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Diagnosis and management of canine chronic kidney disease due to Ehrlichia

canis

Article · January 2017

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 SKUAST Journal of Research 19(1): 160-163; (2017) Case Series

Diagnosis and management of Ehrlichia canis associated chronic kidney disease

(CKD) in three Labrador dogs

Sahiba Mann1, S.K. Uppal1, S.A. Hussain1* and L.D. Singla2

1
Department of Veterinary Medicine, 2Department of Veterinary Parasitology
Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141 004 (India)
*Division of Clinical Veterinary Medicine, Ethics and Jurisprudence, Faculty of Veterinary Sciences and
Animal Husbandry, Sher-e-Kashmir University of Agricultural Science and Technology of Kashmir-
Shuhama, Alusteng, Srinagar-190 006, Jammu and Kashmir (India)
*e-mail: draashiqhussain@gmail.com

(Received 25 April, 2016; revised received 06 January, 2017; accepted 29 January, 2017)

Renal failure may develop subsequent to acute kidney injury or chronic kidney disease (CKD). CKD may be
characterized by a wide spectrum of lesions; minor structural defect in one kidney to extensive loss of
nephrons affecting both the kidneys (Polzin, 2011). Although prevalence of E. canis is quite high in Punjab,
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but has not been associated with CKD in canines. The present report describes the features of CKD in three
Labrador dogs affected with ehrlichiosis.
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Case Presentation: The present study was undertaken at Department of Veterinary Medicine and Small
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Animal Clinic, Teaching Veterinary Hospital, Guru Angad Dev Veterinary and Animal Sciences University,
Ludhiana. During the year 2013, 41 from a total of 12814 dogs presented with specific complaints indicative
of renal insufficiency were subjected to detailed clinical examination and laboratory evaluation.
Case 1: A five year old female Labrador was presented with history of recurrent episodes of fever
(>104oF), vomition (4-5 times a day), polyuria and polydipsia from six days. The dog was anorectic from last
four days and had slight melena. There was no known history of tick infestation. The dog had been fully
vaccinated and dewormed, and was being fed a non-vegetarian diet. Symptomatic treatment by owner has
9%), had poor body
condition and pale mucous membranes. Rectal temperatures (105.6 o 2 sec), heart
rate (120 beats/min), respiration rate (40/min) were elevated and auscultation of lungs revealed mild crackles.
Both blood smear and dot ELISA were positive for E. canis. The findings of hematology, biochemical
analysis, blood acid base gas analysis and blood pressure measurements are presented in Tables 1 and 2.
Systolic as well as diastolic blood pressures were measured using an oscillometer (Surgivet) from the radial
as well femoral artery each and an average of the two readings was taken.
Case 2: This case was of a 4.5 year old female Labrador having history of fever (>104oF), tick
infestation, polyuria and polydipsia from 10 days. The dog had been fully vaccinated and dewormed. The
diet of the dog was non-vegetarian but the dog was anorectic from last seven days. The dog had been treated
symptomatically without any favorable response except temporary decrease in body temperature.
8%), severely anemic and had poor body
condition. Similar to first case rectal temperatures (103.2 o 2 sec), heart rate (110
beats/min), respiration rate (45/min) were elevated. Blood smear was negative while dot ELISA for E canis
was positive. The blood pressure measurements and laboratory evaluation findings are presented in Tables 1
and 2.
Case 3: Third dog was a fully vaccinated six year old male Labrador. The dog had history of fever
(>104oF), tick infestation, polyuria and polydipsia from 7 days, and anorexia from six days. Although
symptomatic treatment had resulted in temporary decrease in body temperature but the dog had developed
melena. Clinical examination revealed poor body condition, dullness, kyphosis, severe dehydration ( 10%)
and pale mucous membranes. Similar to other two cases the physical examination parameters were abnormal
(rectal temperatures (103oF), capillary refill time ( 2 sec), heart rate (120 beats/min) and respiration rate
(42/min). Blood smear examination did not reveal any E. canis but dot ELISA was positive. The findings of
hemato-biochemical and blood acid base gas analysis, and blood pressure measurements are presented in
Tables 1 and 2.
 Diagnosis and management of E. canis associated CKD in dogs 161

