Vets on the Balkans - an online journal for veterinarians from the Balkans

Basic anaesthesia of brachycefalic dog

January 16, 2022

Dr Denica Djodjeva

Blue Cross Veterinary Clinic

Sofia, Bulgaria

Quite often in our practice we have to sedate or keep under anaesthesia brachycephalic dogs and cats. This is associated with some stress for us, given the peculiarities of the breed. In this article I will try to briefly present the main key points in the anesthesia of brachycephalic breeds, which has gained great popularity in recent years. Will pay attention to their anatomical and physiological features, which are a prerequisite for complications during anesthesia, and how to avoid them and reduce the risk.

The main specificity of them is the so-called brachycephalic syndrome ( BOAS). It may include narrowed nostrils, a long soft palate, a hypoplastic trachea, or an inverted laryngeal sac. It can be re-applied and used for prolonged trauma to the pharyngeal soft tissues and trachea, which can cause soft tissue outflow or tracheal collapse. This trauma most often occurs when the animal is intubated. Gastroesophageal reflux should not be forgotten, also high vagal tone.

In severe cases of BOAS, airway obstruction may benefit from the development of pulmonary edema. The pathophysiology of post-obstructive pulmonary edema includes the effect of negative intrathoracic pressure on fluid distribution and subsequent hypoxia. High negative intrathoracic pressure causes an increase in venous return to the right atrium, which increases the pulmonary artery, while left ventricular function is reduced and afterload is increased. The end result is increased hydrostatic pressure, which aids in the movement of fluids from the capillaries in the interstitium and thus causes pulmonary outflow. Rapid recognition of this condition and taking temporary measures, such as maintaining airway patency, adequate oxygen supply and, if necessary, PPV administration. Diuretics may also be used, but it should be anticipated that hypovolaemia and hypoperfusion may occur during anesthesia and clinical delivery should be considered. And because of the risk of soft tisuue and pulmonary oedema, it’s beneficial to add an corticosteroid in low dose, as prevention. Unless there are a serious contraindications. There are different anaesthesia protocols with dexamethason or methylprednisolon, it’s a matter of personal choice.

Deep sedation in these patients is performed with excessive relaxation of the pectoral muscles and aggravation of airway obstruction. Even if the patient is aggressive, it is good to adhere to lower doses of premedication. The most commonly used combination is of a sedative component, for example an alpha-2-agonist and an opioid. A tranquilizer such as acepromazine and benzodiazepines such as diazepam or midazolam may also be used. Accordingly, the doses are at the discretion and according to the desired effect and treatment. In the table below I quote some of the most commonly used pre- anaesthetic drugs with the value of the dose. There are no restrictions and contraindications to the use of narcotic drugs in this breed. For induction you can use a different combinations, as benzodiazepine+ propofol or benzodiazepine+ ketamine. Your choice mainly depends on what the end result you whant. In brachycefalic breeds it is recommended the induction to be smooth and fast, so the most suitable drug in this case is propofol.

Given the peculiarity of the birth, it is very important to monitor the brachycephalic patient during the pre-aesthetic period, as relaxation of the pectoral muscles further complicates breathing, reduces the number of respiratory movements and the appropriate patient does not fall into hypoxia. It is recommended that the patient be preoxygenated during the pre-anesthetic period. The administration of 100% oxygen before induction of anesthesia prolongs the time to the onset of arterial hypoxemia.

When intubating a brachycephalic patient, prepare several tube sizes, apparently up to two sizes smaller than you think would be appropriate. It will be useful if you use a laryngoscope, especially when your patient has a long soft palate, as it will help ensure good visibility to the airways.

It is common practice to maintain the patient under inhalation anesthesia during the operation. Isoflurane is most commonly used for this purpose. It should be borne in mind that, like other inhaled anesthetics, it produces a dose-dependent reduction in myocardial contractility, systemic vascular resistance and cardiac preload, followed by a reduction in mean arterial pressure (MAP) and cardiac output in a dose-dependent manner; therefore, the evaporator settings should be kept as low as possible while maintaining an adequate depth of anesthesia.

In brachycephalic breeds, there is a very strong vasovagal tone, which can cause bradycardia, which in turn can lead to AV block or even cardiac arrest. The most common reason for increased vagal tone is severe pain. Advice on this reason for good pain relief of this breed is extremely important. However, if the patient develops severe bradycardia, a use of anticholinergic in an appropriate emergency dose is indicated.

As mentioned earlier, another common complication is gastroesophageal reflux, which can occur at any stage of anesthesia. This can lead to airway obstruction and aspiration pneumonia. Advice for this reason is recommended in the anesthesia protocol to include antiemetics, unless there are serious contraindications. It is recomended to be applied proton pump inhibitors as omeprasole, 4 hours before the planed anaesthesia.

The recovery period is also not to be underestimated. Here it is important to constantly monitor the patient and be extubated, when we are sure that all reflexes have returned. Especially the swallowing one. The best time to extubate is when our patient has muscle tone in the lower jaw and tries to cough up the endotracheal tubus itself or even better if the patient is tring to chews it. It is important to be positioned in a sternal position with appropriate continuous monitoring.

The anaesthesia of these specific breeds is not so complicated, if know their features and for what to watch out for. With more carefulness and knowinge there is nothing to be afraid of.

Tabl. Most commonly used pre- anaesthetic drugs

Drug	Benefit	Side effects	Peak onset/duration of action	IM dose
Dexmedetomidine, Medetomidine	Profound sedation, reversible, some analgesic properties, drug sparing (reduction in induction drugs needed)	Dose dependent bradycardia	5-15 min IM 2- 3 min IV	Dexmedetomidine 5-15 µg/ kg Medetomidine 3- 10 µg/ kg
Butorphanol	Mild analgesia, good sedation	Poor analgesia and should not be used for surgical patients	10–15min/lasts for 60–90min	0.1–0.4mg/kg
Buprenorphine	Moderate analgesia, mild sedation	Moderate analgesia	10- 15 min IV 15-30min IM /can be given q 6–8 h	0.01–0.04mg/kg
Methadone	Good analgesia	If given too fast, IV can cause bradycardia and respiratory depression	30min/can be given q 4 – 6 h	0.1–0.4mg/kg
Acepromazine	Good anxiolytic, sedation improved when administered with an opioid	Hypotension, unreliable sedation when used alone, not reversible	35–40min IM 10- 15 IV /can be given q 4–6h	0.01–0.05mg/kg

Diagnosis of multiple myeloma in a Labrador Retriever

November 28, 2021

Florin Cristian Delureanu

MRCVS, DVM

November 2021

History

A 12 years old intact male labrador retriever was presented to the practice in 05.03.2021 with a history of diarrhea and hyporexia. The diarrhea was present for few days and the appetite was decreased for about 2 weeks but there were moments when the patient was eating normally. The patient was up to date with the booster vaccination and was regulary using antyparasitic treatment.

