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Ask Dr. Michael Salkin Your Own Question
Dr. Michael Salkin
Dr. Michael Salkin, Veterinarian
Category: Dog
Satisfied Customers: 32817
Experience:  University of California at Davis graduate veterinarian with 45 years of experience.
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Our dog age 6, has just passed way with renal failure. Upon

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Our dog age 6, has just passed way with renal failure. Upon looking at her records at the vets, we found that she seems to have had signs of kidney disease prior to this.
I.e. Jan '11 BUN 11,Ca 3.05 Crea 178
Dec'11 BUN 11 Ca 3.25 Crea 242 Amylase 1377
July '12 BUN. 16 Crea 289

She had partial seizures since the age of two and we had requested blood tests to check on her health.
Should we have been told about this?

Aloha! You're speaking to Dr. Michael Salkin
My condolences for your loss of Bracken. I need for you to please tell me whether test results are in common or international units. For example, is the BUN of 11 and calcium of 3.05 in mg/dL or mmol/L? The creatinine is most assuredly in mmol/L.

Do you also have urinalysis results which you can post?

Customer: replied 4 years ago.
I can only report the number in brackets which I guess are the normal ranges. Perhaps that would help.

These appear after blood tests, so I guess they reported only the abnormal results.
Thank you for the additional information. I went ahead and changed everything into international units. To answer your question directly, then, yes, you should have been apprised of the fact that there was a progressive increase in the creatinine which was already abnormally increased in January 11. The BUN, however, was normal until July 12, but isn't as accurate an indicator of the glomerular filtration rate (the best assessment of how well the kidneys are functioning) as is the creatinine. The two calciums were elevated which are unfavorable prognostic findings if primary renal disease exists. Calcium also increases secondary to malignancy and hyperparathyroidism, however. It's important to perform urinalyses concomitant with these blood tests in order to clarify if the abnormal blood tests are due to pre-renal disorders (such as those that reduce blood supply to the kidneys) or due to disease in the kidneys themselves.

I would pleased to review any other test results you might have. Please respond with further questions or concerns if you wish.
Customer: replied 4 years ago.
In September of last year she was itching. The vet gave her Dexafort (by injection) and repeated that4 weeks later. It was after that that the bones in her face became enlarged. (One side). She seemed to go downhill from there.
The Dexafort is an antihistaminic corticosteroid. Steroids can certainly exacerbate renal disease but if the bones in her face enlarged, I would have to assume that malignancy was involved. Were you told why her bones enlarged?
Customer: replied 4 years ago.
Well the vet first suggested that she had an abscess which had affected the bones and he gave an antibiotic. She was quite low after that. We then took her records to another vet who said she was in renal failure (no tests) and the hypertrophy (?) of her face was due to secondary renal hyperparathyroidism!
Now, we are so confused. I think we need to know exactly how she died and whether we could have done more. When we took her to the vet simply itching, she seemed to be healthy . We knew no more!

We might see skull and jaw lesions ("rubber jaw") in growing dogs with renal secondary hyperparathyroidism but this isn't something we expect to see in the adult - much less facial swelling due to this type of hyperparathyroidism. X-rays of her face should have been taken as soon as her face changed. They would have shown diffuse demineralization if hyperparathyroidism were responsible but either bone lysis or proliferation if cancer were present. A urinalysis as soon as the abnormal creatinine and calcium were found in January 11 was essential and I would have performed PTH and PTHrP blood tests to see the parathyroid glands were involved in renal disease or a malignancy causing hypercalcemia.

The major problem I see is that Bracken wasn't addressed properly as long as 2 years ago. Now we're faced with trying to clarify why she died without having the necessary tools to do so. We're left with necropsying her at this point but she would have had to be refrigerated and necropsied within a day or so post-mortem. I regret that I can't be more specific for you. There's simply too much information missing.


answer to duplicate post: yes, I agree that neither the antibiotics nor corticosteroid were responsible for her renal failure. There was evidence of renal failure far earlier as mentioned above. Please stay in this conversation if you wish to consult further. I marked your new post as a duplicate as ordered by my moderator. This avoids your being charged twice.

