Veterinary CE 4/27/17: Chronic Kidney Disease & Proteinuria

 


Labels: education events lecture Internal Medicine Dr Tobin





Zee's Story

Steve Munt’s family was on a routine run to a shelter for rabbit food in 2011 when they met Zee, and fell in love. “We brought her home, and she instantly enriched our lives, and has brought great joy to all she has touched,” says Steve. 

Within months, the family adopted two more cats, including six-month-old Dublin, whom Zee adopted as her own — the two were inseparable. Sadly, Dublin soon became ill with FIP, an incurable illness. After exhausting every option for his recovery, the family said goodbye in January 2012. “When I came home from Dublin's last trip to the vet, Zee licked my tears,” says Steve. “She comforted me through the night.” 

After losing Dublin, Zee was sluggish and uninterested in playing. Several vet visits failed to find a problem. Then she coughed up hairballs, and her energy improved. The family adopted additional cats, one of whom became Zee's playmate, helping her resume a fairly normal life. Still, Steve says, “She was not the same cat who loved to frolic with Dublin.” He now believes this was when Zee’s real health issues began. 

Still, it would be two years before finding a proper diagnosis — chronic renal failure — during which time Steve says her kidneys were deteriorating.

Chronic renal failure (kidney disease) is a leading cause of death in domestic cats, affecting as many as one in three. “Kidneys have a built-in reserve capacity,” Steve explains. “Sadly, symptoms may not appear, and bloodwork can be normal, until two-thirds of kidney function has been lost.”

In 2014, at age four, Zee became seriously ill. Given just a 5% chance of survival, the veterinarian’s recommendation: euthanize her. 

“I looked into Zee's eyes, as well as my heart, and knew what I had to do,” says Steve. “Zee was an amazing cat and an important part of our family; I would not lose her without a fight.”   

And fight he did. “I learned all I could about her illness, and assembled a top-notch medical team.” 

The first step was a blood transfusion, a dramatic chapter in its own right. The hospital had none of Zee’s rare type-B blood, but managed — on extremely short notice — to reach the owners of a cat who did. This superhero likely saved Zee’s life with the donation of a single pint — all that stood between life or death for her that night. 

While Zee survived, Steve says, “Our fight has just begun” and that this marked the beginning of his “education into veterinary specialists.” 

Zee’s team would eventually include an internist, cardiologist, surgeon, anesthesiologist, dentist, and acupuncturist. But first she would meet “the cat whisperer.” 

Following her blood transfusion, Zee was in a slump. Hiding out in a shopping bag in a closet, she would emerge only occasionally, sit very still, then quickly return to the bag. She would not eat or drink. “I feared I was losing her.” Steve contacted a woman at the shelter, who agreed to visit. She belly-crawled to Zee’s hiding place, and “Zee came to life,” Steve recalls. The woman helped with environmental changes, including a window perch with a view. Soon after, Zee’s signs of life improved even more when “a stranger arrived . . . .” 

A sweet orange boy that Steve soon learned lived nearby “came a calling.” Zee seemed to know and be smitten with him, and learning that he was born shortly after Dublin's departure, Steve felt he knew him, too. Zee's energy and desire to live continued to rise. 

The next step in Zee’s care was to see an internal medicine specialist who diagnosed stage 3 kidney disease (median survival time: 778 days). Additional testing indicated Zee was losing protein through her urine, further reducing her median survival time to 276 days. Also finding a slightly enlarged heart, the doctor referred Zee to a cardiologist. An echocardiogram added a diagnosis of hypertrophic cardiomyopathy, or thickening of the heart muscle. Medication addressed both issues, and Zee responded with improving labs and weight gain. 

Through his extensive research, Steve found that — with strict criteria — kidney transplants were available to cats. He soon discovered, however, that she was “too healthy” for one. His research then led him to stem cell therapy. While such therapy for feline kidney disease was not approved by the FDA at that time, Steve wrangled a compassionate use exception, giving Zee a green light. 

By this time Steve was working with doctors at CVRC, who had performed stem cell therapy on dogs for muscle and joint issues, but not on cats or for kidney disease. While the doctor was skeptical it would make a difference, Steve’s persuasion won again: she agreed to perform the procedure. 

Before Zee’s journey, Steve says his experience with “the vet world” was, “A vet is a vet is . . . a vet. Then, at the specialty hospitals, I found higher quality doctors — even more notably, higher quality vet techs. When I was initially referred to an internal medical specialist at CVRC, I thought: ‘specialists?’ I had no idea there were [veterinary] specialists.” 

“There was an obvious elevated status. Now I always say, ‘If I ever get really sick I’m dressing up as a cat and coming to CVRC.’” 

