AMIE'S KIDNEY STONES
Note: The author has had no veterinary or medical training. She has merely documented her experience with her dog's health problems. Be sure to check with your veterinarian before acting on any information you see here. Please be reminded that the information presented here is not necessarily sage advice. In fact, it often includes misinformation and fallacious logic. The purpose is to show the progression of knowledge, what was tested and the confusion that a pet owner confronts when there are symptoms that aren't readily fixed.
Let Amie's experience assist you in charting your pet's course for treatment. Persistence pays off. The more you know, the more you can affect a positive treatment plan with your vet.
Note: Amie's tones were calcium oxalate. Her symptoms and treatment are specific to this type of stones.
When Amie was a year old I asked the vet about her fish breath. It used to be that doctors used things like skin tone, sound of palpitations and breath smell as important diagnostic techniques. The vet didn't have a clue. I also mentioned that she was very barky. He recommended obedience training. She had just completed a course and I knew her barkiness was a symptom.
A year later I mentioned the fish breath again. It is so strong at times and not at others. The fishiness is related to her barking. For most of Amie's life we had noticed her trembling. She wasn't cold and it didn't seem to bother her. When I held her I could feel spasms and contractions which seemed to be below her waist. The veterinarian diagnosed her with epilepsy and prescribed medicine (which I did not get). He said the fish breath is because of epilepsy. I knew her trembling was not epilepsy. Is fish breath actually related to epilepsy?
The vet suggested I contact the breeder to find out if any of the other dogs in her litter were sick. The breeder said, "My dogs are all healthy" and refused to speak with me about the health of Amie's litter-mates and parents. We now know that kidney problems can be hereditary and show up most often in specific breeds (see Links).
In May of 1992, when Amie was two years old, crystals were found in her urine. She is paper-trained, and I noticed that when the urine had dried, the paper sparkled. I didn't think that was a good sign.
A urinalysis confirmed that there were crystals in her urine and it was presumed that bladder stones were present. The vet wanted to immediately rush Amie into bladder surgery. I though if it were myself, I'd want a second opinion. At least maybe there is a way to be sure before we cut. I asked for x-rays. The vet acquiesced.
The x-rays showed no bladder stones. The vet merely shrugged and said, "Sometimes they don't show up on x-rays." (Note: They especially don't show up when they are in the kidney, not in the bladder.)
I was told that this wasn't an emergency. Then why the rush to cut? The flyer I was given said the most common bladder stones form only in the presence of a urinary tract infection. I asked if maybe we should work on handling the infection. The vet was not eager to discuss this option but he eventually prescribed Cephalexin, an antibiotic.
The urinalysis did not identify the type of crystals. STOP! Before you do anything else, determine the type of crystals. There are several types: calcium, oxalate, cysteine, struvite, and uric acid. The veterinarian presumed Amie's crystals were struvite because that is the most common type. But treatment depends on what type of stones are being produced. Hill's Pet Food Company has four Prescription Diets for stone-forming dogs depending on the type of stone. Not knowing this information, I agreed to put her on the S/D diet "to dissolve the stones" and then to later put her on
C/D "to prevent them". We later found out that there is no Hills formula which will dissolve Amie's type of stones - calcium oxalate.
Calcium oxalate stones have outer layers of calcium oxalate and a center of calcium phosphate. The stone may have started as an infection, or struvite stone, and then grew with layer of calcium oxalate.
About 90% of all dog stones are struvite. I think that a 10% chance that the stones are not struvite is a big enough reason to test further to determine the type of stone before prescribing anything.
When I read the label on the S/D and C/D diets, I thought - how can this be healthy? Aside from the first few ingredients it was all chemicals. I was also concerned because I suspected by now that Amie's allergies were due to some ingredients in commercial food. I asked if the vet could recommend a homemade diet that controls urinary infections and crystals. When I suggested that I make homemade food (without sugar, preservatives, etc.) and add the substance designed to dissolve crystals, the vet practically went ballistic. He did a dance of anger - the veins in his neck were popping and his voice was raised. An assistant removed him from the reception area and another vet angrily informed me that the S/D diet is the only treatment there is and if I cared about my dog, I should take her and go home.
I was NOT pleased with the way I had been treated by this vet - the rush to perform surgery, the absence of diagnostics, the arrogant certainty in the face of no evidence that Amie had epilepsy and bladder stones. This vet treated my mom and me as meat with dollars. No time for questions - questions show a lack of confidence in THE
DOCTOR, and take up valuable time for other paying customers.
I decided to get a second opinion. Before my next appointment I read as much as I could find on urinary infections and bladder stones.
