PERITONEAL DIALYSIS IN A SPHYNX CAT WITH ACUTE RENAL AND LIVER FAILURE

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Dr Bogdan Vitelaru

Bogdan Alexandru VIŢĂLARU

University of Agronomic Sciences and Veterinary Medicine of Bucharest, 59 Mărăşti Blvd, District 1, 011464, Bucharest, Romania, Phone: +4021.318.25.64, Fax: + 4021.318.25.67, Email: alexandrumv@yahoo.com

Corresponding author email: alexandrumv@yahoo.com

Abstract

A 11-year-old 3.1 kg, castrated, female Sphinx cat was referred to the Clinic of the Faculty of Veterinary Medicine Bucharest for acute onset vomiting, loss of appetite, anorexia, faintness, sharp breath, inability to exercise, oliguria and lethargy. Results from a complete blood (cell) count (CBC), serum chemical profile, and urinalysis submitted at that time were abnormal. The patient had hyperglycaemia (Glu-164mg/dl), acute renal failure (Crea-3.4mg/dl, BUN-117mg/dl) and acute liver failure (ALT-744U/L, TBIL-11.8mg/dl). The ALKP was 155U/L. The rectal temperature was 37,4ºC, the patient presented anaemic mucous membranes, mild dehydration (persistent skin fold thickness 2-3 seconds) and slight sensitivity to palpation in the renal lanyard. The established treatment consisted in peritoneal dialysis, rehydration and electrolyte balance, parenteral nutrition. We used PD4 peritoneal dialysis Dianeal 200 ml (1000ml / sqm). The patient was submitted to intravenous fluidotherapy with 5% Dextrose, Sodium Chloride 0.9 %, Aspatofort, Ondansetron, Metoclopramide and Duphalyte, CRI for 18 days. Abdominal ultrasound showed bile duct obstruction, abundant sludge in the gallbladder and mild modification in kidneys. Recommendation for oral treatment: Ipakitine bid, Azodyl bid and kidney diet food. The patient started to eat voluntary after 8 days of treatment. TBIL went up to 23.3mg/ml after the first 7 days and then started to decrease until it reached 0.9mg/dl at the end of the parenteral treatment. BUN and Creatinine values decreased to normal after the first 7 days of peritoneal dialysis and parenteral treatment. Peritoneal dialysis therapy plays an important role in renal failure in cats, especially in the elderly and weighing up to 10 kg. Elevated levels of creatinine and urea, hyperkalemia, hyper phosphatemia, or metabolic acidosis which do not yield to treatment can be solved using peritoneal dialysis. It also has a good effect in acute liver failure, cleaning the high levels of bilirubine.

Key words: peritoneal, dialysis, creatinine, urea, bilirubine

INTRODUCTION

Peritoneal dialysis is a technique whereby infusion of dialysis solution into the peritoneal cavity is followed by a variable dwell time and subsequent drainage. During peritoneal dialysis, solutes and fluids are exchanged between the capillary blood and the intraperitoneal fluid through a biologic membrane, the peritoneum. Inadequate renal function leads to disturbance in the removal of the extra fluid and waste products. It removes the waste product and extra fluid from the body in renal failure in small animal practice. Peritoneal dialysis is more accessible, more affordable and easier to administer to the small animal patient. The most common indication for peritoneal dialysis in cats is acute renal failure (ARF). Peritoneal dialysis is an important therapeutic tool for mitigating clinical signs of uraemia and giving the kidneys time to recover in cats with acute kidney injury when conventional therapy is no longer effective (Bhatt et al., 2011).
Peritoneal dialysis is a modality of renal replacement therapy that is commonly used in human medicine for treatment of chronic kidney disease and end-stage kidney failure. Peritoneal dialysis uses the peritoneum as a membrane across which fluids and uremic solutes are exchanged. In this process, dialysate is instilled into the peritoneal cavity and, through the process of diffusion and osmosis, water, toxins, electrolytes, and other small molecules, allowed to equilibrate (Cooper and Labato, 2011).
Peritoneal dialysis uses the peritoneum as a semi permeable layer for dialysis in which excess water, ions and solute in the blood pass through a semi permeable membrane to sterile solution which is known as dialysate via diffusion, osmosis and filtration. The three-layered peritoneal membrane consists of 1) themesothelium, a continuousmonolayer of flat cells, and their basement membranes; 2) a very compliant interstitium; and 3) the capillary wall, consisting of a continuous layer of mainly non-fenestrated endothelial cells, supported by a basement membrane. The mesothelial layer is considered to be less of a transport barrier to fluid and solutes, including macromolecules, than is the endothelial layer (Clough and Michel, 1988). Solute transport rates are assessed by the rates of their equilibration between the peritoneal capillary blood and dialysate. The ratio of solute concentrations in dialysate and plasma at specific times during the dwell signifies the extent of solute transport. Creatinine and urea clearance rates are the most commonly used indices of dialysis adequacy in clinical settings. Contributions of residual renal clearances are significant in determining the adequacy of dialysis (Flessner et al., 1985).