Physical examination

At the moment of examination the patient was bright, alert, with normal temperature (38.7 °C), the palpable lymphnodes were normal in size, nothing abnormal detected in the oral cavity and thoracic ascultation unremarkable. A mass of approximate 5cm diameter with soft consistency, mobile, and without local reaction on the surrounding soft tissue was identified in the xiphoid area.

Investigations

Initially general blood tests including complete blood count, biochemistry, electrolytes and total T4 were performed as a routine screening in order to identify any abnormalities. The results from the haemoleucogram demonstrate mild microcytic hypochromic non-regenerative/ pre-regenrative anemia, neutropenia, monocytopenia and eosinopenia. On the biochemistry just hyperproteinaemia due to increased globulins was the single abnormality. Also the thyroid hormone was under the normal reference range (picture 1).

Coroborating the blood results with the history and the clinical examination the following differential diagnostic list was discussed with the owner: occult chronic blood loss, iron deficiency, inflammatory/infectiouse cause, neoplastic, immune mediated disease, endocrine (anemia secondary to hypothyroidism), gammopathies.

Aditional history: the last time when the patient went to a veterinary practice was 5 months prior for the regular booster vaccination.

Because of no evident clinical symptoms the presumption of chronic blood loss due to diarrhoea or anemia secondary to hypothyroidism was suspected. After discussion with the owner the decision of repeating blood tests in 4 days was taken. The patient was discharged with oral probiotics and was put on gastro intestinal veterinary diet to treat the diarrhoea. At reevaluation blood was collected and was send to the reference laboratory for complete blood count and blood smear interpretation, SDMA, Coomb’s test and C-reactive protein and complete thyroid panel including total T4, freeT4, cTSH, thyroglobulin autoandibody

The SDMA was normal also the thyroid panel was normal and negative on thyroglobulin autoandibody. The C-reactive protein was mildly elevated and the Coomb’s test was negative. On haematology the anemia had the same characteristics but was normocytic the reticulocytes and platelets under the normal limit. There were no modifications on the leucogram compared with the one performed at the first presentation (picture 2).

The blood film was evaluated and a mild microcytosis and no increased in polycromasia was noted. Marked rouleaux formation and occasional metarubricyte were present too and leucopenia was confirmed. Estimation of free platelets (3-8 platelets seen per HPF) suggested platelet numbers are mildly/moderately decreased with and very small platelet clumps seen was identified.

Based on the second blood tests (pancytopenia is observed but also marked rouleaux and occasional metarubricyte) and hyperglobulinaemia from the initial blood tests a suspicion of neoplastic disease like multiple myeloma or lymphoma less likely non-neoplastic disorders like monoclonal gammopatihes (Erlichiosis or Dirofilariasis) because the patient was regulary using antiparasitic medication and no history of travelling. In the same day results were reported to the owner and additional questions regarding the origin, travel status and lameness episodes were asked to the owner in order to find more informations. There was no history of travelling, the dog origin was United Kingdom and transitory episode of weakness were observed in the past months.

Further investigations

To investigate more the suspicion serum and urine protein electrophoresis, urinalysis including urine protein creatinine ratio, radiographs and bone marrow aspiration were recommended. Five days later the patient presented to the practice but the owner accepted initially just the non-invasive investigation and declined the x-rays and bone marrow aspiration. An additional in house haemoleucogram was performed at this stage to monitor the trend of the red and white blood cells (picture 3)

The urinalysis revealed proteinuria 3+ and a pH of 8 with active sediment and no crystals or casts, the urine beign collected via urethral catheterisation. The urine protein creatinine ratio was marked elevated (picture 4).

At serum protein electrophoresis hypoalbuminaemia was present with a mild increase in alpha 1 globulins and marked increase in gamma globulins migrating in a gamma region and a depletion of the globulins thereafter, consistent with a monoclonal band (picture 5)

The urine protein electrophoresis showed that majority of the protein was presented in the alpha-beta region and this was interpreted as overflow proteinuria secondary to the marked gammopaty present at the serum protein electrophoresis. No bands consisting with Bence Jones protein were noted but this would be masked by the overflow proteinuria (picture 6).

After these last results a highly suspicion of neoplastic disease was made. Radiography and bone marrow aspiration were recommended to confirm the disease. The owners were reluctant to put the dog under sedation because in the past he had general anesthesia and was not stable according to the previouse veterinarian. At this moment the patient was sent to a referral center to have the imagistic investigation.

In 09.04.2021 the patient arrived at the referral center for the last investigations. After clinical examination a firm mobile mass was noted in the caudal abdomen. Initially HLG, blood film evaluation, ionised calcium and 4Dx were performed followed by CT scan of the thorax and abdomen and fine needle aspiration of the liver, spleen and abdominal mass ultrasound guided. The ionised calcium was mild elevated (1.95 mmol/L), the 4Dx was negative. The haematology findings consist with normal white blood cell count with a slight improvement from the 5th March and a stable red blood cell count (HCT 31%) – with a mild non-regenerative anaemia. An initial review of the CT scan confirms the presence of a 4.5-5cm encapsulated mass in the caudal abdomen, with no obvious association with the intestinal wall. A small amount of free fluid is present between the liver lobes. After these investigations the patient was sent home with Fortekor as a treatment of proteinuria.

Seven days later the full CT report, aspirates results and blood smear interpretation were ready.

Cytology interpretation

A detailed haematology showed a mild, normocytic normochromic, poorly regenerative anaemia (HCT 36.9%, reticulocyte count 95.05×109/L). His white blood cell and platelet count were low-normal. There was no evidence to support haemolysis and leucocyte morphology was unremarkable.

Aspirates from the liver and spleen identify a population of extremely atypical plasma cells, supportive of multiple myeloma. Prominent extra medullary haematopoiesis is also noted within the spleen.

Aspirates from the caudal abdominal mass show adipocytes and a mixed inflammatory cell population, comprising of neutrophils ageing in situ and undergoing pyknosis. An atypical plasmacytoid population is identified but in low numbers, suggesting infiltration with myeloma.

CT findings from the report

Musculoskeletal:

There are multifocal osteolytic lesions throughout the entire included portion of the skeleton, including essentially all included vertebrae (thoracic, lumbar, sacral), multiple ribs, the sternebrae, the proximal humeri, the pelvis and the proximal femurs (picture 7).

Thorax:

No soft tissue attenuating pulmonary nodules are identified. There are multiple small (<5mm), mineral attenuating, geometrically shaped foci throughout the pulmonary parenchyma (predominately within the periphery), consistent with benign osteomata.

Abdomen:

An ovoid, well encapsulated mass is identified within the mesentery of the right caudal abdomen, which measures approximately 4.7cm x 4cm x 5.7cm (height x length x width) (picture 8). The mass is predominately fat attenuating, with a soft tissue attenuating rim and patchy regions of internal soft tissue attenuation (which ranges in appearance from ill-defined to linear).

A soft tissue attenuating (isoattenuating to the adjacent renal cortical tissue on pre-contrast), minimally contrast enhancing nodule, measuring approximately 1cm in largest diameter, is present in the right lateral renal cortex (picture 9).

