Neither did I, but, as the patient was here, I had no choice but to listen.

As much as we have all heard the admonition to “take the medicine until it’s all gone,” and “don’t take other people’s medications,” we still do it.

And we hear stories about it here in the practice almost every day.

Few are this bad, though.

Deuce's right eye was burned by another pet's ear medicine.

Deuce came in for a routine, well-patient examination. As Kristi began to ask questions about his general welfare, she got to the last question, “Is there any area you want Dr. Randolph to pay special attention to?”

“Why, yes,” Deuce’s owner said. “Sunday his right eye was red and my wife put some of Bogie’s eye ‘drops’ in it and it pretty quickly began to look better. That was two days ago, and it looks pretty good now.”

“I’ll tell Dr. Randolph and we’ll get Deuce examined right away,” Kristi replied.

Kristi came into the laboratory, where I was peering into the microscope, and gave me Deuce’s history. Now, I don’t claim to have a photographic memory, by any means, but I asked Kristi, “Have we ever treated an eye problem for Bogie?”

She looked at the ceiling thoughtfully for a moment, then said, “I don’t know, I’ll go look in the computer.”

While we had evaluated Bogie for two ear problems and several times for routine preventive care visits, there was no indication that we had ever seen him for an eye problem.

“Drops” was one of the key words I had latched onto in the statement, because we have several medications in “drops” form for ears, but most of our eye medications are in ointment form.

And, yes, we had dispensed medicine in “drops” form for Bogie’s ears.

A quick glance at the package insert showed that its constitution included 55% ethyl alcohol.

That’s right, the same stuff you put in your car’s gas tank.

When I looked at the eye I was not at all surprised that the eye wasn’t, in fact, better, but was extremely red. I was surprised when the fluorescein stain didn’t show any corneal damage. In fact, I fully expected the cornea to be totally wiped away.

Keep in mind that corneal damage is known in humans to be the second most painful thing we experience, the only more painful condition is passing a kidney stone.

Even though Deuce didn’t suffer corneal damage from this incident, I’m sure he experienced a very intense burning sensation every time Mom put the ear drops in his eye.

So, please, follow the instructions for proper disposal of leftover and unwanted medication, and avoid painful episodes such as Deuce experienced.

See you tomorrow, Dr. Randolph.

We explained there that restarting heartworm preventive without a test is a dangerous proposition, and could even result in a reaction that could kill your dog.

Sheba might not have seen tomorrow if she had not had a heartworm test today

Well, just this morning, it happened.

No, not a reaction, but a dog, Sheba Lee, who had missed two months of heartworm preventive, tested positive on the Heska® test pictured.

Had Sheba simply re-started her heartworm preventive without today’s test, she might not have seen Wednesday.

Your pet’s doctor knows what he’s talking about when he makes recommendations about your pets’ care. I’m not asking you to trust him blindly, that would be ridiculous. By all means if something comes up that conflicts with logic, obtain a second opinion.

Just don’t dismiss what he says without an abundance of caution and a lot of professional guidance.

The practice of medicine, human or veterinary, is extremely complicated. It is far more complicated than the explanations we give day-to-day, which we often simplify for the layman.

In this case, following our recommendations saved Sheba Lee’s life.

The blue line by "C" (for control) means the test worked properly, the red line by "T" means Sheba has heartworms.

See you tomorrow, Dr. Randolph.

Geographically, the first result on our laboratory’s report that relates to the kidneys is BUN, or Blood Urea Nitrogen. Put most simply BUN is a measure of one waste product of protein metabolism. When dietary protein is used by the body, molecules of nitrogen are given off as a waste ingredient if the nitrogen is not used for building new dog or cat protein. The kidneys should “filter” that and many other waste products from the bloodstream. When they fail to, BUN measurement rises above accepted normal levels. For our laboratory, normal BUN is considered to be 6-31 for the dog and 14-36 for the cat.

Pearl’s BUN is 65, slightly more than twice the maximum of normal.

Another measurement of filtering ability of the kidneys is creatinine. Creatinine is a breakdown product of creatine phosphate (or phosphocreatine), a phosphorylated source of energy for skeletal muscle. Creatinine is created at a fairly constant rate through the day, then is removed by the kidneys. Like BUN, then, elevations in blood levels of creatinine reflect a lower filtration rate of the kidneys and, thus, increasing kidney failure. For our laboratory, normal creatinine is considered to be 0.5-1.6 for the dog and 0.6-2.4 for the cat.

