9 year old Chihuahua with benign splenic mass diagnosed with IMHA – Page 2

Keymaster

Taylor,
Mary Straus says:
“Proteinuria: If more than a trace amount of protein is found in the urine, you should do a urine protein:creatinine (UPC) ratio to determine how significant it is. Significance to some extent is related to the stage of kidney disease: for dogs with normal kidney function (creatinine < 1.5), a UPC of 2.0 or less should be investigated for an underlying cause and closely monitored, while those with UPC > 2.0 should be treated. For dogs with creatinine levels above 1.4, UPC over 0.5 should be treated.”

So you see that there is a relationship between two kidney values and that is a critical value to know.

Also from her site:
“IDEXX Laboratories introduced a new test, the SDMA, for detecting loss of kidney function in 2015. This test can detect reduced kidney function when creatinine, BUN (Urea), and urine specific gravity are all still normal. It will be included with standard blood chemistry tests.

Urine specific gravity decreases when about 2/3 of kidney function has been lost, followed by increases in creatinine and BUN (Urea) when about 75% of kidney function has been lost. Prior to that point, the kidneys are able to function adequately even though they are not operating at full efficiency. The SDMA test identifies kidney disease on average when there is 40% loss of function (25% loss is the minimum level at which this test can detect a problem). On average, SDMA increases above normal about ten months (range: 2-27 months) earlier than creatinine rises above the normal range. Note, however, that a steady rise in creatinine over time, even if still within the normal range, may also signal loss of kidney function.

Remember that dogs, like people, need only half of one kidney (25% total function) in order to maintain normal kidney function. That’s why people can donate a kidney and remain perfectly healthy.”

So the question is, did your vet do an SDMA screening test and if they did what were the results. My vet is very excited about this new test because it helps her catch kidney problems much earlier than just using the standard chem screen.

So I don’t know what to say until I see either a chem screen or the results of an SDMA screening.

I do know, however, that you should assume there is some level of kidney involvement and feed accordingly.

Mary says this:
“Based on research done in the last ten years (see is a Low Protein Diet Necessary or Desirable?), that the only time it is necessary to feed a low protein diet is when your dog is uremic, which generally means BUN is over 80 mg/dL (equivalent to 28.6 mmol/L), creatinine is over 4.0 mg/dL (equivalent to 354 µmol/L), and the dog is showing symptoms such as vomiting, nausea,inappetence, ulcers and lethargy, which are caused by the build-up of nitrogen in the blood. Even then, feeding low protein will not extend life, but it will help the dog feel better. Subcutaneous fluids can also help at this time (and before).

If your dog has significant amounts of protein in the urine (urine protein:creatinine ratio above 1.0), then you may need to reduce protein moderately, enough to control the proteinuria, but a really low-protein diet is not considered beneficial, as it can lead to hypoalbuminemia (low albumin levels). It’s best to feed at least 1 gram of protein per pound of body weight daily (the grams of protein must be calculated from a nutritional analysis, it is NOT the same as grams of meat).

If your dog is not uremic, then the consensus seems to be to feed a moderate amount of very high quality protein. Eggs have the highest quality protein (although egg yolks are high in phosphorus), followed by meat (raw or cooked). The lowest quality protein comes from grains.”

We just don’t know which of these conditions apply, though you said he has been showing some signs such as inappetence? That doesn’t necessarily equate to a problem with uremia, it could be a side effect of the surgery and anesthesia.

By the way, if they offer to you to do a bone marrow biopsy, please decline right now. It is an invasive test, requires anesthesia and probably won’t improve the protocol of treatment that you are on right now. Let’s see how well he recovers after his surgery and then evaluate this in a few weeks.
my best, patrice

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Patrice

Keymaster

Taylor,
So we have some interesting and revealing exam results. As I suspected there is non-regenerative anemia. The reticulocyte (baby blood cells made in the bone marrow) absolute value is 62,800, which is not a sufficient regenerative response by the bone marrow in relationship to the abnormally low value of HCT of 19.5% . This value should be closer to 150,000 reticulocytes.

Normocytic non-regenerative anemia simply means that the red blood cells in circulation are normal looking, they are the right size and shape and color, they hold the proper amount of hemoglobin and carry the proper amount of oxygen. There just aren’t enough of them anymore and this means he has anemia. Each day we normally destroy a small number of old worn out red blood cells and discard or recycle the elements. This is a normal process. It is not normal for the marrow to stop producing reticulocytes each day.

So at some point the bone marrow stopped making red blood cells. OR the accessory spleen, the benign growth they removed, and the spleen were providing the function of making red blood cells. This is called extramedullary hematopoiesis. This is the making of red blood cells in another location other than the bone marrow.

