Indian J. Vet. Med. Vol. 41, No. 2, 2021 pp.
58-61 Clinical Articles
Management of Chronic Kidney Disease in a dog with Intermittent Hemodialysis
Randhir Singh
Department of Teaching Veterinary Clinical Complex (TVCC), Guru Angad Dev Veterinary and Animal Sciences
University, Ludhiana - 141 004, Punjab
Abstract
A case of 2 years old French Mastiff breed dog with history of anorexia, lethargy, mild diarrhoea and halitosis
was presented in Medicine emergency at Multispecialty Veterinary Hospital, Guru Angad Dev Veterinary and
Animal Sciences University, Ludhiana, Punjab. The hemato-biochemical profile, urine analysis, radiographic
and ultrasound findings of dog indicated stage IV chronic kidney disease (CKD). Intermittent hemodialysis
(IHD) was selected as treatment of choice as the dog was already on standard treatment from past five days
with no significant improvement in condition. After two IHD sessions, the dog showed quick improvement
with reduction in uremic toxins, correction of electrolyte imbalance and improved quality of life.
Keywords: CKD, Intermittent hemodialysis, Dog
Chronic kidney disease (CKD), also known as other toxins (Cowgill and Francey, 2012; Fischer et al.,
chronic renal failure (CRF), is a condition in which the 2004). In veterinary practice, the prognosis and treatment
kidneys gradually lose their functional ability. The normal time for IHD vary depending on the seriousness of the
kidneys filter waste and excess fluids from the blood underlying cause, the degree of renal damage, and the
of dogs, which are then excreted in the urine. As CKD occurrence of comorbidities (Bloom and Labato, 2011).
progresses, harmful amounts of fluid, electrolytes, and
wastes accumulate in the body (Polzin, 2011). Being a Case History and Observations
progressive disorder that results in functional changes in A 2 years old male French Mastiff breed dog
the renal parenchyma, CKD is a now a day commonly weighing 43 Kg was presented at Medicine emergency
diagnosed in small animal internal medicine practice, with of multispecialty Veterinary hospital, Guru Angad
high comorbidity and mortality rates, with a prevalence of Dev Veterinary and Animal Sciences University,
0.5-1.0 per cent in canines and 1.0-3.0 per cent in felines Ludhiana, Punjab with history of anorexia, diarrhea,
(Roura, 2018). Canine patients with CKD stage III having vomiting, dark yellow urine and halitosis from past
serum creatinine levels of 2.1-5.0 mg/dl show mild to eight days. Previously, from past five days, the dog
moderate azotemia and clinical symptoms, requiring was on prescription medicine from a private veterinary
round-the-clock monitoring and patient treatment, practitioner which included Dextrose normal saline
whereas dogs in stage IV having serum creatinine levels (DNS), furosemide and Metoclopramide. On presentation,
of >5.0 mg/dl are at an increased risk of systemic clinical the dog was dull with rectal temperature – 102.50F, heart
signs involving multiple organ involvement and extreme rate- 110bpm, respiration rate-34 breaths/minute, Blood
uremic crisis (Polzin, 2013). pressure (Doppler)- 155 mmHg, mucous membrane-
Intermittent hemodialysis (IHD) is a form of congested, and normal lymph nodes. Oral examination
extracorporeal renal replacement therapy (RRT) that revealed halitosis with no appreciable ulcers. Blood,
includes a series of brief hemodialysis sessions over a urine and serum samples were again taken from dog for
period of time with the goal of restoring equilibrium to the evaluation of complete blood count (CBC), urine specific
patient’s metabolic profile and homeostasis, which would gravity, proteinuria, microscopic evaluation of urine and
otherwise be lost due to the pansystemic effects of extreme biochemical profile (ALT, GGT, total protein, albumin,
uremia (Bloom & Labato, 2011). In dogs with CKD, the glucose, BUN, creatinine, Na, K, P, Cl, and Ca). X-ray
primary aim of IHD is to enhance chronic progressive of chest (lateral and VD views) along with ultrasound
azotemia, correct acid-base, fluid, and electrolyte of abdomen was also carried out. Results revealed Hb-
imbalances, and remove nitrogenous compounds and 7.8 g/dl, PCV- 21.50 per cent, TEC-3.55x106, TLC-
17,070 involving neutrophilic leukocytosis with few
toxic cells (N-84%, L-12%) and platelet count- 306x103.
