Brody: 9 year old Maltipoo

[Tim]

Hello,
My wonderful pup, Brody, has always been healthy, but suddenly things changed the day after labor day.

Tuesday, the day after labor day, my wife picked up Brody from her moms house and found that Brody pooped all over the house. He usually doesn’t do that so that was a red flag. When Brody came by our house, we both noticed he was lethargic and seemed warmer than usual. When we took him outside he thankfully wound up peeing on the concrete because we saw that he was peeing blood. We rushed him to the vet immediately and were able to do some blood work. The results came in on Wednesday and the vet said there were some issues with his liver and thyroid. The vet wanted to prescribe some medication to help with his liver.

In response, we wanted to get an ultrasound, but they, nor, 2 other places in the area could get him in that day.

Luckily, I was informed about a Veterinary Specialty Center in Buffalo Grove, IL from my coworkers. Everyone said that this place is just “different” compared to other vets. They were able to see him that day. Contrary to what we thought we would find, his ultrasound results were great. Nothing alarming at all. It wasn’t until we got into the room with an emergency room doctor that we heard that Brody most likely has IMHA.

What really popped up to the doctor about his blood work was the “moderate” presence of Spherocytes, something that is almost always prevalent with this disease. After doing some further testing they confirmed that he does have IMHA.

After this we decided to admit Brody on Wednesday night. When they first checked his red blood cell count it was 20. Then it went down to 19. When it went down to 15 Thursday at 8am the doctor called and said they want to do a blood transfusion.

Right after the transfusion his rbc was 32.

After 8 hours it was still 32.

After another 8 hours it was 29. We also found out his Billy Rueben count went from 6 to 9. The nurse suggested that it could simply be from a lack of electrolytes and his potassium not being where it needs to be.

Up until this point I was able to see him after each update. I noticed that little by little he started doing some typical Brody things that we haven’t seen in 3 days, which was good. But the next time I visited, he was just acting different.

We found out that 8 hours later that he dropped to 23.

At this point the doctor wanted to wait on doing another transfusion.

8 hours later he was at still at 21,

8 hours later he was at 21 and his Billy Rueben count went from 9 to 3! When we visted at this point his rbc was 21 and we were elated to see him bark, wanting to play, seeming more alert, starting to eat more, etc. His urine looks better as well.

To be honest, because of the way he was acting we had our hopes up that we might be able to take him home today. So when we heard that his RBC dropped to 18 at 1 am today we were a little discouraged.

As of right now, he has been there for 3.5 days. We have visted his 2-3 times each day. Am I right in assuming that the blood transfusions aren’t what is going to fix the issue? The blood transfusions just increase his RBC enough to give time for the cyclosporine, prednisone, and fluids to actually start working, right?

I do want to say that I am incredibly happy with all the staff. They know their stuff. I came to this realization when I spoke with one of the internal medicine doctors. He wound up telling me that he feels they have a higher success rate than most Vet offices because when they have IMHA patients because they treat it much more aggressively with two different medications.

In addition, they are 1 of 9 offices in the United States that can perform the procedure, TPE! According to the doctor that have a roughly a 90% success rate when performing the TPE procedure. My family is committed to doing anything for Brody financially. We don’t have pet insurance, but it doesn’t matter. He’s a family member and we are willing to do anything for him.

Do you or Dr. Dodds know about TPE? I know it is a new life saving procedure, but want to know more. We are obviously at a wonderful office so they are surely knowledgeable about this, but in my opinion, you should alway try to get as much information as possible.
Tim

[Patrice]

Tim,
I am so sorry to read about Brody and the suddenness of his symptoms. It sounds like you have found a clinic that you are really comfortable with. That goes a long way in providing good emergency care.

Diagnostics are very important with evaluating, diagnosis and treatment of IMHA. IMHA stands for immune mediated hemolytic anemia and the word “mediated” really says it all. Something is leading the body’s immune system to “not be tolerant of self.”

We have found that there are usually multiple triggers before a dog develops this condition. The 4 main triggers are: genetic predisposition: certain breeds are more susceptible to autoimmune disease, stress: this can be recent vaccinations, infections: bacterial or viral (such as tick disease or leptospirosis), hormonal influences: especially sex hormones. Under these main categories are literally dozens of triggers that can combine to set this off.

History is important because it uncovers some of these triggers. A good example is a older female unspayed dog of a breed that is more susceptible to autoimmune disease and she receives too many booster vaccinations. Other triggers may lead her to quickly develop IMHA.

You refer to Brody as “pup” does this mean he is a puppy? We often do see puppies get too many vaccinations all at one time. It would be helpful to know his age and breed. What about his history? Anything unusual? Tick bites, spiders, eating something bad, a bout with bacteria or the doggie flu?

