Chronic renal failure adn acute pancreatitis

Re: Chronic renal failure adn acute pancreatitis

Kara Gibson — Sat, 24 Jan 2015 01:48:32 GMT

Dog continued to deteriorate and ascites became more pronounced so he was PTS.

Re: Chronic renal failure adn acute pancreatitis

Rach — Fri, 23 Jan 2015 23:51:03 GMT

My interpretation of the low Na:K would be that it is caused by hyperkalaemia, the sodium is in the reference range. Hyperkalaemia is apparently quite common in dogs on renal diet and ACEi, as in this case.

Re: Chronic renal failure adn acute pancreatitis

Anthony Todd — Fri, 23 Jan 2015 15:09:46 GMT

What happened and how's the dog?

Re: Chronic renal failure adn acute pancreatitis

Martin Atkinson — Thu, 08 Jan 2015 15:33:41 GMT

Back to the OP. Has anyone thought about Addison's disease in this case with a Na:K ratio of 23?

Re: Chronic renal failure adn acute pancreatitis

Graham Bilbrough — Tue, 06 Jan 2015 22:15:58 GMT

Hi, John

I don't know this study; however, there are plenty that suggest cPL is a useful assay. It is noteworthy that the authors use a cut-off of 200 units for cPL. It would be interesting to repeat the analysis using the recommended cut-off of 400 units. I know some of the authors and I will try and catch them at BSAVA Congress or similar.

Thanks

Graham

Re: Chronic renal failure adn acute pancreatitis

John Flynn — Tue, 06 Jan 2015 21:58:51 GMT

Re SNAP CPL, this conversation has probably occurred on this site elsewhere (and I have no desire to distract from the clinical case being discussed), but I can see very little (if anything) in favour of this over a quantitative "normal" lipase?

Just in case, I looked afresh just now and the only new thing I found (I didn't look hard) was from a ECVIM-CA 2014 abstract and it is hardly likely to change my mind:

"The results of the multifactorial analysis and cPLi assay results were compared to the clinical scores. Using amylase and lipase data alone, the algorithm gave a sensitivity of 81.8% and specificity of 93.3%, compared to cPLi results for the same samples of 63.6% and 86.7% respectively when both methods were referred to clinical scoring."

Re: Chronic renal failure adn acute pancreatitis

Andrew Kent — Tue, 06 Jan 2015 19:21:34 GMT

[quote user="Graham Bilbrough"]I am NOT concerned that the renal failure would influence the result of the SNAP cPL.[/quote]

I would agree that the evidence supports this and probably mis-phrased by initial post - my point was that we don't know with this test whether this is a pancreatitis or whether this is just suggesting a pancreas which is reacting to something else going on in the body.

[quote user="John Flynn"]Not knowledgeable enough to help with the key questions, but is that hyperkalaemia repeatable? Would it be worth a cortisol to rule-out addisons (I appreciate not a classic presentation)?[/quote]

I agree this could be a good thing to do.

Andy

Re: Chronic renal failure adn acute pancreatitis

Graham Bilbrough — Tue, 06 Jan 2015 18:56:13 GMT

Hi, Kara

I am NOT concerned that the renal failure would influence the result of the SNAP cPL. However, without the quantification of Spec cPL, we cannot firmly conclude the patient has pancreatitis. What was the density of the sample 'spot'? The SNAP device gives an 'abnormal' result when the cPL concentration is greater than 200 units ie. the concentration is abnormally high. We avoid the term 'positive'. However, we state that a concentration greater than 400 units is consistent with pancreatitis.

http://www.idexx.co.uk/pdf/en_gb/smallanimal/snap/cpl/snap-cpl-accuracy-white-paper.pdf

If you want more details, we can chat on the 'phone.

All best wishes

Graham

Re: Chronic renal failure adn acute pancreatitis

John Flynn — Tue, 06 Jan 2015 18:52:28 GMT

Not knowledgeable enough to help with the key questions, but is that hyperkalaemia repeatable? Would it be worth a cortisol to rule-out addisons (I appreciate not a classic presentation)?

Re: Chronic renal failure adn acute pancreatitis

Anthony Todd — Tue, 06 Jan 2015 18:02:14 GMT

What do people think are the chances of recovery to "home and happy"?

When is the point reached when someone asks "Is further treatment fair to the dog?"

