Question Details
PLN In A Dog
by valariedvm - March 30, 2018    View Case Report
Cooper is a 4 year old, ~70 lb MN bully breed. His dam was a rescue that tried to kill him after he was whelped so the rescuer kept him.

Primary complaint is PLN with elevated blood pressure. For the last 2 weeks, he has been ADR, occasional vomiting and in the last 48 hours chronic vomiting and lethargy.

He also has a history of seizures (no meds, resolved w/ acup), skin allergies and itch (hot spots, ear infections, pododermatitis, yeast; tx: Apoquel), anaplasmosis (+) and elevated amylase.

Current diet is formulated by a veterinary nutritionist at Missouri - 75% white potato, 25% chicken, duck fat, hemp seed oil and a multi-vitamin/mineral supplement from Balance It.

I started seeing this case on 2/21/18, a little over a month ago.

I have lots of history and can fill in but thought I'd cut to the chase. Based on his 2/10/18 lab results (bp, UP:UC, BUN, Cr, P) I started him on XCHT (1500mg BID) and SRT (1500mg BID). His BUN, Cr have gone up and after about 2 weeks on XCHT/SRT, he started to get worse clinically.

Blood work 3/22:
Cr 3.6 (range 0.5-1.5)(hx: 2.8 - 2/10, 3.2 - 12/6)
SDMA 21 (range 0-14) (hx: 22 - 2/10, NA - 12/6)
BUN 52 (range 9-31) (hx: 40-2/10, 38 - 12/6)
Amylase 1891 (range 337-1469) (hx: 1527 - 2/10, NA 12/6)
BP sys 142, dia 103, MAP 111 on 3/21
(FYI, TT4 is 1.8, range 1-4)

While on a raw diet in July 2016 is UP:UC was 2.2, which was the beginning of his PLN diagnosis and treatment. 1/31/18 his UP:UC was 4.1

Current medications:
Enalapril 10 mg
Amlodipine 5 mg
Apoquel 16 mg
Had been on Si Miao San until 2/21 when I switched him to Xiao Chai Hu Tang and San Ren Tang.

Of course, it seems he's gotten worse when I switched him from SMS to XCHT/SRT. Is this simply a matter of going back to SMS and rechecking blood work? At this point, I've d/c'd the XCHT/SRT. Looking for any insights, comments, suggestions, things I should pursue.

With gratitude,
by naturevet
April 9, 2018
Hi Valarie,

Give the history of inflammatory disorders and the young age, I would also have wondered if this was an inflammatory condition, calling for SRT and XCHT. The UPC and lack of response, however, suggest deficiency, and the need for a Rehmannia based formula.

When a case has strikes both for and against both general approaches, it becomes a matter of trial and error. Why would both conditions be supported? It's because there is a cycle of inflammation that occurs in the kidney where acute inflammatory states are followed by unresolved chronic ones. You may have caught the dog as it was vacillating from an acute state to a chronic state, in which case Rehmannia formulas are needed. In the event that the dog constantly swings back and forth, we sometimes use a blended approach, prescribing both Rehmannia Eight and San Ren Tang in equal amounts

That being said, I'd suggest you go ahead and switch to Rehmannia Eight for now, and see what that does. You need a few weeks to properly judge an approach.

If his numbers improve, then hypotensive drugs may make him worse and should be used with caution. A response to Rehmannia suggests the hypertension is an adaptive response, with the goal of increasing renal blood flow, which a hypotensive drug would compromise

The other observation I have is regarding the diet. If he stabilizes or slightly improves on a Rehmannia-based formula, he needs a normal protein diet, not the high starch one currently provided. If he improves, then higher (i.e. normal) protein levels are indicated to support renal blood flow and reduce hypertension. The concomitant use of Rehmannia would prevent any renal hypertension from a normal protein diet. The increased blood flow would clear phosphorus, eliminating it as a concern

Hopefully this helps. Let us know how it goes. He may end up needing both San Ren Tang and Rehmannia, but for now, let's test the Rehmannia theory

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