HYPERPHOPSPHATEMIA: DIET AND PHOSPHATE BINDERS

pharmacrSerum 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

kcmega3A 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.

 

 

New ‘European Stream’ at 2021 Virtual VMG-SPVS Congress

vmgThursday 13-Friday 14 May 2021

 

Veterinary professionals around the world with an interest in business, leadership and management are invited to join this year’s VMG-SPVS Congress, which will provide inspiration and the latest insights and learning from speakers from the UK, North America and Europe. New this year is a stream of lectures specifically for European veterinary professionals and chaired by Torill Mosent, Vice Chair of the Federation of Veterinarians of Europe and President of the Norwegian Veterinary Association.

 

The largest non-clinical veterinary conference in Europe, VMG-SPVS Congress offers state-of-the-art learning and development in all aspects of veterinary business, including financial planning, business strategy, HR and people management, marketing and sustainability.  Speakers this year include:

28/11/2019 A link in the chain: Tackling mental health, poverty and loneliness through pet ownership All Rights Reserved - Helen Yates- T: +44 (0)7790805960 Local copyright law applies to all print & online usage. Fees charged will comply with standard space rates and usage for that country, region or state.

28/11/2019
A link in the chain: Tackling mental health, poverty and loneliness through pet ownership
All Rights Reserved – Helen Yates- T: +44 (0)7790805960
Local copyright law applies to all print & online usage. Fees charged will comply with standard space rates and usage for that country, region or state.

  • US coach Katherine Eitel Belt, who will explore how the development of ‘courageous’, unscripted conversations with clients, colleagues and audiences can achieve extraordinary results.
  • Canadian social worker, Professor Angie Arora who will discuss ‘Veterinary social work – a new paradigm’. Angie was principal investigator in a research study to develop guidelines for veterinary teams to better support clients through their pets’ end of life.
  • David Giraldi, Managing Director of Vet Partners, Italy, who will discuss ‘Practice Consolidation: What Europe can learn from a mature veterinary market’.

 

All live sessions will feature a speaker Q&A and the opportunity to participate in polls. The virtual congress platform also offers delegates the opportunity to engage with other attendees and to browse the large online exhibition.

 

The full programme is available here with all lectures available to delegates for three months following congress so they can watch them at a convenient time.

 

Commenting, VMG President Rich Casey, said: “As VMG-SPVS Congress is virtual this year, it offers a fantastic opportunity for delegates to join us from Europe – or indeed – around the world, for two days of exciting, affordable and highly engaging learning.”

 

Anna Judson, SPVS President, said: “We are particularly excited to host our new ‘European stream’, this year.  The profession on the continent faces some specific challenges and we have brought together experts from across Europe to discuss them and offer potential strategies and solutions.”

 

Group tickets start at just GBP100 for access to the whole event – with discounts available for single ticket purchase for those who are VMG or SPVS members.

 

Click here to register.

General remarks on Chronic Kidney Disease (CKD)

ph cross 1                  Treatment of CKD aims at:

  • Improving both clinical condition and quality of life
  • Prolonging survival time
  • Slowing the progression of renal disease

Once chronic kidney disease has been diagnosed, it is recommended:

  1. Stop any drugs with certain or potential nephrotoxicity;
  2. Identify and treat any concurrent disease influencing renal function and determining renal damage. In some patients, other pathologic conditions (such as endocrinopathies) can make difficult either staging renal disease and setting an adequate therapy;
  3. Investigate all causes leading to renal damage and, if possible, treat it. Sometimes, a renal biopsy can be useful to evaluate histologic lesions; in case of proteinuria, results of renal biopsy can provide a specific diagnosis and therapy;
  4. To apply a conservative approach of clinical conditions associated to kidney failure such as metabolic, acid-base and electrolytic imbalances. Therapy is addressed to correct hydration and mineral disorders, acid-base alterations and nutritional impairments. Patients benefit from symptomatic treatment improving their quality of life although azotemia is not significantly modified as this is undoubtedly just one of the factors contributing to the clinical picture of renal patients.

