Kidney, GI and Skin Issues

[DJ30]

I need your help. Angel is 12 years old and had a checkup last week with rabies vaccine and blood work. She has increased kidney values. Her urea (BUN) is 16.5 (reference value is 3.2-11.0 mmol/L). Her creatinine is 204 (reference value is 44-133 umol/L). Her SDMA is 19 (reference value is 0-14 ug/dL). Our vet wants to do a urinalysis before she comments on her kidneys, but I wasn't able to get a sample yet.

Angel has been on Tylosin 50 mg once daily since October 2017 for colitis. She was on Metronidazole (chicken flavoured) for about 6 weeks in addition to the Tylosin. We wanted to wean her off Tylosin as we don't want her to build an antibiotic resistance and be on a medication long term. Vet said she has never seen an antibiotic resistance with Tylosin. She said it's a little different in that it's a GI antibiotic, and it doesn't affect most of the normal flora of their body. It really targets the GI. She said we could just stop it as the dose is low. We stopped it Thursday and Friday, and Friday night she had flatulence and started to develop loose stools again. She vomited a little of her dinner overnight. Therefore, we restarted Tylosin Saturday morning as we normally give it with breakfast. On Sunday after midnight, she vomited one soft undigested kibble. We're hoping to get her loose stools under control soon. We feed Wellness whitefish and sweet potato dry kibble. When she first developed symptoms, we were told to try a novel protein. We tried Wellness duck and oatmeal, which didn't help. We then tried Royal Canin GI Fiber response, but she had an allergic reaction to the chicken. She scratched a lot as a puppy when we gave her chicken flavoured kibble, which is why we went with Wellness whitefish and sweet potato. Vet thought she might have outgrown the allergy, which is why we tried again. Due to her latest GI symptoms and kidney values, I ordered Rayne Crocodilia-Maint dry kibble as it's a novel protein good for GI and skin issues with even lower protein. It also has prebiotics (fructooligosaccharides).

https://static1.squarespace.com/stat...iets_June2.pdf

I still want to try to wean her off Tylosin if possible. I want to try digestive enzymes and probiotics. Vet doesn't think she needs digestive enzymes. She said it's for dogs who can't digest and for very specific conditions. She wouldn't use it for Angel. She said if we want to try a probiotic there is Purina FortiFlora, which is recommended by the veterinary college. From the website I see it only has one probiotic and the protein is 43%. This was before we got the blood work back. Tylosin is expensive, and I want to give her something natural and less expensive. If nothing else works, we'll definitely keep her on Tylosin. Do you agree that a digestive enzyme isn't necessary? Is it better for a probiotic to have more strains? I'm considering NWC Total Zymes plus Probiotics (NWC Naturals Pet Products | Probiotics For Dogs | Cats | Pets), which I can order from amazon.ca. I want something that is easily accessible in Canada. If we don't need digestive enzymes, there is NWC Total-Biotics (Best Probiotic | For Dogs | Cats | Total-Biotics | Benefits). Are these safe for her kidneys? Do you have any suggestions? Does she need a prebiotic in the supplement?

I'll give you Angel's history now.

Angel had a lump on her right ear in 2015, which got bigger. Our vet removed it, and the pathology results showed it to be a benign tumour called a histiocytoma, which we were told would not grow back. However, she developed another one right by that area. We tried Betaderm 0.1%. She then developed one on the left ear. We saw a dermatologist and tried synotic but it didn't help. We then tried Tetracycline/Niacinamide and topical Protopic. As she responded to this, she was diagnosed with reactive histiocytosis. She has developed lumps and bumps on and off over the years on her ears and body (some epitrichial cysts). The derm said the symptoms can wax and wane. In April/May 2016 she developed white heads around her anus with crusting. The crusts resolved leaving hyperpigmentation. In December 2016 she had dry skin under the tail and we were prescribed Douxo Pyo pads and Surolan. She has had at least two ear infections during her life where she also used Surolan. She had a lump at the base of her tail, which was removed and found to be an early benign keratoacanthoma.

Angel started burrowing under the blanket in 2016 or maybe earlier. In December she started to lose hair around her right eye, and sometime after she started to lose hair around the left eye. In early 2018 the bridge of her nose became bald. Both ears had dry patches, for which I used coconut oil. The dryness went away but so did the hair in those areas. The derm said possible causes for the hair loss are hormonal (thyroid/Cushing's), Demodex and ringworm. When we first saw him in 2015, he said Yorkies can be asymptomatic carriers of ringworm (Kerion). He took a sample with tape from her nose but didn't see anything under the microscope. He could do a skin scraping as Demodex mange mites are deep within the skin. For ringworm he could do a fungal culture (toothbrush technique). We held off on these two tests. He prescribed Duoxo Pyo pads for the bridge of her nose for fungal infection. We used it for 21 days, and the hair is growing back. I emailed him a picture, and I'm waiting for a response.

