Role of hemodialysis in the management of dogs and cats with renal failure

Successful hemodialysis treatment of a Quarter Horse mare with silver maple leaf toxicity and acute kidney injury

An adult American Quarter Horse mare presented for pigmenturia and lethargy of 12 hours' duration and was diagnosed with silver maple leaf toxicity. The mare had intravascular hemolysis and azotemia. The mare was treated with a transfusion of whole blood, fluids administered IV, antibiotics, oxygen insufflation, and supportive care. The azotemia persisted despite conventional medical management and hemodialysis was elected. After 2 intermittent hemodialysis treatments over 3 days, the azotemia almost resolved, clinical signs improved, and the mare was discharged. The blood urea nitrogen, creatinine, and electrolyte concentrations remained normal 6 months later after examination by the referring veterinarian. Hemodialysis treatment can be feasible in horses if equipment and expertise are available and should be considered as a treatment option if indicated.

International renal interest society best practice consensus guidelines for intermittent hemodialysis in dogs and cats

Intermittent hemodialysis (IHD) is an advanced adjunctive standard of care for severe acute kidney injury (AKI) and other indications. Most animals with AKI are managed medically, however, when the disease is severe, medical management may not control the consequences of the disease, and animals with a potential for renal recovery may die from the consequences of uremia before recovery has occurred. Extracorporeal therapies aid the management of AKI by expanding the window of opportunity for recovery of sufficient kidney function to become dialysis independent. Intermittent hemodialysis (IHD) was introduced into veterinary medicine over 50 years ago, however, updated guidelines for the delivery of IHD have not been published for several decades. To that end, the International Renal Interest Society (IRIS) constituted a Working Group to establish best practice guidelines for the safe and effective delivery of IHD to animals with indications for dialytic intervention. The IRIS Working Group generated 60 consensus statements and supporting rational for a spectrum of prescription and management categories required for delivery of IHD on designated intermittent dialysis platforms (i.e., AKI, chronic hemodialysis and intoxications). A formal consensus method was used to validate the recommendations by a blinded jury of 12 veterinarians considered experts in extracorporeal therapies and actively performing IHD. Each vote provided a level of agreement for each recommendation proposed by the Working Group. To achieve a consensus, a minimum of 75% of the voting participants had to "strongly agree" or "agree" with the recommendation.

Retrospective evaluation of 22 dogs with leptospirosis treated with extracorporeal renal replacement therapies (2018-2021)

BACKGROUND

Outcomes of dogs with acute kidney injury secondary to leptospirosis (AKI-L) treated using renal replacement therapies (RRT) are poorly characterized.

HYPOTHESIS/OBJECTIVES

Describe survival to discharge, short (≤30 days) and long-term (≥6 months) outcomes of AKI-L dogs receiving RRT and determine if there is a significant difference in maximum blood urea nitrogen (maxBUN), maximum creatinine (maxCr), maximum bilirubin (maxBili) and the number of body systems affected between survivors and non-survivors.

ANIMALS

Twenty-two client-owned dogs with AKI-L receiving RRT.

METHODS

Retrospective medical record review of dogs with AKI-L that received RRT between 2018 and 2021.

RESULTS

Sixteen of 22 (73%) dogs survived to discharge. Of the survivors, 13 (81%) were alive >30 days from discharge and 12 (75%) were alive at 6 months from discharge. Factors significantly higher in non-survivors included number of body systems affected (survivors: 1 (19%), 2 (50%), 3 (25%) and 4 (6%) vs non-survivors: 3 (33.3%), and 4 (66.7%); P = .01) and median maxBili (survivors: 1.9 mg/dL; range, 0.1-41.6 vs non-survivors: 21.0 mg/dL; range, 12.3-38.9; P = .02). There was no significant difference in median maxBUN (survivors: 153.0 mg/dL; range, 67-257 vs non-survivors: 185.5 mg/dL; range, 102-218; P = .44) and median maxCr (survivors: 9.8 mg/dL; range, 6.2-15.9 vs non-survivors: 9.8 mg/dL; range, 8.4-13.5; P = .69) between survivors and non-survivors.

CONCLUSIONS AND CLINICAL IMPORTANCE

Regardless of azotemia severity, dogs with AKI-L receiving RRT have a good survival rate to discharge. The number of body systems affected and hyperbilirubinemia might be associated with worse outcomes.

