Friday, September 25, 2015

2311. BKTP - Heart, kidney and prostatic diseases in a 13-year-old Chihuahua - the good brother

Sep 26, 2015

"This chihuahua keeps eating one hamburger a day instead of a careful kidney diet," I was told by the sister that the dog would not eat the Prescription K/D diet advised by Vet 1. "So, the kidneys will get worse and the twice weekly dialysis will need to be done. In addition, there is low red blood cell and haemoglobin.

"This dog has kidney failure as the recent blood test shows high levels of urea and creatinine. Kidney failure means that the dog kidneys are unable to remove waste products such as urea, from the blood. It is NOT the inability to make urine,

Sep 16, 2015. Vet 1 had treated by inserting the needle to aspirate 15 ml of urine. But the dog cannot pee this morning.

At Vet 1, heart murmurs Grade 4. Heart attack 3 years ago but revived.
               kidney failure SC drip every 3 days from Jun to Sep 2015.
               prostatic enlargement 2 weeks ago (see x-ray). Given Tardak inj. weekly.

ADMITTED Sep 16, 2015
SURGERY-  Urethrostomy
Atopine 0.5ml SC, Oral foretekor 5 (1/2 tab), Fursemide 1.0 ml SC.
Gas anasethesia.
Catether obstructed at front of os penis.
Incision behind the os penis. Stoine removed.
Press bladder to express the urine and to locate the  urethra which is 1.3 mm in diameter only. Anchor catheter into neary tissues.
4 mm stone across, removed from behind the os pens.

Urine test on Sep 17, 2015.
pH 6.0 (5-8)   . SG 1.012 (1.005-1.030). Protein 2+, Ketones +, Blood 4+_
white blood cells 10
red blood cells >1800.
Epithelia cells 15

Crystals Nil

Blood test on Sep 23, 2015
Glucose 9.3 (3.9-6)
Calcium 2.34 (1.5-3.6). Normal.

Urea 90.9  (4.2-6.3)
Creatinine 357 (89-177). Kidney failure. Fluid under the skin is needed twice  week.  

Haemoglobin 9.5 (12-18)
Red cell count  3.5  (5.5 - 8.5).  Anaemia


1. A low protein diet to reduce the workload on the kidneys. Prescription K/D diet is best but the owners have no perseverance to train the dog to eat it. So, a daily hamburger again.

2. A phosphate binder. Phosphorus increase in the blood due to impaired filtration by the kidneys. This makes the dog lethargic and has poor appetite. Certain drugs will bind excess phosphates in the intestines so that they are not absorbed.

3. Fluids given at home.
Presently, the first vet recommends twice a week 250 ml Hartmann's solution under the skin. This continually make the kidney function again via diuresis. This can be done at home once daily to once weekly depending on the degree of kidney failure.

4. A drug to regulate the parathyroid gland and calcium levels. If blood phosphorus increase, the parathryroid gland removes calcium from the bones to increase blood calcium level. This is to make calcium phosphorus ratio at 2:1 which is the normal ratio. Calcitrol can be used to reduce the function of the parathyroid gland and increase calcium absorption from the gut. This will be done if there is abnormal function of the parathyroid gland.

4. A drug to stimulate the bone marrow to produce new red blood cells. Blood test shows this cat now has low red blood cells and haemoglobin. Epogen, Procrit or synthetic forms of erythropoietin will correct the anaemia in most dogs. Some dogs' immune system make antibodies against the drug.

Much depends on the disease and ability to perform the follow-up care. Possibly up to 4 years.



Wed Sep 16, 2015

Unusual twos.  Two cases from the owners of a 13-year-old cat and a 13-year-old dog from the same neighbourhood in North Singapore in successive days. As Singaporeans prefer proximity, I rarely have one case from North Singapore during the past years. The location is a 30-minute drive away and it has nearer clinics than Toa Payoh Vets. 

Vet 1 from the same clinic in North Singapore treated both cases from owners unrelated and unknown to one another. So I was much surprised at the coincidences of two sick 13-year-olds. 

CASE 1 ON SEP 15, 2015
The first case was a cat not eating and lethargic. I got a blood test done as Vet 1 had done X-rays and ultrasound but was not given the permission to do X-rays. The cat did not recover and so the owner consulted me for a second opinion. She consented to X-rays which showed a low platelet count indicating toxicity causing the left kidney to be painful.

TREATMENT - Dental scaling (gingivitis on back teeth and tartar). Left ear irrigation. IV drip x 1 bottle Hartmans with antibiotic and painkiller. Overnight inpatient. The next day, the cat ate and was meowing happily. Went home.

In retrospect, the owner recalled a possible ingestion of commercial ear drops purchased from the pet shop as the owner noted that the old cat pawed at the ear drops after she had put inside the left ear. The cat could have been poisoned resulting in ear pain. This was not obvious without the blood test. Cats are very sensitive to chemicals.  