In December 2017 vet ordered thyroid panel and fT4 EQD. Total T4 was 13.4 (reference value 13.0-53.0 nmol/L); total T3 was 0.83 (reference value (0.90-2.10 nmol/L); free T4 by ED was 16.7 (reference value 9.0-47.4 pmol/L); cTSH was 0.11 (reference value 0.00-0.60 ng/mL); thyroglobulin autoantibody was negative. Pathologist thought thyroid hormone levels were adequate. In June 2018 We repeated the fTF EQD and it's 25.7.

Angel has been monitored for Cushing's disease over the past few years as she drinks a lot of water to the point of vomiting it up at times and urinates more. We did two LDDST (2016 and 2017), which were normal. Her urinalyses have also been normal except for July 2016, when the specific gravity was a bit low (1.018), i.e. more diluted than desired. Her SDMA (reference value 0-14 ug/dL) has been increasing over the years (April 2016: 12; June 2016: 14; March 2017: 17; December 2017: 23; June 2018: 19). Her creatinine is really elevated now at 204 (reference value 44-133). These are the creatinine values over the years - April 2016: 127; June 2016: 123; March 2017: 97; December 2017: 105). Now her urea (BUN) from June 2018 is elevated at 204 (reference value is 44-133).

Angel was diagnosed with nuclear sclerosis a few years ago and then cataracts some time later. As our vet mentioned the cataracts were getting worse, on October 2, 2017, we took her to an opthalmologist, who didn't mention the cataracts but diagnosed her with progressive retinal degeneration. On October 4, 2017, she had the lump removed at the base of her tail (early benign keratoacanthoma). Nine days later she developed loose stools with blood and mucus. We never figured out a medical cause from all the testing (stool, blood work and ultrasound). We finished a chlorhexidine bottle for her teeth on December 24, 2017, and when we opened it to rinse out for recycling, we saw black spots inside the bottle, which we thought was mold! The expiry date was March 2018. Vet didn't know if this was the cause for the colitis, but she didn't think it was likely and the derm agreed. The only cause I could think of was stress from the ophthalmology and lump removal appointments being 2 days apart.

We saw another eye vet (not a board certified ophthalmologist) in April 2018 for another opinion. He diagnosed Angel with bilateral cataracts with retinal degeneration and lenticular sclerosis. He recommended Ocu-GLO vision supplement. We stopped that temporarily due to the colitis as it causes Angel's stool colour to be pinky/red.

Sorry for the long post, but I'd like to get any feedback that will help us with Angel's issues.

[DJ30]

I forgot to mention that Angel weighs around 1.6 kg. She is supposed to take her heartworm medication (Sentinel) on July1. Is it safe with her elevated kidney values? Thank you.

[Wylie's Mom]

Oh gosh, so very sorry to read of her difficult history - I know exactly how this feels too, with my late Wylie -- it's tough and complicated.


I would most def get a urinalysis asap, and see if there is protein in the urine - if yes, the vet will likely want to run a UCP.


As far as enzymes and probiotic - hard to say if this could help, but it does with some dogs - especially those who've had their GI flora messed up by some infection or whatnot.


Have you yet tried Royal Canin Hydrolized Protein? It really may be worth trying.


Has an ultrasound of her abdomen ever been done?

[DJ30]

Thank you for your response. Sorry to hear about Wylie.

We did a urinalysis. Vet says everything looks good. Urine specific gravity is on the low end of the normal range (ideal should be >1.035), but kidney concentration ability is adequate at 1.032. Her previous results were 1.031 (Jan and Dec 2017) and 1.030 (Jul 2017).

She sent me a copy of the results, and I noticed that her pH level has decreased to 5.0 from 7.0. I see TR for protein, which I believe means trace. WBC and RBC = *<1 HPF; bacteria, Cocci; bacteria, rods; squamous epithelial cells; non-squamous epithelial cells; calcium oxalate dihydrate crystals; struvite crystals; unclassified crystals = *None to rare; hyaline casts = *>1 /LPF; non-hyaline casts = *Suspect presence*. I don't know what all this means. Does "rare" mean some are seen?

Vet wants to retest kidney enzymes (urea, creat) and urine specific gravity in 1 month. If enzymes are still elevated (or higher), then a low protein (i.e. kidney) diet may be indicated. However, since she is on a strict hypoallergenic alligator diet, she would like the derm's input on her food and the recent results.

We haven't started the supplement yet, but her stool is now back to normal with reduced volume and frequency but still has some mucus at times after starting the new food. We may try the supplement in another week. On Monday her pad was covered in very loose stool with a little blood and mucus, and some of it was pale almost whitish, which I've never seen before. I emailed the vet, but she didn't comment on it. I read that it could mean stool moved too fast through the GI tract to pick up the bile which changes the color to the normal brown.

Vet said we could give her Sentinel if she's feeling better, but I decided not to give it to her today. I want to wait until we retest blood work and urine first as I don't want to overwhelm her system by putting more chemicals in it.

