WALLE SOLBERG CASE REPORT

Dialysis of Walle:
Jerry A. Thornhill, DVM, DACVIM
Nephrology & Dialysis
Veterinary Specialty Center
1515 Busch Parkway
Buffalo Grove, IL 60089

Key Words: Acute Kidney Injury (AKI), oliguria, polyuria, hemodialysis (HD), Leptospirosis, Glomerular Filtration Rate (GFR)

Abstract

The following case report documents the successful outcome of a juvenile canine patient, obligating one -week of hemodialysis (HD) life support, for dialysis dependent Acute Kidney Injury (AKI), induced by the contraction of the severe infectious disease of Leptospirosis.

Case Presentation

Walle, a delightful, 2-year-old male, Pitt Bull mix, canine patient, presented to the Veterinary Specialty Center (VSC) in Buffalo Grove, IL on the weekend of September 10th / 11th (2011) for potential HD intervention, having been transferred from the Animal Emergency Clinic (AEC) of Rockford, IL, due to the development of rapidly advancing renal failure, clinically unresponsive to conservative medical management application.

Upon admittance to VSC and placement of the patient into the ICU, it became increasingly apparent over the ensuing 24-48 hour period, that Walle was not responding to application of specialized medications of Furosemide and Dopamine, collectively designed to stimulate urine production. Volumetric urine collection data during this period revealed that the patient was deficit in adequate urine generation to support life's biochemical functions oliguria; and concomitant uremic blood indicators (BUN, creatinine and phosphorus) were steadily on the rise.

Thus, as was discussed with Walle's family, the patient had clearly become “dialysis dependent” for life support. Based on the clinical evaluation by our Radiology team, that both renal structures revealed anatomical integrity on ultrasound review, coupled with the abrupt development of Walle's renal failure disorder; the diagnosis of AKI, of unknown origin (albeit, the infectious disease of Leptospirosis was highly suspicioned – pending test results)could be rendered.

Also discussed, was the Renal team's intuition, that because of the anatomical integrity of the renal structures, daily dialysis application for Walle might only require a conservative estimate of seven to ten days for a successful outcome, in which the patient would begin to produce adequate urine, coupled with a lessening of uremic blood indicators; as renal recovery from the AKI insult hopefully developed.

Dialysis Experience

In preparation for HD, under general anesthesia, a “double lumen” silicone HD catheter (11.5 Fr) was tunneled and secured into the right jugular vein for chronic maintenance blood flow (“to and from” the patient via, double lumen, single vein access; with disproportional volume length: short limb @ 1.1 ml, long limb @ 1.4 ml, respectively), and stored with a 100 % heparin lock.

Each daily HD session, designed for an 8-hr run, was implemented by the Gambro PrismaFlex Hemodialysis/Continuous Renal Replacement Therapy (CRRT) Machine and disposable PrismaFlex M-60 Hemodialzer Circuitry Unit.

A total of six HD sessions (five days continuous, followed by a one day break, then concluded on the next day), allowed for Walle's renal function to recover, with the patient's ramped up urine production polyuria, attendant with the recovery, adequate to sustain life's biochemical functions.

Walle's pre-dialysis renal function, associated with the patient's oliguria, was significantly depressed, with the measured GFR at a quantitative 3.94 % (N = 100 %). At the close of the sixth HD session, in conjunction with the patient's development of polyuria, Walle's GFR was measured at 6.74 %; with the decision to “wait and see” if further intervention of HD sessions (based on sequential daily BUN & serum creatinine generation data) might be indicated. Intervention was not needed; as Walle's polyuria progressed, and his GFR measurement steadily rose to 7.92 %, by the end of the fourth day “post” HD application.

On the second day of HD application, test results of the Leptospirosis query, revealed Walle to be “positive” for the infectious disease; with the Serovars of L. Grippotyphosa, L. Pomona & L. Bratislava pathologically elevated. Prophylactically, due to the index of suspicion for presence of Leptospirosis, Walle had already been placed on the antimicrobial combo of Amoxicillin & Doxycycline medications on first day of admittance to VSC, as part of the continued ICU therapeutic management regimen.

Commensurate with the infectious disease of Leptospirosis, Walle's liver enzymes became accelerated whilst in the ICU (albeit, expected, due to the presence of L. Pomona), due to “hepatocellular” injury attendant with dissemination of “toxins” liberated by the organisms of the disease complex.

Off Dialysis Support and Discharge

By the fourth day “post” HD, with the patient's GFR at 7.92 %, coupled with Walle's sustained polyuria and renewed exuberance for life (abundant energy), in conjunction with the family's overwhelming support, the decision to discharge the patient back to Rockford, IL for home care, was made.

In preparation for release from VSC, Walle's double lumen HD catheter was removed, and the family was trained on the application of SQ fluid therapy, in conjunction with instruction on administration of the daily therapeutic management program to be employed.

