Seeking transfusion advice and general input. – Page 2

Sheena

Guest

Hi Allison

I am so pleased you are here – we will do everything to help you that we can. Thank yoiu very much for all the bloodwork, test results etc. There is every chance that Benni will make a great recovery. I can assure you we’ve all been at our wit’s end trying to cope with the early stages. I’m so very sorry you are going through this & I understand how stressful & horrible it is.

Number one – Vally’s advice is spot on -please stop all those supplements that boost the immune system. The last thing you want to do is stimulate it – we want to suppress it.

Diseases such as ehrlichiosis, pyruvate kinase deficiency (a genetic deficiency found in some breeds) septicaemia, poisons & some drugs such as the antibiotic cephalosporin & estrogen are guilty of invading/damaging the bone marrow – this happened to my dog Worzel. 99% sure it was ehrlichiosis. He didn’t have myelofibrosis, but he did have bone marrow failure. All his reticulocytes were destroyed before getting a chance to enter the blood stream. Had had NO reticulocytes (baby red cells) whatsover coming out of that bone marrow. After getting antibiotics & a second longer acting immuno-suppressant after consulting my wonderful specialist, he started to have loads of reticulocytes after about 2 weeks. I hope you will find some hope in this story – although he was seriously ill, he made a complete recovery into remission & he is right beside me over 3 years later at the grand old age of 15+. When we found out he had responded – our patience & trust in the treatment payed off – we were so glad we found a specialist who knew what he was doing & added in the azathioprine. Finding & eliminating or controlling the cause is important of course.

The preferred drug is usually cyclosporine though, and if the azathioprine hadn’t worked, we would have used that next, so I would absolutely push hard for this to be added. You will find other stories on this site of dogs only on prednisone. Any dog who does not respond very quickly MUST have a second immuno-suppressant to make a full recovery. I cannot emphasise what Vally has said more.

Is there any chance Danni has had antibiotic treatment in the near or distant past, or could he have accidentally ingested contraceptive pills or HRT, or anything that he shouldn’t have eaten? Finding the cause would be such a great start. I notice your vets have done Tick tests etc. What would be very useful is the blood smear results reviewed by the technologist mentioned on the blood test – sometimes strange & interesting cells are seen which can give us an insight into the cause – a bit of detective work!

There is a however – myelofibrosis may need a slightly different treatment approach – we need to be absolutely sure what you are dealing with – I am NOT an expert on myelofibrosis, but I am expecting Danni’s treatment will probably be the same – I am NOT 100% sure. For this reason, I would urge you contact Dr Jean Dodds as soon as possible. I feel Danni needs someone of her knowledge & experience to look at all the results, maybe consult with your vets & advise you on the best way forward. There is nothing you cannot overcome.

Danni’s thyroid function – the T4 level is the rock bottom of normal. He may well benefit from thyroxine, as Vally mentioned. Again, I would prefer Dr Dodds advised you on this as Danni may be slightly different with his problem.

One very important & hopeful pointI would like to be happy about is that when the bone marrow doesn’t work too well, blood cells are produced in other organs such as the spleen & liver – stem cells plant themselves in there & help to boost production. Quite amazing how the body finds ways to heal itself. On Danni’s tests, your vets found that his spleen is producing blood cells, which is good& often happens with diseases like this – this is called extramedullary hematopoesis – you can read about it here:
https://www.secondchanceaihadogs.com/AIHA_Terms/extramedullary-hematopoiesis/

The other thing I deperately want you to read is the story of Patrice’s dog Chance whom this website is named after:

https://www.secondchanceaihadogs.com/our-stories/chance/

I think a lot of this story will sound familiar to you & Danni- I have a good feeling that Danni’s treatment will be the same as Chance’s. Chance had no functioning bone marrow & he made a full recovery with the right treatment – please read that at the beginning he was only on prednisone – this did not work & he became emaciated & very weak – we do NOT want this to happen to Danni – he needs further help right now. Her vets were happy to consult with Dr Jean Dodds & suddenly, he was getting better when the cyclosporine kicked in. This is honestly one of the most unusual cases you will ever come across – Patrice NEVER gave up, neither did Dr Dodds, and this story is very important for you to read & to take HOPE from. Cyclosporine turned Chance around. So did being on antibiotics for the time when Chance was unable to fight infection due to low neutrophils – they are the lovely cells that attack bacteria etc & protect us. Also note the Vitamin B12, denamarin & stomach protector (sucralfate).

