Liver Enzymes

[Tamara]

Hi Beth, I haven’t been around as much this last week or so and am not caught up on what’s happening with Heathy — I”m so sorry you’re going through such a difficult time with him. I wanted to mention a possibility with the change in the smell of his breath. That could be an indicator that his kidneys are struggling, which can also be a side effect of the pred. In Ashki’s case, his kidney chemistry has been normal but he is proteinuric, he is dumping protein in his urine, so I have had to change his diet and have added fish oil and vit E and we also added an ACE (which is a blood pressure med but also affects how the kidneys filter). His proteinuria was improving but when we increased the pred and cyclosporine (cyclo can also stress the kidneys) after he relapsed it went up again. I am hoping that it will improve again as we reduce the prednisone and cyclo. At any rate, you may want to ask your vet to do an urinalysis and UPC if the urinary protein is high. Be forewarned, a UPC (urinary protein/creatinine ratio) is expensive. A normal UPC is less than 0,5 and Ashki’s was 20 (!) when we discovered it. It got down to 2.3, but last time we checked it was back up to 5 something. We’re going to check it again in 2 weeks.
I’m thinking of you and Heathy and sending big hugs and lots of love to you both.
tamara and ashki xoxox

[admin]

Hi Beth. I hope Heathy is feeling better. I think all our pups feel lousy the first few days after reduction (yes, 25% – I go way overboard, every 30 days – Sadie relapsed due to weaning too fast – but it was REAL fast – you’re not doing that). Then they rebound and start feeling better and better, getting off some of the horrible but absolutely necessary drugs.

I don’t know if anyone else here has used it, but I have been giving Sadie Nutramax’s Crananidin, for any urninary problems, which I buy on Amazon. It’s expensive, around $55.00 for 75 tabs, which can be cut in half. If I catch it right away (dark urine and will sometimes even seem thick AND she trys to clean herself (she’s not a dog that licks at all). So, I “clean” her after each time out (with a clean, warm paper towel). Then I start the Crananidin. I give her one tab a day for about 10 days, and then go to a 1/2 tab for a while, until I think she’s better. Some people use it as a deterrent measure and I understand it does great. My vet had recommended it long ago. I would ask your vet and/or Dr. Dodds about possibly using it.

I think our pups are prone to pick up so much having their immune systems compromised. Each pup seems to have their particular “ailment” that comes and goes. But once you know what MIGHT happen, you become a hawk watching for the tall-tell signs so you can jump on it and hope it does not get out of control. That’s the trick, right?! It really stinks and absolutely keeps us up at night, right?!?! And the monitoring thing, to be sure they’re still breathing is the worse. Yep – we too have all been there.

Because of her relapse in October 2014 and continuing to wean (SLOW, SLOW – down to 7.5mg prednisone only, daily), we again are dealing with her usual “ailments” – palsy, urinary upset, tummy upset, darn tapeworms this time (flea).

I have spent the last two weeks dealing with the flea problem – in FLORIDA where they love to live. I have put down Diatomaceous Earth until I’m frosty white, combed with a flea comb as many times a day as she’ll allow AND bathed her in “holistic” flea shampoo (which kills some and only stuns others – then sit there and pick off any “stunned” stinking fleas, put in Dawn dish soap mixture to kill). Well guess what – it’s much better. Thank goodness!!!

So, it’s a continuum – combatting the forces of this evil disease. You are being so diligent and doing such a great job. Heathy is doing well, overall, and that’s because of you. He’s such a lovely, lucky, handsome boy.

Sadie and I are sending our love and kisses his way. xoxo Linda and Sadie

[Beth]

Hi All,
Things are getting slowly worse with Heathy, i got his blood/chem results back today and his liver values are now up again, quotes from the Vet “His ALT is now up to 2,219 (it was 1,736) and his Alk Phos is up to 8,033 (it was 5,462). His bilirubin level has crept up a tad as well. It is just a tenth of a point above high end of normal, but I am really concerned. His blood sugar and his protein levels are still normal.
His white blood cell count has really gone up again – it’s up to 28,300, so I am concerned about that as well.” “I am also a little worried because his PCV dropped a little to 36. So, I don’t think we can taper the steroids this week, I think we’ll have to wait another week.”
So she has prescribed him two antibiotics, metronidazole and baytril and another drug called ursodiol.
She thinks he may have a liver infection.
I once again dont know if we are making the situation worse by putting more drugs in him, that could all have interactions and potential side effects. I was just reading about baytril and it seems it can raise liver enzymes as a reaction in some cases.
I feel like Heathy is become one big test tube of drug interactions and his poor system hasn’t got a chance to try and heal itself. Everything is so focussed on his liver that i dont think we’d even pick up on the fact that his kidneys or GI might be suffering.
Is it wise to give him the three more drugs?
Also his PCV dropped since wednesday (3-4 %) after we had come down from 80 to 60 mg of pred last sunday. So the vet wants to hold out on tapering anymore right now. Is a slight drop to be expected?
Patrice, yes we had Heathy on cyclosporine for a week at the start then i realized how much it would cost (around $1000 a month) and so had to take him off it as i cant afford that.
Any advice always hugely appreciated,
Beth and Heathy
x
Ps he has been on denamarin a week now (two tablets) and is on one marin tablet a day too, and also hepatosupport which also has milk thistle in. I think i worked out that this is about 400mg of milk thistle. Is this enough?

