Caring For Our Dog (Shih Tzu) With Chronic Kidney Disease (CKD)

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Disclaimer: This post should not be considered medical advice. Please consult with a trained veterinarian and pet nutritionist when deciding how to best care for your pet.

In January 2022 Ralphie was diagnosed with Chronic Kidney Disease (CKD) and my husband and I were devastated. I joined a few Facebook Groups about managing CKD and many of the posts I read in the CKD Facebook Group made the disease sound hopeless. It’s mentally and emotionally draining caring for our dog with CKD so I haven’t been online as much. Since the initial diagnosis Ralphie has remained stable at Iris Stage 2 with a low protein diet. I’m grateful that I have the flexibility to work from home to ensure that he eats and takes his medications on schedule. After the most recent visit the vet said that we can follow up in 4-6 months now that his values are stable.

EARLY WARNING SIGNS

Ralphie is our first dog so we didn’t realize his gradual change in appetite was a sign that something wasn’t quite right. We thought we were dealing with a picky eater as Ralphie went from a puppy with a ravenous appetite to a progressively finicky eater as an adult dog. Oftentimes before the CKD diagnosis and switch to a low protein diet we had to hand feed him to get him started and/or to help him finish his meals.

Ralphie prefers eating on a flat surface such as a silicone mat. He gobbles up his dinner within 2 minutes. I was slow to take a good picture since he’s almost done here.

My husband was the one that noticed that Ralphie prefers to eat on a flat surface versus out of a raised bowl. At one point he also took to eating best on top of our bed so I would lay down a towel so that he wouldn’t get food all over. We did break him of this latter habit since he eats well anywhere now including in the car if we’re out. I have to remember to pack one of his silicone feeding mats in the cooler with his food because he still refuses to eat out of a bowl.

Occasionally he would lick the air which is a sign of nausea. He also started drinking a lot of water especially at night (which I thought was due to the dry winter heat) and he was producing large volumes of urine. We never restricted his access to water at night which is good because he needs to stay hydrated with his condition. We always ensure that he has plenty of fresh water and he has 3 water bowls filled at all times around our condo.

It’s helpful that Ralphie is trained to go outside as well as indoors so that his bladder is relieved especially during inclement weather. If he needs to pee outside of his scheduled walks he will go into the playpen with the pee pad on his own or he’ll go potty if I ask him to go (he will also whine if he doesn’t really have to go yet). At his stage of CKD he hasn’t had any accidents and he still has good bladder control so he prefers to hold it until we go outside for a walk. (Here is his current potty setup and these Prince training pads from boxed.com are very absorbent and often sold out.)

OFFICIAL DIAGNOSIS

On the day after Christmas (2021) we brought Ralphie to the emergency vet because we noticed some blood on the tip of his penis (below) and a small pool of blood in the spot where he’d been napping on the sofa. An NSAID panel showed elevated kidney values (BUN 41, Creatinine 2.3), trace protein and low urine specific gravity (1.010). An x-ray ruled out visible kidney stones. The emergency vet gave him fluids and they offered to keep him overnight with fluid therapy but we opted to care for him at home with antibiotics (Clavamox) to treat a possible infection.

We followed up with our regular vet as recommended after a week on the antibiotics to re-check Ralphie’s kidney levels and this time they collected a sterile urine sample. Unfortunately, his kidney levels were still elevated (BUN 46, Creatinine 1.9) on January 6th. Follow up full blood work in late January indicated a loss of kidney function which they determined to be chronic (versus acute).

Ralphie’s ultrasound images (above) show normal size kidneys but they are irregular in their overall shape. (Renal dysplasia is known to affect Shih Tzus more than other breeds.) Based on his young age the Internal Medicine Specialist said that he was born with irregular kidneys (congenital malformation). The specialist also noted some cysts with the largest being 1cm in diameter.

We wanted to know how long would we have with Ralphie at Stage 2 but the Specialist said that they couldn’t give us a time frame. They reassured us that some dogs can surprise us with how well they do on the right diet especially for someone as young as Ralphie. They recommended working with a nutritionist as soon as possible since a balanced, low protein diet would help protect his remaining kidney function.

I obsessively dug through posts in the CKD Facebook group and I felt more hopeful and informed after reading advice from dog owners who managed the disease for years. It was like searching for a needle in a haystack but 8 years is the longest I could find for an owner whose dog was diagnosed at a young age. Based on recent comments  in the group their dog is still stable with early stage CKD. However, 8 years is an exception rather than the norm. More experienced owners even said that when the disease is managed and stable their senior dogs passed due to other reasons/conditions.

Prior to securing a nutritionist I introduced kefir to Ralphie’s diet in January after reading this article. Within a few days Ralphie’s appetite returned and he began to eat all of his meals voluntarily. I also looked into low protein and kidney friendly treats. I tried giving him a little bit of freeze dried green tripe (2 grams) after reading that it’s a good treat for picky eaters on various resources including Dog Aware. (The nutritionist suggested that I cut out the freeze dried green tripe since it’s raw but I still give him a little bit since it helps with his tear stains.) Previously we spent a lot on various brands of dog food (his favorite was Stewart Raw Naturals Freeze Dried Dog Food in the beef flavor) and treats but I had to give away all of the dog food and most of his treats because they were all high in protein.