As general recommendations, clinically stable dogs and cats affected from CKD should undergo a clinical examination and laboratory evaluations based on their IRIS stage (www.iris-kidney.com)

  • every 12 months in IRIS stage 1
  • every 6 months in IRIS stage 2
  • every 4 months in IRIS stage 3
  • every 6-8 weeks in IRIS stage 4

Clinical Evaluation– Other than general and particular clinical examination, a special attention goes to the nutritional condition of the patient, determined by body weight, Body Condition and Muscle Condition Score (available both for dogs and cats at WSAVA). Nutritional status of patients affected by CKD is related to risk of developing uremic crisis and mortality: bad nutritional condition is associated to higher risk of uremic crisis and mortality for renal related causes. Blood pressure is determined too and hypertensive patients are put under treatment.

Laboratory exams– Once CKD has been diagnosed, Veterinarian proceeds to request the laboratory exams useful to identify concurrent pathologies known to determine renal damage or the progression of kidney disease. After the initial evaluation of a complete blood count, biochemistry and urinalysis (included UPC) the Veterinarian will be requesting further exams based on patient’s laboratory results and clinical history such as exams for infectious disease, endocrinopathies, ect.

Below are IRIS stages and most common disorders by stage (modified from Polzin, 2006 and 2019)

 

Clinical signs IRIS stage
Polyuria/Polydipsia 1-4
Proteinuria 1-4
Hypertension 1-4*
Urinary infection 1-4
Hyperphosphatemia 2-4
Hypopotassemia 3-4
Anemia 3-4
Metabolic Acidosis 3-4
Anorexia and weight loss 3-4
Vomit 3-4
Dehydration 3-4

*although it is possible to identify hypertensive patients in any stage of the disease, the prevalence of hypertension increases with increasing of IRIS staging

 

 

 

Idiopathic Renal Hematuria in a mongrel dog

(case report)

 

PLAMENDr. Plamen M. Kirov, DVM, MVSc, MSc

Timisoara -Romania, and Sofia-Bulgaria

 

Introduction

 

Hematuria describes a condition in which is observed presence of blood in the urine. It could be a result of diseases of the urinary tract – kidney, ureter, urinary bladder, urethra; or by diseases of the genital tract – prostate, penis, prepuce, uterus, vagina, vestibule. It can be classified as: macroscopic (visible to the naked eye), or microscopic (increased number of RBC in the urine, observed during microscopic examination). In general, hematuria can be a result of multiple reasons, as follows [1]:

 

  • Urinary tract origin
    • Trauma
    • Urolithiasis
    • Neoplasia
    • Inflammations (UTI, etc.)
    • Parasites (Dioctophyma renale)
    • Coagulopathy (Warfarin intoxications, etc.)
    • Renal infarction
    • Renal pelvic hematoma
    • Vascular malformations
    • Kidney polycystic disease

 

  • Genital tract origin
    • Trauma, Neoplastic or Inflammatory diseases of the genital tract
    • Estrus
    • Subinvolution of placental sites

 

 

For Idiopathic Renal Hematuria, we speak when the origin of RBC in the urine cannot be associated with any of the above-enumerated reasons and is of a renal origin. It is a very rare condition, which occurs in middle and big-sized young dogs (younger than 5 years of age), occasionally has been observed in older dogs and cats. Microscopic IRH is found by incidence during urine microscopic exams when macroscopic one is observed by the owners and described as unusual darker coloration of the urine. The condition is mostly unilateral and can be periodic – with a period of no bleeding. Since there is a release of RBC into the urine, anemia can be present in ranges from none to severe. Further, we will take a look and discuss the available treatment options.

 

 

Clinical case

 

The dog was brought to me by his owner, who observed “Cola-like” coloration of the urine in the last 2-3 days. According to the owner’s description, there are no changes of the dog’s behavior and, according to him, the micturition is normal and does not cause discomfort.

 

The patient:

  • 3-year-old male mongrel dog
  • 25 kg BW, normal body score
  • Neutered when he was 8 months of age
  • Vaccinations up to date and according to the protocol
  • Living indoors
  • No data for traumas
  • No medications or treatments in the last 6 months

 

Physical examination

During the physical examination, no abnormalities were observed, body temperature, heart and respiratory rate, and blood pressure were in the normal ranges. No any tegument abnormalities or signs of traumas. Dog temperament was relaxed and friendly.