Nephrology in Veterinary Medicine

Veterinary nephrology is a specialized field of veterinary medicine providing a high level of care for animals with all types of kidney disease. Veterinarians complete extensive training to become board-certified in veterinary nephrology-urology. Companion animal nephrology is the most advanced field; however, all species are afflicted by a variety of renal disorders. Most naturally occurring animal kidney diseases have similar disorders found in people; where veterinary research is lacking, clinical management is often modified from standard of care in people. Veterinarians have become adept at scaling down procedures to safely perform them on dogs and cats weighing only a few kilograms. Advanced diagnostics (renal biopsy, cystoscopy, fluoroscopic studies, etc. ) and therapeutics (renal replacement therapy, interventional endourology, etc. ) are commonly performed within the practice of veterinary nephrology-urology. Collaboration between veterinary and human nephrologists may advance both disciplines and improve care for people and animals alike.

Extracorporeal Therapies in the Emergency Room and Intensive Care Unit

Extracorporeal treatments create opportunity for removing disease causing solutes within blood. Intoxications, renal failure, and immune-mediated diseases may be managed with these treatments, often providing new hope for patients with severe or refractory disease. Understanding solute pharmacokinetics and the limitations of each type of extracorporeal technique can allow for the selection of the optimal treatment modality.

Renal dialysis and long-term treatment of a dog with kidney disease associated with canine leishmaniosis

Background

Renal disease is considered the main cause of natural mortality in dogs with canine leishmaniosis. The pathological mechanisms associated with kidney injury in canine leishmaniosis include immune complex glomerulonephritis, tubulointerstitial nephritis and occasionally renal amyloidosis. Proteinuria is a frequent finding in canine leishmaniosis and its quantification by the urine protein-creatinine ratio (UPC) is an important parameter in the staging of canine lesihmaniosis as presented by the LeishVet group.

Results

A 4.5 year-old spayed female Belgian Malinois dog was presented to the Hebrew University Veterinary Teaching hospital with epistaxis and rhinitis and diagnosed also with proteinuria and acute kidney injury (AKI IRIS grade V) associated with canine leishmaniosis that developed to LeishVet stage III with chronic kidney disease (CKD) after stabilization. Clinicopathologic abnormalities included azotemia with a peak creatinine concentration of 7.76 mg/dl (reference interval, 0.3–1.2 ng/dl), hypoalbuminemia (1.76 g/dl, reference interval 3-4.4 g/dl), hyperglobulinemia (4.54 g/dl, reference interval 1.8–3.9 g/dl) and proteinuria (urine protein/creatinine ratio 15.6, normal < 0.2). Serology by the enzyme-linked immunosorbent assay (ELISA) for Leishmania infantum was positive with high antibody levels. The dog was hospitalized and treated with intermittent hemodialysis, feeding through an esophageal feeding tube, medical treatment for protein losing nephropathy and antileishmanial treatment with allopurinol. Kidney function gradually improved and the dog’s creatinine levels and proteinuria decreased until complete normalization two years after the acute insult. However, rhinitis and sneezing persisted and although the anti-leishmanial antibodies decreased over time, the dog remains constantly seropositive.

Conclusions

To our knowledge, this is the first report of hemodialysis management of AKI associated with canine leishmaniosis. Hemodialysis was imperative in stabilizing the dog’s renal disease and controlling its azotemia. It demostrates that hemodialysis can be beneficial in the management of acute deterioration of kidney disease in canine leishmaniosis.

Electronic supplementary material

The online version of this article (10.1186/s13071-018-2719-6) contains supplementary material, which is available to authorized users.

Long-term outcome of cats and dogs with acute kidney injury treated with intermittent hemodialysis: 135 cases (1997-2010)

OBJECTIVE

To determine the long-term outcome for small animal patients with acute kidney injury (AKI) treated with intermittent hemodialysis (IHD).

DESIGN

Retrospective case series.

ANIMALS

42 cats and 93 dogs treated with IHD for AKI.

PROCEDURES

Medical records of cats and dogs treated with IHD for AKI from January 1997 to October 2010 were reviewed. Standard methods of survival analysis with Kaplan-Meier product limit curves were used. The log-rank, Mann-Whitney, and Kruskal-Wallis tests were used to determine whether outcome, number of IHD treatments, or duration of hospitalization was different when dogs and cats were classified according to specific variables.

