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
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).
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