Pearl’s creatinine is 3.1, slightly less than twice the maximum of normal.

Blood electrolytes that are not normally controlled by the kidneys but which may become elevated in kidney failure include phosphorous and potassium. Like BUN and creatinine, these elements become elevated simply because of failure to be removed by the kidneys. For our laboratory, normal phosphorous is considered to be 2.5-6.0 for the dog and 2.4-8.2 for the cat and dog potassium 3.6-5.5, cat potassium 3.4-5.6.

Pearl’s phosphorous is 5.9, just under the maximum of normal. Her potassium is 6.1, a little higher than normal.

Renal Uremia or azotemia are terms that refer to the buildup in the blood of protein-breakdown waste products that have not been removed by failing kidneys. For the pet owner, the most notable sign of uremia is a strong odor to the breath. As these waste products build up in the bloodstream some are transformed into a gaseous state that crosses from the blood into expired air in the lungs.

Water intake is crucial to the long-term survival of the kidney failure pet. Dehydration may cause poor, sluggish blood flow to the kidneys, pushing the kidney failure patient into a downward spiral from which he cannot recover.

Further, the more water a pet with bad kidneys drinks, the more “flushing action” is effected onto the kidneys and the more waste products are removed from the bloodstream. Indeed, in later stages we often administer fluid therapy to pets for that very reason. Change drinking water at least daily and keep the water clean and inviting to encourage maximum intake.

Special diets, such as the Hill’s Prescription Diet k/d that Pearl eats, help to prolong the kidney failure pet’s life by limiting protein intake. Of course, a dog or cat with bad kidneys needs to eat protein to live just like everyone else. What he doesn’t need, though, is excess protein that his body can’t use anyway.

For ease of explanation and understanding we will use large, round numbers in this analogy. Let’s say your pet eats 20 pounds of food each day of a 50% protein diet. So, he takes in 10 pounds of protein each day. However, only half of that protein is usable by the body. Still, all 10 pounds of protein have to be “processed” by the kidneys. If, though, we feed a special diet that has protein that is nearly 100% digestible, he can eat half as much protein and the kidneys have only half as much work to do, but still get all of the protein nutrition he needs. The net result is that there is less waste from protein metabolism for the aging kidneys to process, and uremia is avoided.

Oral medications called “phosphate binders” can also be added to a diet to “bind” the dietary phosphate in the gastrointestinal tract, thus reducing the load of excessive phosphorous in the bloodstream.

If phosphorous levels are not controlled, the body reacts to raise calcium levels to maintain a balance of the two ions. The result is a condition called renal secondary hyperparathyroidism, which results in soft, malleable bones that can break easily.

Anemia can result from kidney failure. The extent of anemia is typically proportional to the physical size of the kidneys. Kidneys have many, many functions beyond making urine and getting rid of waste products. One of those functions is forming a hormone, erythropoietin. As erythropoietin circulates through the bloodstream it bathes the bone marrow and stimulates it to produce red blood cells (RBCs). Anemia results in lethargy, shortness of breath and paleness. Erythropoietin is available commercially, and may be injected in the late stages of renal failure. Pets may create protective antibodies to erythropoietin, thinking it is a foreign substance that might be dangerous to the body, causing it to be broken down before it can do its work. That is why erythropoietin treatment is reserved for patients in late-stage kidney failure.

Weight loss typically accompanies kidney failure because aging kidneys do not return all of the protein they filter back to the bloodstream as healthy kidneys do. As that protein is lost in the urine, the body “borrows” protein from muscles and other structures, but has no reserves to “pay it back.” Thus, a pet in kidney failure tends to get bony and skinny as muscle wasting occurs.

Perhaps the most noticeable factor to pet owners is the change in water intake and urine output. Most pets in kidney failure lose the ability to control urine specific gravity. As a result, they drink water constantly and that water “goes right through them.” Though stated above, is bears repeating that water must be kept fresh and available at all times to prevent dehydration.