 

Clinical diagnostic tests

The CBC was normal, with an RBC count near the left border reference value. Tests for Babesiosis and Lyme disease were negative. A sterile probe of urine was collected by US-guided cystocentesis and examined. Urine-specific gravity was slightly elevated, presence of erythrocyte was confirmed by microscopic examination, microbiological culture was negative. Pigmenturia was excluded after centrifugation of the urine sample, which resulted in a clear separation between RBC (collected at the bottom of the test tube) and urine (supernatant).

The performed x-ray did not reveal any abnormalities (uroliths, tumors). The ultrasound examination did not result in any abnormalities in the urogenital tract – renal parenchyma was with normal structure.

Idiopathic Renal Hematuria was diagnosed by exclusion as a result of performed test procedures and obtained results.

Additional information about the diagnostic approaches for hematuria in dogs and cats can be found in [2]

 

 

 

 

 

 

Treatment options

For treating Idiopathic Renal Hematuria we have few options available, we could differentiate as:

 

  • Invasive. Surgical cauterization of both ureters before the urinary bladder, and observing which kidney is the bleeding one, sclerotization of the kidney with povidone-iodine and silver nitrate [3][4] [5]. This method can be used and for bilateral hematuria. For cases with unilateral bleeding leading to severe anemia, ureteronephrectomy is recommended [1]

 

Since the dog doesn’t present anemia and invasive methods are more complex for performance and maintenance, I have directed my decision towards a non-invasive treatment option.

 

  • Non-invasive. It was described that IRH results from elevated blood pressure inside the glomerular arterioles leading to their higher permeability for RBC. This was observed by multiple studies and reports and the effect of ACE2 inhibitors, especially Benazepril, over the arterioles in the renal glomerulus was demonstrated [6] [7] [8]. In addition, during my studies in FMV-Timisoara, I had the opportunity to observe the treatment of a hunting dog with IRH, using Benazepril with good results (Dr. Doru Morar, FMV-Timisoara).

 

The dog was treated with Benazepril in dose 0.40mg/kg per os every 24h. In the following days was observed visible reduction of the hematuria – by the owner’s account, urine coloration became normal. Repeated urinalysis revealed the persistent microscopic presence of RBC with a tendency of reduction during the time. Blood pressure was normal and without indications for hypotension during treatment.

 

 

Conclusion

Dogs diagnosed with IRH with absent to mild anemia can profit from treatment plan with ACE2 inhibitors – surgical methods are not widely available, are expensive, require hospitalization of the animals, and nephrectomy deteriorates the quality of life for young animals (in cases the IRH becomes bilateral this can lead to a negative outcome for the patient).

Olympic runner leads virtual run at BSAVA Congress

BSAVA-Logo-with-Strap-Blue-500WOlympic Athlete Laura Muir is helping host a virtual run at BSAVA Virtual Congress (25-27 March 2021) this year, to highlight the physical and mental health benefits of being active. She has made three inspirational videos to encourage delegates to step out for wellbeing.

 

As well as being a qualified vet, having studied at the University of Glasgow, Laura Muir is the British record holder over the 1500m, a five-time European Champion and is aiming to claim her first Olympic medal at the Tokyo Olympics this summer. She will be encouraging Congress delegates to put their best running feet forward during the three days of Congress.

 

Laura has made three illuminating videos to show how she has successfully balanced running with her veterinary studies, revealing the low points as well as the high points and how the key is to focus on the positives. In the videos Laura is interviewed by vet and runner Brian Faulkner who achieved the extraordinary feat of running 31 marathons in 31 days. Brian will also be speaking at Congress in the Lessons from Lockdown session on the Saturday.

bsva

“There are so many things in life you can’t control,” said Laura. “My own philosophy that keeps me going is ‘do the best that you can do’.  For students it’s about remembering all the hard work they’ve put in over the years. To get to where they are in vet school, is a huge achievement in itself.  For practitioners who perhaps have had a bad day, taking a moment to remember just how many animals they’ve helped might just keep that negative experience in context.”

 

Brian Faulkner agrees; drawing on his coaching experience, he refers to something he affectionately calls ‘bitch spay-ophobia’.  When students and colleagues become fearful that they may cause more harm than good he reminds them of the bigger picture and that the long-term benefits of performing such procedures are the very reason why many wanted to become vets in the first place.

 

Participants can support each other by posting details of their run or walk on the Congress platform in the Health and Wellbeing chat room. There are no set times or distance, and delegates are encouraged to take part at a pace, time and location that suits them. Prizes will be awarded for the best selfie taken and posted on Twitter or Instagram tagged #BSAVAVirtualRun .

