Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10S2017019

Abstract
Pink presented to Home to Heaven (HTH) for a hospice consultation having developed life limiting hyperkalemia secondary to chronic kidney disease (CKD). Acupuncture was offered and initiated at the time of her hospice consultation. Pink responded extremely well to treatment and after three initial treatments within the first two weeks, she has been maintained on a monthly schedule. Pink is still in treatment and doing well at the time of writing.

History and Presentation
Pink, 14yr old FS Maltese, had been treated at her referral veterinarian (rDVM) for proteinuric, hypertensive, CKD prior to presentation with HTH. She has been maintained on amlodipine, enalapril, and a diet of Hill’s K/D. In addition she has had a heart murmur for many years that was never worked up. Historically she had surgery for a cruciate injury on her right stifle and has been treated with opioids for secondary osteoarthritis (OA).
Pink’s renal dysfunction was first identified on bloodwork ~4 years prior (records not available.) The aforementioned treatments were initiated at that time. She first became clinical for her azotemia in June 2017 (BUN 108 mg/dL, Creatinine 2.9 mg/dL, Phos 8.0 mg/dL). An abdominal ultrasound at that time revealed decreased corticomedullary junction and mild pyelectasia bilaterally. She was hospitalized for diuresis, while her symptoms improved her azotemia persisted. At her wellness exam September 2017, an incidental urinary tract infection was diagnosed and treated. Bloodwork around that time showed progression of azotemia (BUN 112 mg/dL, Crea 2.0 mg/dL, phos 9.0 mg/dL) in addition to hyperkalemia (6.0 mEq/L). Epikatin was started. One week later (November 2017) Pink was presented for exam due to inappropriate urination, tremoring, weakness, ataxia, and confusion. Repeat bloodwork at that time revealed further progression of azotemia with worsening hyperkalemia (BUN 143 mg/dL, Crea 3.3 mg/dL, Phos 11.7 mg/dL, K+ 7.6 mmol/L). At that time the rDVM discussed symptoms being related to marked hyperkalemia and secondary to suspected acute renal failure due to rapid progression. In hospital diuresis was offered though due to guarded prognosis, euthanasia was advised and patient was discharged for at home euthanasia.

Physical Exam and Clinical Assessments
On exam Pink was quiet, alert, and responsive with intermittent full body tremors. Her vital signs were normal and she was noted to be 5% dehydrated. A grade 4/6 left basilar systolic murmur was auscultated, no arrhythmia was noted. Mild periodontal disease was found. Crepitus was palpable in stifles and elbows bilaterally. Neurologic exam revealed no overt neurologic deficits. Myofascial exam revealed tight bands in the lateral cervical regions and infraspinatus muscles. Warmth and tenderness was appreciated over Pink’s thoracolumbar region (T/L). Due to the desire for hospice care no additional diagnostics were performed at the time of exam.

Medical Decision Making
Due to documented hyperkalemia and consistent clinical signs, I felt targeting Pink’s renal dysfunction with acupuncture would be most effective. Additionally I decided to target trigger points and taught bands in Pink’s cervical and T/L regions to minimize windup and visceromotor reflexes. Sympathetic hyperactivity of the kidneys can lead to vascoconstriction of afferent arterioles and decreased GFR as well as hypertension. Improving the ability of kidneys to regulate autonomic input would help improve kidney function.

Differential Diagnoses
With the available rDVM records and blood work differential diagnoses were chronic kidney disease or acute on chronic kidney disease possibly secondary to historic bactiuria, hypertension, or chronic ACE-I use.

Definitive Diagnosis
As patient was seen in a hospice setting and no further diagnostics were elected, I could only evaluate response to treatment. I do not feel my treatment could alter persistent bactiuria and as patient was on ACE-I for many years I feel this is less likely. My putative diagnosis would be chronic kidney disease (IRIS stage IV hypertensive proteinuric).

Acupuncture Treatments
Treatment plan was designed to target kidney points including front mu and back shu/‘kidney tiara’ points, additionally focusing on quieting sympathetic tone to the kidneys and balancing autonomic tone. Points that would address Pink’s taught bands/trigger points and OA were included as tolerated. Evidence in rats has shown electroacupuncture and moxibustion improved blood pressure, serum creatinine, and overall renal function after twice weekly sessions for 8 weeks (Paterno et al 2008). While electroacupuncture was available it was not utilized in her case due to sensitivity with dry needling and use of Seirin 0.16G 15mm. Laser was not available.
Initial treatment included dry needling performed at GV 20, 14, 4; Bai Hui; BL 23 and 52 (bilateral); GB 25 (L).This treatment was performed two additional times approximately five days apart. With scientific evidence of twice weekly treatments for 2 months improving renal function (Paterno et al 2008) more treatments were recommended though declined due to financial limitations. Pink has been maintained on a once monthly routine additionally addressing any musculoskeletal/OA related pain. She has continued all previously prescribed medications.

Outcomes, Discussions, and References
Qualitatively, owners reported marked improvement after a single treatment. Improvement was characterized by increased energy, activity, higher tail carriage, and lack of tremors. These signs were appreciated at follow-up appointments in addition to decreased T/L sensitivity. Again due to hospice care and financial constraints no quantitative measures (diagnostics) are available. As acupuncture was the only change in treatment, meaning all medications were left as prescribed, all outcomes are believed to be in response to acupuncture alone. This case was an excellent first acupuncture case that served as an example of the power of acupuncture beyond pain control. In addition to the medical response I quickly learned the importance of a light hand in managing a sensitive and small (~8lb) patient.
Paterno JC et al. Electroacupuncture and moxibustion decrease renal sympathetic activity and retard progression of renal disease in rats Kidney Blood Press Res 2012; 35(5): 355-364.


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