Steve says he appreciated that at CVRC, “No one was dictating to me, like: ‘This is what we need to do.’ The doctor was educating me, and I got to see her process — it felt like a partnership.” Steve says his suggestions were listened to — like the possibility of a kidney transplant and later stem cell therapy — adding, “I could share research I had done and she was very open to it.” He says that while the doctor felt skeptical that stem cell therapy would be beneficial for Zee, “she didn’t feel it would cause harm, and said: ‘If you’re going to do it, do it now.’” 

They did. After two infusions two weeks apart, Zee’s kidney function was improving, as was her energy — dramatically. “She was active and gaining weight.”

By early 2015, Zee was better than ever. But chronic kidney disease is progressive, and Steve remains vigilant in her treatment. “Without it she would decline,” he says. “It is a battle we currently are winning.”   

Also continuing his research, Steve found that acupuncture was sometimes used to treat chronic kidney disease in cats. He carefully chose a practitioner and made an appointment. “I knew immediately I had made the right choice,” he says. “The initial result was nothing short of amazing. Within minutes of arriving home, Zee had a very distinct response to her treatment.” 

Zee continues to receive regular acupuncture and monitoring by her internist and cardiologist. Steve also gives her a daily probiotic “which can help metabolize toxic waste in the gut, before it hits the bloodstream.” Also with prescription meds and diet, Zee continues to improve. “The need for a kidney transplant seems unlikely anytime soon,” he says. Since beginning acupuncture, she’s gained more weight, and her urine protein levels have improved 66%. While additional stem cell infusions will be provided if needed, Zee hasn’t had one since 2014, and based on the efficacy of acupuncture, Steve feels the need might not arise at all. 

Nearly two years after hearing “euthanize her,” Zee is very much alive, happy, healthy and active. Her CKD has reversed, and is now in remission. 

While that’s certainly thanks to Steve’s investment of love, time and extensive research, he says: “I can’t say enough good things about CVRC. I believe if I had not been put in touch with them, Zee wouldn’t be here. I was able to work with the doctors toward my desired outcome. I didn’t care about the percentages like chances (or not) of survival. I felt if she had a chance of making it, let’s go for it. I don’t think I could’ve done that with any other vet. It’s such a different level of respect . . . a different world.” 

Postscript….

Steve and Zee’s experience led to Zee cultivating a Twitter feed where she now has more than 6000 followers. Steve is working on a book to help other pet parents understand the causes, effects, and possible solutions for chronic feline kidney disease. 

Find Zee on Twitter via @growingupzee.


Labels: Stories





Bella's Story

A beautiful Vizsla who will soon celebrate her 12th birthday, Bella was the first purebred Tamara Wecker ever had. “I was the girl who brought home strays and rescues,” she laughs. But her then-husband had always loved and had them, and when Tamara’s dog passed away at age 15, “we went and picked her out.”

She was 8 or 9 weeks old, and “looked like a lil orange marshmallow,” Tamara smiles. “We’ve had lots and lots of bonding time.”

After divorcing in 2007, “It was just the two of us for quite some time,” says Tamara. “We did have people renting over the years, which Bella, being so social, absolutely loved.” So social, that often when they went to the dog park, “Bella would give a quick hello to the dogs, then go to the nearest group of humans and find someone to lean on.  She loves everyone.”

“Even now she has a lot of energy,” says Tamara, adding that she has slowed down a little, as she’s becoming an older lady. “We don’t really do dog parks anymore, but we do long walks, and she absolutely loves going to the beach.”

“She’s pretty flexible . . . she just likes to get out, meet people, and she has several walking routes she has to check”, Tamara laughs. “You’ve gotta check the day’s pee-mail!”

While healthy, “Bella was always a lumpy girl. She was probably pretty average, but with her short, fine coat I could really see the lumps.”

Tamara was vigilant about having any new lump checked, “And I was often told, ‘this is nothing’ — almost like I was a nuisance.”

When Bella was 10, two lumps showed up “overnight” on the backs of her legs. “What was strange . . . first the location, but they were perfectly even. I thought this is not normal — something’s wrong.”

The family vet diagnosed Bella with lymphoma a few days before Memorial Day. They explained that it could be treated, but not cured.

“Something came over me that . . . nope, it’s not her time yet,” says Tamara. “I asked Bella what she wanted me to do in this. I got the feeling she was not done.”

Her vet recommended Bella go to Cascade Veterinary Referral Center, saying “the doctors are just amazing — if anyone can help you with this, they can.”

Treatment began with steroids, and then six months of chemotherapy.

“She did much better than I imagined,” says Tamara. “I had to get past the difference between what humans go through. The doctor explained that Bella’s chemotherapy regimen was a tiny fraction of what is given humans, and that dogs don’t usually suffer significant side effects.