MATERIALS AND METHODS

An 11-year-old, 3.1 kg, castrated, female Sphinx cat was referred on November the 10th 2014 to the Clinic of the Faculty of Veterinary Medicine Bucharest for acute onset vomiting, loss of appetite, anorexia, faintness, sharp breath, inability to exercise, oliguria and lethargy. The physical examination revealed that the patient was anorexic, lethargic, had inability to exercise and a pronounced yellowish colour of skin and mucosa. Results from a complete blood cell count (CBC), serum chemical profile, and urinalysis submitted at that time were abnormal. The rectal temperature was 37.4ºC the patient presented slight sensitivity to palpation in the renal lanyard. Abdominal ultrasound showed mild modification in kidneys. The established treatment consisted in peritoneal dialysis, rehydration and electrolyte balance, parenteral nutrition. The patient was also submitted to intravenous fluidotherapy with 5% Dextrose, Sodium Chloride 0.9%, Aspatofort, Ondansetron, Metoclopramide and Duphalyte, CRI (Kushwaha and Singh, 2008).

RESULTS AND DISCUSSIONS

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Fig 1

The patient was presented with abnormal blood biochemistry values in the first day. The patient had hyperglycemia – Glucose – 164 mg/dl (reference range 71-159 mg/dL), acute renal failure (Creatinine – 3.4 mg/dl – reference range 0.8-2.4 mg/dL, BUN – 117 mg/dl – reference range 16-36 mg/dL) and acute liver failure (ALT – 744 U/L – reference range 12-130 U/L, TBIL – 11.8 mg/dl – reference range 0.0-0.9 mg/dL). The ALKP was 155 U/L – reference range 14-111 U/L. The rectal temperature was 37.4ºC, the patient presented yellow anaemic mucous membranes, mild dehydration (persistent skin fold thickness 2-3 seconds) and slight sensitivity to palpation in the renal lanyard.
Abdominal ultrasound showed mild modification in kidneys. Recommendation for oral treatment: Ipakitine bid, Azodyl bid and kidney diet food.
The established treatment consisted in peritoneal dialysis, rehydration and electrolyte balance, parenteral nutrition. We used PD4 peritoneal dialysis Dianeal 200 ml (1000 ml/sqm) after placing the peritoneal catheter and after we managed to accommodate the patient with the peritoneal distension. Aseptic technique is imperative for the peritoneal dialysis (the use of surgical scrub and sterile surgical technique during catheter placement, as well as the use of sterile gloves, disinfectants, and the careful handling of dialysate fluids, catheters, and catheter line during dialysis), (Thornhill, 1981). The catheter enters the abdomen on midline at the level of the umbilicus and it is directed caudally and positioned in the lower pelvis (Figure 1).

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Fig 2

The patient was also submitted to intravenous fluidotherapy with 5% Dextrose, Sodium Chloride 0.9%, Aspatofort, Ondansetron, Metoclopramide and Duphalyte, CRI.
On 11th of November 2014, the first day of treatment, the patient was presented with 37.5°C body temperature and we started administrating fluidotherapy IV in a volume set at 30 ml per hour twice a day: Dextrose 5% 15 ml, Sodium Chloride 0.9% 30 ml, Aspatofort 1 ml and subcutaneous Emeset 0.4 ml. Peritoneal dialysis was performed infusing 200 ml Dianeal PD4 (1000 ml/sqm) and we collected 130 ml after 4 hours of dwelling (Figure 2).

On the next two days we used the same protocol of peritoneal dialysis and we managed to recover this time 160-180 ml after 4 hours. The fluidotherapy remained the same, 30 ml/h and the temperature dropped at 37°C. On the 13th of November the blood tests showed: Glu 196 mg/dL (reference range 71-159 mg/dL), BUN decreased to 73 mg/dL (reference range 16-36 mg/dL), and the creatinine decreased at a normal value of 1.6 mg/dL (reference range 0.8-2.4 mg/dL). The transaminaze ALT and ALKP also decreased: ALT 509 U/L (reference range 12-130 U/L), ALKP 121 U/L (reference range 14-111 U/L) but the total bilirubin (TBIL) increased at 18.4 mg/dL (reference range 0.0-0.9 mg/dL). The pancreatic lipase dropped at 59 U/L (reference range 100-1400 U/L).
On November the 14th, the patient presented hyperthermia (40.2°C) and we performed a second abdominal ultrasound exam where we noticed the bile duct obstruction and abundant sludge in the gallbladder. The IV fluidotherapy was modified to: Dextrose 10% 7.5 ml, Sodium Chloride 0.9% 50 ml, Aspatofort 2 ml, Duphalyte 15 ml and Metoclopramide 0.3 ml twice a day. The same protocol of peritoneal dialysis have been used and we managed to recover 160-180 ml after 4 hours. We followed the same treatment for the next two days and the temperature decreased at 39.2°C. On the 16th of November we performed a complete blood count which shown granulocytosis and thrombocytosis which indicated mostly an infection corroborated with a kidney disease. The following days the temperature dropped at 38.4°C and we administered, at a constant-rate of infusion of 20 ml per hour for 12 hours per day, Dextrose 10% 30 ml, Sodium Chloride 0.9% 200 ml, Aspatofort 8 ml, Duphalyte 15 ml and Metoclopramide 2 ml.
On the 18th we run biochemistry blood tests and the results were quite remarkable: BUN, creatinine and glucose came back to normal reference rates. Glu 120 mg/dL (reference range 71-159 mg/dL), BUN decreased to 33 mg/dL (reference range 16-36 mg/dL), and the creatinine maintained at a normal value of 2.0 mg/dL (reference range 0.8-2.4 mg/dL). The only parameters which remain high were ALT, TBIL and GGT. ALT was 469 U/L (reference range 12-130 U/L), TBIL decreased to 5.8 mg/dL (reference range 0.0-0.9 mg/dL) and GGT decreased to 10 U/L (referance range 0-1 U/L). The same protocols of peritoneal dialysis have been used and we managed to recover 180 ml after 4 hours.
We followed the same treatment for the next four days and the temperature went back to a normal value of 38.4°C. On the 21st of November we run biochemistry blood tests and the ALT decreased to 387 U/L (reference range 12-130 U/L), TBIL decreased to 3.5 mg/dL (reference range 0.0-0.9 mg/dL) and GGT decreased to 8 U/L (reference range 0-1 U/L). The same protocols of peritoneal dialysis have been used and we managed to recover 180 ml after 4 hours. On the 21st of November, our patient presented appetite for the first time and eat voluntary. From this moment it started to eat every two hours renal diet and drink by herself. We decided to stop the peritoneal dialysis, the peritoneal catheter was removed and dialysis was discontinued. The patient’s condition has improved significantly (Table 1).