Discharge instruction included recommendation of the following:

1. SQ Normosol @ 500 ml 2 xs daily.
2. Amoxicillin (500 mg) @ 1 cap 2 xs daily.
3. Doxycycline (100 mg) @ 1 caps 2 xs daily.
4. Denamarin (425 mg -Large) @ 1 tab 1x daily.
5. Ursodiol (300 mg) @ 1cap 1x daily.
6. Renvela (800 mg) @ ½ tab 2 xs daily.
7. Azodyl @ 2 caps a.m., 1 cap p.m.
8. Epakitin (300 gm Canister) @ 2-scoops in food, 2 xs daily.
9. Zantac (75 mg) @ ½ tab 2 xs daily.
** Normosol selected over Lactated Ringers Solution as the maintenance fluid, due to the Liver Enzyme elevation**

To remain closely attached to Walle's clinical aftercare; we suggested a recheck appointment for the patient at our facility, within a four to seven day window after the discharge date, to provide continued monitoring of laboratory parameters and to make therapeutic course adjustments, if indicated.

Follow-Up/Recheck

Walle returned to VSC facility, one week after discharge, with the message from the family that the patient was doing exceedingly well at home, with daily improvements in appetite, energy and playfulness.

The physical examination revealed Walle to be healthy in appearance, with no pathology noted on auscultation of the chest or on palpation of the abdomen. No peripheral limb edema was noted and no ascites was present on ballottement.

Recruited clinical data on Walle revealed the patient's azotemia to be relatively moderate, with the BUN and serum creatinine elevated @ 52 & 5.3 mg/dl, respectively; accompanied however, by stabilization in Ca and PO4 (12.0 & 4.8 mg/dl, respectively), Na and K (147 & 3.6 mEq/L, respectively), total protein and Albumin (7.7 & 3.2 gm/dl, respectively) and HCT (50.2 %) parameters.

The Blood Gas study was stabilized, with the plasma HCO3 @ 18.3 and Base Excess @ -7 mmol/L, respectively; as was the non-invasive BP @ 166 mmHg. Urine protein spillage was mild (UPC @ 1.18:1 Ratio), and serum cholesterol remained elevated @ 386 mg/dl.

As expected, liver enzymes remained elevated, but the patient's T. Bilirubin improved from an elevated 2.3 mg/dl at time of discharge, to a respectful 0.8 mg/dl, on the current sampling, in support of hepatic convalescence.

Measurement of Walle's renal function (computer-modeled GFR program, individualized for the dog and cat), revealed stabilization in the patient's GFR @ 8.03 %, which represented slight improvement from a GFR of 7.92 %, recorded one week previously.

With the results of the comparative data in hand, except for an extended two week application of Walle's antimicrobials (i.e., Amoxicillin & Doxycycline), we elected to maintain the conservative medical management regimen currently employed; centered on continued application of the SQ fluid program, for at least a projected three month window of estimated polyuric renal recovery.

Closing Comments

As discussed with Walle's family; in our clinical experience, AKI “dialysis dependent” patients, fortunate to be weaned off the “life support” modality, generally recruit renal function over the ensuing polyuric three month recovery period, enough to generate a documented GFR in the 15 to 25 % range.

As stated previously, this degree of functional renal recovery, would be adequate to sustain a patient off dialysis, if the administration of renal prophylactic compounds, initially designed to address disorders of hyperphosphatemia and hypertension, has been adopted; and prudent, interval, laboratory monitoring, to guide all phases of conservative medical management, has been employed.

With reference to Walle's positive diagnosis of Leptospirosis; the need for re-testing for “activity” of the disease, post-infection, has become somewhat of a controversial conundrum, especially when treatment of the patient with Doxycycline has been employed, as the antimicrobial theoretically eradicates shedding of the organism in the urine, within four to seven days of application.

Therefore, unless reinfection were to occur, we would not expect a patient, previously treated with Doxycycline, to ever have a positive urine Polymerase Chain Reaction test result – a test for Leptospirosis, conventionally utilized to identify a “carrier host”, in a non-treated suspect .

Plus, since natural exposure and subsequent clinical development of Leptospirosis basically vaccinates the host against the disease; we would expect the aforementioned positive Serovars registered for Walle, to remain elevated for several months, post infection. And, although the titer elevation following natural infection might be more prolonged, than titer elevation noted with post 4-Serovar vaccination; the “consensus statement” on Leptospirosis, compiled by the ACVIM Committee in 2010, made a strong recommendation for patients, in either case (natural infection or vaccination), to receive one year vaccination boosters for Leptospirosis.

Therefore, if Leptospirosis infection has set up residence in renal tissue, sequentially compounded by microorganism replication in the renal tubular cell, leading to acute tubular cell inflammation, edema and necrosis, followed by overall AKI development, with or without “oliguric” dialysis dependency; then, monitoring of renal function (not tracking of Leptospirosis Serovars), unequivocally, becomes the tool for measuring the patient's recovery process, in the short-term ICU environment, and in the follow-up long-term at home convalescent environment.

Thus, frequent recheck examinations of Walle's laboratory data, after discharge from the ICU (weekly for the first month, then lengthened to monthly visits), would provide the needed information to ascertain the patient's clinical progress and to make therapeutic corrections, if indicated, for health care management, based on cumulative data reviews.

In closing, the HD experience with Walle, showed that a canine patient with oliguric AKI, predisposed to by contraction of the severe infectious disease of Leptospirosis, can be successfully managed during the critical renal “shut down” period, with dialysis application, until partial renal function returns, and dialysis dependency has been relinquished.