Bella did experience some, including stomach upset, sensitivity to touch, and bouts of being more tired than usual. However, once treatment started, “she was in remission almost right away.”

“At 10 she was still like a puppy, she had so much energy!” says Tamara. But during treatment, Tamara says there were times that, “instead of walking the usual few miles, she’d just stop, turn around, and say, ‘not today.’ She’s a total rock star . . . I wish I were more like my dog.”

After the prescribed six months of chemo and steroids, Bella was placed on metronomic therapy, which Tamara explains is a tiny dose of chemo from which she saw no side effects. “CVRC gave me the option, although it still isn’t widely used . . .  it was mostly prophylactic, but it seemed like a good idea after everything she’d been through.”

Tamara says this has been an ongoing learning experience, adding that now, as Bella moves into her senior years, she’s learning even more. What does she look forward to in the years ahead?

“I hope its years,” she replies. “One thing Cascade really gave me is that what’s happening right now is how it’s supposed to be. She’s going into her old age and the issues that go along with that. I’m just thankful we had the opportunity to get to this part.”

“We’ve had a lot of great time together,” Tamara says. “Even during treatment she was still my Bella.”

Some days, when buried in a book or watching a movie, Tamara finds herself suddenly drawn out. “I’ll stop what I’m doing and make time to just sit with her and be in the moment. We communicate so well after all we’ve been through. I just try to be a good listener.”

Postscript: While the above seemed the end of Tamara’s telling of Bella’s story so far, she added the following, which readers may enjoy.

“I’m a few blocks away from Cascade . . . I didn’t even really understand the resource that was there.

“I can’t even get Bella to leave. She LOVES them! She adores them. I practically have to drag her out of there.”

“I can’t imagine having gone through this with anyone else. They made me feel like everything was going to be okay. I’ll do anything that helps gets that out there.”


Labels: Stories





Arwen's Story

Bill and Chris got Arwen, a beautiful purebred Rough Coat Collie, as a “six- to seven-week‐old teensie puppy, " says Bill. "We'd gone to a breeder in Lebanon, picker her out, and went home to wait for her to be old enough to leave the nest."

The day they picked her up, they made an appointment for a puppy check with their Newberg vet. Upon examination, the vet declared that Arwen appeared to be healthy, but her vulva was positioned too far into her body cavity. This condition could lead to infection in some dogs and could be dealt with a procedure in the future if needed.

The family went home with their new addition. They were hopeful of quick pack acceptance by their two current dogs, Pepan (100-lb 10-year-old male Rough Coat Collie) who is a sweet but stern soul; and Manchu, a 110‐lb six-year-old male Great Pyrenees. Within two weeks, Arwen and the boys found their pecking order and bonded into the pack structure. Manchu became like a puppy again, enjoying the companionship of his new girlfriend.

Within the first couple of weeks of Arwen’s arrival, the family noticed some abnormal behaviors. She appeared to have trouble urinating, and also was having some drippy urine discharge when she lay down.   

Back to the vet they went, and Arwen was prescribed medication for a bladder infection. After a short time with no slowing of the dripping, they returned to the Newberg vet. After confirming there was no longer infection, the vet suggested they try medication for bladder control. This too was unsuccessful and alternative options were discussed.

Arwen was then referred to Cascade Veterinary Referral Center. The Family vet said they were the leaders in orthoscopic surgery for bladder issues.  Not only was the doctor renowned in his field, Bill says, but he actually invented the procedure they were considering for Arwen.

“The doctor was absolutely fabulous,” says Bill. “The entire staff was just great with Arwen . . . and also with our other two dogs, who came along with us to some of her appointments.”

Bill says when they arrived at CVRC, Arwen walked right up to the doctor, who sat right down on the floor with her. "Basically we were all sitting on the floor — it was pretty amazing."

The doctor determined that Arwen had an ectopic ureter. “The kidney has a tube to the bladder." Bill explains. "The bladder holds urine, which then passes through the urethra." In Arwens case, the bladder wasn't properly connected to her kidney.

The doctor suggested various options. Arwen’s family especially appreciated that he gave a detailed, step-by-step explanation of all the options, and plenty of time to discuss her options. An example of the decision-making process was that the doctor planned to go in with a scope and said, ‘If I’m up there and find a problem, I need to know whether you want me to go ahead [and fix it] or stop.” The family thought this was excellent, because they were drawn into the decision-making process prior to the procedure. “It was the best brainstorming session conducted based on facts and probable solutions that any pet parent could hope for,” says Chris. “I appreciated the fact that we were part of the solution and that we had an active voice in the direction prior to the procedure.”

The family gave the go ahead, and the procedure was successful.  