We followed the same venous treatment for the next seven days and the temperature maintained at a normal value of 38.4°C. On the 28th of November we run biochemistry blood tests and BUN was 46 mg/dL (reference range 16-36 mg/dL) and all the other parameters maintained in normal ranges of value. The patient’s condition has improved significantly

Parameter 10.11 13.11 18.11 21.11 28.11
Glucose
(71-159 mg/dL) 164 196 120 129 94
BUN
(16-36 mg/dL) 117 73 33 34 46
Creatinine
(0.8-2.4 mg/dL) 3.4 1.6 2.0 1.7 1.4
ALT
(12-130 U/L) 744 509 469 367 109
GGT
(0-1 U/L) 0 15 10 8 0
TBIL
(0.0-0.9 mg/dL) 11.8 18.4 5.8 3.5 0.9

We decided to discontinue the venous treatment and we recommended oral treatment: Ipakitine bid, Azodyl bid and kidney diet food.
In comparison with the literature, the decrease in BUN and creatinine were quite remarkable, the BUN decreasing from 117 mg/dL to 33 mg/dL in eight days and the Creatinine from 3.4 mg/dL to 1.6 mg/dL in three days.

CONCLUSIONS
Peritoneal dialysis therapy plays an important role in renal failure in cats, especially in the elderly and weighing up to 10 kg. Elevated levels of creatinine and urea, hyperkalemia, hyper phosphatemia, or metabolic acidosis which do not yield to treatment can be solved using peritoneal dialysis. It also has a good effect in acute liver failure, cleaning the high levels of bilirubine.

REFERENCES
Bhatt, R. H., Suthar, D. N., 2011, Peritoneal dialysis in acute renal failure in canines: A review. J. R. UkaniVet. World, Vol.4(11): 517-521
Clough, G. and Michel, C. C., 1988. Quantitative comparisons of hydraulic permeability and endothelial intercellular cleft dimensions in single form capillaries. J Physiol ; 405:563–576.
Cooper, R. L. and Labato, M. A., 2011. Peritoneal dialysis in veterinary medicine. 41(1):91-113.
Flessner, M. F., Dedrick, R. L. and Schultz, J. S., 1985. Exchange of macromolecules between peritoneal cavity and plasma. Am J Physiol ; 248: 15.
Kushwaha, R., Singh, N., 2008. Peritoneal dialysis în animals – A review. The Internet Journal of Veterinary Medicine. Volume 7 Number 1.
Stojimirovici, B.; Trbojevic-Stankovic, J., 2007. Animal models în peritoneal dyalisis, Scand. J. La. Anim, Sci. Vol. 34, No 4
Thornhill JA. 1981. Peritoneal dialysis în the dog and cat: an update. Compend Cortin Educ Prac Vet, 3, 20-34

 

Polycystic kideny disease (PKD) in ferret

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Dr Krasimira Kodjanikolova, DVM, Mr Sc Imaging diagnostic

Dr Krasimira Kodjanikolova, DVM, Mr Sc Imaging diagnostic

Veterinary Clinic NOVA, sofia,Bulgaria

Clinical case

Ferret Sunny, 5 years old, castrated

Anamnesis :

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Fluid therapy in ferret

The feret presented at the clinic apatic,not active from 1 month, the appetite went down, dehydratated.

Exam:

Normal temperature

Blood test: light form of anemia, the biochemical part of the test was normal.

Ultrasound examination:

Ultrasonographic evaluation indicates the presence of cysts of varying size in the right kidney, as the body has lost its normal arhistructure.

Single cyst in the left kidney associated with renal pelvis;

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Right kidney

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Cyst of the right kidney

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Right Adrenal Gland

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Right Adrenal Gland

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Left kidney

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Left Adrenal Gland

Adrenal glands –without changes.

