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CASE REPORT: TREATMENT OF AN ELDERLY DOG WITH

CONCURRENT HEART DISEASE AND ACUTE UREMIA BY
HEMODIALYSIS

Article · June 2014

DOI: 10.1142/S1682648514500127

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台灣獸醫誌
Case Report:
TaiwanTreatment
Vet J 39 of
(3):an150-157,
Elderly Dog
2013with Concurrent Heart Disease and Acute Uremia by Hemodialysis 150

Case Report: Treatment of an Elderly Dog with Concurrent Heart

Disease and Acute Uremia by Hemodialysis
1,2
Kun-Wei CHAN, 1,2 Tsung-Ying PING, 1,2 Shih-Jen CHOU, 1,2 Zhi-Jia ZHENG,
1,2
Wei-Cheng YANG, 1,2 Jyh-Mirn LAI, 1,2 Dan-Yuan LO, 1,2 Chih-Cheng CHANG, *1,2 Jui-Te WU

(Received: November 13, 2012. Accepted: December 26, 2012.)

ABSTRACT A 15-year-old mixed-breed dog that presented with anorexia and lethargy for 4 mon-
ths was diagnosed with chronic kidney disease (CKD) and cardiac disease. The patient presented cli-
nically in poor physical condition showing stupor and acute vomiting. Complete blood count (CBC)
and serum biochemical analysis showed severe anemia and blood urea nitrogen (BUN, 145 mg/dL);
creatinine (3.9 mg/dL) and phosphorus (17.2 mmol/L) were also elevated. Hemodialysis was performed
after fluid therapy did not improve the condition of the patient. Hemodialysis successfully treated the
acute-phase CKD and improved the kidney compensation function. [Chan KW, Ping TY, Chou SJ, Zheng
ZJ, Yang WC, Lai JM, Lo DY, Chang CC, * Wu JT. Treatment of an Elderly Dog with Concurrent Heart Dis-
ease and Acute Uremia by Hemodialysis. Taiwan Vet J 39 (3): 150-157, 2013. * Corresponding author TEL:
886-05-2732953, FAX: 886-5-2732917, E-mail: jtwu@mail.ncyu.edu.tw]

INTRODUCTION (CKD) in the acute phase.