The liver and spleen are diffusely mildly enlarged, with rounded margins, however they demonstrate normal attenuation and contrast enhancement. A mildly enlarged splenic lymph node is also present.

Diagnosis: Multiple myeloma – advanced stage

Discussion

Multiple myeloma is a lymphoproliferative cancer arising from plasma cells and their precursors, characterised by clonal proliferation of plasma cells infiltrating the bone marrow and then affecting other organs such as the spleen. Diagnosis of MM usually follows the demonstration of bone marrow or

visceral organ plasmacytosis, the presence of osteolytic bone lesions and the presence of urine myeloma proteins. Renal disease is present in approximately one-quarter to one half of dogs with MM, and azotemia is observed in 30% to 40% of cats.

Bence Jones proteinuria was not evident in the pacient urine protein electrophoresis due to overflow proteinuria secondary to the marked gammopaty. Bence Jones proteinuria occurs in approximately 25% to 40% and hypercalcemia is reported in 15% to 50% of dogs with multiple myeloma. The clinical signs can vary from lethargy and weakness to inappetence, weight loss, lameness, polyuria/polydipsia, bleeding diathesis and central nervouse system deficits. The patient presented with a history of mild inappetence and isolated episodes of lameness.

Chemotherapy is effective at reducing malignant cell burden and to improve the quality of life of the patient. Variouse alkylating agents such as melphalan, cyclophosphamide, chlorambucil, lomustine can be used together with steroid therapy. The most common protocol is a combination between melphalan and prednisolone. This protocol is usually well tolerated by the vast majority of the dogs, the most clinically significant toxic events beign represented by myelosuppression and delayed thrombocytopenia.

After the last investigations performed at the referral center the patient started to deteriorate significantly this manifested by presence of a severe swelling over the left side of the face associated with pain and ptyalis. Two days later, a chemotherapeutic protocol including melphalan, cyclophosphamide orally with intravenous dexamethasone was started. Despite this, the dog developed neutropenia and pyrexia, raising concern for sepsis. As a result, a decision was made to euthanase him one day later.

Junior Assistant Clinicians (10 Posts),University of Glasgow

October 16, 2021

University of Glasgow

College of Medical, Veterinary and Life Sciences

School of Veterinary Medicine

Junior Assistant Clinicians (10 Posts)

Vacancy Ref: 067987

Salary: Grade, level 6, £29,614 – £33,309, per annum

We are looking to appoint a number of Junior Assistant Clinicians to deliver small animal veterinary clinical and care service under the supervision of experienced and fully qualified staff. You will, on a rotating basis, participate and assist, under supervision in Referral Clinical activities, in the areas such as anaesthesia, emergency medicine, internal medicine, oncology, radiology, neurology, soft tissue surgery and orthopaedics as directed by the Hospital Board. You will also, on a rotating basis, participate, and have direct case responsibility, in a Primary Care Out of Hours service. In all these activities, you will support student training and receive appropriate training yourself as required.

This 1-year position will count as an Internship for future residency applications and successful candidates will receive a certificate of completion of internship. The posts offer the early stage clinical experience required as vets prepare for further specialist training, for example through residencies and masters formal training programmes.

We welcome applications from candidates with a degree that is registerable with the Royal College of Veterinary Surgeons and practical clinical experience and training with companion animals (this may include undergraduate courses with a significant practical component and periods of extra-mural studies)

The School of Veterinary Medicine has an excellent international reputation in teaching, clinical services and research and is accredited by the Royal College of Veterinary Surgeons (RCVS), the European Association of Establishments of Veterinary Education (EAEVE) and the American Veterinary Medical Association (AVMA). Our purpose built hospital is one of the most sophisticated in Europe allowing companion animals from across the United Kingdom to benefit for the most advanced care available 24 hours a day, 7 days a week throughout the year from some of the best specialist vets in the world.

The School is located in the picturesque Garscube Estate, 10 minutes drive from the vibrant “West End” of Glasgow, and less than one hour from Loch Lomond. Glasgow is the largest city in Scotland and the third largest in the UK, and has recently been named the top cultural and creative centre in the UK in a European Commission report (https://composite-indicators.jrc.ec.europa.eu/cultural-creative-cities-monitor/).

The University of Glasgow has recently been named University of the Year at the Times Higher Education Awards 2020. The University offers a wide range of benefits and discounts https://www.gla.ac.uk/myglasgow/humanresources/new/newstart/workingatglasgow/
Visit our website for further information on The University of Glasgow’s School of Veterinary Medicine: https://www.gla.ac.uk/schools/vet/

Informal Enquiries should be directed to Professor Ian Ramsey, Ian.Ramsey@glasgow.ac.uk

Apply online at: https://my.corehr.com/pls/uogrecruit/erq_jobspec_version_4.jobspec?p_id=067987

The University of Glasgow is the current Times Higher Education (THE) University of the Year.

The School of Veterinary Medicine holds an Athena SWAN Silver departmental award. The award recognises commitment to tackling gender inequality in higher education.

It is the University of Glasgow’s mission to foster an inclusive climate, which ensures equality in our working, learning, research and teaching environment.

We strongly endorse the principles of Athena SWAN, including a supportive and flexible working environment, with commitment from all levels of the organisation in promoting gender equity.

The University of Glasgow, charity number SC004401.

Pemphigus foliaceus in a cat

October 8, 2021

Dr Spas Spasov

Veterinary Center Dr Antonov

Varna, Bulgaria

1.Case History

The cat is 3 y old ,female non castrated ,regular vaccinated ,tick and flea treatment with advocate .

The problem of the cat begane one year ago in with claw bed problems ( yellow puss from there ) ,the cat have also lesions on its ears and nose .

In other clinic in other country my other vet is start with antibiotics and steroid therapy (improvement for few months )

2.Clinical presentation

Paronychia, crusty and scaly nose ,crusty and scaly ears, pruritus, painful walking no other skin lesions and symptoms .

3.Differential diagnoses

Fungal infection

Pemphigus Foliaceus

Demodecosis

Pyodermia

Allergy

4.Diagnostic approach

CBC and Biochemistry –Unremarkable

DTM – Negative

Skin scrape and scotch tape – Negative

Cytology – Neutrophils ,bacteria ( cocci ) and acantholytic cells .

Microbiology ( Staff .aureus )

5.Therapeutic approach

14 days Amoxicillin and clavulanic acid and topical therapy with chlorexiderm 4 % ( almost no improvement)

New cytology – Normal neutrophils and acantholytic cells (no bacteria )

Punch biopsy of nail bed .

Pathohistologi report :

Report – Histopathology release date: 23.02.2021

Description

There were examined 5 representative sections (Hematoxylin-Eosin stain) from each sample, showing

similar histopathological appearance:

Epidermis with orthokeratotic hyperkeratosis, spongiosis and crusts (composed of acantholitic cells and

neutrophils). Superfcial and deep dermis show oedema, perivasculary to diffuse infammatory infltrate

with eosinophils, few mast cells, few lymphocytes and plasma cells. The hair follicles are in telogen and

catagen phases. The glands (apocrine and sebaceous glands) are well represented, without any

changes. There is no evidence of neoplasia, parasites or fungi in the examined sections.