Treatment:

Fluid therapy and NSAID

TREATMENT OF A RETROPERITONEAL ABSCESS BY OMENTALIZATION IN AN ORANGUTAN (PONGO PYGMAEUS PYGMAEUS

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Norin Chai, DVM., MSc., MSc.V., PhD, Dipl. ECZM (ZHM)

 

Norin Chai, DVM., MSc., MSc.V., PhD, Dipl. ECZM (ZHM)

Clinical case

 

A 38-yr-old female wild-born Bornean orangutan (Pongo pygmaeus pygmaeus) with no major clinical problems, presented with chronic lethargy and difficulty in locomotion. The animal was housed at the Me´nagerie du Jardin des Plantes- National Museum of Natural History (Paris, France) with two males and two females, all captive-born. The orangutan developed mild lethargy, anorexia, and at times, mental deficits. Clinical signs progressed from weakness and less frequent ambulation to permanent dorsal recumbency, lateral recumbency, or both.

On day 1, 1 wk after the onset of clinical signs, the orangutan was immobilized with 300 mg of ketamine hydrochloride (4.8 mg/kg i.m.) by Blow dart. Anesthesia was maintained by intermittent supplemental boluses of 200 mg of ketamine every 20 min (3.2 mg/kg i.v.). A constant slow rate infusion intravenously of 0.9% NaCl was administered.

The orangutan’s respiratory rate, heart rate, and pulse oximetry were monitored with a hand-held pulse oximeter. Physical examination and palpation revealed a mild chronic periodontal disease and a left retroperitoneal mass. Hematology, serum biochemistries, thyroid panel, and transthoracic echocardiogram were within normal limits. Serologic titers for herpes simplex type II, herpes B, and herpes SA8; human and simian immunodeficiency; measles; and rubella were negative. Lateral and ventrodorsal abdominal radiographs demonstrated no clear and remarkable lesion other than mild arthrosis on the lumbar vertebras.

blood sampling

TREATMENT OF A RETROPERITONEAL ABSCESS BY OMENTALIZATION IN AN ORANGUTAN (PONGO PYGMAEUS PYGMAEUS)

Abdominal ultrasonography revealed a mass composed by two hypoechogenic cavities with regular margins compatible with a 12-cm X 8-cm X 8-cm left retroperitoneal abscess, cranial and dorsal to the bladder. Guided by ultrasonography, aspirate from the fluid pocket resulted in the collection of purulent liquid. A cytology examination of the fluid revealed high cellularity, with an inflammatory cell population composed entirely of neutrophils and a heterogeneous bacterial population composed of high numbers of cocci and bacilli, often observed intracellularly.

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TREATMENT OF A RETROPERITONEAL ABSCESS BY OMENTALIZATION IN AN ORANGUTAN (PONGO PYGMAEUS PYGMAEUS)

The specimen was sent for bacterial culture and sensitivity. On the basis of these findings, a diagnosis of a retroperitoneal abscess, pyometra, or both was made. The animal received 40 mg of meloxicam (0.64 mg/kg s.c.). An exploratory laparotomy revealed a normal uterus, a retroperitoneal abscess, and enlarged lymph nodes. The abscess was adhered to the bladder, the mesentery, and the soft tissues adjacent to the mass. The mass ruptured upon handling, thus releasing a substantial quantity of pus into the abdominal cavity. The abdominal and abscess cavities were drained using surgical suction. The volume of pus was estimated to be approximately 500 ml. The site was initially rinsed with sterile 0.9% NaCl. Suction was used to evacuate the fluid, and the process was repeated several times. In addition, 800 mg of gentamicin (12.8 mg/kg) was then poured into the abdominal cavity and evenly distributed. Digital exploration of the abscess revealed a ramification close to the vertebral canal.A lumbar-sacral fistulization was suspected. Because of the difficulty separating the abscess from its attachments, only a small portion of the visible membrane was removed. Two bacterial species were cultured from the initial ultrasoundguided aspirate of purulent fluid: Streptococcus and Escherichia coli. Both of these organisms were susceptible to cephalosporins and fluoroquinolones. Histologic examination of the membrane confirmed an inflammatory component rather than a neoplastic process.

The decision was made to create a physiologic drain of the abscess with a functioning omental flap, as described previously in humans, dogs and cats. The remaining abscess cavity was then packed with omentum. The omentum was attached to the abscess membrane with two simple large sutures by using an absorbable suture material. The abdominal wall was closed in two layers (peritoneum and muscular layers) with a continuous suture pattern by using a monofilament nonabsorbable suture material. The skin was closed by a hypodermic running suture, and a simple interrupted suture pattern by using an absorbable suture material. After completion of the surgery, and while still immobilized, the animal was administered 40 mg of meloxicam (0.64 mg/kg s.c.) and 5 ml of a solution containing ascorbic acid, thiamine, pyridoxine, and niacin (Nutra B, Fort Dodge; 0.2 ml/kg i.m.). Systemic antibiotics were administered via injection and include 560 mg of cefovecin (8.58 mg/kg s.c.) and 540 mg of danofloxacine (8.28 mg/kg s.c.). In total, 1,200 mg of ketamine had been administrated to the orangutan to achieve a 125-min period of anaesthesia. The total surgical time was 50 min, and recovery was uneventful and rapid. The animal was placed in its enclosure in lateral recumbency. Forty-five minutes after the last ketamine bolus, the animal demonstrated normal activity and was moving and sitting. A postsurgical analgesia treatment was initiated with 45 mg of meloxicam (0.69 mg/kg p.o., s.i.d. for 5 days.