The new vet was much more compassionate. A urine test did not find crystals in the urine, no bacteria, pH OK. Because crystals had been found, he suggested giving Amie the Hill's canned C/D diet and vitamin C, which is a urinary acidifier. The new vet copied pages from a textbook about stones and allergies. He gave me a Hill's flyer with recipes for homemade foods. He suggested I try feeding Amie acid-producing foods and to test her for allergies with the Elimination Diet. Unfortunately, Amie's urine pH tends fluctuate and my attempts to help her only made matters worse - another example of the reason to discern the type of crystals before prescribing.
Amie was wetting her bed irregularly and I didn't think this was normal. The vet didn't know why. I mentioned that her barking was increased and it was not a behavioral thing. Could it be related to her bed wetting and urinary problem? The vet shrugged and recommended obedience training. (Didn't I just say this wasn't about behavior?)
I asked about her fish breath. The vet shrugged. Why do vets get glassy-eyed (like they may be talking to a nut-case) when I ask about fish breath? It was 1997 that I discovered in an article a connection between human kidney stones and bad breath.
I mentioned that one of my books suggested using sodium sulfate cell salts for alkalinity. The vet had never heard of cell salts. Based on the info the vet gave me I began experimenting with her diet. Acid is needed to absorb calcium. Acid-forming foods include wheat, oats, peanuts, soy, fish (more than meat), eggs, potatoes, lemon.
I happened to have a role of wide spectrum pH paper and began checking her urine pH each time. It was 5 years later that I learned to check pH only of the first urination of the day. In checking every urination I misled myself about the affect of foods on urine pH. When I had researched epilepsy earlier, I found that alkalosis causes twitching. Could her high pHs be related to the twitching?
I thought that giving her all acidifying foods in the proportions of the homemade recipes would stabilize her urine pH at 5.0-6.0 as quickly as the C/D diet. She did not improve and I am relieved to see that I only experimented a day and a half before putting her back on the C/D diet. All my attempts at trying to keep her urine pH low, increased her ability to form stones.
I did learn a great deal about what agrees and doesn't agree with Amie. Her reaction to some foods was instantaneous. By noting her behavior on a log such as disinterest in the food, barkiness, tendency to bite, expression on her face, fever, growliness, I could see what didn't work for her - regardless of the effect on her urine. I was able to correlate a very high pH with her almost shrill barking.
Amie stayed on the C/D diet, but by August she was losing hair from intense scratching. She had a flea infestation that lasted through December. Tests were begun to diagnose her skin problems. I changed dog foods several times, hoping to find one that wouldn't make her itch and would stabilize her urine pH. She would stop itching and forming dandruff but the urinary problem would get worse - as indicated by feverishness, barking and abnormal pH readings. I would switch back to the C/D diet and within a day she would start scratching again.
By January of 1993 her fish breath was strong. The vet said it was probably because of tooth tartar and sold me a pet toothbrush. He also suggested it may be a kidney problem. Because Amie doesn't drink much water, and never has, the vet really did not expect the kidney to be the source of the problem. She was growly and uncomfortable, often moaning softly while she lay on a pillow. Why can't we figure out what is making her sick?
The next month Amie began urinating on rugs. The vet said that dogs test their owners for dominance every now and then. That made sense, because Amie does test us, but I believed this inappropriate placement of her urine was a strong signal that something wasn't right. If she had found just one spot for urinating I might have thought she just wanted another spot, but she was going all over the house.
I started the Elimination Diet several times, trying to get her off the C/D diet long enough to test her for allergy-producing foods. I continued to switch back and forth from the C/D diet to Hill's d/d diet and other "hypoallergenic" dog foods. I kept experimenting with homemade diets I had seen in dog owner manuals and other
sources, always going back to C/D to "manage" her urinary problem. I was starting to be resigned to managing Amie's allergies and urinary problems by switching from a hypoallergenic diet to the C/D when necessary - never having her comfortable with both conditions at the same time. I find it interesting now to discover that Dr. Wendell O. Benfield believes that deficient kidneys can cause skin problems.
By August of 1995 Amie was miserable. Her skin had open sores, she was feverish, she wasn't able to jump on or off the couch (another indication of urinary problems), fish-breathy, growly, barky. I was scared. I was disgusted the last time I saw the vet who shrugged and said, "Sometimes you never figure these things out". Couldn't he see she wasn't well? Where was his compassion now? Why no sense of urgency?
FOUND THE RIGHT VET
I decided to get yet another opinion. My natural food store owner recommended Claudia Lewis, DVM, who happened to in practice nearby. One of the first things Claudia asked was, "When was the last time she had a urinalysis?" Answer:
When I switched to the last vet, several years ago. I felt foolish. I had been trying to find out what was wrong with Amie and her old vet never thought of retesting her so I didn't, either.