Lethargic and anorexic for 7 days. The owner had purchased ear drops  to treat the left ear discharge since April 2015. Treated by Vet 1. Ok. Problem came back in June and so she decided to buy the pet shop's ear drops which irritated the cat around 7 days before the sickness. The likely cause could be the chemical toxicity affecting the left kidney which has a radio-dense stone of 3 mm in diameter.

No hairball snacks and treats
Only First Choice For Senior Cats
Warned that the left kidney had a stone which could cause kidney pain and swelling later. As at Sep 17, 2015, the cat was eating and drinking and was active. There was no ear discharge.

The old dog's veterinary bills amounted to a large sum and so the brother who works in the same building as Toa Payoh Vets referred the sister to me.
"As the dog had heart, kidney and prostatic diseases, the bills will add up," I said to the brother today. "Chronic diseases tend to cost much to treat."  Many Singaporean owners only look at the absolute amount and would pronounce to the world: "This vet is expensive and cut-throat."

"Very high risk of death on the op table," I said to the brother and sister as the chihuahua had this loud heart murmurs of Grade 4 confirmed by Vet 1.
"50%?" the brother said.
"Hard to say it is 50:50," I would not be precise as the dog's bladder swelled up to a mango size.
Vet 1 had taken out 15 ml of the urine from the bladder by cystocentesis and given a Tardak injection to reduce the massive prostatic swelling which could cause urination problems. Two weeks ago, he had given one and the dog had no problem urinating.

On going home, the dog just could not pee and some urine dribbled out despite treatment by Vet 1. This appeared to have shaken the confidence of the owner and so the brother asked her to consult me. 

The bladder ballooned.
"It is death if you don't operate. It may be death if you opeerate," the brother told the sister. There was no time to waste. 

Weight 3.5 kg. T=37.8C. Cyanotic mucous membrane.

1. I gave 1/2 tablet Fortekor 5 orally and inject frusemide 1 ml SC and waited for 1.5 hours. The bladder had swollen to a ballon.

2. IV drip. IV baytril and tolfedine.
3. Atropine 0.6 ml SC
4. No sedatives
5. Isoflurane gas only.
6. Catether blocked from behind the os penis where the stone was lodged. Marker pen to draw the length of catether at the obstruction. This confirms that the enlarged prostate was not the cause of this anuria as the prostate could be having tumours. In any case, Vet 1 had given Tardak injection the day before.
7. I electro-incise behind the os penis and pre-scrotal for around 3cm length. A large 4mm x 4mm brown stone was seen. 3 smaller ones of 2 mm across were seen.
8. I located the urether which was around 1.3 mm in diameter as my assistant compressed the bladder, squirting out the urine.
9. I inserted the cat catheter into the narrow urethra and stitched up the 4 holes.
10. I stitch skin and muscles to either side so as not to close up the wound in front of the catheter.

The whole process of start of anaethesia by mask to completion of stitching took around 40 minutes. The dog was alive and woke up as soon as the gas was taken off. This was a big relief to me.

A vet book mentioned sedation and local anaesthetic for dogs with kidney or serious health problems. In this case, the heart disease was bad. So, no sedation.

2. In normal urethrostomy, the catether can be seen as the urethra is incised 2-4 cm since it is placed inside from the penile tip. In this case, I had to open behind the obstruction and so was not able to view the very narrow 1.3 mm cathether of this chihuahua. I used the squirting urine to locate it and anchor the cat's cathether.

3. Today, 16 hours post-op, the dog is active and alert.

4. I advise neutering in case the prostate swelled up more to obstruct urine flow, instead of Tardak injections regularly. The anaesthetic risks of dying are there.

5. Urine test and stone analysis need to be done as a minimum. I did not ask for blood test as the owner was not in favour of additional medical cost.

6. As to the need for regular weekly SC dialysis by Vet 1, I told the brother that he ought to have blood test to check on the kidneys and whether there is still renal failure. In the meantime the dog is given Hartmann's 250 ml SC once a week.    

SEP 18, 2015
I sent the Chihuahua back on Day 2 but he licked his wound causing bleeding. There was another dog in the apartment wanting to play with him.

The dog came back and I saw a large pink purplish bruise on the right side of the scrotal area due to licking. As an in-patient, he had no distractions and was recuperating well. The owner wished to have him in-patient for the next 3 days. The catheter was still in place and the urine coming out looked clear. The dog is an in-patient now and will be given dialysis SC today.    

The prostatic enlargement will cause urination problem later and Tardak injections may need to be given regularly. A neuter would be best but the owners have their worries about anaesthetic risks and so did not accept my advice. The neuter surgery is much shorter than this urethrostomy but the risks are still there. If the dog had been neutered at a young age, there will be no prostatic hypertrophy which could cause obstruction to the flow of urine.

During surgery, I noticed that the urine from the distended bladder did not flow freely after I removed the 4-mm x 4mm urethral stone. My assistant had to compress the bladder manually to release the urine. So, it is possible that the enlarged prostate or prostatic tumour will cause dysuria.

Neuter will be the best advice but the owners think of anaesthetic risks and death and so, nothing will be done till another dysuria episode comes.

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