Sorta new here — need advice on new AIHA diagnosis in hospitalized dog

[Vally]

The link Sheena gave me isn’t working, so I’ve asked her to check that – that’s why it’s not “below”.

Vally

[Sheena]

Links

http://www.eclinpath.com/chemistry/liver/cholestasis/bilirubin/

http://www.ncbi.nlm.nih.gov/pubmed/17144823

[Lauren]

I thought I’d give an update on Ernie. He’s still fighting and making very very very gradual improvements, but improvements nonetheless. He has had three plasmapheresis procedures, which seems to have gotten his IMHA under control and allowed the drugs to kick in. The concern now is that they have never seen bilirubin so high because his disease has been so aggressive, and while it came down, they are still seeing some neurological signs. So currently I am waiting on an MRI, which he is either having or about to have, and which we hope will tell us whether it’s just bilirubin or a potential clot/bleeding. If it is just bilirubin, the teaching hospital may be able to offer funding to help cover some costs, because he is such a unique case. The plasmapheresis allowed him to make it as far as he has, and he has proven to be a fighter. So regardless of what happens next, he has taught the vets there more about this awful disease, and we have all tried our hardest.

We could use your thoughts for the best outcome on the MRI and a successful round of anesthesia.

[Sheena]

Glad to hear Ernie is holding his own & is improving. Was he on anti-clotting meds? If so, hopefully it isn’t a clot – as an ex-nurse I’d rather deal with a bleed than a clot, but both are treatable of course. I imagine the anaesthetic for an MRI scan will be very quick – sedation seems more likely.

I live in France, so can’t help on the insurance front – sorry!

[Lauren]

His MRI was clear! So all the neurological symptoms are attributed to the bilirubin at this point. So we are still facing many unknowns — they don’t know how he will tolerate these levels as his body works to clear it. The numbers are very gradually decreasing, but with levels so high, there was a lot of excess in his tissue.

He has been on anti-clotting meds from the beginning, so hopefully they will continue to help keep him clear of clots.

This is such a difficult stage, I am trying to stay optimistic, but I also don’t want to be caught off guard if something happens. I keep fearing that my phone will ring with bad news because he is still so critical. I know this isn’t ever going to go away completely, but it’s so hard having him still hospitalized and out of it.

[Sheena]

Great news, Lauren. One step at a time, even a little baby step forward is an improvement. I completely understand you are not at ease – no way would I be either – & there are always pitfalls & problems – we deal with each one as we travel along.

[Lauren]

Hi again,

Can you all tell me what the range is for seeing regeneration? Looks like destruction is under control at the moment, but they still aren’t seeing more than a few reticulycytes. They are expecting it to take another 3-5 days and aren’t particularly concerned just yet, but if course I am. He’s on dexamethasone and mycophenalete so far for immunosuppressives, but as I understand it that doesn’t really make a difference in regeneration. I know some of you all have been through this and am hoping for some input.

Thanks!
Lauren

[Patrice]

Lauren,
With ANY level of anemia (that would be a PCV or HCT below 38% and less than 5.5 million red blood cells), in order to be considered regenerative the absolute number of reticulocytes must be equal to or greater than 60,000 or 1%. And indeed, when there is no anemia (PCV HCT equal to or greater than 38%) the average normal value of reticulocytes stays steady at about 1%, 60,000 absolute. This applies to humans as well as canines! And the body carefully modulates this values with intricate feedback loops. It is an amazing process.

The greater the anemia, the higher this value must be to be considered adequate regeneration. This is the hardest part to understand. There are several math formulas that help determine the proper level of regeneration that must occur depending on the seriousness of anemia.

For example a dog has a PCV HCT of 18%, which is considered severe anemia. Ideally it would be nice to see values of absolute reticulocytes upwards of 300,000-500,000 and percentages like 3-4-5%!

With bone marrow failure, Chance had, the first time we were at the vets, a PCV of 30 and he had only 13,000 reticulocytes. This set off a trigger of a very dangerous indication that something was very wrong. And he also had extremely low white blood cells so he was also considered to have neutropenia, failure to make white blood cells. Luckily he was making platelets or it would have been very severe, this would be called pancytopenia, the loss of all blood cell lines. You can read Chance’s story, along with all the other stories here:
https://www.secondchanceaihadogs.com/our-stories/chance/

Reticulocytes are immature red blood cells, larger than normal because they contain the RNA from their development stage. When the red blood cells are stained with purple and viewed under a microscope they have a reticular appearance (spotty) and that is why they are called reticulocytes!

It takes reticulocytes about 3-5 days to mature, drop the RNA and become ready to begin carrying oxygen in the hemoglobin molecule to the body cells. So if you look at a CBC and see a large value for reticulocytes you can expect within a week to see a huge increase in the number of red blood cells and a decrease in the reticulocyte values, does this make sense to you?

It is unfortunately more common now-a-days to see canine bone marrow failure due to an autoimmune attack at the deepest level of the bone marrow, the precursor cells. This was Dr. Dodds determination with Chance.

I am not, nor is she, a proponent of immediate bone marrow biopsies when a dog is non-regenerative. We prefer to recommend a trial of the bone marrow failure protocol to see if there is any response to a higher dose of several immunosuppressives (including cyclosporine). If there is a response, then it confirms the diagnosis of an autoimmune attack on the bone marrow. If there isn’t a response then further testing can possibly include a bone marrow biopsy, among other tests. It is preferable in the beginning to save your money for one or more blood transfusions.

We put Chance on Dr. Dodds’ bone marrow protocol and within 3-4 weeks he began to respond with moderate regeneration. It took months after that for him to recover completely from his condition and the side effects of the drugs.

Please upload your CBC on the Urgent Advice page. I will look at it, do some math and let you know what I find.

If you have any questions about what I have written, please let me know.
my best, patrice