Table 1: Hemato- biochemical of three dogs with E. canis induced CKD on the day of presentation
(Day 0) and after treatment
Post treatment
Reference Day 0
Parameter Day 15 Day 30
range
Case 1 Case 2 Case 3 Case 1 Case 2 Case 3 Case 1 Case 2 Case 3
Hemoglobin (g/dL) 11.9-18.9 8.3 2.8 3.6 11.2 4 8.6 11.8 5.2 7.3
PCV (%) 35-57 22.4 10.8 11 36.2 14.2 296 38.0 15.0 20.7
WBC (×103/μL 5-14.1 5.04 5.4 4.9 7.5 10.4 3.9 8.7 12.6 4.2
Neutrophils (%) 58-85 84 90 88 82 84 80 74 78 75
Lymphocytes (%) 8-21 16 10 12 17 16 20 24 18 25
Platelets (×103/μL 211-621 156 101 29 196 183 155 350 304 101
TEC (×106/μL 4.95-7.87 3.24 1.9 2.34 3.61 3.2 4.2 5.4 4.8 3.8
BUN (mg/dL) 8-28 62 48 45 52 40 130 38 34 99
Creatinine (mg/dL) 0.5-1.7 5.1 3.7 4.2 4.3 3.1 8 3.1 2.8 10
Total Protein (g/dL) 5.4-7.5 6.7 5.6 8 6.4 6.3 6.7 6.6 5.9 7.1
Albumin (g/dL) 2.3-3.1 1.9 1.4 2 2.2 1.8 2 2.3 1.4 2.8
Globulin (g/dL) 2.7-4.4 4.8 4.2 6 4.4 4.5 4.7 4.3 4.5 4.3
ALT (U/L) 10-109 152 95 96 135 159 150 121 109 145
ALP (U/L) 1-114 234 256 167 201 254 240 127 129 363
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Bilirubin (mg/dL) 0-0.3 0.5 0.5 0.4 0.4 0.4 0.9 0.1 0.3 0.8
Calcium (mg/dL) 9.1-11.7 12 9.7 8 11.2 10.7 11 11.4 10.7 12.8
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Phosphorus(mg/dL) 2.9-5.3 11 6.9 8 8.6 7.3 12 5.2 4.9 12.4

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Magnesium (mg/dL) 1.6-2.4 1.2 1.8 2.1 1.3 2 1.1 1.2 1.9 1
Glucose (mg/dL) 76-119 100 70 80 95 75 120 98 72 118
Cholesterol (mg/dL) 135-278 160 125 150 175 110 158 164 103 160
Triglyceride (mg/dL) - 80 31 57 50 80 94 82
Sodium (mmol/L) 142-152 145 166 156 150 148 143 143 181 141
Potassium(mmol/L) 3.9-5.1 4 3.7 5 4.4 4.5 5 4.2 4 4
Chloride (mmol/L) 110-124 111 125 115 118 113 112 116 132 101
Medical Management: Oxytetracycline hydrochloride (20 mg/kg, IV) stat followed by tab.
doxycycline (10mg/kg, OD) up to 5 days after the dogs were negative for E. canis. All these dogs were also
infused Lactated Ringers solution (15-20 ml/kg), furosemide (2-6 mg/kg, bid I/V) metoclopramide (0.2-0.4
mg/kg, I/M bid), and ranitidine (2 mg/kg, bid, I/M). Maintenance fluids were continued intravenously at 40-
60ml/kg/day. Aluminum hydroxide containing phosphate binder (30-60 mg/kg/day) was prescribed in
installments along with the meals. Once the patients regained appetite, they were advised the following
homemade renal diet: 1 cup boiled rice/1.5 cups boiled potatoes, ½ egg/ ½ cup cooked chicken, ½ tbsp fat
(ghee, malai, butter), 1 tab containing Calcium carbonate (500 mg) plus Vitamin D (250 IU), ½ tbsp B-
complex multi-vitamins syrup, ½ capsule containing omega-3 fatty acids and ½ capsule vitamin E.
Ehrlichiosis was responsible for 7.3% (3/41) of the dogs with CKD, but the prevalence among the total
number of dogs presented for treatment during year 2013 was low (0.02%, 3/12814). The findings like high
grade fever, anemia and pancytopenia were prominent in dogs with E. canis infection. Polyuria, polydipsia
and weight loss are the specific symptoms of CKD (Heine and Here, 2007; Roberrtson and Seguin, 2013).
The blood smear examination lacks sensitivity as very less numbers of E canis organisms can be
demonstrated. It is important to mention that without the use of dot ELSIA E. canis infection in these dogs
would have not been possible. Dot ELISA test was negative in all the three dogs on day 15 of treatment,
indicating effectiveness of the modality.
Hemato-biochemical analysis revealed non-regenerative-normocytic-normochromic anemia,
leucopenia, thrombocytopenia, slight liver dysfunction and moderate to severe increase in BUN and
creatinine. On the basis of International Renal Interest Society guidelines (Stage 2: serum creatinine =
1.4-2.0mg/dl; stage 3: serum creatinine = 2.1-5.0mg/dl; stage 4: serum creatinine > 5.0mg/dl), first case had
stage 4 and other two dogs had stage 3 CKD. Other biochemical parameters were within the normal reference
range except altered Ca: P ratio. Lack of awareness among the owners about the importance of regular health
screening of their pets may be the reason for presentation of the animals in the late stage of the diseases.
(Ahmad et al., 2001) reported secondary immune mediated hemolytic anemia in E. canis positive dogs.
 162 Sahiba Mann et al.