There were examined 5 representative sections (PAS stain – fungi) from each sample, showing similar

histopathological appearance:

NEGATIVE

Interpretation

The histopathological appearance is consistent with hyperkeratosis, suppurative epidermitis, chronicactive dermatitis with eosinophilic component (allergic component).

Comments

The histopathological aspects are suggestive for pemphigus foliaceus. Suspicion is confirmed.

Therapy :

Prednisolon tablets 2 mg per kg twice a day for 14 days then slowly reduce dose to a minimum working dosage .

6 moths later the cat was perfect then ,the owners call regular just to tell us that everything is ok .

Diagnose :

Pemphigus foliaceus

CORRECTIVE OSTEOTOMIES OF COMPLICATED BONE MALFORMATIONS, USING RIGID FIXATION WITH MIKROMED IMPLANTS

September 21, 2021

by the Department for orthopedic diagnostic, surgery and anesthesia in clinics “Dobro hrumvane” – dr. Kirilov, dr. D. Ivanov, dr. Ts. Ivanov, dr. Nikolov, dr. Kotsev, dr. Bochukova, technician Kirilova

Corrective osteotomies, especially the ones caused by combined and complicated malformations of the antebrachium and the crus are truly challenging surgeries, both for the surgeon, and the implants being used. Except by their design and material (steel/titanium), these implants differ also by their qualities such as elasticity, strength, long term quality of the locking mechanisms. The quality of the surgical titanium or steel, being used, along with their manufacturing technology are significantly important for the overall quality of the manufactured implants. Further below, in this abstract, we present 4 orthopedic cases, which required a maximally rigid fixation to be applied. Working on these cases, allowed us to challenge the strength and locking quality of the Mikromed implants.

Case 1: Male dog, Frodo, mixed breed, aprox. 35 kg

In its early age, the patient suffered a trauma to its elbow and antebrachium, creating a malunion, which in the long term lead to permanent elbow damage, radio-ulnar synostosis and high-grade external torsion and valgus of the distal antebrachium:

Pre-op antebrachial valgus:

Pre-op antebrachial external torsion:

Frodo pre-op video:

A double plating corrective osteotomy was performed, using a 3.5 mm locking DCP Mikromed plate and 3.5 mm locking and non-locking screws (this system also accommodates 2.7 and 4.0 mm screws) and a second, straight, non-loking Mikromed DCP plate with cortical 2.7mm screws. In this kind of surgery, it is crucial to have very strong implants and locking and to do precise calculations for the corrective angles to be achieved. Precise contouring of the medially placed non-locking implant is also very important for the successful outcome.

Post-op X-ray CrCd:

Post-op X-ray LAT:

Frodo 18H post-op video:

https://youtu.be/8wVnvzzpb-E

Final result: perfect bone healing and normal leg usage

Case 2: Male dog, Michail, mixed breed, aprox. 13 kg

The patient suffers from congenital bilateral antebtachial deformity – high-grade internal torsion and varus.

Pre-op antebrachial varus right leg:

Pre-op antebrachial internal torsion right leg:

Pre-op antebrachial varus left leg:

Pre-op antebrachial internal torsion left leg:

Video pre-op:

A single plate corrective osteotomy was performed (this was possible due to the low weight of the patient). A straight support 2.4 mm locking Mikromed plate was used, along with 2.7 mm locking and non-locking screws (the system also accommodates 2.4 mm screws). The plates was applied in an oblique fashion, instead of purely cranially, due to the need for excessive contouring, which is a serious challenge for the strength of the plate and the stability of the locking and the whole fixation in the post-op period.

X-ray picture 5 min post-op LAT:

X-ray picture 5 min post-op CrCd:

Final result: perfect bone healing and normal leg usage

X-ray picture 6 months post-op LAT:

Case 3: Male dog, Ares, GSD, aprox. 30 kg

The patient suffered a high-energy trauma to its stifle and curs in its early age, which stopped the development of the proximal portion of the tibial plateau, thus making it “sink” in relation to the tibial crest and leading to a shift of it surface in relation to the femoral condyles. Additionally a synostosis between tibia and fibula was found. The patient demonstrated intensifying lameness and more and more severe pain, especially upon limb extension. In addition, a low-grade lumbo-sacral instability was diagnosed during imaging.

Ares X-ray picture pre-op LAT:

Ares X-ray piicture pre-op CrCd:

A block resection of the tibial plateau was performed, during which the plateau was elevated and leveled. Ilial bone autografts were used to fill the gap, formed between the two tibial fragments. A straight support locking Mikromed 3.5 mm DCP plate plus 4.0 locking screws were used. The correct and adequate leveling of the tibial plateau was crucial, along with strength of the plate and the reliable locking, which were subjected to serious biological forces. In addition to that, the patient had an energetic temper.

Ares X-ray picture 24H post-op LAT:

Ares X-ray picture 24H post-op CrCd:

Ares X-ray picture 6 months post-op LAT:

Ares X-ray picture 6 months post-op CrCd:

Result: perfect healing and limb use, even years after completion of the surgery.

Ares CT 2 y post-op:

Ares video 2 y post-op:

https://youtu.be/cDpzO229GcU

Case 4: Male dog, Nuki, mixed breed,aprox 25 kg

The patient suffered from a rare congenital elbow deformation: the proximal radius and ulna exhibited “mirror view” morphology in the sagittal plane: the ulnar trochlear notch and its coronoid processes were placed at the opposite site. There was no weight baring on the limb due to this, which lead to maximal muscle atrophy. The carpal joint was in permanent flexion and extension was impossible to achieve. All soft tissues related to the elbow joint exhibited atypical morphology.

Nuky X-ray picture pre-op LAT:

Nuky X-ray piicture pre-op CrCd:

In the are moments of leg “usage” Nuky treaded in this way:

An elbow arthrodesis along with a minor (around 25 mm) limb shortening was performed. An angle of 110-130 degrees between the humerus and antebrachium was impossible to be achieved, because of the altered soft tissue morphology and due to the risk of worsening the carpal situation. Due to that, a laterally applied curved non-locking DCP Mikromed plate was used, instead of the typical caudally applied straight plate.

Medial application of the plate is usually recommended, but in this case we decided to once again challenge and trust the Mikromed implant, being laterally applied.

Nuky video 3 days post-op:

Nuky video 1 W post-op:

https://youtu.be/alVKE2AJtF0

Nuky video 2 W post-op:

Result: full bone healing and good limb use. Home carried physiotherapy helped the particular patient overcome the permanent carpal flexion and evaluate shoulder muscles.

Nuky X-ray picture 6 months post-op LAT:

Nuky X-ray picture 6 months post-op CrCd:

Nuky video 10 months post-op:

Conclusion: The corrective osteotomies require precise pre-surgical planning, regarding both the osteotomy geometry and the choice of implants to be used. The Mikromed implants possess the required strength and locking quality to withstand even excessive orthopedic challenges, especially in the area of rigid fixation.