No, we haven't tried the Royal Canin Hydrolyzed Protein. It was suggested, but we didn't want to risk another allergic reaction and waste our money. Vet said chicken protein is too small for immune system to recognize, so she should not have a reaction to it. We only used a little of the Royal Canin GI Fiber response and had to donate the whole bag to a shelter because of Angel scratching. That is why we are trying Rayne Crocodilia.

We did an abdominal ultrasound on December 22, 2017:

"Abdominal Ultrasound Report

1. small intestine: normal wall layering and thickness, slight speckling and streaking of mucosal layer

2. spleen: normal size and shape, few small (0.4-0.6cm) slightly hypoechoic areas that do not deform the surface of the capsule. r/o nodular hyperplasia or extramedullary hematopoesis

3. kidneys: normal size and shape, slight dilation of right renal pelvis r/o incidental vs mild pyelonephritis, consider UA

A: The stomach, small bowel and colon are normal in appearance. The mucosal speckling and streaking is very subtle as may not be significant. No signs of neoplasia, FB, obstruction or poor motility. The mucosal speckling could suggest some degree of small bowel inflammation vs incidental finding. B12/folate levels if abnormal may help to cornirm some degree of small intestingal involvement, however the clinical signs sound mostly large bowel in nature. The normal appearing colon does not r/o inflammaiton but does make neoplasia less likely.
r/o: Colitis - Bacterial, parasitic, dietary (allergic or fiber responsive) and idiopathic IBD

recomm blood work to r/o metabolic dz including atypical addisons dz, B12/folate
if bloodwork is normal, treat for above causes of colitis:
1. tylocine (long term)
2. metronidazole bid x 6 weeks
3. consider deworming w/ panacur (repeat in 3 weeks)
4. change to balanced high fiber diet or hydrolyzed hypoallergenic diet w/ fiber supplementation

if poor response to tx, consider fecal culture and endoscopic biopsies"

[DJ30]

In July 2018 Angel's creatinine was 93 and urea was 9.7; however, the SDMA was still elevated at 19 with trace of protein in her urine. Her specific gravity was 1.017.

We found out that Rayne is experiencing unforeseen challenges getting the Crocodilia-MAINT diet into Canada. "At this time the wet Crocodilia-MAINT diet is no longer available and we may not be able to supply the dry moving forward." Vet said it's to do with fisheries laws.

She had a flare up of her IBD after she was given really ripe banana, and we had to add Metronidazole twice a day for a while. She never had problems eating banana before, but I gave her some banana a few days in a row with her dinner so she would take the Ocu-GLO vision supplement. Only the last piece I gave her was really brown, mushy and ripe. I read that Metronidazole can cause neurological changes so I wanted to wean her off this. We are now giving liquid Tylosin 0.5 mL twice a day, and we were able to wean Angel off the Metronidazole.

We have been slowly transitioning Angel from Rayne Crocodilia to Tom and Sawyer kangaroo fresh dog meal. She loves the food but it is expensive. Her stool has improved as it is formed except she has some mucus.

https://shop.tomandsawyer.com/collec...redient-recipe

Urine protein:creatinine ratio test done recently was normal. Her specific gravity is 1.016. There is no longer any trace of protein in her urine. Yay!

We're looking for other food options that are less costly. Because there is no significant proteinuria, Rayne suggests that trying to find a restricted protein diet may not be necessary and to focus more on novel proteins.

We don't know if Angel has any grain sensitivities. We can give her white rice on occasion with no problem. She used to eat Wellness Whitefish and Sweet Potato (https://www.wellnesspetfood.com/natu...h-sweet-potato), but a year ago she developed IBD. We don't know if she developed an allergy to this food or what the cause of the IBD was. It was really good for her skin issues though as she didn't scratch or bite herself as often.

I know the FDA is doing an investigation regarding grain-free dog food and heart disease. It is concerning and confusing. I'm looking at some pre-mix dog foods, and I heard that taurine is in the meat you add. What do you think of the pre-mixes below as options?

Do you think Sojos Mix-A-Meal grain-free pre-mix (fruit and veggie recipe) or Sojos Original Mix-A-Meal pre-mix recipe dog food is an option? I would add cooked instead of raw meat.

https://www.sojos.com/mix-meal/sojos...e-mix-dog-food
https://www.sojos.com/mix-meal/sojos...e-mix-dog-food

For Angel's issues Hilary's JAM Limited Antigen Lentils sounds good, but should we avoid this as lentils are the main ingredient? The Healthy Adult Dog is grain-free and has more ingredients (apples, sweet potatoes, carrots, celery, cabbage, tomatoes, blueberries, broccoli, pumpkin, spinach), which sound great but could potentially be allergens. These two pre-mixes are offered in a trial size.

HILARY'S BLEND JUST ADD MEAT

There is also Dr. Harvey's Canine Health Miracle Dog Food pre-mix.

https://www.drharveys.com/products/d...racle-dog-food

Any help would be greatly appreciated as our vet doesn't seem to know a lot about nutrition.