In humans, retroperitoneal abscesses are not common clinical conditions. The causes of retroperitoneal abscesses include psoas abscess, necrotizing fasciitis, pancreatitis, perforated acute appendicitis, and duodenal diverticulum perforation. The abscesses are often diagnosed by a computed tomography scan. Draining of the abscess without any surgery may be sufficient in some cases, such as a psoas abscess. However, in rare cases, retroperitoneal abscesses may be lethal, even after surgical drainage. In both dogs and cats, retroperitoneal abscesses are usually unilateral. They can be associated with trauma, infection, and depositions of foreign material during surgical procedures and urinary extravasation. In this report, culture isolation of Streptococcus and E. coli suggests that infection was consistent with an ascending bacterial infection from the lower urinary tract, reproductive system, or digestive system. However, no cultures of other organs or fluids were performed to attempt to localize the source of infection. Actually, omentalization is considered to be the treatment of choice for prostatic and pancreatic abscesses in dogs as well as for large and chronic nonhealing wounds, uterine abscesses, and idiopathic chylothorax in a cat. The omentum contains aggregates of blind lymphoid capillaries that provide lymphatic drainage of the peritoneal cavity.  This treatment has not been reported previously in orangutans. Omentalization was successful in providing a continuous method of fluid drainage for this retroperitoneal abscess, with minimal requirement for postoperative procedures of the animal.

Fibrocartilagenous embolic myelopathy

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Dr. Ionuţ Alexandru Ciupercă, CCRP, CVA (IVAS)

Dr. Ionuţ Alexandru Ciupercă, CCRP, CVA (IVAS)

VetPhysioCenter Bucureşti

Email: ionut@vetcenter.ro

Fibrocartilagenous embolism it is a spinal cord infarction caused by a vascular emboli, presumed to be fibrocartilage. It may produce bilateral or unilateral signs and can happen anywhere in the spinal cord, the thoraco-lumbar region being the most common. Usually it has a sudden onset and a full development in 12 hours. There are 50% chance of spontaneous recovery if it shows signs of improvement within the first week.

It is a nonpainful acute disease, seen only in nonchondrodystrophic breeds. It is very important to differentiate from the intervertebral disk disease, either protrusion or extrusion. This condition is less common in small dogs or cats. Any region of the spinal cord may be affected, and the spinal cord segments dictate the specific neurologic deficits. Very common are also asymmetric or unilateral signs. Also, ataxia, paresis or paralysis may affect all limbs or only pelvic limbs. There can be a loss of deep pain sensation caudal to the lesion.

Diagnosis is based on the clinical picture and by exclusion of other possible causes. The most important clues are the signalment, the acute onset, the stationary course of the disease and the absence of pain. The differential diagnosis include intervertebral disk disease, trauma, neoplasia and inflammatory disease. The best imaging modality is the MRI showing usually signal changes suggestive of focal spinal cord infraction.

There isn’t any specific treatment for this condition even though corticosteroids are used, but there is a lack of scientific evidence that they might work. Physical therapy and nursing care are the most beneficial treatment modalities to use; about 85% of the patients recover, depending of the severity of the lesions (De Risio and others, 2007).

Sara - assisted walking

Sara-assiced walking

Sara it is a 2 years old intact female Labrador retriever with a sudden onset of paraplegia; the disease started with a lameness of the left hind leg, then with a proprioceptive ataxia and in 2 hours she was already paraplegic.

Sara X-ray

Sara X-Ray

Sara MRI

Sara MRI

Sara did an MRI immediately which revealed a unique hyper signal medullary lesion of about 3 centimeters localized at the level of L2-L3 intervertebral disk. The lesion was consistent with a vascular disorder caused by a fibrocartilagenous emboli.

Sara started a therapy with corticosteroids for a week and also vitamins and antioxidants. The second day after the incident she started also rehabilitation.

At the first visit the patient was paraplegic with no deep pain sensation and also incontinent. The spinal reflexes were present and normal and the cutaneous trunci reflex was lost at the level of L3 – L4.

Sara on ground treadmill

Sara on ground treadmill

For the first sessions she did transcutaneous electrical nerve stimulation for 30 minutes followed by   class IV laser therapy, 8 – 10 joules per square centimeter. After that modalities we started static balance exercises on the peanut shaped physio roll and reflex exercises on the proprioceptive plate. We introduced also the underwater treadmill but she was not able to move the hind legs.

For the home exercises we recommended to the owners to perform passive range of motion exercises and assisted standing followed by weight shifting exercises, 2-3 times a day; also, we instructed them to try the flexor – reflex exercise.

Sara - therabands on ground treadmill

Sara – therabands on ground treadmill

The sessions were performed twice a week and after 10 days she was already able to maintain the standing position on her own, and also started to show some motion in the hind legs. After 5 sessions she started to perform walking in the underwater treadmill; for the home exercise we instructed the owners to start with assisted walking exercise and more weight shifting and balance exercises.

After 6 sessions she became ambulatory but with severe proprioceptive and motor deficits, so we introduced also ground treadmill with incline and then with resistive elastic bands. We increased the time spend in the underwater treadmill up to 25 minutes and also, gradually, we introduced cavaletti rails and weave polls exercise.

For the home program she had to walk assisted on inclines, on stairs, on sand and grass, and also to start sit-to-stand exercises.