A urinalysis was performed.Claudia gave Amie a corticosteroid injection for the skin problem. She prescribed an antibiotic and Ammonil, which is a urine acidifier. It was appropriate that Claudia assume Amie needed an acidifier because on her intake form I reported that Amie's urine pH tended to be high - higher than normal 5.0. Acidifying her urine actually promotes her type of stones. It was my misunderstanding of urine pH and not knowing her type of stones which kept us on the acidifying track for two years. A little knowledge is dangerous.
I continued researching urinary problems in dogs. One source said urinary problems can occur especially in small dogs when it eats dry dog food. It eats to fill itself and then doesn't have room for enough water to help digestion. No vet has had much interest in this theory, but I changed to canned dog foods, anyway, for the water content. Someone told me of her friend's dog, which had the same set of problems and nothing worked. She tried homemade chicken soup with vegetables and the dog improved. That same week on TV I saw a program about research which involved boiled chicken bones helping immune deficiencies. This jibed with my thinking about the nutritional value of whole, natural, freshly produced foods with fresh ingredients. (See Links - Dog Foods)
Amie improved enough to board her for a few days in December but it was obvious to me that this is not a well dog. She would have days where she didn't want to get out of bed, interspersed with short periods of enormous playfulness and enthusiasm. If there hadn't been such a contrast in her mood and activity level, I would have thought she was just a lethargic adult dog. She was put on a new urine acidifier, Methioform.
I researched alternative remedies in pets and humans, but by this time it had been four years since crystals were found in Amie's urine. She was probably beyond the subtleties of naturopathy. An acupressure book showed the urinary system and skin acupressure points. We began pressing those spots when Amie would allow us to.
Someone recommended Bach Flower Remedies, which I have never been able to relate to her symptoms. I read articles on human urinary problems and tried to figure out if the remedies would work for Amie. The homeopathic remedy berberis vulgaris was mentioned in an alternative health book. Basically I decided that I was not willing to guess at dosage, experimenting that way with her life.
I found a vet on the Internet who was stumped about what to do for her diet. He thought her urinary problems might be related to her skin problems and visa versa. He said he wouldn't be surprised if the cause of both was vaccinations. He said acupuncture might work, but it is trial-and-error at best. He made some diet recommendations which did not help either problem.
By the end of March Amie was not feeling well. Claudia prescribed Cephalexin (antibiotic).
May of 1996 Amie had been on the C/D diet for quite a while. She was getting weaker. She was growly, feverish and didn't have enough energy to scratch. I gave her a plate of steamed vegetables, not really expecting that she'd eat it, but she demanded three more plates. Within about an hour she ran to get her ball and played a short while. The change was so dramatic we had to think it was due to her getting some real food.
By mid-May Claudia switched her to Cephalexin. By the end of May she was getting Cloxacillin. Mid-July she was getting dl-Methionine. I began food testing again. Three days after trying a venison-buckwheat groats diet she was much more mellow and comfortable. I was really encouraged. Maybe the diet was fixing both the barking and itching problems.
In August Amie began eating her urine-soaked newspapers. What is this about? She was urinating all over the house again. A urine sample was taken to Claudia. It showed her pH was in the normal range, but there was a bladder infection with lymph and blood in her urine. Claudia sent the sample to the lab. The lab confirmed a bladder infection. Amoxicillin (antibiotic) was prescribed. By mid-August she was still chewing her papers, urinating in the house, throwing up occasionally. She was trembly and growly. She smelled like urine. She was sometimes feverish and often limp and listless. I thought this was the beginning of the end.
The lab found yeast in her urine, which might be a systemic yeast infection, Candidia. She had a strep bacterial infection that wasn't sensitive to the drug we had been giving her. She was put on Vitro, a new antibiotic and Baytril, an antibiotic. Within a day she was eating again - she almost never has appetite problems.
I called the Hill's hotline, but they would not speak with me. Claudia called and it recommended that Amie be put on Prednisone steroids to manage the allergies and indirectly work on the urinary problem.
NARROWING THE SEARCH
Claudia suggested that we take Amie to Michigan State University Veterinary Clinic. First we needed to get abdominal x-rays. Eric Heitman, DVM at the Ottawa Animal Hospital took the x-rays. What a nice man! It was an IVP (intra-venous pyelogram) x-ray in which a dye is injected into the vein so the organs can be seen well on the x-ray. Air is blown into the bladder so any stones can be seen. He said that if Amie had not been such a small dog, the x-rays might not have showed her kidneys and would not have shown a small white spot in the right kidney. It could be a kidney stone or tumor. Amie wet the bed that night, apparently due to the catheterization.