Vaginal tumor in a dog

September 5, 2021

Case history and clinical findings

Dr. Mirela Marinova DVM, EVSSAR member , MVC Bulgaria

Dr. Miroslav Genov DVM, PhD, EVSSAR member, MVC Bulgaria

A 14 kg, 13-year-old female cocker spaniel for truffle hunting was examined for a swelling in the perineal region. As informed by the owner the bitch had given birth once in the past and was in heat two months ago. The swelling appeared one year ago, but had enlarged aggressively the previous month. The dog had been facing difficulty defecating.

Clinical examination revealed palpable little dense masses in the mammary glands. The swelling turned out to be a firm vaginal mass compressing the colon.

CBC and biochemistry profile showed no changes. An ultrasound showed no accumulation of fluid, the ovaries were normal, the bitch was in anoestrus.

Owner was recommended surgical removal of the mass with episiotomy and castration.

The patient was prepared in advance for vaginectomy in case removal of the mass with episiotomy was impossible.

Surgical procedure

Episiotomy was performed for examination of the masses. We started removing them consecutively with an electrosurgical knife. Their location was beneath the mucosa and were removed easily without loss of wall integrity. A part of the vaginal mucosa was hyperplastic so it was also removed. The urethra was unaffected. The vagina was sutured and it’s normal structure was restored.

The second part of the surgery was ovariohysterectomy. No changes in the ovaries and uterine were visualized.

After the castration, careful visual inspection of the uterine stump and the vagina led us to a big mass in the pelvic cavity that compressed the colon. The abdominal cavity was opened caudally to pecten ossis pubis and the uterine stump was pulled cranially. The mass was localised at pars cervicalis. After it’s removal the vaginal wall was sutured.

Post-operative period

The recovery was smooth. Control of the urine bladder was kept and normal defecating restored.

The postoperative edema disappeared in 2 weeks.

Diagnosis

A part of the resected mass was send to laboratory for histopathological diagnosis resulting vaginal polyps- benign non-neoplastic proliferations of well differentiated fibrous tissue, covered by regularly structured hyperplastic epithelium.

Vaginal tumors

Tumors of the female reproductive tract are divided in two categories: arising from the ovaries and those derived from the tubular genitalia.

Genital tract tumours are usually seen in medium-aged (mean age 10 years) non-spayed dogs. Vulvar tumors in dogs are rare- 2,5% of all canine tumors with 70% of them being benign.

https://www.youtube.com/watch?v=SHCML_LI2pw

https://www.youtube.com/watch?v=Dsg-ClVJPpY

Tumors of mesenchymal origin, leiomyomas, fibroleiomyomas and fibromas occur most commonly. Leiomyosarcomas, lipomas, mastocytomas, adenocarcinomas, squamous cell carcinomas occur much less frequently. Transmissible venereal tumors (that spreads during coitus) can also appear in dogs. Transitional cell carcinoma of the urinary tract occasionally extend into the vagina and vestibule. Metastasis to the vagina is extremely rare.

Smooth muscle tumors and polyps of the tubular part of the genital system are common in the bitch. The growth of many of these benign tumours is associated with the ovarian secretion of oestrogen. Therefore, unless the bitch is receiving exogenous oestrogens, it is very unusual to find them in an spayed animal. Leiomyomas appear to be steroid-hormone dependent- around 56% of them have estrogen receptors and 84% express progesterone receptors. This type of tumor is associated with estrogen secreting tumors or ovarian follicular cysts. Spontaneous regression has been observed after castration or treatment with progesterone receptor antagonist.

About 85% of leiomyomas occurring in the reproductive tract in the bitch arise from the vagina, vestibule and vulva. Boxers are predisposed.

Benign vaginal tumours may present as either extraluminal or intraluminal forms. Extraluminal are usually well encapsulated and their growth results in a noticeable perineal swelling. Intraluminal tumours tend to be attached to the wall of the vestibule or vagina. The are often ovoid and firm. Sometimes they can protrude from the vulva. Large intraluminal tumours may become traumatized, oedematous and infected and their appearance may be similar to that of vaginal hyperplasia. Sometimes with the development of the tumour mammary gland tumours, ovarian cysts and cystic endometrial hyperplasia can be seen simultaneously.

Benign tumours can reach 10-12 cm in diameter. When it’s small the consistency is fleshy, but as it develops it becomes firm and hard due to increase in connective tissue ( so called “fibroid”). Small vaginal masses are are asymptomatic unless protruded form the vulva and they can only be discovered by coincidence during vaginal inspection.

Clinical signs include bulging of the perineum, dysuria, stranguria, haematuria, vulvar bleeding and discharge, faecal tenesmus, constipation. Usually there are no changes in the CBC. Radiographs of the caudal abdomen may suggest the presence of vaginal tumor but will not be enough for a definitive diagnosis or it’s location. Endoscopy is an excellent way to visualize the vaginal mucosa and the presence of polyps. Histological examination is considered to be the gold standard in determining the type of the tumor. Surgical resection with ovariohysterectomy ( reduces the risk ot recurrence) provide great outcomes for patients. Digital vaginal and rectal examinations are performed monthly to monitor for tumor recurrence.

References:

Jane M. Dobson and B. Duncan X. Lascelles, BSAVA Manual of Canine and Feline Oncology, Third Edition, 17: 257-259
David E. Noakes, Timothy J. Parkinson, Gary C.W. England, Arthur’s Veterinary Reproduction and Obstetrics, 9^th Edition, 5: 649-651
Robert Klopfleisch, Veterinary oncology, 5: 141-143
Linda G. Shell, DVM, DACVIM, Tanya Gustafson DVM, Vaginal/Vulvar Neoplasia
B. Kand and D.L. Holmberg, Department of veterinary anesthesiology, radiology and surgery, Western College of Veterinary Medicine, Univeristy of Saskatchewan, Case Report: Vaginal leiomyoma in dog
Tuli Dey, Bhajan Chandra Das, Syed Imran, Mohammed B. Bostami, Bibek C. Sutradhar, Sonnet Poddar, University ot Veterinary medicine, Bangladesh, Case report: Surgical Management of Canine Vaginal Leiomyoma of a bitch

Learn ans Travel-Iva Novak, final year veterinary student from the University of Zagreb, Croatia

August 22, 2021

Iva Novak, a final year veterinary student from the University of Zagreb, Croatia share with us her amazing experience:

After living one year in a pandemic, I decided to take one last chance at an Erasmus adventure before graduating this summer. When I came to Padova, I first took a couple of days to explore the beautiful Prato della Valle, Palazzo Bo and the historic center; and also find my way to the clinic. The San Marco veterinary clinic and laboratory is located outside of the city itself, halfway from Padova to Vincenza, another beautiful Italian city. The location makes it available to clients and owners from all over Italy, but also Spain, France, Switzerland and the Balkans. It stretches over 50,000 square meters and 2 floors, with a terrace that gives a wonderful view of the nearby fields.