Sara - underwater treadmill

Sara – underwater treadmill

After 12 sessions, Sara is now ambulatory with mild proprioceptive deficit on the left hind leg at walking, and a little bit more uncoordinated at trotting and turning. The strengthening exercises were increased with more resistive elastic bands on the ground treadmill and with more speed on the inclines, and of course with higher speed and lower water in the underwater treadmill.

She is still doing rehabilitation because we need to correct all the proprioceptive deficit, as much as possible, and also to increase the muscle mass in the hind legs. We are also very happy because during the rehabilitation we were able to reduce her weight with 6 kilograms, from a body condition score of 8 out of 10 to a 6 / 10.

References:

  1. Bockstahler, Barbara; Levine, D.; Millis, D. “Essential Facts of Physiotherapy in Dogs and Cats. Rehabilitation and Pain Management”  –  2004
  2. Millis D.L.; Levine D. “Canine Rehabilitation and Physical Therapy” 2nd; Elsevier, 2014

Treatment of uterine leiomyoma , Case report

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Dr Miroslav Todorov Blue Cross Small Animal Veterinary Clinic , Sofia, Bulgaria

Uterine tumors consist of 0.3 to 0.4% of all canine tumors. Leiomyomas and leiomyosarcomas are the most common, accounting for approximately 90% and 10%  respectively. These are tumors which arise from smooth muscle cells. The gastrointestinal tract is most commonly affected, but these tumors could affect also the genitourinary tract, the spleen, the liver and the subcutaneous tissue.

The etiology of uterine tumors is still unknown. Mutations of the fibroid-type mediator subcomplex 12 gene (MED12) have been found in a few canine genital leiomyomas but the role of these mutations in uterine tumors is unknown. Canine uterine leiomyomas may be hormone-dependent, as this appears true in humans and in the case of canine vaginal/vulvar leiomyomas.

Uterine tumors can be clinically silent for a long period of time. Intact females may exhibit abnormal estrous cycles, with or without vaginal discharge. Dogs with uterine neoplasia may be infertile. Stranguria, dysuria and or constipation may occur secondary to physical obstruction by the mass. Abdominal distention, with or without a palpable abdominal mass, may be detected. Nonspecific signs of anorexia, lethargy, depression, weight loss, polydipsia, polyuria and vomiting may also be present. Some of these signs may be related to concurrent pyometra within the abnormal uterus.

Paraneoplastic syndromes associated with these tumors (more often with gastrointestinal location) are hypoglycaemia, diabetes incipidus and secondary erthyrocytosis.

Case history:

A  6 year old huskey, female intact was presented with complaints that it hasn’t been able to defecate normally for about a week. The dog was anorexic and during the last 2 days it started vomiting.

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Blood test

Clinical examination: The dog was in a depressive state, with normal temperature – 38,6˚C. The dog felt discomfort after abdominal palpation. The heart and lung sounds were normal. After examination of the genital area pale secretions from the vulva were discovered.

We took blood for blood count, biochemistry analysis and heartworm testing. The results on the blood count were WNL. From the biochemistry there were only increased numbers of ALAT – 116,9(5 – 60) IU and ASAT – 244.8 (5 – 55)IU. (fig.1) Heartworm – negative.

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x-ray

An X-ray of the dog’s abdomen was taken and a large mass located at the caudal part of the abdomen was discovered(fig.). This mass was compressing the urinary bladder, and the small and large intestines. The rectum was empty. After that we did an ultrasound of the abdomen and we found that this is a solitary mass, with hyperechoic density. Before going to surgery we took another X-ray of the thorax – everything was normal.

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Fig .3

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Fig. 4

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Fig.6

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Fig 7

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Fig. 5

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Fig.8

The dog was put under general anaesthesia and diagnostic medial laparotomy was performed. A large mass, coming from the uterine cervical area, was discovered. This mass was connected with the rectum and the urinary bladder (fig.3;4)The surgery from the begging started as normal ovariohysterectomy. The two ovaries were visualised and a ligature was placed on around the suspensory ligament and the vessels of the ovaries within the broad ligament and after that the uterus was separated from the mesometrium. When we reached the mass, we started to bluntly dissect the mass from the urinary bladder and the rectum. We managed to remove the mass from the rectum without complications. We separated the urinary bladder and about 3 cm of the urethra (fig.5). We did one linear cut of the proximal part of the mass – about 1-1,5 cm away from the urethra. This was tissue that was covering the tumor and when we opened a hole in it the neoplastic lesion was accessible for removal (fig.6). Slowly we separated the tumor from the rest of the tissues and we put a circular suture around the remnant vaginal tissue.Additionally we put several simple interrupted sutures of the same structures and at the end we managed to close the defect (fig.7 and 8).

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Fig. 9

After that the area was cleaned with saline and the surgery was finished in a standard way.

 

 

The removed mass was with size 27/14 cm and weight of 1,3 kg. This is the biggest uterine mass removed at this point at my practice (fig.9). The mass was sent to a foreign laboratory for histology (fig.10). The results were consistent with Leiomyoma.

 

The only complication during the postoperative period was urinary incontinence. We treat this with Propalin(Phenylpropanolamine) but to this point the dog didn’t respond and is still incontinent. During the last conversation with the owner we discussed control check-up and additional treatment plans for the incontinence.