 

For extra motivation runners will be able to join the BSAVA running community via the Health and Wellbeing chat room where they can pose questions for Laura and other runners and can share their own experiences and achievements.  Attendees can listen to the three motivating videos from Laura at the Health and Wellbeing stand in the exhibition, in which she speaks about Laura the athlete, Laura the vet and Laura the person.

 

“Whether you are a seasoned runner or have never broken out of a walk we are encouraging everyone to participate,” said BSAVA President Professor Ian Ramsey. “Becoming more active is beneficial to health and wellbeing in so many ways and we are hoping to inspire delegates to lace up their trainers, clock up some miles and feel the difference.”

 

It’s free to join the BSAVA Virtual Run and you can sign up  here.

 

BSAVA Run is part of a motivating range of wellbeing sessions at Congress this year: Keynote speakers Dr Ranj and Jenny Campbell drawing on their own experiences to emphasise the importance of wellbeing. In addition, delegates can exercise their bodies as well as their minds with yoga and some restorative meditation practices.

To register now visit https://www.bsavaevents.com/bsavacongress2021/en/page/home

For information on how to become a BSAVA member visit https://www.bsava.com/Membership/Member-categories

Suture material reactions: fistulas and granulomas. Review of several clinical cases

tetDr Tetiana Khramova

Veterinary Surgeon at Khramova STS Soft tissue surgery
 Kyiev, Ukraine

 

Complications on unabsorbable suture materials are not widespead in the countries where absorbable suture material or tissue sealing with electrocautery or Ligasure devices are used. But it’s still seen as a consequence of using unabsorbable multifilament suture material. It is considered, that such reactions arise because of lack of sterility during the surgery, and bacteria forming biofilms on the sutures as a result. As a reaction from the body granulomas form around the sutures and lately they might cause formation of fistulas. The most common surgeries when we can see such complications are bitch spays.

 

Periods of time, when fistula(s) form can be quite different. From my personal experience it can happen a cuople of weeks after the surgery, but it also happens as late as several years after spaying. The longest period in my practice was 10 years after the surgery.

 

The clinical appearance is usually typical: owners notice fistula(s) on the abdomen or lateral parts of the pet with exudate or pus. Rarely it can be just a painful skin inflammation on the flank without actually a fistula there. A lot of dogs demonstrate unwillingness to run and jump without any obvious lameness. Another clinical sign can be pollakiuria in the cases when granuloma forms around the uterus stump.

 

The tentative diagnosis can be made via clinical appearance. But in all the cases it’s mandatory to perform an ultrasound of the abdomen in order to check all the possible granulomas, that can be asymptomatic. The areas of interest during the ultrasound are caudal poles of the kidneys and uterus stump.  It’s quite important to check whether the ureters are involved in the granulomas, as it makes the case much more complicated. CT can be much more useful in checking the organ involvement and planning the surgery.

The fistula on the flank iscompletely resolved after surgery The granuloma adherent to the kidney. The omentum is also involved The granuloma and sutures inside

The СBСs are usually unremarcable or with signs of inflammation. In cases where granulomas have formed around the ureters the patient can show signs of azotemia (post-renal) and we will see high urea and creatinine in biochemistry panel.

 

The only possible option to treat the patient is surgical removal of the granulomas with the suture material inside or just the suture material from the ventral body wall. The therapeutic approach: using antimicrobials, flushing and draining the fistulas can help for some period of time, but then the problem will arise again.

The hydronephrotic kidney (caused by granuloma) The removed granuloma The suture material and the absess around it on the uterus stump (adherent with the bladder and intestines) The uterus stump adherent to the bladder The uterus stump granuloma on the ultrasound

The surgical approach to such cases is always the same: remove all the sutures from the body wall (often with a part of it in case of severe inflammation and thickening) and remove all the sutures and granulomas from the abdomen via middle-line laparotomy. Nevertheless, a lot of such surgeries are quite complicated because granulomas tend to be firmly connected with kidneys and it’s mandatory to remove them without injury of the kidneys. Another problem can be to free the ureter from the granuloma without breaking it or sometimes you have to reimplant them to the bladder or partly resect. It can be quite tricky to remove the granuloma from the uterus stump as they tend to be firmly connected with the dorsal part of the bladder. Sometimes other organs can be involved like omentum and intestines that leads to partial resection.