Caught in the early stages, renal failure such as Pearl’s is not an immediate death sentence, though it seems likely that, in the absence of other life-threatening conditions, it will be the ultimate cause of Pearl’s demise.

Prognosis is difficult because of the nature of kidneys. We are born with about ten times as much functional kidney tissue as we need. Losing a little here and a little there as years go by means that we have plenty of kidney function until 90% is lost. Therefore, it is only when 9% or less remains that we have abnormalities that we can detect on laboratory tests. Determining whether there is 9%, 8%, 7% or some other quantity is impossible, though it can be approximated with ultrasound and a radiographic dye test called intravenous pyelography or IVP.

The most important factor to remember if your pet’s kidneys are failing is to control the diet and follow your pet’s doctor’s advice exactly. Treatment of dog and cat chronic renal failure is far more complicated than can be explained here, and every element of that treatment must be exact if your pet is to maximize his survival time.

Thirty years ago this client’s statement would have applied to any pet over six years of age.

Twenty years ago that age limitation might have been set at age ten.

For the last ten years age, alone, is not a consideration for which patients we will anesthetize and which ones we won’t.

Today we have excellent diagnostic tests, such as the chemistry profile to determine whether kidneys, liver and other blood parameters are in a satisfactory range to ensure safe anesthesia. We have detailed complete blood counts (CBCs) to know whether there are sufficient cellular elements such as red blood cells, white blood cells and platelets for safety. The urinalysis yields data we can use along with the blood test results to know even more about the body’s overall health.

In 2010 we are three generations ahead of inhalant maintenance anesthetics we used in 1980 when I graduated from Auburn University’s College of Veterinary Medicine. Where a pet with a borderline liver or kidneys might not have survived even a short anesthetic procedure thirty years ago, today the same pet might emerge healthy from even a lengthy surgery or dental care.

Which brings us to today’s post about our precious poodle, Pearl.

Recently we noticed that Pearl had lost weight. Perhaps we suspected prior to “recently,” but were in denial. As she grows older and is losing her vision and her hearing, we really aren’t up to more bad news. Frankly, we still haven’t gotten over the loss of her brother, Peyton and probably never will.

Pearl has always been a dietary self-regulator, never eating more than she needs for proper health and nutrition. As a result, she’s always had a trim build, and we are able to just scoop up a bowl of food, put it on the floor while we have supper and pick it up later. We first began to notice that there was more food than usual left in her bowl. She has eaten Prescription Diet t/d in the original size for years and years, but when I accidentally brought home the “small bites” version of t/d we noticed that she ate it better.

Even though her physical examination was mostly normal, just to be sure she wasn’t having any metabolic problems I submitted samples for a chemistry profile, CBC, urinalysis and thyroid level.

Everything came back normal except for her kidney numbers, which are about twice the maximum of normal. As bad as that sounds, it’s really not so bad for a 16-year old dog. Still, it does mean she is in kidney failure, and that will likely be the cause of her eventual demise.

So, what does Pearl’s kidney failure have to do with anesthetizing old dogs? Read on.

After we discovered that Pearl no longer wanted to eat a large kibble like t/d, and we had her abnormal laboratory test results, we decided to change her diet to Prescription Diet k/d instead.  k/d is formulated specifically for patients with kidney and liver problems. For some time her breath has been a little objectionable, but I began to notice that there seemed to be “foul” component to it now, which implied infection might be present. Further investigation proved that calculus buildup was substantial, as is common in older dogs, and that infection in the gums was a problem.

After long discussions and prayer, Brenda and I decided to proceed with anesthesia, dental cleaning, polishing and fluoride treatment for Pearl.

The night before her procedure I administered Convenia to Pearl to begin the process of lowering oral bacterial numbers well before the procedure.

We began the day by introducing fluid therapy to flush waste products from the bloodstream that the kidneys were not removing. After an hour on the IV pump we transitioned Pearl to surgery, anesthetized her, and began to remove the calculus above and below the gumline. That part was uneventful and our Cardell monitor assured us that all systems were operating as they should. We polished her teeth, applied a fluoride treatment and woke her up.

To continue flushing out waste products we maintained Pearl on the IV pump for the remainder of the day until it was time for both of us to go home.