Please continue our conversation if you wish.

Customer: replied 4 years ago.

I understand the problem. We were only ever told that the blood tests were fine, so we couldn't do any more. It certainly seems that she was ill and the anti inflammatories and antibiotics could not have caused the renal failure. Would you agree?

That's puzzling. The blood tests were clearly not fine. Correct, the antiinflammatories and antibiotics didn't cause her renal failure.
Customer: replied 4 years ago.
Sorry to persist, but I need to be clearer in my mind. She definitely had the "rubber jaw" as I understand it. She had a mouth ulcer and her teeth became loose at the end. Would such a condition have been brewing over a year or so, or would something have provoked it?
Would her renal condition have suddenly developed into acute renal failure virtually in December ? She was so ill at the end and yet in August /September she seemed so fit and healthy.
It takes quite a while for secondary renal hyperparathyroidism to develop so, yes, chronic renal failure was present - as was evidenced by her tests as far back as January 11. Oral ulcers are common with chronic renal failure.

Yes, it's called "acute on chronic" when our patients peracutely (suddenly) worsen when suffering a chronic disease process.
Customer: replied 4 years ago.
Is it possible then that the hypearathyroidism could have been inherited? She seems so young to have developed this.
Secondary renal hyperparathyroidism isn't inherited but something like renal dysplasia - poorly formed kidneys at birth - are seen. Curiously, I just had a conversation with my professor of long ago who in the course of conversation mentioned that he hadn't seen rubber jaw associated with secondary renal hyperparathyroidism in many, many years. This is because diets have improved so much as has our knowledge of the disease.

I can't understand why obviously abnormal test results were interpreted as being "fine" - not once but also in subsequent testing.
Customer: replied 4 years ago.
We find it hard to believe. We called each time for the results of the tests and were told they were"fine". However they appear to have entered the abnormal signs onto her records. Obviously we didn't see the records until we changed vets at the end!
We just wish we had known.
I'm sure that you find this as unacceptable as I. If you're so inclined, addressing the vet with your concern about the test results would be my next step and if you weren't given a reasonable explanation for the vet's interpretation of those results, it would be prudent to consult peer review of the veterinary association to which the vet belongs. We can't bring Bracken back but we might avoid further malpractice in the future.
Customer: replied 4 years ago.
We probably should do that , as you say, to avoid this happening to any other dog. Should we acquire another dog , we have decided that we would as for the full results of any test together with normal ranges, so that we would be armed with some knowledge. I am a teacher and not a vet, but I have recently gained so much knowledge in this area. As owners we trust the vet and this is where we went wrong.
We are devastated over the loss of Bracken, as are many local dog walkers. We keep blaming ourselves and wishing we could have done more. ( My husband had a heart attack two days after she died. He's ok now). Our last dog died aged 14 and we found that easier to accept.
I understand. You're not expected to need to question your professionals but a healthy dose of skepticism can be prudent.

If you have questions or concerns as you proceed please let me know.
Customer: replied 4 years ago.
It would be interesting to know how he would have proceeded if we had stayed with him in October when she was just itching.
Indeed. Far from me to look into the minds of other vets. As past head of peer review for my veterinary association I found levels of care to be everything from exemplary to in any profession, I expect.
Customer: replied 4 years ago.
Yes, I would agree with you there. Thank you so much for your help at this time. I will endeavour to let you know how things develop. I have noted your name. Shall I just return to this site to make contact?
Yvonne Beston

Yes, Yvonne, you're welcome to return to our conversation even after rating. If you happen to lose me you can always request me through my profile here:

You're quite welcome.
Dr. Michael Salkin and other Dog Specialists are ready to help you
Customer: replied 4 years ago.
Many thanks.
All the best
Thank you for your kind accept. I appreciate it.

You may receive an inappropriate follow up from the site ostensibly from me. It wasn't and I apologize in advance should you receive it.

Please disregard the info request.