 

In severe cases you can observe hydronephrosis because of the mechanical compression of the ureter, and in such cases the kidney must be removed.

 

After removing granulomas it’s important to check whether all the suture material has been removed, and to flush and suture the peritoneum. The actual absesses around the sutures are quite rare.

 

After closing the abdomen don’t forget to check and flush and maybe drain if nessesary all the fistulas.  If you have removed all the implants, the fistulas will resolve in about a week.

 

The prognisis in such cases depends on how much all the other organs (kidneys, ureters, bladder) are involved in granulomas, so it can vary from excellent to grave.

 

Short term result after Integrated Tanscutaneous Amputee Prosthesis for hock joint neoplasia

1575875879547blobCorresponding author:

Dr. Vladislav Zlatinov

Central Vet Clinic – Sofia

E-mail: doctorzlatinov@gmail.com

 

 

 

 

Introduction

 zl 1

Synovial cell sarcoma is the most common joint tumor in dogs. It is a malignant neoplasm arising from mesenchymal cells outside the synovial membrane of joints and bursas1 . In dogs, synovial cell sarcomas usually occur in large breeds, with a predisposition for flat-coated and golden retrievers1,2 . Middle-aged dogs are most commonly affected, and there is no sex predilection. Synovial cell sarcomas usually involve the larger joints, but any joint can be affected.

Other joint tumors reported in dogs include fibrosarcoma, myxoma, malignant giant cell tumor of soft tissue and others. Recently, histiocytic sarcomas have been reported in the periarticular tissue of large appendicular joints3 .

Synovial cell sarcomas are locally aggressive with a moderate-to-high metastatic potential, depending on histologic grade. The average survival time with SCS is around 30 months, which is significantly better prognosis compared to the most common canine neoplasia- osteosarcoma.

 

Limb amputation is recommended for treatment of the SCS tumor because local recurrence is significantly lower compared to marginal resection.

In the recent years, an amputation alternative- limb sparing procedure, was developed. The first animal case (2008) with integrated prosthesis included bilateral tibial stem implantation4. The more recent procedure ITAP (Integrated Tanscutaneous Amputee Prosthesis)-Stanmore Implants Worldwide Ltd, UK, is demanding technique that consists of low limb amputation and  metal stem medullary canal insertion, aiming long term bone-implant integration. Suggested period for this integration has been suggested to be 6 weeks5. This is the most vulnerable period that demands high degree of implant stability, allowing bone tissue ingrowth into the implant micropores.  Once stable implant- stem fixation occurs, an external limb prosthesis attachment gives the opportunity for weight baring and some degree of limb functional recovery.

 

 

 

 

Abstract

 

This case report presents the short term functional result after application of ITAP technique in a five years old golden retriever. The dog’s tarsal joint was affected by synovial sarcoma. Custom manufactured implant with rigid locking plate fixation was developed. The goal of the implant design was solid fixation allowance of immediate weight baring, even before the stem integration. The follow up period of the case is 3 months post operatively. The patient revealed very good pain free limb function, starting almost immediately after the amputation.

 

Case report

 

A 5 years old male Golden retriever dog, weighting 39 kg was presented at Central Vet Clinic – Sofia. The owner reported low grade lameness with the left hind leg, lasting for more than one month and badly responding to NSAIDs.

 

 

Clinical examination

 

We did a thorough clinical exam, revealing normal over-all condition, moderate obese body score, choleric temperament. We found mild (II/IV) left hind leg weight baring lameness. Thickening of the left hock joint was noticed. Mildy decreased ROM with mild pain were appreciated in the affected joint.

 

 

Diagnostics

v5

Orthogonal radiographs of the left hock revealed diffuse intrinsic joint swelling. We found aggressive bone lysis areas (mostly severe at distal fibula)  and moderate aggressive periosteal reaction (mostly affecting the tarsal bones). No abnormalities were detected on preoperative 3-view thoracic radiographs, abdominal ultrasound, echocardiography, and blood tests.

 

Fine- needle aspirates were taken. Cytology revealed numerous clusters of plump, oval to spindloid cells often with moderate cellular atypia. Considering this , the signalment and the imaging findings, a diagnosis of joint sarcoma was suggested.