Hemodialysis is an effective therapy that is used CASE HISTORY, DIAGNOSIS AND

to remove uremic toxins and correct deficits and ex-
cesses in fluids, electrolytes, and acid-base imbalan-
ces associated with renal failure. Numerous veterinary
cases have reported that hemodialysis is an effective
method to reduce blood metabolite and toxin concen-
trations for acute kidney injuries when supportive care
cannot improve the situation [5]. In this case, the se-
vere uremia of the patient was markedly improved
with hemodialysis treatment, which supports the effi-
cacy of this treatment for chronic kidney disease
TREATMENT
A 15-year-old spayed female mixed-breed dog
weighing 7.2 kg was referred to National Chiayi Uni-
versity Veterinary Teaching Hospital on June 5, 2011.
The patient was fed home-made food and lived out-
doors, and had complete records of heart worm pre-
vention and deworming; however, a complete vaccin-
ation record was not provided. According to the
owner’s description, the patient was in a stupor and
151 Kun-Wei Chan et al
was vomiting for 1 week. A lack of appetite and exer-
cise intolerance was observed since February 2011.
The owner took the patient to the local clinic because
the dog collapsed suddenly in mid-May 2011. Al-
though intravenous fluid therapy was provided by the
local clinic for 2 days, the patient’s situation did not
improve. Consequently, the owner took the dog to an-
other local clinic for assistance but the patient’s condi-
tion did not improve.
On initial presentation, the dog showed stupor
with lateral recumbency. The heart-rate was 138 bpm,
Abdominal radiographs revealed atrophy of both
kidneys (arrow).
Thoracic radiographs exhibited cardiomegaly on
right lateral view. VHS: 11 (Reference range: 8.5-10.5)
respiration was 54 bpm, and the rectal temperature
was 38.6℃. The dog was in poor physical condition,
ranging from 2 to 4 on the body condition score chart
(Ralston Purina Company, St Louis, Mo), 7% de-
hydration status, and the muscles of both hind limbs
showed atrophy by palpation. Auscultation of the tho-
rax revealed a type IV-V/VI heart murmur [6].
A blood sample was processed for complete
blood count (CBC) and serum biochemical analysis,
and a urine sample was taken for urinalysis. Low
packed cell volume (24.7%), low hemoglobin (9.4 g/
dL) and low red blood cell (RBC) concentration
(3.93×106/ L) were noted in the CBC. In the serum
biochemistry, elevated blood urea nitrogen (BUN, 145
mg/dL), elevated creatinine (3.9 mg/dL), elevated as-
partate aminotransferase (170 U/L), elevated total bi-
lirubin (0.8 U/L), hypoalbuminemia (2.1 g/dL), hyper-
chloremia (127 mmol/L) and hyperphosphatemia
(17.2 mmol/L) were noted [8]. The mean arterial
blood pressure was 101 mmHg. Urine analysis reveal-
ed proteinuria and isosthenuria (specific gravity
1.010) by using a clinical refractometer. Multiple
granular casts were detected by urine sediment exam-
ination. Abdominal radiographs displayed atrophy of
both bilateral kidneys (Fig. 1), and thoracic radio-
graphs exhibited heart enlargement on the right lateral
ventricle (Fig. 2). Abdominal ultrasonographs showed
dissimilar sizes of the bilateral kidneys and an irregu-
lar edge to the left kidney (Fig. 3).
Abdominal ultrasonographs showed dissimilar
size of bilateral kidneys and irregular edge of the left kid-
ney
 Case Report: Treatment of an Elderly Dog with Concurrent Heart Disease and Acute Uremia by Hemodialysis
CKD was suspected, based on the duration of sig-
ns, the significant uremia (elevated BUN and creati-
nine values), hematology examinations (moderate
anemia, hypoalbuminemia, and hyperphosphatemia),
urinalysis (isosthenuric urine with proteinuria and cyl-
indruria), and imaging results (atrophy of both kidneys
and irregular edges). Simultaneously, mitral regurgita-
tion (MR) and tricuspid regurgitation (TR) were diag-
nosed by color flow Doppler echocardiography (LOG-
IQ 400 CL PRO, GE Healthcare, Taipei, TW).
The dog was treated with medical therapy: intra-
venous fluid therapy, containing B-complex® 2 mL
(each milliliter contains thiamine HCl 100 mg, ribofla-
vin 5 mg, pyridoxine HCl 2 mg, niacinamide 50 mg,
and dexpanthenol 5 mg) and ascorbic acid 100 mg
with 0.45% sodium chloride solution 500 mL, 5 mL/
kg/h for dehydration; pimobendan 0.25 mg/kg po bid
and benazepril 0.25 mg/kg po bid for cardiac disease;
Wellpine® 2.5 mg/kg po bid, Azodyl® one capsule/5
lbs po sid, and Erythropoietin (EPO) 100 U/kg sc
q3-4d for moderate anemia.
Within 48 h of fluid therapy, azotemia did not im-
prove, the plasma BUN was 134 mg/dL, and creati-
nine had increased from 3.9 to 4.2 mg/dL. Because a
decubitus ulcer had formed on the right forelimb after
2 days of hospitalization, enrofloxacin was adminis-
tered 0.1 mg/kg sc bid. Hemodialysis was chosen as
the preferred treatment in this case because the medi-
cal therapy did not resolve the azotemia within 2 days.
As preparation for dialysis, a temporary double-lumen
7 Fr × 20 cm dialysis catheter (Hemodialysis Conc.
A-35, Chi Sheng Chemical Corporation, Hsinchu,
TW) was placed aseptically into the right jugular vein,
followed by 1 h 42 min of dialysis. The hemodialysis
prescription used a polystyrene dialyzer with a dialy-
sate (Hemodialysis Conc. BS-22, Chi Sheng Chemical
Corporation, Hsinchu, TW) flow rate of 500 mL/h,
and the blood processing rate was 5 mL/kg/min. Dur-
ing hemodialysis, CBC, serum biochemistry, and ac-
tivated clotting time (ACT) were monitored every 30
min to prevent a rapid decline of serum osmolality,
which was induced by excessive dialysis. After the fir-
st dialysis treatment, BUN and creatinine values im-
proved, decreasing to 121 and 3.0 mg/dL, respectiv-
ely. The patient did not appear to have dialysis dis-
equilibrium syndrome (DDS).
152
A 2.5-h dialysis treatment was performed 2 days
after the first dialysis treatment, and the post-dialysis
BUN and creatinine values were 90 and 1.5 mg/dL, re-
spectively. The patient’s condition improved after 2
treatments with hemodialysis. Because the patient re-
fused to eat, even by feeding by nurses, we suspected
that a gastrointestinal ulcer might exist. A feeding tube
was placed to provide adequate energy and nutrition
for the patient.
After hemodialysis, BUN and creatinine improv-
ed to 95 and 1.9 mg/dL, respectively. The patient re-
mained on fluid therapy and oral medicine for cardiac
and renal difficulties. The CBC and serum biochem-
ical examination were monitored every 2 or 3 days
continually. The results of serum biochemical examin-
ation showed that the BUN and the creatinine values
had improved (Tables 1 and 2). The creatinine value
recovered to 1.0 mg/dL on June 27, 2011. The BUN
value was approximately 30 mg/dL on August 30,
2011. The CBC examination showed that the packed
cell volume, hemoglobin, and the RBC concentrations
had improved to 31.9 %, 11.4 g/dL, and 5.75×106/ L,
respectively. The electrolytes, including sodium, po-
tassium, chlorine, calcium, and phosphorous, were un-
der control. However, the patient died on September
23, 2011. The body was preserved for pathological
examination.
At the necropsy, the dog appeared emaciated, and
a 1.5 × 2.0 cm decubitus ulcer (poor vascular per-
fusion was caused by her cardiac condition, and the
muscle of the limbs showed severe atrophy) was found
on the right fore-limb. Bilateral kidneys with an ir-
regular edge both showed atrophy (Fig. 4). Cystic dila-
tion of the tubules in the medulla was observed. The
liver was swollen and was yellowish-brown, and the
gall bladder was tumefaction-filled with bile. The
spleen appeared pale, and focal hemorrhage of the
pancreas was observed. Ulcers in the stomach and in-
testines were observed, and the wall of the urinary
bladder had thickened. The heart appeared enlarged,
and both the right and left parts of the heart were filled
with clotted blood.
Histopathologically, numerous nephrons were re-
placed by fibrous tissue proliferation and hemosiderin
in the tubular epithelial cells was noted in both kid-
neys (Fig. 5). In addition, interstitial nephritis with
153 Kun-Wei Chan et al