My first day I was greeted by Dr. Busato who gave me a tour of the clinic, which seemed like a spaceship to me, as I was impressed with magnetic name cards that opened the clinic’s doors! It was nice to put a face to the name of the person I had been messaging with to plan this whole visit, and as expected Dr. Busato was as nice and welcoming in person as she was over email. I am not the best Italian speaker but it turned out that there was no language barrier as everyone at the clinic spoke English and I had no trouble following cases.

To get me started, my first week I was put in the hospitalization ward; where each day one doctor is in charge, but the nurses are the true heart and engine, with over 100 cages, often full, and the nurses still know every patient’s quirks and details. The patients are divided into 6 rooms: for cats, dogs, dogs’ oncology, cats’ oncology, dogs’ infectious and cats’ infectious ward. The intensive care unit is separate and equipped with special beds for patients that can be moved to different areas of the clinic, specialized monitoring devices to provide optimal patient care and diagnostics, CPAP, continuous electrocardiographs, fresh gas and oxygen flow for each patient and round the clock care given by the amazing team lead by Dr. Rocchi. We gave hope and a fighting chance to every animal that walked through the clinic’s door and thanks to doctors Pelizzola, Grossi, Botto and Pallares I practiced my E-FAST skills, ultrasound volemic status assessment, wound management; and there was always good food at morning rounds.

The scale of the clinic is so that if I were to write about each department, this article would turn into a book! San Marco is a tertiary clinic so it provides patients with general medicine and specialist care in neurology, cardiology, nephrology, dermatology, oncology, ophthalmology, orthopaedics, nutrition, and behavior science but one of the most important departments there is radiology. I learned just how big of a part echography can play in disease diagnostics and control check-ups and I also spent one week studying CT diagnostics, which was a whole new world for me. I was lent literature to prepare since CT diagnostics weren’t a part of my studies at the University of Zagreb, and with the help of Dr Negro I was quickly able to follow and recognize pathologies in multiplanar reformatted reconstruction and three-dimensional volume renderings.

As a referral clinic they take in over 6000 patients a year, so cases were abundant but I learned even more during the weekly evening lectures and clinical cases presented almost daily by the clinic’s rotating and specialist interns. The clinic is research oriented, they publish around 30 peer reviewed papers every year and they also provide professional training, traineeships, specialised and rotating internships and residency with evening lectures, seminars and congresses that I have all been attending.

My morning would start in the staff kitchen, where I got to master my coffee-making skills with the instructions given to me by the clinic’s interns, and during lunch, we would exchange pasta recipes. In cardiology, Dr Ledda taught me how to use spectral, flow, and tissue doppler and being one of the doctors that can perform interventional radiology he taught me the theoretical part of it as well. Out of internal medicine, I had the honour of working with Dr Furlanello, Dr Zoia, and Dr Pantaleo. We would receive their own patients, as well as consultations and referrals from other clinics all over Italy.

Since my time there was short compared to the number of procedures they perform at the clinic, out of ophthalmology I was able to only attend one electroretinography on a Tibetan mastiff with SARD syndrome. During surgery week, I observed a TTT with trochleoplasty, nodulectomy with a flap, extrahepatic portocaval shunt closing with fluoroscopic portography and a correction of tibial varus among other procedures. I also helped perform bronchoscopy, rhinoscopy, colonoscopy, gastroscopy with duodenoscopy, and uretroscopy. The endoscopy equipment was also used for intracervical artificial insemination, which was performed by a doctor Ferré.

In the end, one of the things you can’t miss when you first walk into the San Marco clinic is the big swimming pool that can be seen from the waiting room. It is used for physical therapy but I can’t say I didn’t see any of the staff jumps in just before it is supposed to be emptied. At physical therapy, they explained to me the history and progress of every patient and taught me how to use laser therapy in theory and practice along with applied hydrotherapy in the pool or the underwater treadmill.

Now, after 3 months, my adventure is coming to an end, I plan on visiting all the beautiful places in Veneto and surrounding regions I still haven’t seen, like Bologna, Verona and Milano.

I embarked on an Erasmus in the middle of the pandemic but I was lucky to be welcomed into an amazingly organized clinic, following the rules and measurements put in place, my Erasmus experience was barely affected by the pandemic. I am thrilled to have had this opportunity to meet amazing people who work in the same field as me. I can recommend San Marco Vet Clinic to colleagues that want either basic training or to further their skills with specialist grade education. Thank You to everyone who shared their knowledge with me. I will treasure it for a lifetime.

Canine juvenile cellulitis – a case misdiagnosed as meloxicam allergy

August 16, 2021

Authors:

Tsvetan Velev¹, Anna Valerieva², Plamena Novakova², Elitsa Valerieva³, Elena Petkova², Tsvetelina Lazarova¹, Maria Staevska², Miroslav Todorov¹

Affiliations:

¹ Veterinary clinic “Blue Cross”, Pancharevo, Sofia, Bulgaria; ² Department of Allergology, University Hospital “Alexandrovska”, Medical University of Sofia, Bulgaria; ³ Dr. Shterev Hospital, Sofia, Bulgaria;

Abstract

Herein, we report a rare case of canine juvenile cellulitis misinterpreted as meloxicam allergy. Early diagnosis and proper treatment of the condition is associated with a very good prognosis. It is recommended that therapy should be aggressive and initiated as soon as diagnosis is made in order to avoid scarring, secondary infections and to maintain a favorable prognosis. Additional treatment includes topical medications (eg. antimycotics, antibiotics and steroids) along with antiseptic dressings. Awareness of this condition must be improved as the severity of juvenile cellulitis may lead to euthanasia, therefore it is of vital importance that the disease is considered and explored early, and proper treatment is initiated promptly

Key words: juvenile cellulitis, puppy strangles, canine drug allergy, misdiagnosis, autoimmune cellulitis, sterile granulomatous dermatitis, juvenile pyoderma

Introduction

Juvenile cellulitis (also known as juvenile sterile granulomatous dermatitis and lymphadenitis, juvenile pyoderma or puppy strangles) is a rare sterile granulomatous disorder that commonly affects the face, pinnae and submandibular lymph nodes of young puppies between 3 weeks and 8 months old (1). Clinical signs of juvenile cellulitis include fever, lymphadenopathy as well as bilaterally symmetric, pruritic lesions in the periocular areas, face, muzzle, pinnae and inguinal regions. Symptoms progress to crusting and alopecia. Lesions typically form fistulae that drain. A typical feature which also gave rise to the term “puppy strangles”, is submandibular lymphadenopathy. Apart from all these findings, affected dogs are usually active and in good general health (2,3).

Figure 1. Bilateral symmetric, pruritic granulomatous lesions of the muzzle and the periocular areas.