Leiomyomas are benign tumors that comprise 85-90% of all canine uterine tumors.2 They tend to be slow growing, noninvasive, and do not metastasize.Usually  an ovariohysterectomy is curative.

 

 

 

 

The mesenchymal stem cells therapy in veterinary practice. Current opportunities and limitations.

Dr Peter Eftimov

General information

Mesenchymal stem cells (MSC) are multipotent stromal cells that can differentiate into a variety of cell types, including osteoblasts, chondrocytes, and adipocytes. There are evidences that MSC can be differentiated into oligodendrocyte and dopaminergic neurons, with further clinical applications.

Because the cells, called MSCs by many labs today, can encompass multipotent cells derived from other non-marrow tissues, such as umbilical cord blood, adipose tissue, adult muscle, corneal stroma or the dental pulp of deciduous baby teeth, yet do not have the capacity to reconstitute an entire organ, the term Multipotent Stromal Cell has been proposed as a better replacement.

The International Society for Cellular Therapy has provided the following minimum criteria for defining multipotent human mesenchymal stromal cells:

1) plastic-adherent under standard culture conditions;

2) positive for expression of CD105, CD73, and CD90, and absent for expression of hematopoietic cell surface markers CD34, CD45, CD11a, CD19, and HLA-DR;

3) under specific stimulus, cells should differentiate into osteocytes, adipocytes, and chondrocytes in vitro.

Case reports

Treatment of severe osteoarthritis in 12 years old German sheperd dog vie celluar-substitution therapy with Mesenchymal Stem Cells 

Duc, 12 years old German Shepard was presented at the clinic with progressive lameness of the pelvic limbs, which deteriorates in cold days, exercise intolerance and signs of severe pain. He was treated for over a year with NSAID (including selective COX-2 inhibitors), combined with food supplements. The treatment didn’t succeed to alleviate symptoms – in fact, when presented at clinic the patient barely could move his legs and have impaired urinary function.

After confirming the diagnosis with a radiographic examination (fig.1), and taking into account the age of the animal, we decided to attempt cellular-based treatment using adipose derived MSCs, rather than total hip replacement.

Biopsy of approximately 20 grams subcutaneous fat was taken and MSCs (CD44+, CD90+, CD105+) were derived, following standard protocol. After two passages they reached target concentration of 3.106cells/ml and were applied intra-articulary  in both coxofemoral joints. Pain alleviation with sub second improvement of the gait was observed 6 days after treatment, and 4 weeks after application of the MSC the dog tolerates long walks (over 40 minutes) and doesn’t show any signs of pain.

Six months after the procedure, Duc visited us again this time with progressive osteoarthritic changes in both elbows and cauda equina syndrome (fig. 2).   Another course of cell-based treatment was suggested – via intravenous infusion of stem cells, but the owner preferred topical treatment with hyaluronic acid. It was applied in both elbow joints, but after mild improvement Duc condition deteriorates (lameness with thoracic limbs, urinary incontinention, severe pain and loss of appetite) and after another 3 months he was euthanized.

It is remarkable that he never experienced pain in hip joints after MSC treatment. That fact and the fast recovery after first intervention were highly appreciated by the owner, but the relatively high cost of the cellular therapy, prevented him for taking the decision for another procedure

Treatment of chronic kidney disease (CKD) in a dog and in a cat

1. Treatment of 5 years old male dog with CKD

Lucky is a 5 years old miniature Poodle was presented in deteriorated condition with ongoing conservative treatment of CKD stage 3 (according to IRIS classification) After ultrasound examination we decided to include him in the program for MSC treatment.

Biopsy was performed and MSC were isolated and cultured to the therapeutic concentration (2*106 cells/ml).

Due to his severe condition cells were applied intravenously (to avoid general anesthesia risk). After initial improvement, Lucky deteriorated and discontinued food intake. Another procedure was made and this time cells were administered intra-renaly under the ultrasound guidance. Prior to that, he was subjected to a peritoneal dialysis, in order to diminish the levels of toxic metabolites. Unfortunately, no definitive improvement was observed and shortly after the procedure, the owners took decision to euthanize Lucky

2. Treatment of 14 years old male cat with CKD

Macho, 14 years old cat, was presented with typical signs of CKD (weight loss, decreasing of the appetite, polydipsia and polyuria). He was subjected to a peritoneal dialysis one year ago, after deterioration of his condition and since then was on a standard protocol for treatment of CKD i.e., nutritional supplementation and special diet.

After initial examination ,a biopsy of subcutaneous adipose tissuewas taken, and MSC were isololated and prepared for intra-renal application,which was made under ultrasound guidance.The improvement was quick and stable- the cat regained his appetite, and the values of creatinine measured after the procedure continues to decrease.

We work on a second case of a cat with CKD now.

Treatment of n.radialis paralysis in a cat.

Naida was found on the street and brought to our clinic with a dull trauma of  the abdomen, elbow bent low, curved dorsal paw and inability to stepping on his front right leg. Following the screening, we found lack of surface sensitivity on the rostral surface of the limb and lack of deep sensitivity. Our working diagnosis was trauma to the radial nerve. The condition is more common in dogs than in cats and is often the consequence of a hit by a car or falling from above. After considering other options as carpal arthrodesis, amputation or transposition of n.ulnaris we chose to start a procedure of MSC treatment.