RESULTS

The overall survival rate at the time of hospital discharge was 50% (21/42) for cats and 53% (49/93) for dogs. The overall survival rate 30 days after hospital discharge was 48% (20/42) for cats and 42% (39/93) for dogs. The overall survival rate 365 days after hospital discharge was 38% (16/42) for cats and 33% (31/93) for dogs. For all-cause mortality, the median survival time was 7 days (95% confidence interval, 0 to 835 days) for cats and 9 days (95% confidence interval, 0 to 55 days) for dogs.

CONCLUSIONS AND CLINICAL RELEVANCE

Cats and dogs with AKI treated with IHD have survival rates similar to those of human patients. Although there was a high mortality rate prior to hospital discharge, those patients that survived to discharge had a high probability of long-term survival.

Urea kinetics and intermittent dialysis prescription in small animals

Hemodialysis improves survival for animals with acute kidney injury beyond what would be expected with conventional management of the same animals. Clinical evidence and experience in human patients suggest a role for earlier intervention with renal replacement to avoid the morbidity of uremia and to promote better metabolic stability and recovery. For a large population of animal patients, it is the advanced standard for the management of acute and chronic uremia, life-threatening poisoning, and fluid overload for which there is no alternative therapy.

Extracorporeal removal of drugs and toxins

Renal replacement therapies (RRT) are increasingly used for the treatment of acute and chronic kidney diseases as well as intoxications and accidental drug overdoses. These therapies offer a mechanism for the removal of toxic substances from the patient's blood and supplement the standard detoxification protocols. If instituted early, RRT can have a significant effect on the course of the toxicity; however, this process is not selective for the removal of only harmful products and can also result in the clearance of medications intended for therapeutic use.

Therapies for feline chronic kidney disease. What is the evidence?

Practical relevance Successful treatment and prevention of kidney disease in pet animals requires a multidimensional approach to identify and eliminate causes or exacerbating factors, provide professional examination and care on a regular basis, and plan and implement a comprehensive treatment program when necessary.

Evidence base Over the years, many therapeutic and preventive interventions have been developed or advocated for chronic kidney disease (CKD), but evidence of efficacy or effectiveness is often lacking or highly variable. Accordingly, the main objective of this systematic review was to identify and critically appraise the evidence supporting various approaches to managing feline CKD; namely, fluid therapy, calcitrioi therapy, antihypertensive therapy, ACE inhibitor therapy, erythropoietic hormone replacement therapy, potassium supplementation, antioxidant supplementation, alkalinization therapy, dietary phosphorus restriction and intestinal phosphate binders, therapeutic renal foods, assisted feeding, dialysis and renal transplantation.

Adequação de um sistema de hemodiálise em eqüinos

Realizou-se a adequação da técnica de hemodiálise com eqüinos, distribuídos em quatro grupos experimentais de seis animais cada. Os animais do grupo I foram submetidos a cateterismo central unilateral (grupo-controle); os do grupo II foram submetidos a cateterismo central unilateral com cateter duplo-lúmen e a uma sessão de hemodiálise de seis horas; os do grupo III a cateterismo central unilateral com cateter duplo-lúmen e duas sessões de hemodiálise de seis horas e os do grupo IV a cateterismo central bilateral com cateter monolúmen e a uma sessão de hemodiálise de seis horas. Empregaram-se xilazina 10% (0,4mg/kg) e acepromazina 2% (0,008mg/kg) via intravenosa para sedação. Foram utilizados dois hemodialisadores conectados em série, do tipo fibras ocas, baixo fluxo, membrana de polissulfona e área de 1,8m². O fluxo sangüíneo médio foi de 319,18±97,41ml/minuto, associado a um fluxo de dialisato de 500ml/min. A anticoagulação foi feita com heparina sódica em 100UI/kg para primming, repetida na dose de 53,86±18,61UI/kg/hora. Foram avaliados: tempo de coagulação, tempo de protrombina, tempo de tromboplastina parcial ativada e contagem plaquetária, e verificado trombocitopenia nos grupos dialisados. O melhor acesso vascular foi proporcionado pelo cateterismo unilateral com cateter lúmen-duplo (Grupos II e III), podendo a técnica de hemodiálise ser empregada na espécie eqüina, com dialisadores de alta eficiência, em sessão de seis horas de diálise.

Urinary tract emergencies

A review of common emergencies of the urinary system is presented, with a focus on initial stabilization and treatment. Urethral obstruction, uroperitoneum, and acute renal failure are discussed.

