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Discussion Starter #1
Little background, I have a 4 year old female shepherd (spayed) that I am fostering for work. She has heartworm, just got her first injection last week Monday (6/23). Had a rough go after that and was put on to Pred and Doxy starting 6/26. She's been up and down since, mostly up till this past week she's been so-so. Took her in for an exam, vet noticed her eye whites were yellowish. We sent bloodwork and came back all liver enzymes very elevated.
T.Billirubin 1.2 (normal 0-0.6)
Gamma GT 84 (normal 0-10)
ALT 4473 (normal 10-69) The lab Repeated and confirmed this
AST 408 (normal 0-67) Lab repeated and confirmed also
Alk Phos 1268 (normal 7-64)

Other things out of normal range were:
T protein 8.4 (normal 5.1-7.3)
Albumen 2.4 (normal 2.6-3.6)
D.Billirubin 0.5 (normal 0-0.2)

Her blood sample was Icteric

Right now we are trying to flush her system by having her on IV fluids. She is home with me as that is better than being at the shelter as I can monitor/manage her IV. No more pred but continuing doxy.

She can use prayers and was just wondering if anyone has had experiance with liver issues as such. I myself have never seen such elevated levels before.

Thanks
 

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HOLY SMACK! That is huge-when I was researching ALT stuff I found some as high as 9000 I believe (not sure what the reference range was-but know it wasn't anywhere near that).

You know, now this makes me think that pre-HW treatment bloodwork needs to be done as a matter of procedure to
A. have a reference range
B. to determine if the dog has any health issues that will impact tx

Regardless-do you think she is having a reaction to the Ivermectin?

Do you have access to (if she's well enough) an ultrasound? I've gone to Dr. Homko, who is out of Ithaca, but comes to Rochester on Thursdays and she's really good.

In the meantime have any x-rays been done?

She's not eating Nutro is she? (I know-but...)

Rimadyl?

Also, was this what they were seeing with the aflatoxin thing?

And there is jaundice? Or...???

I mean, I look at those combos of numbers and have no idea. It has to make sense to someone, somewhere.

If my vet had no idea, I'd say let's you call Cornell in case it's some sort of new something that hasn't been confirmed yet.

Crap-when Kramer had a giant liver tumor his ALP was normal and his ALT was 540 I think (something in that range). SO would that possibly mean that this is an acute reaction and not a chronic thing like a tumor? I have no idea if that is an OF COURSE IT IS! question or not.

That is just-yikes. The good news is that the liver bounces back. Kramer's values are normal in all liver functions except just a little step high in the ALT-but have been going down since January-so it's regenerating. Let's hope that it will here.

Is she eating? Dr. Dodd's has a fish based liver cleansing diet that while it might not fix things, would help her liver work less perhaps? As long as you don't use fish from China. I have a link somewhere.

Can you get some Denamarin from work? http://www.nutramaxlabs.com/products/animal/denamarin/denamarin_faq.asp

Prayers on the way.
 

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Hey Allie

I work in Internal Medicine and I have seen dogs with labwork worse than your pups who have done great once the underlying cause was determined and addressed.

I'm guessing that the dog was treated with Immiticide? One of the rarely reported side effects of immiticide is icterus. Perhaps your vet could call Merial and get their take?

Wishing you the best
Joanne, RVT
 

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Discussion Starter #4
First of course we are still a shelter, though we have come far on what we treat. We do lots of heartworm treatments. This girl really didn't have anything prior to starting her treatment that gave us any indication that we should have sent bloodwork out first. We've had some in the past that haven't been in the greatest shape and we have sent pre-bloodwork out before starting their treatments. It would be nice if we could make it a normal thing with all heartworm tx's yes! (But with the number we sometimes have and cost/funding...)

No Ivermectin given yet, just one immiticide injection.

We don't have ultrasound but we have some vet clinics we work with (or know vets at) that have them and I will bring that up to vet Monday to see what his thoughts are (or all 3 of them as we have 3 vets but only one was working today and he's our head vet whom I trust with my own animals).

Chest xrays done prior to treating for heartworm, all was normal no xrays of liver yet.

No not eating Nutro, I have her on vet A/D right now as she has been eating on and off not the greatest but still eating. (was eating good when on Pred but...)

Yellowing she has in the whites of her eyes made us think yes she has jaundice. Her skin is ok though, and gums and skin in ears.

We have contacts at Cornell and I do believe that will be our next call Monday if fluids haven't seemed to help any. Right now biggest thing trying to do is flush her system out. (2 liters a day IV) Slowly so to not fluid overload but needs to get one bag in over 12 hours next over next 12 hours.

I'm hoping it's something that came on acute that we caught early enough that we can reverse it and turn her around and get her better. She's a sweetie.

Will have to check on the Denamarin too.