Following the standard procedure, a biopsy from the abdominal adiposal tissue was taken and MSC were isolated and cultured. A highly concentrated stem cells isolate was injected into the perineural space of n. radialis.

Two weeks after implantation of mesenchymal stem cells we observed (although minimal) surface and deep sensation in the affected limb. Najda began to flex her elbow, indicating recovery of n. musculocutaneus.

 

Atypical ocular manifestation of Angiostrongylus vasorum infection in 6month old Boxer

Dr. Stefan Savov DVM , MRCVS

Ambleside Veterinary Center,first oppinion practice Walton 11287136_10152849621381373_100308255_non Thames, Unided Kingdom

 Inroduction:

Angiostrongylus vasorum(lungworm) is nematode parasite of the pulmonary arteries and right heart of dogs and wild carnivories. The geographic distribution of the parasite includes various countries of Europe, North and South America as well as Africa. The parasite appears to be quite common in well-isolate endemic foci as the South East of England. One of the hot-spots is Surrey, South West of London. Prophylaxis of the parasite in this regions is achieved using various combinations of antiparasitic tablets and/or spot-on products.

In the literature ocular manifestation of the lungworm invasion include inflamation of the posterior segment (uveitis) with or without retinal detachment and/or retinal hemorrhages. Usually the clinical manifestations is bilateral. As a consequence the vision is impaired. G.Payne also reports anterior uveitis with parasite larvae in the anterior chamber.

History:

Female 6 month old Boxer presented to the clinic with three days history of sudden blindness. The owner is the breeder of the dog. The mother of the dog has never been tested for hereditary eye diseases. Last treatment for fleas and worms was 4 month ago with Frontline spot on (Merial) and Drontal plus tablets (Bayer). The dog was in an excellent general condition at the time of the consultation.

Clinical findings:

The dog was examined using a Protable Slit Lamp (HSL-P1), Tonopen (Medronic Solan) and Tonovet (ICare), Direct Ophtalmoscope (Heine omega 200), in dim light enviorment. The dog was bumping into objects and the right eye(OD) was mildy buphthalmic. Pupillary light reflex, Dazzel and Menace reflexeswere missing completely. OD had severe scleral congestion and corneal edema. The intreocular pressure (IOP) was 29 mm/Hg OD and 23mm/Hg OS respectively. Flare was +1and the vitreous was visible in the anterior chamber. The posterior segment was difficult to evaluate. By retro-illuminationwas found ventral posterior subluxation of the lens and normal size, non-reactive pupil(fig.1). The left eye (OS) was free of corneal oedema and easier to evalute (fig.2). The iris was midriatic with normal color. Was observed dorsal posterior lens subluxation and a large amount of vitreous in the anterior chamber. The retina had a slightly blurry appearance. The optic nerve head ( ONH) was in intensive pink color,blurry and oedematous. Was not find evidencefor cupping of the ONH. Gonioscopy was performed of the OS. The iridocorneal anglewas occluded with prolapsed vitreous.

The dog was diagnosed with secondary glaucoma, posterior lens dislocation, posterior uveitis and possible optic neuritis.

Discussion:

Due to the mix clinical signs,fast and definitive diagnose was a challenge. The glaucoma was definitely a consequence of severe vireous herniationinto the anterior chamber. The dog owner reported frequent wild games with severe shaking of the head. The dynamic force created in the inner eyes fluids combined with weakness of the ciliaryzonular fibres could explain the sudden belateral lens and vitreous dislocations. The investigations were focused on finding possible systemic diseases that would correspond with ocular clinical signs. The hematology profile showed mild regenerative anaemia and the biochemistry was unremarkable. The PCR tests for Ehrlichiosis, Anaplasmosis, Hepatozoon canis and Babesia were negative. Most of the diseases are not edemic in the South East of England and normaly appear as imported disease. The geographic position and the age of the dog combined with the inappropriate prophylactic program lead logically to serology testing for Angiostrongylus vasorum (fig 3) . The number of the larvae on the slides was significantly high.

The initial treatment plan includes an ugrent reduction of the high ocular pressure (IOP). Cosopt (Dorzolamide 20mg/mland Timol 5mg/ml) was chosen for the purpose. In this case Prostaglandine analogues, like Latanoprost, were avoided because of the possible pupillary block from the herniated vitreous. Prostaglandines also could deteriorate the uveitis. Oral Prednisolone tablets 1mg/kg, and Febendazole 1mg /kg were include in the treatment. On the follow ups, 2nd, 7th and 14th day after the initial diagnosethe IOP remained low and stable. The clinical sighs of uveitis disappeared. One week after the initial consultaion retinal hyper-reflectivity was observed. EGR and vitrectomy were not performeddue to the financial constrains of the owner. Unfortunately the vision did nor recover. It is questionable whether the blindness was caused from the higher IOP or from the inflamation of the optic nerve.

Conclusion:

Posterior uveitis is well described in the literature as a clinical sign of lungworm infection. Secondary glaucoma is not described as a complication of the disease. The predisposing factors in this case are lack of appropriate parasite prophylaxis, the silent systemic clinical picture and the frequent games involving head shaking. Angyostrongilus vasorum infection could be included in the differential diagnosis pattern for secondary glaucoma.

fig.3

fig.2

fig.2

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