I noticed your vets commented on tapering prednisone as soon as possible. Be very, very careful with this please, please. He must have a normal HCT or PCV for 3-4 weeks at least, i.e. stable, before you consider lowering the drug. Please let us help you with this when the time comes! Hoping it will be soon though.

If Danni needs a transfusion, you can get fully cross matched blood & blood products from Dr Dodds at Hemopet. Let’s hope he will stay steady. 15 is the approximate PCV lower limit for transfusions, but all dogs are different, so it’s not set in stone. Transfusions save lives & make our dogs more comfortable when they are really struggling. BUT they should never take the HCT/PCV over about 25 – here’s more info if you need it:

https://www.secondchanceaihadogs.com/AIHA_Terms/transfusion/

I also notice that this disease is affecting the other cell lines to some extent, as well as the red blood cells, but although the platelets are slightly low, they are nowhere near danger level – but the vets must monitor this carefully too.

I cannot see any reference to agglutination or clotting risk on what your sent us (a big thank you for such great information from the vets – very thorough & useful) but to be sure, the blood smear would reveal that. In most cases of bone marrow failure, such as Worzel & Chance, there is no clotting risk & they do not need anti-clotting medications. We always like to absolutely sure that there is no clotting risk though as clots are the biggest risk with the intravascular haemolysis version of IMHA. It is “different” from bone marrow failure, so you may well not need anything.

There seem to be 2-3 struvite stones in the urine sample. This is usually because of a pH imbalance in the wee! Too alkaline. Please try & keep Danni really well hydrated – lots of water – because getting dehydrated will make this worse. The pred doesn’t help this either as it does make them thirsty & dehydrated. There is also bilirubin, (like Worzel) which indicates red cells are still being destroyed (it reads that this is in late stage maturation or development). When the immuno-suppressants work properly, this will stop. I bought some wee test strips from the chemists & checked his pee regularly. When he suddenly got better, the bilirubin dropped to normal.

As Danni’s anaemia is called hypochromic (pale cells), it is possible that he may need iron supplementation, but this must NEVER be given without approval & full investigation by your vets into ferritin levels etc, as excess iron build up is dangerous.

Like Vally, I think you are looking at the prednisone side effects. Many dogs also have what seems to be a heart murmur when they are severly anaemic. When their PCV improves, the heart resturns to normal – aagain, let’s hope that is the case with Danni. If he didn’t have a murmur before that seems more likely in my opinion. If it is a genuine murmur, you just treat it – no problem. Worzel has had a murmur (MVP) for about 8 years & it is treated with drugs – it has thankfully never got any worse.

Please tell me if there is anything I haven’t explained properly or if you need help with anything else at all, just ask any of us – we just want to get Danni better as soon as possible. I am in France, so we are all awake at different times, meaning someone should be around to help.

I apologise that this is long, but I wanted to cover as much of the test results for you as I possible could. I hope you didn’t fall asleep! I hope I have helped & you now know you must not give up – I am so glad I didn’t & so are my many lovely friends on here. We are all in this together! As Amy would say, we are all floating down the steroid river, trying not to rock the boat!

Supporting hugs to you & Danni- keep on fighting.

