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By Wendy C. Brooks, DVM, DipABVP
Educational Director, VeterinaryPartner.com
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The kidney is normally a tremendous organizer of our small ions. It determines how much calcium to keep and how much to dump. It controls our blood’s pH by controlling which acids and bases to keep and which ones to lose. It controls sodium, potassium, calcium, carbon dioxide, water balance, and more. The kidney filters unwanted toxic biochemicals and gets rid of them in just the right amount of water necessary to maintain hydration. In failure, however, everything goes haywire. The wrong things are dumped, the wrong things are kept, toxins build up and the patient is sick. The state of toxicity that results is uremia or uremic poisoning. Most every animal hospital can provide diuresis: a therapy where extra fluid beyond what the patient can drink is provided, thus giving the kidney its excretion medium so that it can remove toxic waste. This works well in a large number of patients but there comes a time when even with plenty of fluids, the sick kidney simply cannot get the toxins out. For most patients this is the end of the line. In fact, dialysis may be another choice, though it is substantially more expensive than diuresis and centers that perform dialysis for pets are still few and far between. What is Dialysis?
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| picture courtesy of the Animal Medical Center in New York City
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While there is such a thing as peritoneal dialysis, most people are referring to hemodialysis when they talk about someone having to have dialysis treatment for kidney disease. A solution called the dialysate is mixed so as to favor the diffusion of toxins from the blood of the patient across a membrane (the “dialyzer membrane”) into the dialysate. The cleansed blood is then returned to the patient. The dialysis machine has a pump (just as the body has a heart to pump blood) that forces the patient’s blood into the machine. The intravenous catheters used in dialysis are large and long so as to support the appropriate speed of blood flow through the dialyzer. Such catheters are difficult to place; surgery may be necessary to place them. A long-term IV port under the skin may be needed if treatments are to be on going. A single catheter may be in place for months.
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| Dialysis catheter in place - photo courtesy of the Animal Medical Center in New York City
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The treatment lasts 3 to 5 hours (sometimes longer) during which the patient must calmly sit on a table attached to equipment. Treatments typically are performed three times a week either indefinitely (as in chronic renal failure) or until the kidney has healed (as in acute renal failure). There are actually numerous conditions that will benefit from this type of blood “cleansing” besides kidney failure. Electrolyte imbalances, heart failure, and many poisonings can also be treated via hemodialysis. Why is this so Long in Coming to Pets? Part of the problem has been that dialysis machines are generally designed for human patients. The amount of blood that goes through the human dialysis machine is too large a blood loss for a veterinary patient to withstand so smaller machines had to be built. A veterinary dialysis machine had to be designed for patients as small as a 5 or 6-pound cat. Further, a dialysis center requires specially trained staff and 24-hour care. It was difficult to get such centers financed. The procedure is still expensive and requires a dedicated owner but at least it is now an option. How Often is Dialysis Performed on a Patient? The patient who depends on dialysis to relieve the symptoms of uremia must have dialysis three times a week on the average. The pet owner must be able to bring the pet to the dialysis center with this frequency and leave the pet for the several hours needed for the treatment. Kidney transplant patients, or course, only require dialysis until they are well enough for surgery. Patients with a stone obstructing a ureter (the tube connecting the kidney and bladder) will require dialysis only until stable for surgery. Patients who have lost kidney function acutely from a poisoning (usually antifreeze) or infection (usually leptospirosis) typically require a month of therapy while their kidneys heal. Other patients may require therapy indefinitely.
Does Dialysis Reliably Control Uremic Poisoning? Not all patients respond to dialysis. How a given patient will do depends in part on what caused the kidney failure in the first place (toxin vs. infection vs. metabolic causes). Some statistics are: Out of 138 dogs that failed to respond to conventional therapy at the University of California: 40% responded to dialysis. Infectious causes (generally leptospirosis) tend to have a better prognosis. As leptospirosis has re-emerged as a common cause of canine acute kidney failure, the overall response rate for dogs receiving dialysis has improved to 50%. In a study in 2003 with cats requiring hemodialysis, the response rate was 56% (the best was prognosis for those with a ureter obstruction where over 70% survived). At what Point in the Treatment of Kidney Disease is Dialysis Recommended? If dialysis is being considered, it’s best not to wait until conventional therapy has completely failed and the pet is on death’s door. Let your veterinarian know from the start that this is an option you are interested in so that your veterinarian can consult with the dialysis center on the best time to refer. What are the Complications and Disadvantages? A new world of complications (beyond those of conventionally managed kidney patients) is introduced to the renal patient on dialysis. Malnutrition and Nausea
The toxin build-up in kidney failure causes nausea and appetite loss follows. Toxins further cause ulcers in the stomach and intestine, which contribute even more to the loss of appetite. Once the toxins are removed, the intestine heals quickly but appetite loss may persist. Making the nutrition issue worse is the fact that dialysis patient have an increased requirement for protein and calories. It is particularly important for the dialysis patient to get nutrients in one way or another. Feeding tubes or IV feeding may be necessary.
Metabolic Bone Disease
When the sick kidney does not properly excrete phosphorus, calcium is mobilized in a complicated hormonal reaction. Dialysis patients appear to be at higher risk for actual broken bones than are conventionally-managed kidney patients.
