water. Supplements will also be provided as below- - Omega-3 oils from fish. This helps dilate the kidney artery to get the maximum use out of this pair of organs. - Epakitin® - this is a heat treated ground shrimp shell that traps phosphorous to prevent extra calcium losses that will lead to osteoporosis in renal disease The ideal goal of treatment for these patients is to stabilize them for up to 3 years before they begin to worsen. The real outcome is dependent on the underlying disease process. If it is age-related tubulointerstitial disease, this goal is realistic. If it is polycystic kidney disease, the duration of stability can be much shorter. Rechecks are scheduled every 3-6 months if the patient is stable.

Cats in grades 3-4 may be treated as outpatients with the program noted above, plus the addition of subcutaneous fluids (diuresis) to drive out the excessive creatinine. This is a critical component ion keeping cats stable and out of the hospital as long as possible. These patients already have a substantial amount of scar tissue (fibrosis) replacing normal cells, or the creatinine and phosphorus levels would be controlled by the kidney naturally. The frequency and amount of balanced electrolyte fluids to be given will be determined by size, other medical conditions and response to initial care. Some will be on fluids 2 or 3 times weekly, up to twice daily in advanced cases.

The goal is to increase the removal rate for the accumulated uremic toxins.

Note: A great trick is to warm up the bag of fluids in a warm water bath (sink) for 5-10 minutes before administering them to the cat. This will make them more comfortable. The rate of administration can also be helped by using an inflatable pressure cuff. We can order this for you at SOVG at our cost (around $24.00). A standard 10 pound cat dose can be finished in just over 1 minute.

Additionally, these cats may be supplemented with probiotics to control their uremia. Azodyl® is a symbiotic mix that contains a patented mixture of three beneficial bacteria; Enterococcus thermophilus, Lactobacillus acidophilus, and Bifidobacterium longum, combined with a prebiotic (psyllium husk).

Azodyl's bacteria are specifically screened and selected for their high affinity and capacity to metabolize uremic toxins. While this is not yet an evidence-based therapeutic embraced by all veterinarians, it has seemed to help our patient’s quality of life.

See the document on probiotics and prebiotics on this same webpage for more information.

High blood pressure non responsive to diuresis is treated separately with oral medication.

No treatment will cure these patients. Kidney transplants and dialysis are available, but the stress and cost of dialysis ($1000.00/day) makes this only realistic for acute renal patients with a chance for full cure in a few days. Transplant has fallen out of favor due to the high failure rate and lack of donor banks and very limited compatible candidates for kidney donation.

Stage 3-4 cats with severe clinical signs in, advanced dehydration and refuse to eat or vomit must be hospitalized to stabilize them. This process takes 3 to 6 days, on average. Progress is monitored every 48 hours to judge response to care. Some cats will continue to worsen, especially if they fall in to the category of “acute exacerbation of CKD”. These cats have had a prolonged kidney disease status that is suddenly worsened by a clot or multiple stokes, stones blocking the urine outflow (hydronephrosis), etc.

Those cats that do stabilize and become outpatients will have an initial recheck 1 to 3 weeks later, depending on the seriousness of the case. Rechecks are scheduled every 3 months once a program has been established by the initial recheck(s).

3. Hyperthyroidism –

This is the third disease of the most commonly diagnosed cats with increased thirst. These cats suffer from an overactive thyroid gland and have an accelerated physiology so that they typically eat endlessly and still lose weight. They drink more because they dehydrate at an abnormally fast rate. They do not urinate excessively because the extra water taken in is driven off as insensitive water loss. The 'classic' signs of hyperthyroidism are weight loss, usually despite an increased appetite (polyphagia), increased thirst (polydipsia), increased irritability, and restlessness or even hyperactivity. Many affected cats have a rapid heart rate (tachycardia) and develop an unkempt coat. Mild to moderate diarrhea and/or vomiting is also quite common. Some affected cats will be noticeably intolerant of heat and seek out cooler places to sit, and some (especially advanced cases) may pant when they are stressed. Most hyperthyroid cats will show some degree of polyphagia (excessive appetite) and restlessness, but in some advanced cases there will be generalized weakness, lethargy and loss of appetite and the signs will be less characteristic.

The thyroid gland in these cats most often undergoes a change to a benign tumor termed an adenoma. Only about 1-2% of the tumors are cancerous (adenocarcinoma), but these are much more serious and treated differently.