 

A decision for limb sparing surgery by low trans-tibial amputation and integrated limb prosthesis (ITAP) was made.

 

Implant planing and manufacturing

 

A cusv 1tom-made ITAP implant was manufactured using CNC machinery with additional welding process. Medical titanium (grade 4) was used for the production. The implant desired shape and size of the was predetermined using only radiographs. The straight shape and straight medullary canal made the design simple enough, so no necessity for  computer tomography imaging and planning was found.  The ITAP implant components included a 7 mm (rough surface) intramedulary stem, 3, 5 mm locking plate part, drilled titanium collar (flange) and most distally smooth 8 mm titanium rod (outside part). Locking 4 mm screws were produced corresponding to the plate locking mechanism.

 

A custom made exoprostheis was manufactured using combination of plastic polymer, rubber and metal elements. The length was conformed (with mild underestimation) to the natural foot size. Angulation of 135 degree of was planned to mimic the natural hock joint position. Shock absorbing (spring) design was developed.

 

Comment:

The titanium flange role is the reduction of epithelial downgrowth and good soft-tissue integration.

Anesthetic protocol

 

Premedication with Medetomidine and Butorphanol was used, followed by Propofol induction. The maintenance was sustained by Isoflurane and Ketamin drop in the fluid sack. Epidural block with Ropivacaine was provided just before the surgery.

 

Cimicoxib (Cimalgex) was prescribed for 7 days post op. No opioids were used in the recovery period.

 

 

Surgical technique

 

For the surgical intervention, the dog was positioned in dorsal recumbency. After macroscopic evaluation, transverse sharp dissection of  soft tissues, covering the distal tibial dyapihis was done. Four centimetres distance proximally from the edge of the tarsal lump was aimed. Muscles tendons (including common calcaneal tendon) were severed. A strict haemostasis by electrocautery and ligation of the main blood vessels was achieved. Minimally invasive approach (bone tunnelling) was used for the insertion of the plate element under the soft tissue on the medial side. Mild contouring of the proximal plate part was needed to fit the tibia shape. No canal drilling was needed- the stem part was impacted quite easily into the soft bone marrow tissue. Gentle axial hammering ensured good bone to flange contact.

Muscle tendons and crural fascia free ends were sutured to the special designed flange holes. After gentle subcutaneous fat debridement the skin edges were sutured over the flange surface. Special attention was emphasised so the circular skin defect was closed with an “appropriate” tension- no skin abundance, but also with no excessive tension on the stitches.

v4

 

 

Immediate post op care

 

Preventive antibiotic therapy (Amoxcillin calvulonic acid) and NSAIDs (Cimalgex) was prescribed for 7 days

 

A Modified Robert Jones bandage was applied over the amputee stump. The bandage was removed after three days and the exoprosthesis was attached, with similar soft bandage applied around the stump.

 

 

Strict cage rest with very short leash walks was emphasised in the immediate post op period.

 

A recheck radiograph at six weeks post op demonstrated solidly homogenous bone-implant contact area, suggesting osteointegration in process.

 

 

 

 

 

 

 

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Pathohistology diagnosis

 

“Moderate differentiated synovial cell sarcoma.”

 

Atypical spindle shaped cells with indistinct borders and variable amounts of eosinophilic fibrillar cytoplasm and stroma. The long term prognosis is good but still variable.

 

 

 

 

 

Functional result

 

The dog revealed very good comfort after the procedure, with immediate weight baring. Light protective bandage was used to cover the distal stump area and prosthesis for two months post op. The followed period (within 3 months) revealed very fast and pain free limb usage with milld lameness (II/V)

 

Leash walk 6 day  post op.

 

 

Going for a walk 14 day  post op.

 

2 months  post op

 

 

 

3 months  post op

 

CONCLUSION

 

Locking plate ITAP design can provide adequate stability needed for implant osteointegration, while early limb usage is allowed. The role of shock absorbing exoprosthesis for success is unclear. This fast functional recovery can make the ITAP procedure more attractive and better accepted by the owners of pets that need similar limb sparing surgeries. Further investigations may demonstrate ITAP complications variabilities (ratio) and long term results.