Carnitine Deficiency
Carnitine is a nutrient that facilitates the transport of the body’s energy sources. Unfortunately, dialysis inherently depletes the patient of carnitine. Carnitine deficiency results in heart disease, low red blood cell count, and muscle weakness. Supplementation is often necessary for dialysis patients if dialysis is going to be regularly performed for periods longer than one month.
Taurine Deficiency
Taurine is an amino acid of animal protein origin. Like carnitine, taurine is lost in the process of dialysis and that deficiency results in heart disease and (in cats) blindness. This amino acid must be supplemented for long-term dialysis patients.
Problems with the Dialysis Catheter
The catheter may induce formation of a blood clot at the catheter tip. This can interfere with the high blood flow rates necessary for proper dialysis. When a clot occurs, a forceful flushing of the catheter may be adequate to dislodge it but if not, clot-dissolving medications must be used and this becomes expensive and may lead to inability to clot.
Infection from the Dialysis Catheter
An infected dialysis catheter is bad news. The resulting blood infection can be lethal and, at best, requires months of antibiotic therapy. Be aware of the skin turning red or pus at the catheter site. The development of a fever is of great concern so the owner should become familiar with taking the pet’s temperature. How much does Dialysis Cost? In preparation for this article in 2004, we contacted the San Diego dialysis center listed below. We were told that the initial set up with the catheter, first week of treatments, feeding tube placement, etc. typically runs $2500-$3000. After this, each treatment costs $500 (the average patient requires three treatments per week). Where sre the Dialysis Centers for Pets? The following are animal dialysis centers. Where possible, we have included links that include more details about the procedure. I hope to add more centers as they open. If you are aware of an animal dialysis center not listed here, please contact us so it can be included. The Animal Medical Center
510 E. 62nd St.
New York, N.Y. 10021
(212) 838-8100 Tufts Foster Hospital for Small Animals
200 Westboro Road
North Grafton, MA 01536
(508-839-5302) University of California Veterinary Medical Teaching Hospital
Companion Animal Hemodialysis Unit
1 Garrod Dr.
Davis, CA 95616
(530-752-1393 UC Veterinary Medical Center-San Diego
10435 Sorrento Valley Rd, Suite 101
San Diego, CA 92121
phone: (858)875-7505
fax: (858)875-7583
http://www.ucvmc-sd.vetmed.ucdavis.edu/default.cfm
e-mail: sdhemodialysis@vmth.ucdavis.edu Veterinary Hospital of the University of Pennsylvania Hemodialysis Center
Matthew J. Ryan Veterinary Hospital
3900 Delancey St.
University of Pennsylvania
Philadelphia, PA 19104
(215) 898-4680 School of Veterinary Medicine
Louisiana State University
Baton Rouge, LA 70803-8410
225.578.9600 University of Florida, VMTH
2015 SW 16th Avenue
Gainesville, FL 32610
phone:(352)392-2235 ask for hemodialysis coordinator
fax: (352)846-2445 attn: hemodialysis coordinator Continual Renal Replacement Therapy Continual renal replacement therapy (CRRT) is another form of blood filtration similar to dialysis; in fact, which procedure represents the best choice for the human patient is hotly debated in human medicine. While dialysis removes toxins built up over the previous couple of days over a 3 to 5 hour treatment period, CRRT involves continual removal over a 24 to 48 hour period that mimics the patient’s natural kidney function more closely. The idea here is to continually remove toxins until they are all gone if that is possible. Sometimes a couple of treatments are needed. This is not a regularly performed procedure like dialysis. The catheters are similar to the dialysis catheters but because the procedure requires being hooked to the equipment for up to two days, sedation is generally required for this entire period, although this depends on the hospital. Complications focus on problems with low blood calcium (relating to the anticoagulants used – different anticoagulants from those in dialysis) and body temperature issues (between sedation and the room temperature of the filtered blood, the patient tends to get cold). Lower blood flow rates are used in CRRT when compared to hemodialysis, which makes for fewer blood pressure issues. Also the dialysis complications that are seen over time (carnitine deficiency, high dietary calorie requirement, catheter infection, and most of the other issues listed above) are not problems with CRRT because CRRT is a one-time treatment).
Centers performing CRRT include these. (Please let us know of any others and we will add them to the list): Advanced Critical Care and Internal Medicine
City of Angels Veterinary Specialty Center
9599 Jefferson Blvd.
Culver City, CA 90232
310-558-6100 Advanced Critical Care and Internal Medicine
3021 Edinger Ave.
Tustin, CA 92780
949-654-8950
Animal Medical Center at Cooper City Florida
9410 Stirling Road
Cooper City, Florida 33024
954-432-5611 California Animal Referral and Emergency Hospital
301 E. Haley St.
Santa Barbara, CA
805-899-2273
The Center for Specialized Veterinary Care
609-5 Cantiague Rock Road
Westbury, NY 11590
516-420-0000 Chicago Veterinary Kidney Center
1515 Busch Parkway
Buffalo Grove, IL 60089
847-459-7535 DoveLewis Emergency Animal Hospital
1945 NW Pettygrove
Portland, OR 97029
503-228-7281
503-228-0464 (Fax)
Date Published: 10/25/2004 12:44:00 PM
Date Reviewed/Revised: 08/13/2007
  
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