The next day Pearl was spry, just as if nothing had ever happened. She is eating normally, jumping on and off furniture like she always does and generally healthy and happy.

The infection smell on her breath is gone.

Convenia will continue to protect her for 14 days from infectious bacteria that might have been released into the bloodstream during the dental cleaning, so that they do not cause problems in the heart, liver, kidneys or other organs.

Removing the oral inflammation and infection will prevent those problems from taking a further toll on her kidneys, a cost she cannot afford.

Having been safely anesthetized and her teeth shiny and healthy, Pearl can expect to survive longer with kidney failure than she would have with ongoing oral disease taking its toll.

More on kidney failure Monday.

“We can take care of that for you, Mrs. Stephens. Has Bowsie missed any doses of her monthly Revolution?”

“Yes, we just moved into our new house and I lost track of time during the transition. She missed last month. Does that matter?”

If your pet has been off his heartworm preventive and has gotten heartworms he must be tested before restarting heartworm preventive.

“Yes, ma’am, if Bowsie has contracted heartworms during the time she was off her monthly heartworm preventive and the restarts it, she could have a bad reaction that could even be fatal. Indeed, I see in our computer system that your purchase history reflects that you would have administered your last dose of Revolution month-before-last. For Bowsie’s safety she needs to have a blood test to determine whether she has any heartworms now. If the heartworm test is negative we can dispense more Revolution and get her back to excellent protection from heartworms as well as fleas!” said Stephanie.

“Bowsie loves to go bye-bye in the car, so I have her outside right now. Does Dr. Randolph have time to do the test?” inquired Mrs. Stephens.

“As it happens,” Kristi offered, “we have a 30-minute gap before our next appointment that you can fit right into.”

We performed Bowsie’s heartworm test, and, good news, the result was negative. However, that was not the end of the story, so we had one more discussion.

“Even though today’s test is negative, there is a limitation to any heartworm test, and that is that during the time Bowsie has been off of her heartworm preventive, there could be heartworms that are in her body now that are just not old enough to show up on this test. Furthermore, they could be too old to be stopped by restarting her Revolution (or any other heartworm preventive) now, which we will do. So, be sure to administer Bowsie’s Revolution every month for the next six months. Then, when you get a reminder in the mail for a followup heartworm test in six months, if that test comes up positive, we will be able to catch those heartworms early before they have a chance to do a lot of damage. If the test is negative then, we will be very grateful that heartworms didn’t sneak in during the time she was off heartworm preventive.”

“Just remember,” I added, “Bowsie is not out of the woods until she has that followup heartworm test in six months.”

“I understand,” said Mrs. Stephens. “Could Stephanie put the first dose of Revolution on for me now?”

“We will be happy to do that. And, we’ll get Bowsie another treat afterward.”

Bowsie’s situation is a scenario that plays out every single day in every veterinary practice in America. People are busy and forgetful. They lose track of the stickers that come with their heartworm preventive, they overlook the monthly automated e-mail reminder from Pfizer Animal Health, they forget about the automated phone reminder. They unintentionally put their pets at risk for heartworm disease.

Heartworm preventives are prescription medications for a good reason. The federal Food and Drug Administration (FDA) sets regulations for medications that have the potential for harm as well as good. Heartworm preventives really can kill your dog if they are used improperly, so the FDA limits dispensing of heartworm preventives to veterinarians, trained medical professionals who understand both the benefits and the risks.

So, when your pet’s doctor informs you that your pet must have a heartworm test prior to restarting his heartworm preventive, please comply cheerfully. Don’t ask him to “overlook it just this one time,” or “I know my dog doesn’t have heartworms” (not even your veterinarian knows until he has the test results!). He puts your dog’s health first, and has taken an oath to do what is best for his patients.

See you tomorrow, Dr. Randolph.

MMOPVT

Coke has had a lump that comes and goes, diagnosed as a sebaceous cyst.

Of the many types of cancers you don’t want your pets to have, mast cell tumors are among the worst.

In both dogs and cats mast cell tumors most commonly appear as skin growths. They can also be in primary intestinal tumors as well as in the circulating blood as a type of leukemia.

