Kidney Impairment If Money Grew on Trees – Dr Erik Johnson

Some veterinarians are uncommonly lucky and find a customer with a bottomless bank account, and who are ready to spend “Whatever it takes to give my dog the best chance.”

The operating phrases are

“Whatever it takes”, which is music to the ears of a veterinarian on a commission pay scale. Franchises also appreciate the indication that funds are practically unlimited, but, spending that is a moral and ethical issue corrected by the other operating phrase:
“To give my dog the best chance.” Which causes this ideological dichotomy: Do treatments improve the case outcome? Answer: Possibly even DOUBLE the odds in the dog’s favor. Sometimes taking a dog with a 1% chance of positive long range outcome to a full 2%.

This is the structure of diagnostics and care for a franchise when money is no object. MANY of these tests could be avoided with experience.

At the conclusion of the FIRST DAY in the hospital, the total of all the following is $7,285.00
The attending veterinarian gets $1,092.75 added to their monthly commission check.

First, admission on an emergency basis. After all, “A very high Creatinine is an emergency, is it not? Would you actually have us treat your dog tomorrow just to save an emergency fee?” If it’s truly late or after-hours then the fee is appropriate.

Admission to a specialty service within the organization. Because they have Del Finco. NO. It’s NOT THAT COMPLICATED. However, some of the tests they will want to run have to be conducted by specialists because most regular vets aren’t going to run a ‘double-contrast cysto-urethrograph’ looking for malformation or defects in urinary tract structure contributing to the azotemia.

Bloodwork. (Repeated) Even though the dog JUST HAD bloodwork the rationale is that the referring vet had subpar gear, there was a testing error, the numbers may have changed. Things move fast. We should recheck.

Urinalysis. Not a bad test. This is to see how low the specific gravity is and assess cells or infection. Practical value of this: Maybe you get a cell type or germs, red cells and white cells in a “weird” ratio that suggest the kidneys are infected (pyelonephritis) even IF THE DOG IS WALKING AROUND PRACTICALLY NORMAL. (With pyelonephritis the dogs are rather sick.) A urinalysis isn’t a “bad idea” but if the dog is acting “healthy” then kidney infection is unlikely. On a regular budget you can use an oral antibiotic to “hedge your bet” on infection. But I don’t like to.

Kidney ultrasound – You can see how big the renal pelvis is, and how thick the renal cortex is. You can see stones, PCKD (polycystic kidney disease) and calcification. You can’t do anything about any of those things except remove the kidney stones which is UNLIKELY to be the cause of the azotemia but a $3,000 surgery is good for the bottom line and here’s the wind-up and pitch: “You don’t want o leave those inclusions in the kidney if they could be related to the problem DO YOU?” (Guilt = Cha-ching!)

Actual value of kidney ultrasound: It’s a profitable way to “estimate” kidney function severity and prognosis. A big renal pelvis and a thin renal cortex speak to a poor-doer. HOWEVER you could save $400 and treat the dog ….and if it’s a “poor doer” then you know. A big kidney stone, cancer or hydronephrosis would be “good to know” but are extremely rare, and largely (practically) poorly treatable unless money grew on trees. Treatments would be surgical or chemotherapeutic.

Culture of the blood(stream) to see if there is any version of bacteremia / sepsis causing the kidney problem.

Biopsy of the kidney (A needle called a “Jamshidi” needle can collect a long, thin core sample of the renal cortex for evaluation by a nerd looking for amyloidosis, excess deposition of activation immune-complexes, nephron blockage by cellular ‘ghosts’ (skins) as in the case of a hemolytic crisis. Again, money grows on trees, and if the dog is happy and ‘mostly fine’ this is practically impossible except at franchise practices where money grows on trees.

Reticulocyte % – If the body is killing red cells but regenerating them as fast as the body is killing them, you would have a very high retic percent, and a normal hematocrit. This must be tested to differentiate cell -absence (anemia) from hemolysis or non-synthesis due to a lack of erythropoetin.