[Vally]

On my phone so just quickly I personally think you should go ahead with the continued reduction of the prednisone. Yes I always noticed a drop with a reduction but it usually went up again soon after but I realise Heathy isn’t being given a chance to recover from that BUT a PCV of 36 is high enough I think to keep on with the reductions. See what others say because I’m not as understanding of the results and drugs ands.

Beth I dont pretend to be a vet but I think the liver is having difficulty because of the hugh dose pred. The sooner he comes down the better on the liver.

Beth I would send the results through to Dr Dodds and let her know what is suggested and get her input.

Love Vally and Bingo

[Beth]

Hi Valley, thanks! I still think its the pred too, but the Vet keeps getting side tracked by the fact that the ALT is high, she feels more comfortable/ marginally less concerned about the ALP as she knows this will go up with steroids… As far as i can tell the ALT signifies damage. She doesn’t think that the ALT can necessarily be related to the steroids.
I have sent everything to Dr Dodds, also my vet referred me to an internist who i will try and get an appointment with next week.
Do you know if giving antibiotics can do any harm at this point?
Thanks,
Beth and Heathy xx

[admin]

Hi Beth

Not what you wanted to hear, but it’s EARLY DAYS. How is Heathy in himself? Is he eating? Is he still weak? How they feel is so important.

I completely agree with Vally – get him off the pred as soon as safely possible, for sure. The dose he was on has played real havoc & he won’t recover overnight – give it a couple of weeks at least. There is often a small drop in PCV after each pred reduction & he is so near normal that it is not worth panicking about the anemia. And ditto to Vally – tell Dr Dodds everything. The blood tests do look like an infection (neutrophils & monocytes high), Beth, even though we do sometimes see anomalies from machine counted samples.

A sample of urine to confirm this is infection is the easiest way & I am glad they have done this. UTI’s are very common with high pred – another reason to reduce. This stuff is very hard on the kidneys too. Do you have any blood smear results (I know I have asked before – sorry)? Get advice from Dr Dodds about which antibiotic to use, please. Your research is correct on Baytril. I feel like I’m always the harbinger of doom on antibiotics, so I’d rather you get a professional opinion on which is the safest & most appropriate for Heathy. Ursodiol is an acid which occurs naturally & can help the liver detoxify. It sounds like a good idea in principle, but I’ve not heard of it being used before – please check with Dr Dodds. It must be given 2 hrs away from sucralfate.

Here is a link for milk thistle dosing – Dr Dodds has given some guidelines too:
http://www.canine-epilepsy-guardian-angels.com/milk_thistle.htm
It states you can use up to 200mg per 10 lbs of body weight for dogs with liver disease. Divided into smaller doses throughout the day is best. So you have plenty of scope there!

Please, please keep your hopes up – I know you are very worried. Perseverance will pay – so many of us had to learn the hard lesson of putting up with the horrible side effects to earn remission. Heathy is a real fighter & I know you are doing your very best to get him through this.

Love & hugs as always
Sheena x

[Beth]

Hi Sheena,
Its kinda odd because Heathy seems kind of ‘ok’ in the circumstances. He still wants his walks and wants to keep going when i suggest we go back to the house. He is still asking for food all the time and tries to eat anything he can off the ground outside (i have to watch him carefully so he doesn’t) he barks off the balcony, he plays a little ball in the house. The only difference is that he doesn’t seem to be able to get comfortable when lying down (he prefers lying on his front on the hard floor) and is rather restless at night. He is weak but more in a muscular sense, cant get up the stairs too well, and wobbles and falls on the walk sometimes (we have lots of snow so its not too easy with the ice etc)
Ah, so its good news that he didnt have a UTI but my vet suspects a liver infection. I will indeed ask Dr D on the safe antibiotics for him.
Sheena, I’m not quite sure what a blood smear is, as far as im aware he’s only ever had blood tests (cbc/chem/ in house pcv)… I can get one if you think it will tell us more??
Thanks for the milk thistle advice. Im aware of Dr Ds advice on dose but for the life of me i cant find a definite ‘Adult human’ dose to take the 75% dog dose from! The literature differs so much. I wanted to make sure i was giving him enough, but i guess if you guys have seen results from denamarin from the nutramax recommended dose (2 tabs for his size) then that should be enough.
Thankyou for your morale boost advice also, that helps as much as doggy advice. Every time i see the liver enzyme results i go into a panic. My life has been taken over by this, or at least i can’t stop spending every minute of the day working to help him; it just doesn’t seem like an option anymore – to take time out from the situation. I swear since this has started i have not done a single thing for myself, i have not socialized once, have not exercised, only leave the house to shop for his food or drugs or to walk him, its so intense but i cant image anything else right now, it has taken on a life of its own. Its hard to keep my chin up.

Love to all,
Beth and Heathy.
xx

[Beth]

Hi Tamara,

I just looked at Heathys results from his urine test (i thought he may have a UTI) and like u say, he is proteinuria. It doesn’t have a value… It just says “2+ Urine Protein: creatinine ratio testing is recommended (if the sediment is inactive) to determine the clinical significance of proteinuria”. The only other points on the test that seem significant are that the pH is high (7.5) the struvite crystal 2-3 and squamous epithelia 2-3 oh and bilirubin 1+ Not sure if these last figures are significant or not. I know my vet said the serum bilirubin had gone up slightly since the last blood test.
I will quiz my vet about the proteinuria, thanks for the note!
Love Beth and Heathy.