Case-presentation

A 14-week-old miniature Spitz-Pomeranian puppy (regularly vaccinated) spontaneously presented with left hind limb lameness and pain. A hypothesis of possible trauma resulted in intramuscular meloxicam application in two consecutive days with no clinical benefit. Dermatological symptoms occurred after 48 hours and were misinterpreted as meloxicam allergy: bilateral symmetric, pruritic lesions in the periocular areas, face, muzzle, pinnae and inguinal region. This lead to a prescription of antihistamine and low-dose corticosteroid treatment.

Thereafter, the puppy presented also with fever and mandibular lymphadenopathy. Dermatological symptoms progressed to crusting and alopecia, some pustules formed bloody abscesses and drained. Symptoms continued to worsen requiring to rule out various infectious diseases: canine distemper, leishmaniasis, anaplasmosis, babesiasis and toxoplasmosis, all of which resulted negative.

Blood tests were within reference ranges and non-conclusive of an infectious agent. Clinical presentation suggested a diagnosis of autoimmune juvenile cellulitis and high-dose systemic corticosteroid and antibiotic therapy was initiated with clear benefit in less than 12 hours: prednisolone 2 mg/kg + trimethoprim/sulfamethoxazole, together with ocal antiseptic care. Therapy was tapered in 35 days with no signs of a relapse. At the final check, the puppy is 17 months-old with normal development and in good general health.

Figure 2. Bloody abscess on the back (spontaneously drained within few days)

Discussion

The cause and pathogenesis of juvenile cellulitis are not yet fully understood. It was suggested that it is a systemic condition with primary lymphadenopathy resulting in secondary dermatological lesions with some extent of immune dysfunction as well as hereditary components (4). Inflammation in juvenile cellulites is pyogranulomatous with no culprit microorganisms. Cytological findings reveal a nonbacterial aetiology of the disease (5). Analysis of joint fluid often shows signs of sterile suppurative arthritis. Examination of aspirates of affected lymph nodes, pustules, abscesses and joint fluid rarely show any sign of bacterial growth. Biopsy of lesions usually demonstrate discrete or confluent granulomas and pyogranulomas consisting of clusters of large epithelioid macrophages with variably sized cores of neutrophils (6). It was also suggested that since juvenile cellulitis usually occurs at the age when dogs usually receive their first vaccinations with modified-live virus vaccines, there could be a possible pathogenic link between infection with vaccine or other viruses and the evolution of this disease. Data on this association is, however, insufficient. Definitive diagnosis is based on cytological and histopathological analysis as well as on typical findings on complete blood cell count (leucocytosis, neutrophilia, and normocytic-normochromic anaemia) (6).

Juvenile cellulitis is responsive to high-dose corticosteroids which are often prescribed along with antibiotics due to the risk of secondary bacterial infection (5). Rapid and aggressive therapy is recommended in order to maintain a favourable prognosis, to avoid scarring, and to reduce secondary infections (7). The major differential diagnosis includes: canine distemper, demodicosis, bacterial pyoderma, dermatophytosis or an adverse drug reaction, as in the case presented here. However, sterile pus on cytology and responsiveness to corticosteroid treatment differentiate infectious or drug-related causes from juvenile cellulitis. Since juvenile cellulitis is a relatively rare condition, it doesn’t usually come as the first diagnosis in mind and other more common conditions are considered (2). However, as the severity of juvenile cellulitis may lead to euthanasia, it is of vital importance that the disease is considered and explored early, and proper treatment is initiated (8). Juvenile cellulitis is very responsive to high-dose corticosteroids, usually prescribed along with (5). It is recommended that therapy should be aggressive and initiated as soon as diagnosis is made in order to avoid scarring, secondary infections and to maintain a favourable prognosis. Additional treatment includes topical therapy (e.g. terbinafine, oflaxacin, ornidazole and clobestal) along with antiseptic dressings (7).

Figure 4. Dermatological changes of the penile skin.

Conclusion

We report a rare case of canine juvenile cellulitis misinterpreted as meloxicam allergy. If diagnosed early and treated properly the condition is associated with a very good prognosis. It is recommended that therapy should be aggressive and initiated as soon as diagnosis is made in order to avoid scarring, secondary infections and to maintain a favourable prognosis. Additional treatment includes topical medications (e.g. antimycotics, antibiotics and steroids) along with antiseptic dressings. Juvenile cellulitis has a very good prognosis if diagnosed early and treated properly. Complete recovery is typical with a low chance of recurrence (9). Dogs’ condition usually improves markedly by the 14^th day after treatment start. Symptoms are reported to resolve completely within the fourth week (7).

Awareness of this condition must be improved as the severity of juvenile cellulitis may lead to euthanasia, therefore it is of vital importance that the disease is considered and explored early, and proper treatment is initiated promptly.

References:

Kumar AA, Pillai UN, Aipe AA. Clinical management of juvenile cellulitis in a dachshund pup. Intas Polivet 2013; 14:234–235.
Hutchings SM. Juvenile cellulitis in a puppy. Can Vet J 2003;44: 418–49.
Scott DW, Miller WT, Griffin CE. Small Animal Dermatology, 6 ed. Toronto: WB Saunders, 2001:1163–1167.
Dubey P, Sarkar S. Therapeutic management of juvenile cellulitis in Labrador pup. Intas Polivet. 2013; 14:232- 233.
Bassett RJ, Burton GG, Robson DC. Juvenile cellulitis in an 8-month-old dog. Aust Vet J 2005; 83:85.
Reimann KA, Evans MG, Chalifoux LV, et al. Clinicopathologic characterization of canine juvenile cellulitis. Vet Pathol 1989; 26:499–504
Martens S. Juvenile cellulitis in a 7-week-old golden retriever dog. Can Vet J 2016;57: 202–203
Mason IS, Jones J. Juvenile cellulitis in Gordon setters. Vet Rec 1989; 124:642.
Jyothi J, Preethi K, Sathish K. Therapeutic management of juvenile cellulitis in a Labrador retriever puppy. The Pharma Innovation Journal 2017; 6(11): 840-842

HYPERPHOPSPHATEMIA: DIET AND PHOSPHATE BINDERS

July 7, 2021

Serum and plasma phosphorus levels in blood mainly depends on intestinal uptake and urine excretion.

Kidneys have a key role in maintaining serum phosphorus levels, as they can either increase or reduce the quantity excreted with urines. In case of a dog or a cat fed with a high-phosphorus diet, kidneys promote its excretion and the opposite happens with a low-phosphate diet.

In cats and dogs affected by chronic kidney disease, also in the early stages, it’s difficult for the kidney to maintain the phosphate balance because as the kidney function declines, patients tend to phosphorus accumulation: this is called hyperphosphatemia.

In both dogs and cats with renal disease, hyperphosphatemia is mainly caused from a diminished phosphorus excretion (phosphates) and, to a lesser extent, it is consequence of a high acidity of blood (metabolic acidosis).

Hyperphosphatemia is often accompanied to hypocalcemia (low calcium levels in the blood serum), which leads to the increase of parathyroid hormon (PTH) as an attempt to correct calcium concentration in serum.

If hyperphosphatemia is not treated, PTH can be excessively secreted leading to renal secondary hyperparathyroidism, responsible for bone demineralization, renal interstitial and soft tissue mineralization.