Not long after, “We decided to have Arwen fixed at the Newberg vet clinic. After about a month and a half, during which there was no leakage whatsoever, there was a leakage issue from the spaying. “Of course during that time,” Bill chuckles, “we were looking at every little drop on the floor — which turned out to be her brother Manchu’s slobber or something else.”

After her spay, the family vet warned Bill and Chris that Arwen might start leaking again as a result of  the procedure and hormonal changes. In about six weeks, she did.

The family then began giving Arwen artificial hormones every day, to keep her from leaking. “We’d gone full circle!” Bill says in a ‘go figure’ way.

“She is a wonderful kid. It was expensive, but well worth it — every bit of it,” Bill affirms. “Someone else  might have left her as an outside dog . . . or given her away . . . or had her put down. Once we take responsibility [for an animal] it’s our responsibility for life. She’s a wonderful, loving little kid.”


Labels: Stories





Jerry's Story

Longtime pet foster parent Melissa Freels had cared for 12 pets who had gone on to forever families. Then along came foster #13.  Jerry, then a 2-3-year-old Pomeranian mix, never left.

“The way it all happened,” Melissa begins . . .

“Jerry had been with me since December 2012. In May 2014, I adopted my son from Haiti, which had been a long, involved process.”

Returning home with her son, Melissa’s pet sitter told her “Jerry seems kind of depressed.” After a few days Melissa felt something really was wrong and took him to the vet. “His red blood cell count was dangerously low, and my vet referred us to Cascade.”

“It was funny,” Melissa continues, “The month I had taken off to help my son get used to his family and new world, we ended up at the vet — a lot. So this really gave him a crash-course in how important our pets are for us.”

Few cultures outside the US treat pets as family. Many simply can’t afford to.

Jerry was diagnosed with an autoimmune disease. While his body would produce baby red blood cells, it would later destroy them.

“Jerry is a quirky dog,” says Melissa. “He’s very sweet, but he doesn’t like going out and being around other people or dogs, so it was stressful for him.”

The situation was also scary. “At one point we were at the vet twice a week monitoring Jerry’s blood levels and getting transfusions. One thing that came out of it is that Jerry’s become more trusting of people — the staff and doctors at Cascade are like second family now. It’s like, ‘Okay, we’re gonna go see our friends now!’ Even when I drop him off to spend the day.”

“Cascade was really honest about his prognosis, and how optimistic we could be,” Melissa continues. “The prognosis was always . . . guarded.”

“They were also great about working with my vet. I had to do so much blood work regularly, I couldn’t always get to Cascade during the week because of work. So I’d get blood work at my regular vet at Crossroads, who would send it to Cascade.”

Less than nine months into treatment, Melissa says Jerry was doing great and that Dr. Tobin felt he didn’t need such frequent checkups.

“Then he relapsed,” Melissa says. “I joked with him, ‘You just want to see your friends!’”

“But the relapse was bad. His red blood after the relapse was 9 percent — normal is 40.”

Jerry received three to four transfusions within two weeks, some at Cascade, some at an emergency vet. “Dr. Tobin and Dr. Donovan were great about being available on weekends to answer questions,” says Melissa. “I was like, ‘Dear God, please get me through the weekend so I can get to Cascade Monday.”

“Knowing they were always available was really reassuring. They knew exactly what was going on with him, and I didn’t want to go to anyone else.”

In time, “Jerry made it out of that,” Melissa affirms. “At a checkup, the vet who made the referral to Cascade told Jerry, ‘It’s amazing you’re still with us.’ And it is. It’s been tough. He’s on a lot of meds — seven pills in the morning and seven at night,” she says. “And it did affect his personality. Prednisone can make you grumpy, and he didn’t play with our other dog as much.” Now being weaned off prednisone, Jerry is once again playing with the other dog.

“Initially I hid his pills in food. When he relapsed, he wasn’t eating much so that didn’t work.  Now I just pry open his mouth and shove them in — before I couldn’t do that. He’s definitely become more trusting having spent so much time at the vet with different people.”

“Still, he’s a funny dog; he’s uppity,” Melissa laughs. “He lets you know when he doesn’t approve . . . . If he knows something’s in a certain closet — like the vacuum — whether you’re going for the vacuum or not, he’s barking. And he barks in the lobby [at Cascade] to let them know we’re there.”

“One really cool thing . . . this, coming from a seven-year-old . . . I was on Facebook one day and saw a post on Cascade’s page in appreciation of staff or vet techs. I told my son, ‘Look, there’s Jerry’s doctors.’ My son said, ‘Are those all the people who love him?’”

“It was very sweet. I told him, ‘yes, it is.’ They’ve been great; I totally trust them.”

Epilogue:  Melissa reports that in early December (2015) Jerry’s red blood cell count was 40 percent. 


Labels: Stories





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