Blood urea nitrogen (BUN) concentrations during period of hospitalization.

Table 2. Creatinine concentrations during period of hospitalization.

 Case Report: Treatment of an Elderly Dog with Concurrent Heart Disease and Acute Uremia by Hemodialysis
Both kidneys with irregular edge were atrophic.
Renal parenchyma was replaced by fibrous tis-
sue and hemosiderin was present in tubular epithelial cell
of both kidneys (H&E stain, 40x).
Remaining tubular lumens were filled with prote-
inaceous material (H&E stain, 200x).
154
mononuclear leukocyte infiltration was observed. The
majority of the tubular epithelium was swollen and
necrotic, and remnants of the tubular epithelium were
filled with proteinaceous material (Fig. 6). Local con-
gestion and hemosiderin sedimentation and hepato-
cyte swelling and necrosis were noted in the liver. The
myocardium was observed with severe multifocal fat-
ty changes. The lung lesions were characterized by
pulmonary edema and emphysema. Bacterial clumps
in the alveolar wall were considered post-mortem
changes.
DISCUSSION
In kidney disease, CKD is a commonly recogniz-
ed situation in dogs and cats. The kidney lesions are
typically characterized by a permanent reduction in
the number of functioning nephrons. CKD may devel-
op gradually complicated by concurrent prerenal and
postrenal components or reversible active kidney dise-
ases [5]. In certain cases, attempting to correct rever-
sible primary diseases and/or prerenal or postrenal
components of renal dysfunction might result in fail-
ure. Further improvement of kidney function in these
cases should not be expected because kidney tissues
have compensatory and adaptive changes over a large
range [6]. These compensatory mechanisms often lead
to the progressive loss of remaining kidney functions;
this is a major characteristic of CKD [4]. Clinical ob-
servation in the early stage of CKD is not easy because
the animal does not have apparent clinic signs, despite
injury to the kidneys occurring. Rapid deterioration of
the remaining kidney function is unusual in CKD.
Typically, the kidney function of CKD patients re-
mains stable or declines slowly over months or years,
unless excessive kidney injury has been sustained or
CKD is advanced [5]. With well treatment, dogs and
cats with CKD often survive with a good quality of life
for months or years. Although no treatment can cor-
rect irreversible kidney lesions in CKD, clinical and
biochemical consequences of reduced kidney function
can often be managed with supportive therapy. In ad-
dition, the progressive course of CKD may be slowed
by therapeutic intervention [8].
The purpose of CKD treatment is the prevention
and management of complications of decreased kid-
155 Kun-Wei Chan et al
ney function; therapy is designed to slow the loss of
kidney function and maintain the patient with a good
quality of life [2]. Treatment includes conservative
medical management, renal replacement therapy, and
dietary therapy. Renal replacement therapy includes
peritoneal dialysis, hemodialysis, and potential kidney
transplantation. When the patient has severe oliguria
or anuria and conservative medical management can-
not improve azotemia, deficits and excesses in fluids,
electrolytes, and acid-base abnormalities, dialysis
treatments should be performed.
In this case, an aged dog with severe cardiac and
renal problems was referred to the hospital. The initial
condition of the patient was poor. A diagnosis of CKD
was suspected based on the duration of symptons, lab-
oratory examinations (CBC, serum biochemical
examination, and urinalysis), and imaging findings
(radiography examination and ultrasonography exam-
ination). Anemia and uremia related to CKD with er-
ythropoietin deficiency and decreased renal function
were noted, respectively.
We do not know the cause of the CKD, or if it was
primary or secondary. In this case, the renal problem
might have been primary or the CKD might have re-
sulted from her cardiac condition with MR and TR.
When the patient was admitted to the hospital, she pre-
sented with both renal and cardiac problems. The first
goal of treatment was to stabilize her condition. Intra-
venous fluid therapy was given immediately for se-
vere uremia and electrolyte imbalance.
The severe cardiac problems in the patient in-
cluded MR and TR, and cardiac hypertrophy was di-
agnosed on both slides of the heart. Cardiac problems
with a MR velocity of 588 cm/s and a TR velocity of
299 cm/s were noted using continuous-wave Doppler
echocardiography. Classification of heart failure was
Class I(a) by the International Small Animal Cardiac
Health Council (ISACHC) classification of heart fail-
ure in small animals, and Stage C by the American
College of Veterinary Internal Medicine (ACVIM).
Pimobendan and benazepril were administered ac-
cording to the ACVIM guidelines [1]. The patient’s
cardiac output was too poor to supply sufficient blood
to her critical organs; thus, the splanchnic organs and
kidney might have suffered from poor perfusion. In-
sufficient blood supply to the kidneys leads to renal
tissue damage, and gradually progresses to CKD. The
patient’s situation had not improved with 48 h of intra-
venous fluid therapy. Therefore, dialysis treatments,
including peritoneal dialysis and hemodialysis, were
considered for the patient. Instead of peritoneal dial-
ysis, hemodialysis was performed because of the pa-
tient’s age and hypoalbuminemia. The patient was
given a blood transfusion before hemodialysis be-
cause of severe anemia (packed cell volume: 15.2%)
[9]. The central nervous system disturbance, dialysis
disequilibrium syndrome (DDS), is caused by a rapid
dialysis-induced change in the composition of the
blood. The urea reduction ratio (URR) of the first and
second hemodialysis was 0.09 and 0.2, respectively.
The patient did not present symptoms of DDS after
each hemodialysis treatment.
With 2 treatments of hemodialysis, BUN and
creatinine values improved markedly. Simultaneously,
the patient was continually managed with fluid ther-
apy and oral medicine for her cardiac and renal diffic-
ulties. The CBC and serum biochemical examination
were monitored every 2 or 3 days. The statistics sho-
wed that the patient’s kidney function appeared stable,
and her status was considerably better than initially.
According to the International Renal Interest Society
(IRIS), the CKD patient was Stage 1-2 [6]. However,
the patient died because senility and multiple organ
failure were observed with severe multifocal fatty
changes in the myocardium by pathological examin-
ation. However, hemodialysis remained successful in
ameliorating the severe uremia and stabilized the con-
dition of the patient’s kidney function.
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disease. In: Nelson RW, Couto CG. Small animal internal
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 157 Kun-Wei Chan et al