Re: Chronic renal failure adn acute pancreatitis

Andrew Kent — Tue, 06 Jan 2015 11:21:23 GMT

Does the ultrasound of the GI tract look thickened or is there any loss of layering? I would wonder, with the findings you describe, whether there could be a GI tumour rather than just a gastritis. This could then be poorly responsive to medication plus potentially GI bleeding contributing to your raised urea.

If you can't control his nausea/improve his motility then it may be difficult to manage him. I would give the metoclopramide by CRI and potentially add ranitidine as another pro-kinetic also. Then we really need to start getting some food into him, would he tolerate a feeding tube?

The other thing to consider with your free fluid and falling albumin would be a sepsis (perhaps secondary to your GI wall abnormalities) so if the amount of abdominal fluid increases or is accessible a tap might be a good idea.

Andy

Re: Chronic renal failure adn acute pancreatitis

Kara Gibson — Tue, 06 Jan 2015 10:36:42 GMT

Thanks for your prompt reply.

He does look like he has pancreatitis and this is confirmed by ultrasound he also now has profound gastric ileus and the upper gastrointestinal wall is increasing in thickness. His urine from yesterday had pro ++ (no UPC run) and USG 1.018 and has been on fortekor long term for proteinuria. Currently he looks very sick and regularly vomits some fluid from his stomach which on US is full of fluid and not emptying. He is passing urine adequately. He is also on sucralfate, aluminium hydroxide, synulox, buprenorphine, maropitant and metoclopramide. Up until he became ill he was on renal food but we have been offering him GD in the hospital as it is lower fat, however he is completely inappetant. I think the picture looks pretty poor for him (he has been in hospital 4 days and is deteriorating despite treatment).

Re: Chronic renal failure adn acute pancreatitis

Kara Gibson — Tue, 06 Jan 2015 10:36:41 GMT

Thanks for your prompt reply.

Re: Chronic renal failure adn acute pancreatitis

Andrew Kent — Tue, 06 Jan 2015 10:12:45 GMT

Thanks Kara. I would not give this dog colloids at the moment, the albumin is not low enough to be causing ascites on its own so I would think there is another mechanism at play. Equally the fact that his albumin is much lower than his globulin is making me think this may be renal protein loss.

Does the dog clinically look like it has pancreatitis? We have to be a bit careful with the snap cPLI in this context as I would worry it could be false elevation due to the renal disease.

Is the urine output reasonable? Or is there any possibility the dog is becoming oliguric?

I would get a urine sample here for sediment exam and perform a UPC. I think blood pressure would be a good idea also.

What diet is he currently on? and is he receiving any medication?

Andy

Re: Chronic renal failure adn acute pancreatitis

Kara Gibson — Tue, 06 Jan 2015 09:08:07 GMT

Hi Andy,

Initial bloods:

CBC:

Hct 35 (37-55)

Hgb 12 (12-18)

MCHC 34.3 (30-36.9)

Retic 1.1%

WBC 18.5 (6-16.9)

Grans 16.9 (3.3-12)

L/M 1.6 (1.1-6.3)

Plt 507 (175-500)

Biochem:

Glu 4.9 (3.89-7.94)

Urea 34.7 (2.5-9.6)

Crea 384 (44-159)

Phos 3.44 (0.81-2.19)

Ca 2.66 (1.98-3)

TP 47 (52-82)

Alb 23 (22-39)

Glob 24 (25-45)

ALT 45 (10-100)

ALKP 72 (23-212)

TBIL <2 (0-15)

Chol 3.8 (2.84-8.27)

Amyl 1069 (500-1500)

Na 155 (144-160)

K 6.6 (3.5 - 5.8)

Cl 121 (109-122)

In house Idexx snap CPL strong positive

Yesterday some of the biochem parameters were repeated:

TP 43, alb 18, glob 25

PO4 2.73

Urea 34.9 crea 221

Today his protein area as follows:

TP 40 (52-82)

Alb 16 (22-39)

Glob 24 (25-45)

He has been managed for chronic renal failure since April 2014 and has had a couple of acute flare ups that have required hospitalization (but never confirmed pancreatitis before despite checking).

Re: Chronic renal failure adn acute pancreatitis

Andrew Kent — Tue, 06 Jan 2015 08:49:58 GMT

Hi Kara,

Could you post his blood and urine results?

Andy