Diagnosis;

Affected patients can be diagnosed using simple blood tests to evaluate both the total and smaller amount of free (active) thyroid levels. A general blood panel is done to look for concurrent disease and to establish a kidney function baseline. This is very important as some older cats will also have chronic kidney disease (CKD) that is artificially supported by the abnormally high blood flow to the renal arteries during

hyperthyroidism. Once the thyroid levels are reduced, blood flow to the kidneys is also reduced and CKD signs may appear. Blood pressure is generally elevated (secondary hypertension) and creates an unacceptable risk for strokes and aneurysm rupture. Most cats will return to normal blood pressure once they are treated. Those that remain elevated are diagnosed as being primary hypertensive patients, unless another cause can be located. Initial treatment may also uncover hidden kidney disease and adjustments to treatment medication and/or kidney support may be indicated

Treatment:

There are three general methods of treatment, all with their strengths and weaknesses.

A. Medication. A drug named methimazole (Tapazole®) can be given orally as a tablet or liquid for resistant cats twice daily. A transdermal paste for application to the ear can also be compounded for cats that refuse oral medications. Patients are treated at a lower dose initially and then blood levels are rechecked 3-4 weeks later. Complete blood counts are also included, as some cats are intolerant and will suffer blood cell damage due to affects on the bone marrow. This will occur in the first 90 days, if the cat is sensitive to this effect (up to 3% of treated cats). Other potential side effects include lethargy, vomiting, and scratching of the face may occur in up to 10% of cats taking methimazole. These side effects usually occur within the first 3 months of therapy and can often be reduced by starting the cat on a lower dose, and gradually increasing the dose over several weeks. Tolerant cats are rechecked every 12 months to adjust their dose. Kidney failure cats are adjusted to levels slightly above normal to take advantage of the benefits of extra renal blood flow.

The advantage to this approach is that it requires no hospitalization and is monitored as an outpatient. The disadvantages are that the cat is not cured, medication is given twice daily and the cost of blood tests and medication never stops.

B. RadioiodineTherapy(I131).Thisisthepreferredmethodforcatsexpectedto be on medication for hyperthyroidism more than 3 years. This is a cost and effort-based decision as no efforts are required after the cat is stabilized and the initial recheck exam and testing performed. The cost has decreased over the past 20 years and averages about $800.00. This is an excellent option for middle aged cats, and even those up to 12 or 13 years old. Additionally, cats intolerant of methimazole are good candidates. Adenocarcinoma cats should also be screened.

Treatment initially consists of one month of oral methimazole to eliminate the accelerated physiology, blood pressure, etc and to determine if kidney disease has appeared. An initial imaging scan using a mildly radioactive substance to identify the tumor and any additional thyroid tissue is performed at a special imaging center offsite from the clinic. Most cats will have one gland affected. If both are involved, the dose can be tailored to leave functional tissue. This is crucial because the

radioactive iodine dose, which is selectively taken up by only the thyroid gland, needs to be critically calculated. If the tumor also exists in some of the extra islands of cells that are left during thyroid gland migration during development in the uterus, the dose will be too low. If the cat is overdosed, then thyroid supplements need to be started twice daily. Statistically, less than 1% of the cats become hypothyroid using this technique. Some radiologists will use a single maximum dose for all cats. This is not recommended.

For adenocarcinoma cats going to surgery, the thyroid scans are invaluable in finding all of the affected tissues. If both sides are involved and no accessory glands are available for thyroid production, these cats will necessarily need to be supplemented.

The process at the facility licensed by the Nuclear Regulatory Commission generally takes 5 days for the treated patient to urinate out the low level radioactivity for collection and disposal. A thyroid and general blood panel for bone marrow activity and kidney function is taken at SOVG in 30 days. If levels have returned to normal without complications, no more care is required.

C. Surgery.Thiswastheoriginaltreatmentpriortomethimazoleandradioiodine.It involves taking out the affected gland(s). It remains the option of choice for malignant adenocarcinomas.