Here is a good example of how tricky mast cell tumors can be. I had a patient a couple of years ago who came in with a lump on the left rear leg. There was nothing “showing” to the outside, the lesion was completely haired and not inflamed. The only thing that concerned me was the position of the mass and the fact that it appeared to infiltrate the surrounding tissues. Based on that concern, I referred the patient to a nearby specialty center for board-certified veterinary surgeons to remove it. In their protocol, however, masses automatically go through the Oncology service first. The oncologist’s take on the lump was very different from mine.

“As soon as I walked in the room I knew it was a mast cell tumor,” she told me on the phone after her examination. We obtained a fine needle aspirate of the mass, and we can stage it from the results. I discussed with the owner the options of surgery, chemotherapy and radiation. Appropriate treatment will depend on the outcome of the staging.”

When we finished our conversation I hung up the phone shaking my head. Schnockered by a mast cell tumor again!

Even though we are taught in veterinary medical school not to diagnose masses by looking at them, there are many growths that we can make an educated guess about prior to receiving a pathology report. Obviously a board-certified veterinary oncologist has many more opportunities to evaluate growths than a general practitioner, thus she was able to use her experience to correctly evaluate this little dog’s mass. Of course, she didn’t stop there. The oncology doctor obtained specimens for herself and for the pathologist’s evaluation to confirm the diagnosis and to prepare for proper treatment.

Treatment. Mast cell tumors create yet another quagmire.

Most treatment protocols create four categories for mast cell tumors and some create subcategories as well. Aggressiveness of treatment is determined by staging. Those mast cell tumors staged as the mildest may be fully treated with surgery alone if wide margins are obtained. “Margins” refers to the amount of normal tissue between the abnormal growth and outer edge of the surgery site, as observed by the pathologist under his microscope.

Patients with mast cell tumors staged as the most aggressive may be candidates for initial surgical removal followed by radiation and/or chemotherapy. It is not uncommon for cancerous mast cells to travel from a mass to nearby lymph nodes or even lymph nodes throughout the body.

Treatment and prognosis both depend on the outcome of staging. Prognosis may change according to response to treatment. Every case is taken as an individual.

Our advice for Michelle is to make an appointment for her pet to have some sort of testing to reassure her with a specific diagnosis. That might be obtained by fine needle aspirate, cytology or biopsy.

Convenia long-acting antibiotic is saving Sassy from oral pain.

Poor Sassy got into a fight with another dog and it has left her with an extremely painful mouth, wounds, and a fever, implying that there is infection in the wounds. Of course, with oral pain, the last thing we want to do is open her mouth twice every day to give a pill, so Convenia is perfect for solving that problem.

Sassy is extremely happy that we have Convenia as a treatment option.

See you tomorrow, Dr. Randolph.

Note the total absence of a "waist" and the heavy fat over the ribs.

See Sammy grow.

See Sammy get bigger, and bigger, and bigger and…

In this tight economy everyone is looking for a way to save some money, including saving money on pet care.

Today Sammy came to see us with the dual complaints of itchy ears and scooting his behind. Would you care to associate that with his weight problem?

I did.

Sammy has had problems with his ears before, and just before Christmas, 2009, of all times, he had a really bad infection.

Today, though, his ears were itchy, but the cytology test showed that there was no infection in the ear canals.

The “ears and rears” combination always makes veterinarians put canine food allergy on our list of
differential diagnoses.

Of course, we emptied his anal sacs, as that is also a common source of rear-end itchiness in the dog. We found them both to be moderately full and, as mentioned in the post on anal sacs, the three most common predisposing factors to anal sac impaction are obesity, inactivity and constipation. Sammy is two-for-three!

So, it is very likely that Sammy’s mom, someone who likes to save money, could have avoided the cost of the anal sac problem simply by helping Sammy to lose weight.

Excessive weight predisposes dogs to the same problems excessive weight in people does:

• metabolic disease, such as canine diabetes mellitus
• heart disease and heart failure.
• bone diseases
• joint problems, including painful arthritis
• immune system stress
• premature death

Sammy’s mom, then, can save even more money going forward by helping Sammy to lose weight with an exercise program and a diet of Hill’s Prescription Diet r/d. Within six months Sammy should be at his goal weight and he will be healthier, happier, and live longer.

See you tomorrow, Dr. Randolph.