Sheena, Worzel & Ollie xxxx

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Allison

Guest

Hi Linda and Sheena!
Thank you SO VERY MUCH for your responses and compassion. It has meant a lot to me.
I will try to touch base on everything you two have mentioned:
1. His thyroid issue was mentioned by the complementary vet, but the topic kind of got overlooked with everything else. When I go into her office for a PCV check in the morning, I will talk with her about it. But, I will also be requesting thyroxine from the doctors from the animal hospital that are ‘steering the prescription ship. ‘
2. Thank you for mentioning that the milk thistle should be given separately. I started his med regimen tonight with the pred on its own.
3. I have held off on the Zhu Huang Tang, Immucare and Kelp for this evening. I will follow up with the animal hospital on this tomorrow. I can see how it is counterproductive to be supporting the immune system when the whole point is to beat it down.
4. I live in Florida- our PCV check appointment is at 10am. I will let you know what happens.
5. I will ask about a stomach protectant tomorrow as well.
5. His reticulocyte count has been in the ‘normal’ range, which (as you know) is nowhere near what it needs to be or should be.
6. I will call to get a copy of the blood smear report and any other lab work they ran. They’re very good about handing over whatever I ask for.
7. He is a very good dog and has never gotten into anything- not to say that it is impossible, but I have walked away with a cheeseburger in front of him and came back to find it untouched. He’s so incredibly good.
8. The only type of medication that he has been in almost a year is Sentinel and Xanax. The Sentinel has been used as needed, depending on the weather; he has had about 5 (maybe) Xanax in the past year. I have given him Benadryl as needed for allergies (the last time was probably about 2-3 months ago)
Please let me know if I have missed anything.
QUESTIONS:
1. Cyclosporin recommended over the Azathioprine?
2. How far apart should the milk thistle and the meds be given?
3. I have been extremely concerned about his breathing and heart rate, because the vet from the hospital said that this is what I need to monitor as it will be the only way that I will know if he is starting to decline again. I realize that you are probably right about the prednisone causing some of it, but how else can I tell if he is crashing? He is very stoic, so it’s hard to tell with him sometimes.

Thank you again for everything!!
I will keep you posted. 12 hours until PCV check!
Allison and Benni
(Please forgive any typos or grammar errors; the text box is so small, it’s hard to review everything that I am typing!)
PS- Sheena, please don’t worry. I appreciate your help!! His name is actually Bennington- most people actually mess that up, so I was hoping to keep things simple by giving his nickname!

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Sheena

Guest

Hi Allsion & Bennington (GREAT name!)

Don’t worry about the transfusion going over 25 – they did their best to calculate by the sound of it – Vally has explained perfectly why 25 is better, but it’s not disastrous at all. Forget about it.

You are right about the reticulocyte level – it should be higher – that’s what we need to address & adding the cyclosporine may well be the kick start Bennington needs. Yes, it is generally preferred over azathioprine by most vets in the USA because it is better tolerated – I believe that is right, even though my dog Worzel was fine on azathioprine. Azathioprine is also cheap. Some dogs cannot tolerate azathioprine well – it can make them ill with pancreatitis very quickly, or even later on if coupled with a fatty or bad diet, plus in the longer term, it is a bone marrow suppressant. I noticed Worzel’s PCV increased even more as we reduced the azathioprine slowly. So cyclosporine is a better option in a lot of ways. If dogs don’t respond to cyclosporine on it’s own, azathioprine is often added as another kick starter. It is unusual for dogs to need a second long term drug on top of the cyclosporine, but sometimes they do – every dog is different. There are also other drugs such as mycophenolate mofetil, so we do have lots of options to try, no worries! My specialist said we would try every drug possible, or a combination if needed & that we would never give up until we found the right combination. It is true to say that a human would just be topped up with a transfusion until the doctors found the problem & the right drugs – this is true for our dogs too! I hope Patrice’s story helped you.

Good luck with the tests today – I am crossing everything for you – we all are! Please ask for a blood smear – red blood cell morphology information might help us. Abnormal red cells can tell us a lot!

Benni’s breathing & heart rate – hoping it is down to anaemia & the prednisone. Please tell them how concerned you are about this, but have at look at this:

https://www.secondchanceaihadogs.com/AIHA_Terms/iatrogenic-cushings-disease/

This is another reason we don’t want Benni on high dose pred for longer than necessary.

Lastly, I am suspicious about that heartworm medication – some of these treatments definitely trigger IMHA/AIHA, such as Trefexis, ProHeart 6 etc.

Good luck!

Supporting hugs
Sheena & the boys xxxxx

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