4. Hyperadrenocorticocism (Cushing’s disease) - This is a condition where too much cortisol exists in the body. Cortisol is a normal hormone produced by the adrenal glands. It is produced rapidly in times of stress to prepare the body to conserve sodium and water, move fat out of the liver in to the blood as glucose and protects the body against stressful events. Cortisol triggers the metabolism of fat stores in the body as well. There are actually three forms of Cushing’s disease: Two are spontaneous; 1) pituitary-dependent, 2) adrenal-dependent and 3) is a pharmacological side-affect called iatrogenic Cushing’s from the patient being given prescription corticosteroids. Cats VERY RARELY get the first two forms, but are susceptible to the iatrogenic form after being treated with corticosteroids. This is a fairly common medication in cats for controlling allergies, inflammatory bowel disease (IBD), autoimmune diseases, flea dermatitis, unresponsive stomatitis and chronic pancreatitis. The side affects of cortisone use is rare, but recognized, in cats. Increased thirst and urination, accidents in the house, and urinary tract infections occur in almost all Cushing’s patients. A well behaved cat may begin to knock over trash cans and cry for food as they develop an insatiable appetite. Skin infections, recurring bladder infections and wounds may not heal quickly. Diabetic patients’ blood glucose will become impossible to regulate despite previously successful insulin therapy. In the case of oral medications, stopping them or tapering them off slowly can be curative. Be sure to call your pet’s doctor before changing any medication for safety purposes. Some cortisone programs are for life-threatening diseases that must be treated as is. Other drug programs will present a serious problem if suddenly stopped. If the medication has been injected, it must run its projected pharmacokinetic path first. Checking blood sugar levels is recommended.

Dogs:

1. Diabetes mellitus- These patients may or may not be overweight, any age, have rough haircoats due to neglected grooming, may have recent weight loss, are often lethargic or act prematurely aged and are both drinking and urinating at visibly high volumes. Appetites may have been increased, but dropped with less activity recently. This is often the presenting complaint, despite the whole process has been ongoing for months. The uncontrolled sugar in the blood spills into the urine through the kidneys and “sucks’ the water out of the dog. This leads to an excess of urine lost and a need to replace the lost water by drinking. Type 1 diabetes is the most common cause and requires a blood glucose and fructosamine test to confirm it. In dogs, this results from insulin deficiency, a condition in which cells fail to produce insulin properly. This form is aka as insulin- dependent diabetes mellitus - IDDM for short, aka juvenile diabetes. This is not obesity dependent, may be due to a genetic mutation in the insulin gene and leads to a lack of insulin production. A quick blood glucose in-house analysis will help initially identify these patients. Full diagnostics include a blood screen, urinalysis, urine culture (half of the affected dogs will have a bacterial infection of the urinary system). A low carbohydrate, high fiber with high quality protein diet with, insulin therapy will be started to control the long term toxic affects of too much sugar in the blood stream. A more thorough assessment of this disease is presented in the obesity and diabetes document on this same webpage.

2. Kidney disease- The two kidneys provide each dog with 400% more function than is needed to survive. The cells are lost during normal wear and tear as they process the excess and potentially toxic nitrogen from protein breakdown generated by food processing and normal cell death and regeneration. This is called chronic kidney disease (CKD). Acute kidney disease usually has another diagnosis, such as infection, poisoning, car trauma or viral disease. However, chronic infection can be associated with CKD and urine cultures are always recommended. Renal disease dogs are generally presented for PU/PD plus or minus weight loss, vomiting and/or poor appetite and generally are dehydrated. Some are discovered through the annual blood and urine screening tests recommended at SOVG for all patients over 6 years of age. Creatinine levels are analyzed by blood tests taken to evaluate the kidneys ability to eliminate waste products.

Glomerular diseases are a leading cause of renal disease in dogs. These cells are located in the outer regions of the kidney and are responsible for filtering blood in order to create urine. They can be primary, or secondarily disorders associated with other diseases such as infectious diseases, neoplasia, and inflammatory causes and other miscellaneous conditions. Any elevation of creatinine in blood analysis is

highly significant as the kidneys have been compromised to a level of 25% or less functional tissue. In general, dogs with elevated creatinine are considered to be more at risk than cats with the same grade, at least in the first 3 levels.

Diseases associated with glomerular disease in dogs: - Infectious causes- Canine adenovirus 1, bacterial endocarditis, brucellosis, borreliosis, dirofilariasis, erhlichiosis, leishmaniasis, hepatozoonosis, Rocky mountain spotted fever, bartonellosis, babesiosis, blastomycosis, coccidiomycosis, trypanosomiasis, chronic bacterial infections (periodontal diseases, pyoderma, pyometra, septicemia, prostatitis) - Cancers- Leukemia, lymphosarcoma, mastocytosis, primary erythrocytosis, systemic hisitiocytosis, others - Inflammatory diseases - Pancreatitis, prostatitis, systemic lupus erythematosus, other immune-mediated diseases - Other causes- hyperadrenocorticism (Addison’s disease), excessive corticosteroid administration, familial, diabetes mellitus, cyclic hematopoiesis (grey collies), trimethoprim-sulfa therapy, hyperlipidemia, sequelae of acute renal failure, urinary tract infections, urinary stones, obstruction of lower urinary tract, diabetes, hypercalcemia, heart failure, high blood pressure, high level of proteinuria, poor glycemic control in diabetes mellitus - Genetics – breeds predisposed to glomerular disease; Renal dysplasia: Lhasa Apso, Shih Tzu, Standard Poodle, Soft-Coated Wheaten Terrier, Chow-Chow, Alaskan Malamute, Miniature Schnauzer, Dutch Kooiker hound, Golden Retriever