 

 

Transient Postural Vestibulo-Cerebellar Syndrome Case report

svet penDr Svetoslvav Penchev

United Veterinary Clinic

Varna, Bulgaria

 

 

Transient Postural Vestibulo-Cerebellar Syndrome is a condition that present as pronounced vestibulo-cerebellar signs. In this  syndrome transient postural symptoms present as  vestibulo-cerebellar signs after altering the position of the head.Vestibular deficits related to head posture have been described, introducing the relationship of nodulus and uvula pathology to various vestibular signs elicited by the postural changes of the head.

 

 

Case report:

 

Signalment: Adopted from a shelter mix breed female dog without previous history.The age of the dog was estimated to be 7-8 months based on general appearance and teeth condition.

 

 

Case presenting sings: Vestibular episodes during sniffing and eating or head position changing(Transient vestibular signs as vertigo and nystagmus  caused by changing the posture of the head). Symptoms are not progressive.

 

Clinical examination: Good overall condition ; Internal body temperature- 38,9; Normal respiratory and heart rate; Color of mucous membranes – pink; CRT – 1,5 sec.

 

Neurological examination:

 

Mentation: Normal

Behavior: Normal

Gait: Normal( no signs of cerebellar ataxia when the dog plays or runs)

Cranial nerves: normal

There was no change in conscious proprioception and bladder function was normal.

Spinal reflexes were normal.

 

Neuroanatomic localisation: Vestibulocerebellum

 

Differential diagnosis: Idiopatic/Anomaly/Metabolic/Degenerative/Neoplastic/Trauma/Vascular

 

Case work-up:

 

CBC and Biochemistry- without any changes

CRP – 8,7 my/L

 

Magnetic resonance of the head was performed with GE MRI 1.5 Tesla.

1 (1) 2 3 4 4 5 8 9 10

 

MRI findings:

The T1W and T2W sagittal  and transversal images showed reduced size of the nodulus and uvula of the caudal cerebellum  with CSF filling the space normally occupied by cerebellar parenchyma.This is particularly visible on T2W images due to the hyperintensity of the surrounding CSF.These imaging findings were considered most likely to represent congenital caudal cerebellar hypoplasia.

 

There is no histopathological examination providing a definitive diagnosis, but the most likely diagnosis is Congenital Caudal Cerebellar Hypoplasia.

 

No treatment was recommended. There is no progression of the clinical sings 4 months after the examination.

 

 

 

 

normal dog’s anatomy images-  “vet-Anatomy”

 

 

 

 

 

 

 

 

 

 

The use of vacuum assisted closure in the management of septic peritonitis – case report

 

1112Dr Robert Carst

Bucharest Romania

Pet Stuff veterinary hosptal

 

Introduction:

Septic peritonitis is an inflammatory condition of the peritoneum that occurs secondary to microbial contamination. Septic peritonitis may have a wide variety of clinical courses and outcomes, with high morbidity and mortality. The definitive diagnosis usually relies on the identification of toxic and/or degenerate neutrophils with foreign debris and/or intracellular bacteria in the peritoneal fluid. A thorough understanding of the treatment options and prognosis is crucial to decision making and comprehensive care.

 

Despite the numerous advancements in recent years, severe abdominal sepsis (with associated organ failure associated with infection) remains a serious, life-threatening condition with a high mortality rate in both veterinary and human medicine.

 

Vacuum Assisted Closure is a type of therapy used mainly for wound closure; it works by reducing atmospheric pressure on the wound bed.

In septic peritonitis the advantage of Vacuum Assisted Closure is that the system gently pulls fluids out of the abdomen, removes bacteria and helps clean the peritoneal cavity.

The system requires special dressing, a vacuum pump and various types of cycles can be used.

 

In septic peritonitis VAC therapy is used with an open abdomen technique. Open abdomen is a viable alternative to repeated laparatomy or continuous peritoneal lavage. The main advantages of open abdomen are prevention of intra-abdominal hypertension and abdominal compartment syndrome and early identification of intra-abdominal complications. Maintaining an open abdomen creates numerous management challenges – development of fistula and infection.

 

  1. Case presentation:

 

The patient is an 2 years and 6 months old American Staffordshire Terrier, intact female. She presented on September 14th for vomiting. The vomit persisted even after simptomatic treatment, so further investigation was recommended.

 

Initial blood tests were performed – cbc + biochemstry (attachment 1a, 1b 1c).