As the immune system begins destroying RBC, called hemolysis, the cells rupture and spill the contents into the blood. One of the important parts of the RBC is the hemoglobin that carries O2 to the body cells. The yellow coloring of hemoglobin is bilirubin, related to bile. A large quantity of this in the blood can lead the liver and kidneys to have trouble processing and eliminating wastes from the blood, thus the yellowish coloring in the skin. The body has a hard time with all the cellular RBC debris in the blood and is why it is important to use some form of anti-clotting drug to prevent dangerous abnormal clotting. Low dose aspirin has been used and more recently clinics are beginning to use heparin.

The spleen of the dog performs several very important jobs. One is to store blood, another is to manage the older RBC that need to be broken apart and the parts managed by reusing or elimination. A third job is to act as part of the immune system and it is very active in this job. As the older RBC travel through the tortuous narrow pathways in the spleen they break up and are desposed. In addition the immune system part of the spleen targets cells that may contain invaders such as tick diseases. So sometimes the spleen will take “bites” out of the RBC that they identify as containing something foreign to the body. These RBC lose their spherical shape and look like smaller round cells with a bite taken out of them. These are called spherocytes. The are a sign of the spleen imperfectly performing the job of removing RBC. Sometimes the spleen makes a mistake and starts destroying too many RBC. It will become enlarged and vets in the past would try to stop the autoimmune destruction by removing the spleen. This is no longer in much use and I would advise against it.

Transfusions are very important for many reasons, not just to replace damaged RBC. Whole blood transfusions replace all the cellular elements plus plasma which contains things like albumin, a protein that helps maintain the fluid in the vessels. Dogs with low PCV HCT can become hypovolemic. This means that the fluid content in the blood vessels is low and that leads to low blood pressure. A transfusion makes a dog feel better by helping bring up the fluid content in the vessels.

Since the destruction is ongoing, there is continued need for more red blood cells. But the transfusion RBC will drop a bit after transfusions, this is normal.

Yes, buying time for the drugs to work is the critical part in the early days of IMHA. Prednisone or dexamethasone are highly suppressive of the entire immune system and that is a critical part of the treatment. Once the dog is more stable, another drug can be added to assist in the immunosuppression. Ideally, prednisone can be decreased once this other drug is added and is effective. Common drugs are cylosporine and more recently Cellcept. We don’t like the global side effects on the body by prednisone on a long term basis. I always say we need to keep the dog well enough so they can fight the disease and they don’t succumb to the prednisone side effects.

TPE therapeutic plasma exchange is also known as plasmapheresis. This is used in human medicine. I have a friend who was donating this product regularly at the Red Cross for many years. If your clinic has developed a successful way to safely provide this treatment to dogs then it would be helpful.

You can also use a more standard treatment. Dr. Dodds has, for years, recommended the use of Fresh Frozen Plasma from her Hemopet Blood Bank. It is a source of all coagulation factors, albumin, globulins, electrolytes, and other plasma nutrients. It is preferred for treatment or short-term prophylaxis of bleeding disorders and to provide globulins (passive immunity) to alleviate or protect against acute or chronic infectious diseases especially viral disease (e.g. parvovirus). You can see the number of valuable things that are provided by plasma.

It isn’t always necessary to spend a fortune helping your dog. I always advise excellent early diagnostics so the vet can pinpoint contributing conditions that could be treated. Once that is accomplished then the main treatment is the immune-suppression of the immune system until the hemolysis is controlled. Transfusions support this and buy time. They are not benign treatments but they can be very necessary.

I helped a young man with his very sick dog many years ago. He lives halfway around the world from me in Australia. His dog had developed bone marrow failure and the vet told him that he would have to give her a bone marrow transplant. The only place he could get this done was at a University in the US. He was ready to fly the dog over here! It took me days of emailing back and forth to convince him instead to see a colleague of Dr. Dodds in Australia to implement her bone marrow failure protocol, which adds cyclosporine to the treatment. He did it and the young dog survived and went on to live a normal life.

Devastating a whole savings account isn’t always necessary. When you are looking at a newly diagnosed dog, the most important things are to stop the destruction and stabilize the patient. By that I mean getting the body into a state of homeostasis or equilibrium. Making sure the liver and kidney functions are ok, getting the fluid volume and electrolytes up in the blood, suppressing the immune system, providing good nutrition and providing secondary supplements to support the liver and protect the stomach. If you are unable to find or can’t afford TPE don’t panic that you are not giving your dog the best care. Dogs can be very resilient, I have seen some amazing recoveries.

Those dogs that have a harder time may have had some triggers that were very strong. Some specific breeds are very fragile and sensitive to autoimmune conditions. There is a list of breeds that do have more than their share of IMHA.

It might be helpful for you to read Dr. Dodds paper: The Canine Immune System and Disease Resistance.

Find it on this page, at the top left of the page. Click on the picture and it will open a small window. You can click on the arrow to make it a full page tab and then you can save it, print etc.
https://www.secondchanceaihadogs.com/canine-disease-resources

Do you have more questions for me or did you have trouble with the way I explained something?
my best patrice