Primary glomerulopathies: Samoyed (X linked), English Cocker Spaniel (autosomal recessive), Bull Terrier (autosomal dominant), Dalmatian (autosomal dominant), Doberman, Bull Mastiff, Newfoundland, Rottweiler, Pembroke Welsh Corgi, Beagle

Polycystic kidney diseases: Bull Terrier (autosomal dominant), Cairn terrier and West Highland White terrier (autosomal recessive) Amyloidosis: Shar-Pei, English foxhound, Beagle

Immune-mediated glomerulonephritis: Soft-Coated Wheaten Terrier, Bernese Mountain dog (autosomal recessive suspected), Brittany Spaniel (autosomal recessive) Miscellaneous: Basenji - Fanconi Syndrome; German shepherd - multifocal cystoadenocarcinoma (autosomal dominant); Pembroke Welsh Corgi- telangiectasia

Diagnosis:

All dogs suspected to have kidney disease should be diagnosed using- - Standard blood panel, this includes creatinine and phosphorous - Urinalysis - Urine culture (infections rise from 20% in cats 8-10 years to up to 80% in cats

16-18 years old) - Blood pressure (often elevated in renal disease cats)

- Abdominal X-rays for urinary stones and calcification of kidneys - Ultrasound for kidney defects and stones invisible on X-rays - Biopsy –may be indicated if cancers are suspected

The International Renal Interest Society (IRIS) grades the range of progressive kidney dysfunction scale of 1-4 for chronic kidney disease in dogs;

Grade 1 -the first is renal insufficiency and includes cats with a creatinine level of less than 1.4 mg/dl (nonazotemic). The do not exhibit PU/PD unless other causes are present. They have some kidney abnormality, such as poor ability to concentrate urine minerals and salts, irregular anatomy on x-rays or ultrasound or by palpation and blood pressure. These dogs are considered nonazotemic and are generally active and eating well. Their water intake may still be of a normal volume.

Grade 2- creatinine levels are between 1.4-2.0 mg/dl with dog now entering the lower range of azotemia. Many of these patients, especially at the lower end, will appear normal with some having moderate PU/PD signs and/or mild indications, such as weight loss. Blood pressure may or may not be elevated.

Grade 3 – creatinine levels are between 2.1-5.0 mg/dl. Clinical signs are mild to obvious for weight loss, poor appetite, and/or increased vomiting incidences, kidney changes on ultrasound or by palpation, elevated blood pressure and dilute urine with excess protein losses from kidneys.

Grade 4 – creatinine levels are above 5.0 mg/dl. Clinical signs are obvious but vary in severity. Some dogs will be very this, refuse to eat and vomit several times each day, while others are more stable and have entered a state of “chronic maladaption”. This is more likely the longer the degenerative process has taken. Dogs that reach level 3 or 4 quickly via acute renal disease (ARD) via toxins (raisin or antifreeze ingestion, clots or Leptospirosis infection, etc) are severely ill in a very short number of hours.

Treatment: Dogs in grade 1 can be treated with a fairly good short term prognosis using a veterinary prescription, low phosphorous diet. The goal is to get the damaged cells to regenerate wherever possible in the kidney and to return the kidneys to normal function. Lowering the work load on the kidneys is critical to success here. SOVG can provide 3 or 4 different samples at no charge to see what type your dog will accept. These are totally nutritious for other healthy dogs that will be eating along with the patient. Increased water consumption is crucial for stability; use what ever method the dog prefers such as filtered fountains, bowls scrubbed TWICE DAILY, ice cubes in hot weather and automated water fountains attached to a hose. A kiddies’ wading pool in hot weather will do much to reduce water requirements, help prevent heat stroke and provides an extra source of drinking water. Be certain the plastic is thick enough that nails can’t punch a hole in the bottom. Shaded areas for sleeping are also important if the dog will be outside all day.