Following the official diagnosis for CKD, I  reached out to several nutritionists listed on the American College of Veterinary Nutrition site at the beginning of February. Only one nutritionist responded to my inquiry within a few business days. (Another nutritionist also responded much later to say she was fully booked but the email somehow ended up in my junk folder). After completing a detailed questionnaire and a 1 hour virtual consultation in mid February, the nutritionist produced a customized low protein home cooked diet as well as a prescription for various brands of renal kibble in early March.

KIDNEY FRIENDLY DIET

Oxo Tot Glass Block Food Containers (10%/30 calorie treat allowance not pictured)

Ralphie’s home cooked diet allows for 300 calories (per daily
recipe: 302 kcal/day; 23.7% protein calories, 27.6% fat calories, 48.6% carbohydrate calories. 1.167
kcal/gram, 73% moisture) plus an additional 10% treat allowance. The home cooked recipe requires me to supplement his diet with Balance IT Canine K Plus supplements, Nordic Naturals Algae Omega, melted chicken fat and vegetable oil. Meal prep for the home cooked diet is very meticulous since you have to weigh and then portion out everything using a gram scale.

PROTEINURIA

A low protein diet is not meant for growing or healthy dogs but for reference Ralphie’s low protein diet contains 50 grams of chicken (thigh cut) which is about 13 grams of protein. I came across plenty of arguments that protein reduction doesn’t change the rate of progression in the progression of renal/kidney disease in my research to better understand how to manage the disease. However, a low protein diet has helped manage Ralphie’s proteinuria and his latest results hover between negative and trace whenever I recheck the values using these reagent urine test strips. Ralphie’s last urinalysis was in April and our vet said that it wasn’t necessary to continue monthly urinalysis since his values have stabilized. I opted to purchase the urine test strips to check the protein in urine for my own peace of mind even though they’re not a replacement for a urinalysis.

Pet Urine test strips (reviewed here)

CURRENT MEDICATIONS & SUPPLEMENTS

Ralphie started taking Semintra in April 2022 to manage hypertension (high blood pressure) which can further damage impaired kidneys and lead to disease progression. At 0.75ml daily each 10 mg/ml bottle is $118.95 through our vet and lasts about 7 weeks.

The vet also prescribed Omeprazole ($47.95 for 30ml + extra for special shipping and handling since it arrives packed in ice) as an acid reducer in May 2022 since the blood work indicated internal bleeding which they said was likely due to ulcers. I keep daily notes and the issue with the blood in his ejaculate (the original reason we brought him to the emergency vet in December 2021) has not recurred since mid-June.

Omeprazole works by reducing the amount of acid that your stomach produces. I noticed that the peas and larger pieces of sweet potatoes in his diet were whole/undigested in his stool the next day and even a few days later after one 0.5ml dose. I started chopping the peas and sweet potatoes into smaller pieces and it took about 2 weeks for his stools to return to normal. 

I introduced Omeprazole to Ralphie’s diet slowly at starting at 0.25ml (half the dose) once a day. Initially I tried to give him the full dose (0.5ml every 12 hours) as prescribed by the vet but the smell of the food when I set it down triggered him to throw up. When he managed to eat he couldn’t keep down the food and he would regurgitate not long after he ate. Slowly increasing the dosage of the new medication helped his body tolerate it without the unwanted side effect of regurgitation. Once I noticed that his stool returned to normal (which took about 2 weeks) I increased the dose by 0.05ml. He is currently taking 0.5ml in the morning and 0.35ml of Omeprazole in the evening since starting on Omeprazole in May. I recently increased the evening dose by 0.05ml (from 0.30ml to 0.35ml) on September 17th and he ended up regurgitating his meal. He also seemed a bit nauseous since he started to lick the air again but he’s almost back to his normal self as his body adjusts to the increased evening dose of Omeprazole.  

I hand feed Ralphie the Balance IT supplements ($53.35) mixed with unflavored kefir since the I noticed that the supplements change the color of the sweet potatoes if I mix it in with his food. There’s an ingredient in the Balance IT supplement that oxides and the reaction makes the sweet potatoes look like they’re covered in black specks if his food sits out (a rare occurrence these days since now he gobbles up his meals in 2-3 minutes). 10 pouches last about 2 months since Ralphie takes 3 grams daily. The K (for renal disease) version of the Balance IT supplements require a vet code which the nutritionist provided.

I poke a hole in the Nordic Naturals Algae Omega capsules ($45.01 for 120 capsules) and I let Ralphie chew on it with his back molars. I make sure he takes the whole capsule instead of spitting it out. The algae oil smells fishy if you mix it with food so I prefer giving it to him by mouth. If the algae oil gets on his muzzle he obsessively rubs his face on one of his many soft mats (baby tummy time mats) and they end up smelling fishy until I next time I throw them in the laundry (weekly).