Claudia called the next day to talk about the x-rays and said, "Dogs don't get kidney stones - it's that rare." She said the kidney is the worst place to have stones. Less than 5% of all canine uroliths occur in the kidneys or ureters, but those that do become troublesome. She suspected that the stones were calcium oxalate, because it was found in her urine. She didn't think diet could dissolve the stones. She knew that Hill's did not have a pet food for dissolving calcium oxalate stones. Dissolution therapy only works for struvite stones. Hill's U/D diet will prevent calcium oxalate stones
from recurring, but what to do about the ones already formed?
Claudia said that MSU might decide that Amie should have the kidney removed. Surgery risks serious complications. I asked about a procedure I had seen on the Internet in which stones are sucked through a tube. She said there is no catheter her size. Since stones collect bacteria Amie was kept on an antibiotic (Baytril). Claudia had also seen an article in a vet journal about ultrasound or shock wave therapy (lithotripsy) to break up stones. We would see what MSU had to say.
Claudia talked to Hill's and they said to stop the acidifier and to keep her pH at around 7.0.
Claudia said her urine newspaper chewing may due to anxiety, a nutritional deficiency, or pica, a condition in which animals want to eat something other than food. Amie eats her wet newspapers when she is feeling really poorly.
MSU sent some literature that said to avoid feeding sweet potato, nuts, beans, wheat germ, spinach, or rhubarb because they are oxalate-producing. Meat can help precipitate calcium (not a good thing). The venison diet was working very well for her allergies. She hadn't scratched or itched in over a month. Her coat was thick and clean smelling. I was reluctant to make changes in her diet but I began substituting poultry for the venison.
At the beginning of October Amie was urinating about 6 times a day. Her pH remained stable. She was barky, but willing to go for walks. She didn't want to play ball or jump. In mid-October Claudia spoke with MSU. Dr Cheri Johnson said Amie may have Cushing's disease. She said that her chewing papers indicate liver disease. Since she has improved, antibiotics needed to be stopped a few days before a urine culture could be performed. Blood was drawn. During this time Amie alternated between being playful and having symptoms like vomiting and chewing her
The next week Amie's test results showed no liver damage, but a little anemia. She had an electrolyte imbalance which might Clausia said may have been due to the Pred. The really high calcium level must be caused by something. It can ruin the kidneys and cause stones. Her potassium level was very high, which affects the nerves and heart. She had bacteria in the urine but no crystals or yeast. Dr Johnson recommended a test for Addison's Disease.
Claudia felt the electrolyte imbalance was dangerous. Signs to look for are convulsions, vomiting, diarrhea, severe abdominal pain, disorientation, bleeding in the urine or stool, stress, shock, trouble breathing. Now I was really scared.
AMIE GOES TO COLLEGE
MSU said blood tests showed her kidney indicators were up, but not alarming. Her creatinine level was elevated. Over 75% of the kidney must be non-functional before the dog shows any recognizable signs of illness or abnormal urine or blood tests. Claudia said dogs can function with only 25% of their kidneys. Her urine was not concentrating. Ultrasound imaging x-rays showed a stone (calculi) in her right kidney. She had an Addison's test and other diagnostics. Urine culture and endocrine test results were normal. No Addison's disease, normal kidney structure. (See report.)
For the next few days Amie was hot, like a slug, growly and didn't want to be touched. She was wetting the bed. We bought premature baby diapers, but she walked right out of them. Her incontinence must have been due to the procedures, because she hasn't done that again.
I read that brown rice causes stones to be rejected so one more time I tried rice in her food, but she is allergic.
Claudia found an article in a veterinary journal and called to give me the phone number of the vet at Purdue University who is performing ultrasound on canine kidney stones. She also asked if I wanted to do a Cushing's Test. By now we knew she had a kidney stone. We might as well go straight to the stone doctor and not subject Amie to more tests.
We sent Amie's records to Dr Adams at Purdue. He thought there might be a stone in each kidney and he suspected borderline kidney damage. He said she was a good candidate for lithotripsy. Lithotripsy is ultrasound (Extra-Corporeal Shock Wave Lithotripsy - ESWL) applied to shaved skin that breaks up stones.
The damage caused by a stone depends on its location. About 80% of kidnwy stones pass spontaneously in humans. Stones with jagged edges can lodge in the kidney, ureter or at the outlet to the bladder and must be removed.
Because of Amie's small size and the irregular shape (see Photos) of calcium oxalate stones, surgery can be difficult. Lithotripsy works well on small (less than 2 cm) or single stones and is best if the stone is not located in the lower lobe of the kidney. Ultrasound (lithotripsy) is the ideal treatment because it doesn't require surgery or the same degree of anesthesia.
Amie was scheduled for an evaluation at Purdue on December 12, 1996.
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