Supplements will also be provided as below- - Omega-3 oils from fish. This helps dilate the kidney artery to get the maximum use out of this pair of organs. - Epakitin® - this is a heat treated ground shrimp shell that traps phosphorous to prevent extra calcium losses that will lead to osteoporosis in renal disease The ideal goal of treatment for these patients is to stabilize them before they begin to worsen. The real outcome is dependent on the underlying disease process. If it is age- related glomerular disease, this goal is realistic. If it is polycystic kidney disease, the duration of stability can be much shorter. Rechecks are scheduled every 3-6 months if the patient is stable.

Dogs in grades 2-4 may be treated as outpatients with the program noted above, plus the addition of subcutaneous fluids (diuresis) to drive out the excessive creatinine. This is a critical component ion keeping your dog stable and out of the hospital as long as possible. These patients already have a substantial amount of scar tissue (fibrosis) replacing normal cells, or the creatinine and phosphorus levels would be controlled by the kidney naturally. The frequency and amount of balanced electrolyte fluids to be given will be determined by size, other medical conditions and response to initial care. Some will be on fluids 2 or 3 times weekly, up to twice daily in advanced cases.

Note: A great trick is to warm up the bag of fluids in a warm water bath (sink) for 5-10 minutes before administering them to the dog. This will make them more comfortable. The rate of administration can also be helped by using an inflatable pressure cuff. We can order this for you at SOVG at our cost (around $24.00). A standard 30 pound dog dose can be finished in just over 3 minutes.

Additionally, these dogs may be supplemented with probiotics to control their uremia. Azodyl® is a symbiotic mix that contains a patented mixture of three beneficial bacteria; Enterococcus thermophilus, Lactobacillus acidophilus, and Bifidobacterium longum, combined with a prebiotic (psyllium husk).

Azodyl's bacteria are specifically screened and selected for their high affinity and capacity to metabolize uremic toxins. While this is not yet an evidence-based therapeutic embraced by all veterinarians, it has seemed to help our patient’s quality of life.

No treatment will cure these patients. Kidney transplants and dialysis are available, but the stress and cost of dialysis ($1000.00/day) makes this only realistic for acute renal patients with a chance for full cure in a few days. Transplant has fallen out of favor due to the high failure rate and lack of donor banks and very limited compatible candidates for kidney donation.

Stage 3-4 dogs with severe clinical signs, advanced dehydration and refuse to eat or vomit must be hospitalized to stabilize them. This process takes 3 to 6 days, on average. Progress is monitored every 48 hours to judge response to care. Some dogs will continue to worsen, especially if they fall in to the category of “acute exacerbation of chronic kidney disease – aka CKD”. These dogs have had a

prolonged kidney disease status that is suddenly worsened by a clot or multiple stokes, stones blocking the urine outflow (hydronephrosis), etc.

Those patients that do stabilize and become outpatients will have an initial recheck 1 to 3 weeks later, depending on the seriousness of the case. Rechecks are scheduled every 3 months once a program has been established by the initial recheck(s).

3. Hyperadrenocorticocism (Cushing’s disease) - This is a condition where too much cortisol exists in the body. Long term exposure to increased levels of cortisol leads to many deteriorative effects on all parts of the body, especially the liver. Cortisol is a normal hormone produced by the adrenal glands. It is produced rapidly in times of stress to prepare the body to conserve sodium and water, move fat out of the liver in to the blood as glucose and protects the body against stressful events. Cortisol triggers the metabolism of fat stores in the body as well. There are actually three forms of Cushing’s disease: Two are spontaneous; 1) pituitary-dependent, 2) adrenal-dependent and 3) is a pharmacological side-affect called iatrogenic Cushing’s from the patient being given prescription corticosteroids.

Signs of Cushing’s disease may be vague, mild, and/or multi-systemic at first, progressing into a classical appearance as the patient’s disease becomes more advanced. Symptoms may be inappropriately attributed to old-age or senility by owners. Increased thirst and urination, accidents in the house, and urinary tract infections occur in almost all Cushing’s patients. A well behaved indoor dog may begin to knock over trash cans and beg for food as they develop an insatiable appetite. Skin infections, recurring bladder infections and hair-loss (alopecia) become more frequent or severe, and wounds may not heal quickly. A bizarre condition called calcinosis cutis causes calcium to deposit in the skin leaving raised, rock-like formations anywhere on the body can be seen in more advanced cases. Also, muscle mass will atrophy (shrink) and fat will accumulate in the abdomen giving the dog a “pot-bellied” appearance. Diabetic patients’ blood glucose will become impossible to regulate despite previously successful insulin therapy.

Dog owners are directed to the document on adrenal diseases on this same webpage for a more detailed discussion of this important and not uncommon condition in pet dogs.