Fluid Therapy – Some vets run the fluids under the skin and recheck kidney values after a prescribed time. Franchise veterinarians often hospitalize the pet, and run the fluids using an IV pump and calculations on the fluid requirements for maintenance PLUS-SOME for a dialysis effect. The kidney values are monitored every 4 hours. Extremely thorough, extremely profitable and lets a veterinarian feel “as good as a human doctor” for a day. Fluid therapy is a MAINSTAY of the management of renal disease. Especially at first.

A Cardiac Work Up and Serial Tests of Blood Pressure – The glomerular filtration rate and the kidney function overall is dependent on adequate blood flow and “pressure” at the nephron. It is proftable to measure blood pressure, and do perfusion studies to see that the kidneys are getting proper cardiovascular support. This could be the problem. It is very profitable to go down this rabbit hole. Cardiac echocardiogram can give indicators of cardiac condition and even performance.

Constant measurement of Acid:Base Balance under the heavy, almost “redline” fluid therapy.

Checking for other endocrine disorders. Addison’s Disease for example, which is a thousand-dollar work up between blood checks, baseline and suppression / stimulatory cortisol tests.

All These Treatments

After the initial diagnosis, a wealthy patient may be invited to the clinic for weekly measurement of the reticulocytes and red blood cells. When a kidney is “about done” it’s ability to produce the “erythropoetin” hormone which drives red cell production, which causes a gradual anemia. This is a “real thing” but testing for it a lot is driven by thoroughness and profitability. I would check a HCT “in office” once every 2-3 months “just to be sure” the HCT isn’t dropping. Especially so if the pet appeared pale, out of breath or deteriorating in any way.

Erythropoetin therapy. Yes, if your pet is lucky to live long enough it may require injections of Erythropoetin to make sure it can produce red cells. Yes this actually sometimes happens. You can profitably start this when the HCT drops down below normal. You can conservatively start these injections when the HCT is finally low enough to affect the patient.

Lepto testing. Leptospirosis is a disease that can cause damage to the kidney. MAINLY by ruining the glomerulus with the aggregation of “immune-complexes” Testing for Leptospirosis is a higher priority in younger dogs with unexplained kidney disease. As is PCKD (polycystic kidney disease) which is hereditary. A young dog with kidney failure can’t be linked to “old age” the way a 17 year old dog safely can. In young dogs Lepto, Lyme and other tickborne diseases plus checking for AIHA and PKD are all “good ideas” but even then, experience and other markers would mitigate how many tests of WHAT are really needed?

Clotting Times. The kidney can sometimes release valuable proteins through damaged or elderly nephrons/ glomeruli. Loss of these proteins could deprive the liver of the ingredients for the manufacture of “clotting factors” and so the ability to clot should be assessed if money grows on trees. Or for free, you can see if the dog or cat blood clots in the “red top” or even prick the inside of the lip and see how fast it clots.

Contrast Studies of the kidneys, bladder and ureters, and urethra can detect a blockage in the urinary tract from the kidney all the way down to the opening of the urethra. If there is a blockage anywhere along in there, azotemia could be the result. If you run THIS test on the same day as the other testing “because it’s important to rule out this possibility” you can get that testing revenue BEFORE the diagnosis is revealed by another test. “Yes and as expected the biopsies showed a thinner renal cortex with a decrease in the number and quality of nephrons and a drastically reduced GFR. Run on the same day because we didn’t know it was not necessary, we ran a test of the mechanical patency of the tract and it was fine.”

Sounds good actually.

There are so many additional ways to make money on a kidney case. I don’t even have time for the expanded ideas of tick borne serology as a possible contributor to renal disease, testing for oxalates and oxalate damage (from ingestion of antifreeze without the owners knowledge) testing other organs for evidence of injury from toxins or hypoxia (reperfusion injuries) caused by brief catastrophic drops in blood pressure or partial pressure of oxygen. Glomerular filtration rates.

The FACTS in a case matter based on the prevailing age of the dog, or cat. The prevailing CONDITION of the dog or cat. The HYDRATION when presented for assessment. The presence or absence or co-morbidities like GI signs, appetite loss, anemia, pallor, even ascites.