When we are in the uterus, we have no skeletal structure for a period of time so the fetus makes blood in other organs such as the spleen. This is normal until we develop a skeleton and are born. Sometimes after we are born the bone marrow fails to work properly and the body attempts to recover from this by having another organ like the spleen make blood, as it did before we were born. In Chance’s case the growth and his spleen were making his blood as the bone marrow failed due to an autoimmune attack. We removed the growth and the spleen and thus removed his source of new red blood cells. He developed severe non-regenerative anemia and he also stopped making white blood cells. A doubly serious condition.

On your chem screen the albumin is low, by a little, and the bun (a kidney waste value) is very high, as is the creatinine (another waste value.) The glucose is high as well, this is blood sugar (it could be a response to the prednisone.) Alkaline phosphatase is quite high as well, this can be associated with an inflamed liver but also with other inflammatory conditions as well.

The vet has noted in their final diagnosis: Protein Losing Nephropathy, Glomerulonephritis, Acidosis (moderate metabolic) and Normocytic Non-regenerative anemia.

So protein losing nephropathy is loss of protein from the kidneys. So the loss of protein from the kidneys is usually accompanied with a low albumin value. This protein, made by the liver, is in blood to help keep it “viscous.” Right now it is 2 and the low normal value is 2.2, so it’s not low by a lot. When albumin gets too low, fluid begins to leak out of the blood into local tissues, you may be seeing a fluid accumulation in the belly for instance. This influences blood pressure by lowering it and also increases the risk of blood clotting improperly. We do not want to see a further loss of albumin in the blood.

The vet uses another term glomerulonephritis. This is inflammation of the glomeruli, tiny structures in the kidneys that act as filters for the blood. When antibodies and antigens from the immune system are filtered out of the blood they can become trapped in the glomeruli. This alerts the immune system of the body which then attacks the glomeruli.

I am going to take a leap here and ask you if the vet tested at any point for tick diseases? This is really important to know. One particular condition related to Lyme disease is glomerulonephritis or Lyme nephritis, a condition in which the glomeruli in the kidneys which filter the blood are inflamed and destroyed by the immune system.

Please, asap, contact the vet’s office and find out if they performed a SNAP4DX test for tick diseases. If this is a recent exposure to Lyme there may be time to treat it aggressively with doxycycline. You can read about Lyme disease on Gil Ash’s website here:
https://sites.google.com/site/tickbornediseaseindogs/lyme

There is a lot to absorb here so please ask me the questions you need answered. I can explain things in a different way if that will help you understand.
my best patrice

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Patrice

Keymaster

Taylor,
Below my comments are some specific recommended treatment approaches for glomerulonephritis.

Remember that I have shared with you some specific information and the Dog Aware resource about feeding a dog with kidney disease. We now have values for the creatinine and bun, so you can figure out from Mary’s information what you should be doing with the diet, this may be considered moderate or more severe kidney function. I don’t necessarily agree with reducing protein yet, but your guideline is if he “starts showing symptoms such as vomiting, nausea,inappetence, ulcers and lethargy, which are caused by the build-up of nitrogen (failure of the kidneys to remove protein wastes from the blood) in the blood. Even then, feeding low protein will not extend life, but it will help the dog feel better. ”

Subcutaneous fluids can also help at this time . I suggest you have the vet techs show you how to use the sub-q fluids at home. This is very easy and is very productive in flushing the kidneys. They will give you sterile bags of fluid, a large gauge needle to insert in the floppy skin of the neck and a tube. All you need to do is find a lamp or something high to hang the bag on so it is higher than his neck. The needle goes into the loose skin of the neck and the fluid moves under this skin where it absorbed into the body slowly. It takes about 10 min to do this. For a while, the neck will look like a “camel hump.”

Here are the “official” recommendations for treatment.

Immunosuppressive drugs (like prednisone) to suppress immune complex formation. A very low dose of aspirin to prevent clotting within the glomeruli.

Omega-3 fatty acid supplementation (plain ol’ fish oil capsules) to help reduce the inflammatory response and prevent clotting.

Angiotensin-converting enzyme (ACE) inhibitors such as enalapril (used for heart conditions) to minimize protein loss in the urine and to help control blood pressure.

Medications to control high blood pressure

Specialized prescription diets may be used in some instances.

Low protein, low phosphorus diets should be fed to pets in kidney failure. (I agree highly with the low phosphorus, but maintain the protein at normal if possible)

Low sodium diets should be fed to pets with hypertension. ( I don’t necessarily agree with this either but see what the vet suggests)

my best, patrice

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