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Relatively new in the veterinary world, hemodialysis is a highly advanced and potentially life-saving medical treatment to pets with acute kidney failure, including toxin exposures, fulminant infections and ureteral obstructions. Currently, BluePearl Veterinary Partners in Queens is the only veterinary facility in New York City to offer dialysis services for pets.
Consultation with Dr. Christine Iacovetta and Dr. Yuki Tse is encouraged as soon as it is suspected that a patient may benefit from dialysis. Candidacy for dialysis for dogs and cats, prognosis and potential complications will be determined by a brief review of the pet’s history, blood work and current condition.
Dr. Iacovetta or Dr. Tse is available seven days a week to speak with referring veterinarians. Clients are encouraged to have their veterinarian call to refer their pet and provide all available medical history. A knowledgeable staff member can help direct client questions prior to referral if needed.
To discuss a patient’s candidacy for dialysis, or if you have questions, please call (718) 263-0099.
What Is Dialysis?
Dialysis is most frequently used in cases of acute renal failure to remove uremic toxins and maintain normal fluid and electrolyte balance. While dialysis is lifesaving in cases of fulminant kidney disease, it can also be employed early in the course of disease to prevent, rather than reverse, some of the life-threatening complications associated with renal failure. Dialysis therapy does not “fix” an injured kidney, but helps to maintain the patient’s health and prevent suffering while allowing the injured kidney time to heal.
Indications for Hemodialysis
Dialysis is most frequently used to treat renal failure, but is also used successfully to treat acute intoxications (e.g. acetaminophen) and refractory heart failure.
I. RENAL FAILURE – ACUTE
Indications for the use of dialysis in renal failure include both acute and chronic forms of kidney disease.
Uremia, caused by an acute, potentially reversible insult to the kidneys, is by far the most common indication for dialysis in dogs and cats. Dialysis should be considered when the clinical consequences of acute uremia cannot be effectively managed despite the best medical therapy.
Dialysis is an excellent way to maintain the patient’s health during the healing phase of acute renal failure. It is difficult, however, to determine at the onset of treatment how long therapy must continue to allow a patient’s kidney function to improve. In general, with severe renal failure, clients should be financially and emotionally prepared to undertake two to three weeks of dialysis. Many patients, especially those for whom treatment is started early, can transition to an outpatient dialysis schedule that allows the family to play an active role in facilitating recovery.
Common etiologies of acute renal failure that require dialysis include:
• Glomerulonephritis (e.g. Lyme nephritis)
• Nephrotoxins (e.g. ibuprofen, lilies, raisins)
• Preoperative stabilization of ureteral obstruction
• Ischemic injury (e.g. postoperative renal failure)
• Acute renal failure from systemic disease (e.g. pancreatitis or sepsis)
Clear indications to start dialysis include oliguria/ anuria, hyperkalemia and fluid overload. Fluid overload is most commonly detected by increases in weight over the course of several hours or days. Relative indications for dialysis include a creatinine concentration above 5 mg/dl or a steadily increasing creatinine concentration, if the creatinine concentration is below 5 mg/dl.
II. RENAL FAILURE – CHRONIC END-STAGE
Dialysis can be successfully utilized for the treatment of chronic kidney disease, as well. The treatment goals, however, are drastically different compared with those for acute kidney injury. For patients with end-stage chronic kidney disease, the goal of dialysis is to provide an excellent quality of life. Renal transplantation is preferred over chronic dialysis for cats, but the availability and success of transplantation is extremely limited in dogs. Therefore, the majority of chronic dialysis cases are dogs.
Dialysis is also used in the management of acute toxin exposures. Dialysis can hasten the elimination of certain toxins and their metabolites. Typically, only one or two dialysis treatments are needed to remove the offending toxin.
Dialysis has been used in the management of a number of common toxins, including:
• Antifreeze (ethylene glycol)
• Alcohol (ethanol)
Ethylene glycol intoxications should be referred within the first 12 hours of ingestion.
IV. REFRACTORY CONGESTIVE HEART FAILURE
Dialysis can be used to remove excess fluid from patients in congestive heart failure. This form of dialysis is used frequently in people who do not respond to conventional diuretic therapy.
V. THERAPEUTIC PLASMA EXCHANGE
Plasma exchange is the process of filtering and removing the patient’s plasma while returning the rest of the blood components back to them. This technique can be used for certain toxins when they are highly bound to proteins as well as to remove circulating auto-antibodies in immune diseases. In general the treatment for immune disease usually consists of 3 sessions over the course of a week, for intoxications it may be 1 to 2 treatments in the first day or two. Although this adds to the expense of therapy it can limit the need for ongoing blood transfusions, complications from aspiration pneumonia (in the case of Myasthenia Gravis), organ dysfunction from toxic overdoses and the duration of hospitalization which, overall can save costs and/or be life saving.
Cases appropriate to consider:
Immune Mediate Hemolytic Anemia
Highly protein bound toxins/drug overdoses
Other immune disease unresponsive to medical therapy – pemphigus etc
The Patient Experience
The decision to start dialysis for a pet can be financially and emotionally overwhelming, and owners should be prepared to commit to therapy for at least two weeks. Often by the end of a two-week period, or sometimes sooner, it is possible to tell whether a patient’s kidney function is improving. Depending on the patient’s disease process and response to therapy, families can expect their pets to be hospitalized for several days. Families are encouraged to visit during this time.
IF YOU ARE A VETERINARIAN CONSIDERING REFERRAL:
Avoid using the jugular veins in any patient that may be a candidate for dialysis. The blood flow rates necessary to perform dialysis require placement of a large-bore jugular catheter. Dogs and cats have limited options for vascular access, and the jugular veins should be protected if possible. Avoid jugular venipuncture or placing jugular catheters in any patient for whom dialysis is an option.