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On abdominal ultrasound (performed by my colleague, dr. Raluca Munteanu) – a jejunal foreign body with a diameter of 2.4 cm was diagnosed (attachment 2).1

 

Surgery was performed and a nut was retrieved from the patient’s jejunum; also, marked ischemia of the involved intestine was seen and it was decided to continue with an enterectomy of the affected area. 10 cm of jejunum were excised and a termino-terminal apositional suture was performed.

 

On September 15th the patient was discharged and treatment was continued with Amoxicilin + Clavulanic Acid, Metronidazole, Omeprazole and Sucralfat for the following 7 days.

 

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pic 3

Initially, the patient’s clinical evolution was positive, but on October 2nd she presented at the hospital for fecaloid vomit. An abdominal x-ray was performed and a gastric foreign body was detected (picture 3). An endoscopic retrieval was performed and a stone was removed from the patient’s stomach.

 

Patient was discharged with simptomatic treatment, but the vomiting relapsed on October 8th; new abdominal radiographs were performed, free peritoneal fluid and gas were detected and a laparatomy was recomended.

 

Pic 4

pic 4

General anaesthesia was induced according to standard protocol. An exploratory laparatomy was performed and multiple adherences were diagnosed (pic  4); at the point of the previous suture no leakage could be identified, but the intestine was distended with gas and fluid cranial to the enterectomy site.

 

 

 

 

 

 

 

 

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picture 6

Another enterectomy was performed, this time the excised part being approximately 60 cm of the jejunum. Duodenum and ileon were individualized and maintained (picture 6).

After copious peritoneal lavage (500 ml of sterile saline/kg) we decided to try VAC with an open peritoneum for septic peritonitis management. We used an VivanoMed® Abdominal Kit (attachment 7).6

The abdominal wall was sutured to the sponge in the VivanoMed® Abdominal Kit, the draining machine was attached to it and a leakage test was performed (video 1). In order to secure the abdomen a tie-over bandage was used to keep the VAC machine in place.

 

For the next 5 days continous pressure was applied at 40 mmHG. During the first 2 days, approximately 1 litre of septic fluid was drained. In the next 3 days, less and less fluid was obtained.133 134

On day 5, another surgical intervention was performed in order to change the usable parts of the VivanoMed® Abdominal Kit. The following 5 days, fluid collection was decreased and smears from it showed marked reduction of bacteria. On the 10th day no more bacteria could be identified in the peritoneal fluid.

 

On the 10th day, the abdominal kit was removed and routine abdominal closure was performed. Patient was discharged from the hospital and further evolution was good. On the 14th day recheck patient showed no more vomits, stool was normal and general status was good.

 

During VAC therapy – creatinine, BUN and albumin were monitored (attachment 8 and 9)98. Even though hypoalbuminemia persisted throughout the hospitalization period, there was no need for albumin suplementation as no peripheral oedema had developed.

 

  1. Discussion

 

Septic peritonitis is a complex process initiated most commonly by a bacterial focus, causing damage and inflammation of the primary and surrounding organs and usually culminating in circulatory shock, multiorgan failure and death. This process has been historically difficult to treat, with high mortality rates in both veterinary and human patients, despite aggressive medical and surgical treatment.

In this patient a deffinitive source for peritoneal infection could not be determined during later procedures; it is hypothesised that bacterial translocation could have occured secondary to increased permeability of the intestinal mucosa. It is also hypothesised that ingestion of the second foreing body (the gastric stone) was just a simptome of gastrointestinal disturbance.

During the 10 days of VAC treatment patient was hospitalized and closely monitored. Fluid production decreased after the first 2 days of treatment; on the last day no more fluid could be retrieved from the peritoneal cavity. Although the dog was managed with an open abdomen, no signs of pain or discomfort was seen. The patient managed to go out for walks with the VAC machine attached to the abdomen. Pain was controlled with buprenorphine – 10 mcg/kg every 12 hours. During the entire period antibiotherapy was continued and, after VAC placement, steroids (prednisone) were started at a dose of 1 mg/kg/24 h.

Even though in the first days after surgery the patient had developed a short bowel syndrome, on the 14th day recheck stools were back to normal. It is believed that the organism adapted to the shortened jejunum and digestion and absorbtion normalized.

At the time of publishing, the patient is doing well and is now back to presurgical weight and general status.

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