Peritoneal dialysis for management of meloxicam induced acute kidney injury in dog

Introduction

Kidneys are the major organs for maintaining metabolic balance of the body. Acute kidney injury (AKI) acts as a complex syndrome that seldom arises from a single, isolated pathophysiologic process. Timely and accurate identification of AKI, along with a deeper understanding of the diverse pathophysiologic mechanisms underlying its clinical phenotypes, is essential for developing effective therapeutic strategies [1] . Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in veterinary medicine to manage both acute and chronic pain, as well as certain oncologic and neurologic conditions. Their therapeutic and toxic effects stem primarily from inhibition of cyclooxygenase (COX), which reduces the synthesis of prostaglandins which are key mediators of inflammation and pain [2] . The excessive use of non-steroidal anti-inflammatory drugs induce kidney damage and also with other complications like gastrointestinal ailments, allergic reactions etc. [3] . Peritoneal dialysis, while being primarily employed for managing chronic kidney disease, has also been reported as a therapeutic option for acute kidney injury. Beyond kidney-related disorders, it has been utilized for the removal of dialyzable toxins, management of pancreatitis, correction of electrolyte and acid-base imbalances, treatment of refractory congestive heart failure, and certain inborn errors of metabolism. In veterinary medicine, its most frequent application is for acute kidney injury, although it can be indicated for any of these other conditions as well [4].

History and Clinical Signs

A 11-year-old, Female Labrador Retriever weighing about 20 kg was presented to TVCC, College of Veterinary Science and A.H, Anjora with a history of anorexia, bloody diarrhea and vomiting for last 3 days. Detailed anamnesis revealed that the dog was continuously fed with oral meloxicam tablets for past three months. Clinical examination recorded rectal temperature to be 103°F, congested conjunctiva along with dull and depressed condition. Heart rate (96 beats per min) and respiration rate (26 per min) were slightly elevated. The laboratory findings showcased slight anaemia (Hb = 8.9g/dl), packed cell volume (39.82%), total leucocyte count (18450), Neutrophils (75.24%), Lymphocytes (20.45%) and platelet Count (1.25 lakhs). Biochemical profile revealed severe uraemia with blood urea nitrogen values at 180.26 mg/dl and creatinine 10.24 mg/dl. However, liver values revealed nearly normal values of SGPT-37 U/L, ALP-96 U/L, total protein-6.45 g/dl and albumin-2.80 g/dl. Based on history, clinical findings and hematobiochemical findings, the patient was tentatively diagnosed as acute kidney failure and peritoneal dialysis was planned on emergency basis to save life of the patient.

Treatment and Discussion

The dog was placed in right lateral recumbency and site of catheter insertion was prepared aseptically by clipping the hairs from xiphoid to pubic region. After local infiltration of 2% lignocaine, peritoneal dialysis catheter was placed just behind the level of umbilicus via paramedian approach after making a small skin incision followed by stabbing the abdominal muscles with gentle pressure [4] . Three cycles of peritoneal dialysis were carried out using a commercial dialysate solution containing 1.5% glucose. Prior to administration, the solution was warmed to 38°C and maintained at this temperature throughout the procedure. In each cycle, 30 ml/kg of dialysate was infused into the peritoneal cavity, where it was retained for 40 minutes before being drained into a collection bag. The procedure was carried out daily for 5 days which led to uneventful recovery. Supportive therapy was initiated using RL @ 500 ml IV bid, broad spectrum antibiotics enrofloxacin @ 5mg per kg body wt. IV OD, pantoprazole @ 1 mg per kg body wt. IV BID, ondansetron @ 0.5mg per kg body wt. IV BID and vitamin B complex @ 3ml IV BID [5] . Post dialysis, the laboratory findings revealed a significant restoration in the values of haemoglobin, packed cell volume, total leucocyte count, platelets, total protein, albumin, blood urea nitrogen and creatinine values (Table 1). Acute kidney injury (AKI) is a clinical syndrome marked by a rapid rise in serum urea and creatinine levels, accompanied by acid-base disturbances and fluid-electrolyte imbalances resulting from kidney damage of varying severity [6] . In this case, the diagnosis was based on the patient's history, clinical signs, hematological findings, and urine output measurement. The clinical relevance of adverse effects associated with meloxicam administration in small animal clinical practice is of utmost importance because of their high level of usage, and the growing interest in pain management in veterinary medicine [7] . However, meloxicam may cause adverse effects even at therapeutic doses, as well as in cases of overdose, although the exact frequency of such reactions in companion animals is unknown. With prolonged use, meloxicam also has the potential to contribute to the development of proteinuria [8] . Though, meloxicam has wide margin of therapeutic efficacy, over usage of the drug as seen in present case can lead to adverse conditions like acute kidney damage assisted with shock, haemodynamic alterations and hypertension [9] . In Veterinary medicine, peritoneal dialysis (PD) remains the primary treatment for AKI because of its accessibility, simplicity, good cardiovascular tolerance, and lower likelihood of causing the electrolyte imbalances often associated with haemodialysis [10] . Nevertheless, PD has certain limitations, including the requirement for an intact peritoneal cavity, the risk of peritonitis, and protein losses. Additionally, toxin clearance with PD is slower compared to haemodialysis [11] .

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