Veterinary hemodialysis: advances in management and technology

Hemodialysis (HD) is a renal replacement therapy that can enable recovery of patients in acute kidney failure and prolong survival for patients with end-stage kidney failure. HD is also uniquely suited for management of refractory volume overload and removal of certain toxins from the bloodstream. Over the last decade, veterinary experience with HD has deepened and refined and its geographic availability has increased. As awareness of the usefulness and availability of dialytic therapy increases among veterinarians and pet owners and the number of veterinary dialysis facilities increases, dialytic management will become the standard of advanced care for animals with severe intractable uremia.

Veterinary critical care

Veterinary species experience similar perturbations of their health to those of human patients. When the long-term prognosis is good and providing suffering can be minimized, animals stand to benefit greatly from recent advances in the field of emergency and critical care. Outcomes in many conditions in small and large animals have improved markedly in the last 15 years, as management has improved, making the financial and emotional investment in critical care worthwhile for many owners.

Evaluation of three peripheral arteriovenous fistulas for hemodialysis access in dogs

OBJECTIVE

To design and create 3 types of arteriovenous fistulas (AVF) in normal dogs, to monitor the dogs for secondary cardiovascular complications, and to verify adequacy of these fistulas for hemodialysis vascular access.

STUDY DESIGN

Experimental study.

ANIMALS

Four normal adult dogs.

METHODS

Cadaveric dissections were performed, and surgical protocols were generated for carotid-jugular (CJ), brachial-cephalic (BC), and distal caudal femoral-lateral saphenous anastomosis (DCFLS) AVF. Each surgical procedure was then performed in 2 live dogs. Echocardiography was performed at days 0, 1, 3, 7, 14, 28, and 56 to evaluate the dogs for evidence of volume overload secondary to AVF formation. Estimation of luminal diameter and confirmation of fistula patency were performed using percutaneous color Doppler ultrasound. At day 56, hemodialysis was performed using each fistula as a vascular access.

RESULTS

No significant changes occurred in the echocardiographic variables over time. All fistulas were patent at day 56 with mean luminal diameters of 4.5 mm (CJ), 4 mm (BC), and 1.5 mm (DCFLS). The BC fistula was superior for ease of needle placement and stabilization and provided adequate blood flow for clinical hemodialysis.

CONCLUSIONS

Based on this short-term study, arteriovenous fistulas appear to be a safe and effective means for hemodialysis access in dogs.

CLINICAL RELEVANCE

The arteriovenous fistulas described provide an alternative to the central venous catheters currently used for chronic hemodialysis access in dogs.

Acute renal failure caused by lily ingestion in six cats

Acute renal failure was diagnosed in 6 cats that had ingested Easter lily or tiger lily plants. All 6 were treated medically; 2 underwent hemodialysis. Three cats survived the acute episode, and although they had chronic renal failure, they survived for more than 1.5 years. Two cats died despite aggressive medical management, including hemodialysis. One cat was euthanatized shortly after the diagnosis was made. Three of the cats were oliguric or anuric at the time of initial examination, and all 3 died. None of the 3 cats that survived had oliguria or anuria. Various members of the lily family (Liliaceae) can cause nephrotoxicosis in cats, but the toxic principle is not known. Although the prognosis for full recovery of cats with lily toxicosis is poor, long-term survival is possible with supportive care. The prognosis appears to be better for cats with nonoliguric renal failure.

Diagnostic predictors of complications and survival after renal transplantation in cats

OBJECTIVE

To identify preoperative diagnostic results that predict postoperative complications and survival in feline renal-transplant recipients.

STUDY DESIGN

Retrospective clinical study.

ANIMALS

Sixty-one feline renal allograft recipients.

METHODS

Medical records for 61 consecutive cats that underwent renal allograft transplantation between January 1, 1996, and December 1, 1999, were reviewed. Age, diagnosis, body weight, body condition score, preoperative medical treatment, systolic blood pressure, packed cell volume, biochemical parameters at admission and at the time of surgery, postoperative complications, and postoperative survival were recorded. Associations of preoperative data with the occurrence of postoperative complications were determined using logistic regression. Postoperative survival was graphed using a Kaplan-Meier cumulative-survival plot. Associations of covariates with postoperative survival were analyzed using Cox proportional hazards analysis.