病例報告：老年心臟病患犬急性尿症之血液透析處置
1,2
詹昆衛 1,2
兵宗穎 1,2 周世認 1,2 鄭智嘉 1,2 楊瑋誠 1,2
賴治民
1,2
羅登源 1,2 張志成 *1,2 吳瑞得

國立嘉義大學獸醫學系暨研究所 嘉義市
1

2
國立嘉義大學農學院附設動物醫院 嘉義市

（收稿日期：101 年 11 月 13 日。接受日期：101 年 12 月 26 日）

摘要 本病例為一 15 歲雌性混種犬，有厭食、精神不濟的病史。經診斷後發現患犬患有慢性腎病與心臟疾病。臨
床上患犬體態極度消瘦，並出現嘔吐、運動不耐與半昏迷等症狀。配合全血球計數與血清生化學檢查發現，患犬貧血
情形嚴重且有急性尿症的情況，血中尿素氮 (145 mg/dL)、肌酸酐 (3.9 mg/dL) 與血中磷離子濃度 (17.2 mmol/L) 有
明顯的升高。經輸液治療無法有效改善嚴重氮血症的情形後，遂以血液透析作進一步的處置。血液透析治療後，持續
以輸液作為支持性治療，經 3 個月檢測與觀察結果顯示，血液透析成功改善了慢性腎病的急性期，使其呈現一穩定的
狀態，並成功改善患犬腎臟代償的能力。[詹昆衛、兵宗穎、周世認、鄭智嘉、楊瑋誠、賴治民、羅登源、張志成、
吳瑞得。病例報告：老年心臟病患犬急性尿症之血液透析處置。台灣獸醫誌 39 (3)：150-157，2013。* 通訊作者
TEL：886-05-2732953，FAX：886-05-2732917，E-mail：jtwu@mail.ncyu.edu.tw]

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