Studies in dogs affected by chronic kidney disease have shown the efficacy of a low-phosphate diet (0.4% phosphorus on dry matter) in slowing the progression of renal damage and reducing calcium deposition in the kidney.

Patients in IRIS stage 2, 3 e 4 can show hyperphosphatemia that can be diagnosed testing phosphorus levels in blood and correlating results to the patient’s IRIS stage. In stage 2, dogs and cats are hyperphosphatemic with serum phosphorus above 4.6 mg/dL, in stage 3 with a phosporus level above 5 mg/dL and, finally, patients in stage 4 in case of phosphorus above 6,0 mg/dL.

First therapeutic approach in case of hyperphosphatemia of renal origin is administering a renal diet, with a low-phosphate level. It is recommended to check serum phosphorus after 2-4 weeks: diet is efficacious if serum phosphorus is below 4.6 mg/dL in IRIS stage 2, 5.0 mg/dL in stage 3 and below 6.0 mg/dL in stage 4. In case the diet alone is not working, it will be necessary to introduce phosphate binders.

IRIS stage	Phosphorus(mg/dL)	Therapy
1		No
	>4.6	Diet ± Binders
3	>5.0	Diet ± Binders
4	>6.0	Diet ± Binders

Phosphorus-binding agents should be given together with meals or within 2 hours of feeding to maximize their binding of dietary phosphorus. Commonly employed oral phosphorus binders include aluminum hydroxide, calcium carbonate, and calcium acetate. The starting dosage of these phosphorus binders is approximately 60-90 mg/kg/day, usually divided twice, and the dosage should be adjusted by periodic evaluation of the serum phosphorus concentration. Calcium salts may be superior to other intestinal phosphate binders if ionized calcium is moderately to severely decreased, which is common in the later stages of the chronic kidney disease. Animals should be monitored for development of hypercalcemia whenever phosphorus binders containing calcium are used, especially if calcitriol is being administered concurrently.

Pharmacross NormaPhos® PLUS contains calcium carbonate and chitosamine, with Vit.C and folic acid. As a phosphate binding agent, calcium carbonate is considered safe for long term use while chitosamine is a naturally occurring substance that enhances phosphate binding of calcium carbonate and binds uremic toxins, reducing their absorption in the bloodstream. Finally, Vit.C shows antioxidant properties and the adequate content of folic acid supports the red blood cell function.

Dietetic approach to Chronic Kidney Disease

May 17, 2021

A correct dietetic approach is the key of the therapeutic management of either dogs and cats affected by CKD.

Renal diets have some characteristics:

controlled protein level, with proteins of high quality
low phosphorus & sodium
alkalizing agents to control metabolic acidosis often associated to CKD
high content of Vit.B complex
high content in fibers
polyunsatured Omega-3 fatty acids (PUFA) and antioxidants

It is wrong to consider a renal diet a “low protein diet” as there are still many diets with a lower content in proteins, addressed to other diseases, that are not good to be administered to patients affected by CKD.

Some renal diets underwent clinical trials in order to establish their efficacy in slowing the progression of renal damage or reducing the risk of mortality because of uremic crisis in patients affected from renal failure.

Protein content

There is no consensus about the ideal protein content of renal diets for dogs and cats, although it is accepted clinical signs of uremia improve after a renal diet is administered to patients in IRIS stage 3 & 4. For IRIS stage 1 patients there is no consensus about the utility of a renal diet, but it can be introduced to treat other conditions such as proteinuria. The theoretical utility of a low protein diet in slowing the progression of renal damage in IRIS 2 dogs has not been demonstrated yet and is, therefore, anecdotally applied based on studies carried out in other species.

Clinical trials of efficacy

The efficacy of a renal diet in reducing both uremic crisis and mortality of dogs in IRIS stage 3 has been demonstrated in a randomized controlled clinical trial (RCCT). Dogs feeding a renal diet reduced their risk to develop uremic crisis of 75% as well as of 66% for the risk of renal related mortality, compared to dogs fed with a maintenance diet. In the same study, dogs feeding a renal diet showed better quality of life too.

In another trial, cats with serum creatinine between 2.0 and 4.5 mg/dL were randomized into two groups, one feeding a renal diet and the other feeding a maintenance one; the renal diet reduced the risk of developing uremic crisis and death for renal causes.

Furthermore, a clinical trial studied the difference in survival times of cats feeding a renal diet compared to ones eating a maintenance one. Also in this case, there was a significant difference in survival time between the groups: a median of 633 days for cats fed with a renal diet and 264 for those eating a maintenance one.

Diet change

It takes its time to make a patient accept a new diet. Passing to a new diet too fast as well as a force-feeding are all reasons potentially leading a patient to food aversion. Changing a diet too fast can also cause diarrhea, subsequent dehydration and worsening of renal function. The new diet has to be introduced in growing percentage compared to the old one, subdividing the period in 4 phases. Cats, and dogs with selective appetite, will be changing their diet in 4 weeks, while easier patients will be doing it in 2 weeks.

1st period	25% renal diet + 75% current diet
2nd period	50% renal diet + 50% current diet
3rd period	75% renal diet + 25% current diet
4th period	100% renal diet

Therapeutic suggestions and evidence based medicine

Clinical trials demonstrated the efficacy of renal diet in both improving quality of life and survival time, other than reducing the risk of uremic crisis in dogs in IRIS stages 3&4 and cats in stages 2, 3&4. The real utility of a renal diet for dogs in IRIS stage 2 has not been demonstrated yet, although hyperphosphatemic patients may take advantage of a low phosphorus diet. Regardless the IRIS stage, the renal diet should be used in both proteinuric dogs and cats; its efficacy in reducing serum creatinine and urea is evaluated in 4 weeks.

Omega 3 fatty acids are widely used in both dogs and cats affected from chronic kidney disease (CKD). In dogs with proteinuric renal disease, clinical trials demonstrated the efficacy of Omega3 in reducing the protein loss and slowing the progression of renal disease and glomerular damage particularly if administered in association with antioxidants. In cats, no clinical trials evaluating the efficacy of Omega3 in slowing the progression of renal disease is available, although a retrospective study evaluating survival times of cats feeding different diets have showed a longer life-span in those cats eating the greater content of Omega3 fatty acids.

No data is available about the efficacy of Omega3 administered not in association to a renal diet. Both EPA and DHA are useful in course of CKD, even though diet should be supplemented with fish oils mainly represented from EPA and a fewer amount of DHA, at high concentration in EPA and low DHA.

On a side note, it has to be stressed Omega3 deriving from vegetal oils contain ALA, and are converted to a minimal part in EPA and DHA in canines, while cats are not able to convert ALA at all thus resulting in a lack of efficacy in case of CKD.

Content of EPA to be administered to renal patients is 80 mg/kg daily if associated to a renal diet. Pharmacross kcMEGA3, due to its high content of omega 3 fatty acids and the optimal EPA:DHA ratio meets the EPA content requirements for the health of the kidneys.