Corresponding Author: dr.randhirlo@gmail.com
Intermittent Hemodialysis in CKD in a dog 59
Microscopic examination of urine revealed waxy casts levels were kept at 142 mEq/L. The dog was loaded
(figure 1) with urine specific gravity 1.015 and 2+ with levocarnitine @ 1g slow I.V. after end of each IHD
Proteinuria. Biochemical profile revealed ALT- 37 u/L, session (inj. Carnisure 1g/5ml, Torrent Pharmaceuticals
ALKP- 99 u/L, GGT- 06 u/L, Total Protein- 6.7 g/dl, Ltd) and subsequently given oral maintenance dose of
Albumin- 2.7 g/dl, Glucose 103 mg/dl, BUN- 240 mg/dl, levocarnitine @ 500mg P.O. BID (Tab. Carnisure 500mg,
Creatinine- 19.0 mg/dl, Phosphorus-13.9 mg/dl, Na-120 Torrent Pharmaceuticals Ltd) for 15 days. The dog was
mEq/L, K- 5.1 mEq/L and Cl- 86 mEq/L. X-ray of chest also prescribed Amoxycillin and Potassium Clavulante
revealed heart in fourth inter-costal space with increased 600mg I.V. BID X 4 days (inj. Augmentin 600mg, GSK),
sternal contact (figure 2) whereas, abdominal ultrasound Ranitidine @ 2mg/kg S.C. BID X 4 days (inj. Aciloc,
showed hyperechoic renal cortex of both kidneys with Cadila Pharmaceuticals Ltd) and furosemide @ 2mg/
satisfactory cortico-medullary differentiation, distended kg I.M. BID X 4 days (inj. Lasix, Sanofi India Ltd).
urinary bladder, enlarged spleen and mild amount of free The hemato-biochemical profile was carried out both
fluid in abdomen suggestive of ascites. Based on history, before (Pre-session) and after end (Post-session) of each
clinical and laboratory findings, the case was diagnosed IHD session and the results (table 1) showed significant
and treated as CKD stage IV. As the health of dog was reduction in BUN, creatinine, Phosphorus along with
progressively deteriorating even when on prescription correction of electrolyte imbalance after end of each IHD
medicine from last five days, intermittent hemodialysis session. There was also marked clinical improvement in
(IHD) was considered as treatment of choice. Two IHD dog with return of normal appetite, complete cessation
sessions were performed on alternate days with Fresenius of emesis and normal physical activity.
4008S machine, using jugular catheterization with 11.5
Fr. double lumen catheter, Fresenius Fx 8 dialyzer having Discussion
surface area 1.4m2. The dialysate K concentration was Generally, IHD prescriptions for dogs suffering
adjusted to 3.5 mEq/L whereas base and prescribed Na from CKD aims to promote a better quality of life (QOL)
Table 1. Hemato-biochemical profile of dog undergoing IHD
Parameter IHD Session I IHD Session II
(session time: 40 minutes) (session time: 3 Hours)
Pre-Session Post- Session Pre-Session Post- Session
Hb (g/dL) 7.80 7.40 7.90 7.50
PCV (%) 21.50 22.0 21.80 22.50
TLC 17,070 16,760 14,090 14,350
TEC (x106) 3.55 3.69 3.89 4.17
Platelets (x10 ) 3
306 298 249 233
ALT (U/L) 37 40 294 305
ALKP (U/L) 99 101 349 367
GGT (U/L) 06 08 15 18
T. Protein (g/dL) 6.7 6.4 8.4 7.8
Albumin (g/dL) 2.7 2.5 3.1 3.0
BUN (mg/dL) 240 167 136 83.27
Creatinine (mg/dL) 19.0 13.03 6.2 3.39
Phosphorus (mg/dL) 13.9 9.8 9.5 6.27
Sodium (mEq/L) 120 144 148 141
Potassium (mEq/L) 5.1 4.2 4.6 3.96
Chloride (mEq/dL) 86 109 102 106.40
Glucose (mg/dL) 67 60 69 86
Ultrafiltration Goal (UF Goal):- Session I: 100ml; Session II: 500 ml
60 Randhir Singh
Fig. 1. Waxy cast in urine sample Fig. 2. Radiograph of dog showing increased sternal contact
than to reduce the acute uremia signs that are mostly clearance of uremic toxins and correction of electrolyte
observed and reported in the acute phase (Cowgill & imbalance manifested by improved physical activity,