RESULTS

Two parameters were significantly associated with occurrence of postoperative central nervous system (CNS) disorders: blood urea nitrogen concentration (odds ratio = 1.083; 95% CI = 1.018 to 1.148) and serum creatinine concentration (odds ratio = 1.8; 95% CI = 1.413 to 2.187) at the time of surgery. Postoperative survival 6 months after transplantation was 59%, though 3-year survival remained at 42%. Of all covariates investigated, only recipient age (relative hazard = 1.183; 95% CI = 1.039 to 1.334) was significantly associated with survival.

CONCLUSION AND CLINICAL RELEVANCE

Standard measures of preoperative renal dysfunction do not predict postoperative survival in cats after renal transplantation, although an increase in the degree of preoperative azotemia is associated with an increased risk of CNS disorders after surgery. Increased recipient age is associated with decreased survival after renal transplantation.

Treatment and outcome of dogs with leptospirosis: 36 cases (1990-1998)

OBJECTIVE

To characterize serologic and clinical features and outcome of dogs with leptospirosis that were treated conservatively (i.e., medical management alone) or with hemodialysis.

DESIGN

Retrospective study.

ANIMALS

36 dogs with leptospirosis.

PROCEDURE

History; results of physical examinations, ultrasonography, and serologic, hematologic, and serum biochemical analyses; time to resolution of azotemia; and outcome were obtained from medical records. Dogs were treated conservatively (n = 22) or with hemodialysis (14).

RESULTS

Between 1990 and 1998, amount of rainfall was positively correlated with number of cases of leptospirosis identified per year. Serum antibodies against 6 Leptospira serovars were measured, and titers were highest to Leptospira pomona in 16 (44%) dogs, L bratislava in 9 (25%) dogs, and L hardjo in 1 (3%) dog. Eight (22%) dogs had equally high titers to L pomona and L bratislava, 1 (3%) had equally high titers to L grippotyphosa and L canicola, and 1 (3%) had high titers to L grippotyphosa, L pomona, L canicola, and L bratislava. During initial evaluation, all dogs were azotemic. Thirty (83%) dogs survived, including 12 of 14 (86%) dogs treated with hemodialysis and 18 of 22 (82%) treated conservatively. Serum creatinine concentration was similar in both groups after resolution of clinical signs.

CONCLUSIONS AND CLINICAL RELEVANCE

Infection with L pomona and L bratislava was recognized as a cause of leptospirosis in dogs, and resulted in development of acute renal failure with various degrees of azotemia. Prognosis for dogs with mild to moderate azotemia was good with conservative treatment, whereas treatment with hemodialysis appeared to improve prognosis for dogs with severe azotemia.

Applications and outcome of hemodialysis in cats: a review of 29 cases

Hemodialysis (HD) has been used in the management of renal failure in dogs, but its feasibility has not been reported for uremic cats. Therefore, we investigated the technical possibility, efficacy, and complications of intermittent HD in cats with severe uremia. A total of 160 HD treatments were performed on 29 cats with acute renal failure (ARF) (n = 15), chronic renal failure (CRF) (n = 6), or acute on CRF (n = 8) between November 1993 and June 1996. Hemodialysis treatments were performed with transcutaneous dialysis catheters using a bicarbonate-based delivery system, sodium modeling, and volumetric-controlled ultrafiltration. Presenting serum chemistries (mean +/- SD) for all cats were creatinine, 16.4 +/- 7.5 mg/dL; blood urea nitrogen (BUN), 229 +/- 87 mg/dL; phosphate, 15.4 +/- 5.4 mg/dL; potassium, 6.0 +/- 1.6 mEq/L; and HCO3-, 16.0 +/- 4.4 mEq/L. For intensive HD treatments, pre-HD versus post-HD creatinine changed from 10.3 +/- 4.4 to 1.6 +/- 0.9 mg/dL and BUN from 105 +/- 33 to 8 +/- 10 mg/dL. One or more adverse events occurred during 111 (69%) treatments. Dialysis-related events included hypotension, dialysis dysequilibrium, clotting, and bleeding. Nine of 15 (60%) cats with ARF and 1 cat with CRF recovered sufficiently to survive without ongoing need for HD. For the remaining cats, the proximate causes of death were dialysis related in 9 cats, uremia related in 6 cats, and iatrogenic or unknown in 4 cats. Hemodialysis is technically feasible and effectively controls the biochemical disturbances of uremic cats. It is especially valuable for the management of severe ARF, permitting recovery in a large number of cats refractory to conventional therapy. Technical complications and chronic debility, however, may limit its usefulness for cats with advanced CRF.