Question Details
Crystalluria In A Dog
by johnnalsmith - April 21, 2021    View Case Report
Atlas is a 6 year old, male intact, boxer mix that I have been seeing since he was adopted at 6 months old. Atlas had a murmur when he was a puppy so we decided to keep him intact. Currently for a year we have been managing skin allergies/atopy and crystalluria with herbs and diet. Atlas is a fun loving, sweet boxer with a red/full tongue and a bounding, fast pulse. We manage his atopy with OTC antihistamines mostly and bathes, but when it gets bad we will add in a very short course of steroids. His feet are mostly effected and he will lick them raw. March 2020 he was diagnosed with calcium oxalate crystals with stones being ruled out via radiographs. We started him on Royal Canin SO diet (they cannot afford to feed total home cooked diet) with a top dressing of home cooked low oxalate foods. And we started dang gui and peony from Kan (1g BID). His crystals come and go, but still no stones as of January 2021 via rads. However, he has consistent RBC present without infection. His most recent UA shows struvite crystals and an alkaline pH of 7.5. Typially his pH is 5 or 6.
I'm at a loss of where to go from here. We know he's inflamed and really needs to be on an only home cooked low carb diet, but finances do not permit this. Any thoughts on how to manage this guy better? I'm worried he's going to end up with stones and not sure they can do surgery. Especially with his heart murmur.
Thanks!
Replies
by naturevet
April 22, 2021
Hi there,

I see the stone risk as a given as long as he is on kibble or canned food. About as processed as you can get without initiating the metabolic and inflammatory events that precipitate crystal formation is a freeze-dried diet. I would try that here. It can't be any more expensive than s/o.

As for how to acidify the urine to remove the struvites in the absence of infection, either add the amino acid methionine as a supplement (that's what we did in the old days before the urinary diets were around), and/or add Hydrangea and Eupatorium tincture (Natural Path). It doesn't taste great but should remove the blood and acidify the urine. If the owners move to a freeze-dried meat-based diet, that should clinch it.

Note that the notion of low protein diets as a means to reducing calcium oxalate excretion comes from treating humans, which are omnivores.

For carnivorous species, it doesn't make sense from an evolutionary perspective for them to have issues with animal protein. As far as I can tell, it is the processing that is the issue in carnivores, setting in motion renal tubular damage and inflammation that seeds the urine with proteinaceous nidi around which calcium oxalate can accrete. Using the DGSYS + real food meat-based diets wipes out calcium oxalate issues. Meanwhile, the animal protein amino acids will acidify the urine, wiping out struvites (thus the use of methionine).

A side benefit of the above should be the resolution of the skin issues and a general cooling of the dog, to where it has a less red tongue and is less prone to inflammation.

Lastly, to eliminate the risk of calcium oxalate, supplement the dog with potassium citrate. If the dog really does have issues excreting too much calcium, the citrate will bind the calcium and keep it in solution.

Hope this helps you out!

Steve
by johnnalsmith
July 16, 2021
Hi Steve,

Update on Atlas. He has been on a strictly homecooked diet and dang gui shao yao san for 10 weeks now. We repeated a UA about 4 weeks into this regimen and his UA was normal. We just repeated another one today and his struvite crystals are back (3+). His pH is 7.0 without bacteria and minimal WBC elevation.

I'm not sure where to go from here? He still has itchy skin too, despite the homecooked diet. He is being managed on Apoquel right now twice daily.

Thanks for any help.
by naturevet
July 16, 2021
Hi there,

To acidify the urine, Hydrangea and Eupatorium should work (NPHC).

Regarding the recipe they are using, if it has a lot of starches in it (potatoes, rice, corn, etc.), it will still be problematic. It needs to be more 'paleo', based on meat and vegetables. About as starchy as you can get is sweet potatoes. If you have the Manual of Natural Veterinary Medicine, you can find the basic outline of a paleo diet (from Susan Wynn) in the appendix on diets. I cut back on the oil and salt a bit, but otherwise use it as the home cooked diet template.

Lastly, some more details on his skin, pulses and tongue might be helpful. Here are some recommendations for an additional formula to treat the skin:

If he has a weak pulse with dorsal skin lesions primarily, then Chu Shi Wei Ling Tang (Kan's Dispel Dampness and Nourish the Skin) is a good idea. It has some Ze Xie in it to help hinder calcium oxalate crystals.

If his inflammation is more fulminant and his pulses are stronger, then look at Si Miao San

If he has been consistently on a low carb meat-based diet with no carb or kibble snacks at all, and his skin is no better at all, then we might need to look at Xiao Chai Hu Tang + Si Wu Tang for his skin

If there is the possibility of a low grade recurrent bacterial cystitis here, and his skin is a little better, then you could look at Bu Zhong Yi Qi Tang

Hopefully this helps you out!

Steve
by johnnalsmith
November 1, 2021
Hi Steve,

Update on Atlas. He has been on Hydrangea and Eupatorium tincture along with his high protein home prepared diet since last time. I only added the Hydrangea and Eupatorium tincture since his skin is doing well on Apoquel and we are more worried about crystaluria at this moment. His most recent UA came back with a USG of 1.015, pH 8.0 but not blood or crystals present. I'm still a little worried about his pH though. Urine culture was negative.

His skin is mostly his feet and the underside of his belly. He will lick, chew and scratch himself raw to the point of bleeding. Pulse is strong and almost bounding. Tonuge is red. I am thinking about switching to Si Miao San and off of the Dang Gui and Peony. I am worried about making changes that could effect the crystals though.

How long would you keep him on the Hydrangea and Eupatorium tincture? Especially since his pH is still 8.0?

Thank you very much!
Jo
by naturevet
November 2, 2021
Hi Jo,

I'd keep going with the H&E until the dog is more generally well, and I'd go ahead and switch off the DGSYS to something that matches the skin. We are definitely dealing with an excess. The ventral lesion distribution and aggravation from an overall Blood tonic suggests we should be going with a Damp Heat formula, although I would have expected Damp Heat to improve on a home prepared meat and vegetable diet. Have you reviewed their recipe to make sure it does not have a lot of starches in it? If you have, then I would look at trying Xiao Chai Hu Tang as the next place to go. If there is a lot of rice, etc. in it, then try the SMS

A response of the pulse to acupuncture can make it more clear what to try next. If you stimulate important GB points, like GB 34, and the pulse softens, then you should use XCHT. If it's Damp Heat points that help, like SP 9, then SMS is the way to go.

Hopefully that helps you out. I know these cases are hard, but if the owner is patient and you just keep re-evaluating to stay in step with the patient, you can get there.

Steve
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