Francey, 2012). Although, in the present study, IHD was cessation of emesis and improved appetite. The dog was
more efficient at removing nitrogenous end products kept on oral medications like L- carnitine, furosemide,
from the body and correcting electrolyte imbalance, the ranitidine and B-complex supplementation for next one
subsequent morbidities that present along with CKD week. The condition of dog was reassessed after one week
may have implications for the survival of the patient. over phone call with improvement in overall condition
The higher the stage, the more difficult it is to control but reduced appetite. The hemato-biochemical profile
morbidities along with CKD (Melchert et al., 2017) The one week post second dialysis session revealed Hb- 7.7
present case was selected for IHD due to severe refractory g/dL, TLC- 15.5 x 103, BUN- 63.5 mg/dL, creatinine
uremia from last few days. Initially, the first IHD session 3.2 mg/dL and Phosphorus 5.8 mg/dL. The owner was
was deliberately kept less intense and effective owing to prescribed appetite stimulating syrup containing buclizine
severe uremia to avoid sudden hemodynamic changes hydrochloride @ 10ml P.O. BID (Syp. Aptiquik, Pet
leading to major fluid shift. The dialyzer was selected on Mankind) and Amino Acid Supplement @ 15ml P.O.
the basis of dogs’ body weight (Cowgill, 2011) keeping OD (Syp. Healthup pro, Vetoquinol) which improved
a balance between effective surface area and priming the appetite of dog. The last hemato-biochemical profile
volume. The blood flow rate was initially 2ml/kg/min of dog done on 30th day after second dialysis session
during first session which was increased to 5ml/kg/min revealed Hb- 7.5 g/dL, TLC- 14.8 x 103, BUN- 54 mg/
in second session to achieve desired outcomes. There dL and creatinine 2.2 mg/dL and Phosphorus 4.1 mg/dL.
was significant improvement in dog with reduction
in levels of BUN, Creatinine, Phosphorus along with Conclusion
correction of electrolyte imbalances after the end of Though IHD entails more risks due to invasive
second session. After the end of first IHD session, the procedures than conventional care with medicines and
dog appeared more dull and fatigued with no inclination fluid therapy, a well-trained veterinarian may minimize
to stand or move. It was due to the fact that the dialysate these associated risks. No significant problem was
used during IHD was dextrose free and due to which the encountered during IHD sessions suggesting safety of
circulating glucose levels also declined after end of the IHD for dogs with CKD. Survivability may be more
session. This post dialysis fatigue due to hypoglycemia promising in dogs with early stages of CKD, as the
was managed with intra venous infusion of 500ml of probability of patient survival decreases as the disease
5 per cent dextrose and subsequent use of dialysate progresses due to multi-organ involvement. For later
solution with pre-added dextrose during second IHD stages of CKD, a more systemic approach is needed in
session. After two IHD sessions the dog recovered with conjugation with dialysis, since it may include multiple
Intermittent Hemodialysis in CKD in a dog 61
organ failure (heart and liver), and simply correcting Cowgill, L.D. and Francey, T. 2012. Hemodialysis and
uremic signs with dialysis may not be enough. extracorporeal blood purification. In: DiBartola SP, editor.
Fluid, Electrolyte, and Acid-Base Disorders in Small Animal
Practice, 4th ed, Philadelphia: Elsevier; pp. 680–713.
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Received : 12.04.2021
Accepted : 16.09.2021