If Ralphie is still hungry I also supplement his daily intake with renal kibble since the nutritionist said that it’s balanced. A 6 pound bag of Purina Pro Plan Veterinary Diets NF is about $40 and lasts 4 months when fed in addition to his home cooked meals. Ralphie lost about 2 pounds (dropping to 14 pounds) at the start of the new diet so I supplemented his diet with the prescription kibble since 300 calories wasn’t enough. He weighed 16.5 pounds in January 2022 and he currently weighs in at 15 pounds (after he poops and pees and before he eats and drinks water in the morning) which is his ideal weight.

Pictured above is melted chicken fat (fat separated from refrigerated chicken broth). I cut back to 1/4 teaspoon of chicken fat in his home cooked meals since the prescription kibble contains fat and I don’t want Ralphie to end up with pancreatitis. When I’m preparing the chicken thighs for his meals I remove any fat that I can see.

FEEDING SCHEDULE

The portions and feeding schedule took some adjustment because Ralphie went from being a picky eater to being a good eater that is perpetually hungry. He used to eat after a lot of coaxing and hand feeding and he would often throw up yellow bile when he refused to eat anything but treats (he loved Stewart freeze dried beef liver which I would cut into smaller pieces) until my husband came home from work. I used to try to feed him three times a day (breakfast, lunch and dinner) before he was diagnosed with Chronic Kidney Disease with treats in between because I was at a point where I would rather he eat something than nothing.

After the CKD diagnosis I tried to feed Ralphie on the same schedule but I read here that more frequent and smaller meals help to reduce the stress on the kidneys. As noted in this article, multiple small meals means that the stomach isn’t producing large amount of acid at one time to digest larger meals.

Ralphie’s current schedule is as follows:

7:30AM – Omeprazole

8AM – Breakfast

Walk before 9AM (or pee pad before 9AM if I can’t take him out right away)

12PM – Lunch

Second walk in the afternoon between meetings (or pee pad if I can’t take him out right away)

5PM – Dinner (larger potion)

7:30PM – Omeprazole + Semintra

8PM – Small portion + treat

Third walk or pee pad

10PM – Small portion + treat

12-2AM – Snack of home baked sweet potato chews and/or boiled string beans (low protein options)

Pee pad in the middle of the night

Ralphie sleeps through most of the day while I’m working from home. I wake him up for a small meal at lunch and a potty break. There are more portions at night because he has a voracious appetite especially in the middle of the night if he had more active day (if we go out). I try to keep his appetite sated until the next morning to avoid hunger pukes (foamy yellow bile). It’s rare that I sleep in but if I sleep past my multiple alarms then I run the risk of Ralphie throwing up. Nothing wakes me up faster than the sound of a dog throwing up. 

Ralphie loves boiled string beans

PET INSURANCE

I submitted 25 claims this year and Trupanion paid over $3700+ for all of the claims I submitted thus far. Trupanion has paid for 67% of the costs of follow up visits, diagnostic tests, medications and supplements (Semintra, Omeprazole and Balance It K) related to CKD. They do not cover exam fees but they cover 90% of the diagnostic tests and approved costs (e.g. hospitalization, x-rays, blood work, urine analysis) for the lifetime of the condition (after a $100 deductible per new condition). Currently his coverage costs $64.13 per month after the latest increase.

If you’re interested in pet insurance with Trupanion please consider using my referral link. In full disclosure I will receive $25 for each referral (up to $100 per year).

SITUATIONAL ANXIETY

We had to see the vet often at the beginning of Ralphie’s CKD diagnosis and the anticipation of the blood draw required 2 technicians to hold him still and another to do the blood draw. For subsequent visits the vet recommended giving him a combination of gabapentin and trazodone to calm him. He ends up being sleepy and very wobbly for most of the day until the evening when the anxiety medication finally wears off. Gabapentin alone did not work for Ralphie and the effect would wear off as soon as we pulled into the parking lot.

I found that the best way to give him the anxiety medication is to grind the trazodone into a powder, open the Gabapentin capsules, mix the powder with some kefir and feed him the mixture with either my finger as seen here or a syringe. Somtimes Ralphie spits up some of the medicine but the dose is strong enough that he’s still sedated during his visits.

During the last 2 visits to the vet they found that it’s easiest to numb Ralphie’s neck with novocaine in order to draw a sample more easily from his jugular vein. Otherwise it’s been a struggle every time they tried to do the blood draw from the tiny veins in his legs since he’s such a “wiggle worm”. Even though he’s on the anxiety medicine he still manages to put up quite a struggle with the vet and the technicians. He whines in anticipation when they leave the room and he can be “vocal” with his moaning until the blood draw is over and done with.

This hasn’t happened to us with Ralphie’s lab work but I read about mishandled samples in the CKD Facebook page. You should check the Hemolysis value in the test results and ask for a redraw if needed to ensure accurate results. I checked Ralphie’s test results and it shows N for Hemolysis. The footnotes state that an index of N, 1+, 2+ exhibits no significant effect on chemistry values.

Thanks for reading!