However, they did not notice CKD in E. canis positive dogs. E. canis probably causes immune-mediated
damage to the glomerular basement membrane of nephrons leading to renal failure.
Table 2: Blood gas parameters, blood pressure and UP: UC ratio of three dogs with E. canis induced
CKD on day of presentation (Day 0) and after treatment
Post treatment
Day 0
Reference Day 15 Day 30
Parameter
range
Case 1 Case 2 Case 3 Case 1 Case 2 Case 3 Case 1 Case 2 Case 3
pH 7.31-7.42 7.24 7.30 7.24 7.34 7.36 7.28 7.34 7.36 7.25
pCO2 (mmHg) 29-42 28 19 24 34 36 26 38 35 23
HCO3 (mEq/L) 17-24 17.2 12.4 15.4 19.8 20.2 15.2 20 22 12.4
pO2 (mmHg) 85-95 65 55 60 86 88 76 91 90 65
Systolic BP <150 130 110 142 120 112 152 125 116 160
Diastolic BP <95 87 60 90 85 65 95 86 72 100
UP:UC ratio <0.2 0.156 0.142 0.180 0.152 0.144 0.34 0.148 0.146 0.58
The blood gas analysis of the cases described here revealed metabolic acidosis with compensatory
respiratory alkalosis. One of the dogs i.e. case 3, developed hypertension over a period of one month
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(Table 2) which may be attributed to decreased capacity of the kidney to excrete solution, resulting in an
increase in salt sensitivity. This mechanism for hypertension is particularly important in patients with end-
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stage renal disease with extreme reduction in glomerular filtration rate.

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In all three cases, urinalysis revealed normal specific gravity (1.016-1.02) and pH of 5.5, 6 and 5.5,
respectively. Only few urate crystals (case 1) and epithelial and pus cell casts (case 3) were detected.
Subsequent urine examination revealed proteinuria and pus cell casts in case 3. In the present study, the
proteinuria was moderate on day 15 that increased further up to 30th day of treatment indicating deterioration
of the condition in one dog (case 3).
Management of late stage II and stage III is routinely done by the use of dietary modification,
phosphorus restriction, anti-protienurics (ACE-inhibitors and Omega-3 Fatty acids) as well as anti-
hypertensive drugs. Animals in an advanced stage (III and IV) are treated with fluid therapy to compensate
dehydration and electrolyte loss, antacids and anti-emetics and management of acidosis (Grauer, 2009). The
treatment protocol in present cases was as per the above guidelines. The treatment resulted in a favourable
response in case 1 and 2 evident clinically and on laboratory evaluation (Tables 1 and 2). The favorable
response was indicated by a progressive increase in Hb, PCV, platelet count, WBC, blood pH, pCO 2, pO2 and
decrease in azotemia, liver enzymes, phosphorus and HCO 3.
Although case 3 responded to treatment for first 10 days but its condition deteriorated suddenly later.
(Table 1). Benazipril (0.5 mg/kg, od, per os) was added to treatment protocol but the dog died on day 36 th of
treatment. In a study (Troy et al., 1980) on 30 dogs with ehrlichiosis, one dog died as a consequence of renal
failure.
Both the remaining dogs made an uneventful recovery and were doing well up to 7 months of follow up.
Their owners were advised to continue the feeding of the renal specific diet only.
Owing to the high prevalence of E. canis in this area, inclusion of E. canis infection in the list of
etiology for CKD in dogs is suggested.
_______________________
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 Diagnosis and management of E. canis associated CKD in dogs 163

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