I'm always up for new thoughts to bring up to the vets. And I know they are always working to expand our clinical treatment range as shelter vets/clinic.

Thanks!
 

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Discussion Starter #5
Spirits mom- yea we found that today when we were looking up all the rare side affects of Immiticide. I worry more if it was due to that too as what will happen if/when she is better enough to continue her heartworm treatment as she still needs another injection. (Scheduled for 2 weeks from now but not so sure that will be kept scheduled). Will she go through this all over again? Lots of questions, hope to get more answers Monday.
 

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Sending out some prayers to your girl



Have you ruled out Pancreatitis? Does your dog have loose, black, clay-colored (grayish) feces (my dog had this)

Info from "The Dog Care Book - not to scare you, but to try and pin anything down.


Info on the Liver - makes the proteins that provide strength to your dog. Manufactures the clotting agents that stop th bleeding of cuts, and is very important in fat and sugar metabolism. The liver is the great detoxifier - purifying toxins and drugs in your dog's system. it recycles the bodies of dead red blood cells. Some of its products are used to make new red blood cells, others are used to make bile, the green digestive juice stored in the gall bladder that, at mealtime, is released to the intestine through the bile duct to help break large fat molecules into smaller ones. Liver disease or the rapid destruction of red blood cells will release large amounts of bile into the bloodstream, producing jaundice and staining the eyes, gums and skin yellow.


Has your dog be able to eat any sugar free gum, cakes or candy? Grapes? These can cause liver damage. Or any lawn treatments she might have gotten into?

Good luck and hope your sweet girl will be fine.
 

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Yeah-for the bloodwork-I was thinking of that in my little standard policies and procedures list I have in my brain! (as if it matters!)

I just looked up the immiticide and it sounds like it's safer for the liver-that is weird. But anyone can react to anything right?

Does anyone ever react to doxycyclene?

Is her white cell count normal?

Maybe cook for her to get any dog food out of her system? I have no idea. Just tossing easy to do stuff out. Here is one version of the Dr. Dodds diet: http://www.monicasegal.com/aboutus/yahoo017.php and another version (just find out where the fish is farmed! they were showing green water in China today!)
http://www.canine-epilepsy-guardian-angels.com/liver_diet.htm

Bile acids test?

(don't you think my vet earns every penny I spend there-can you imagine dealing with me!)
 

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Discussion Starter #8
Her stools are normal. And as far as I know has not gotten into anything. Has not been alone at all that she could get into anything (being on the htwm tx she is on leash walks only and cage rest).

Everything we found today it was one very rare side affect of Immiticide to cause liver issues.

I haven't seen animals react to doxy before, Doxy is one of the biggest drugs used for such a wide range of things, so I don't think it would be that and I know if vet suspected that we would not be keeping her on it.

Bile acid tests- no.
 

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The thing I hate most about heartworm disease is how devastating it can be and how it can affect dogs in such different ways.

Adopting seniors, I have had 5 heartworm positive dogs, all stage 3 or 4. Of these Caoimhe died from complications of the Immiticide (went into right heart failure), Duncan was successfully treated, and Snow Princess was caval and passed away before I could even get a consult. Feidhlimidh and now Niamh were both assessed and found to have heart disease caused by the heartworms. The cardiologists I saw recommended a slow kill, so both were placed on Heartgard. Feidhlimidh lived for 8 months before dying from brain cancer, and Niamh is still going strong.

When you talk to the docs at Cornell I'd ask for their recommendations for treating again with Immiticide vs. a slow kill with Heartgard. Thankfully the liver is good at "repairing" itself. Hopefully this girls liver damage is not to the point where it won't be able to recover.
 

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Discussion Starter #10
Things aren't looking up for this girl yet. She's not all too happy having an IV hooked up and has pulled her cathier twice now. Stopped eating, and has vomitted a little again today.

Talked to my boss/vet over phone and he said not to even worry about trying to get her to eat right now but just keep trying to get fluids into her. I will be sitting with her all day/night to keep her from pulling IV again.

Just asking for Prayers and hugs for this girl right now.
Thanks
 

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Discussion Starter #12
She has started eating for us and had a good day yesterday and today. And has kept her IV in well.

She is however drinking even more excessivly than before. Strange to me considering she is getting all the IV fluids as well. Also peeing lots, but that's to be expected with the IV fluids. I have to run a full urinalysis but dipstick was normal and color looked good (usually if kidneys are involved her urine would look pale like water).

Thanks for the liver support factors info, will have the vets look into that.
 

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Much better that she's eating and keeping her IV in!

Could she have an infection somewhere-internal or an abcess anywhere? A really bad inflammatory response to something? (I don't even know what that means but remember that with the liver-didn't know what it meant then-except I thought arthritis was causing an increase in ALT)
 

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Discussion Starter #14
Re: Elevated Liver Enzymes UPDATE

It's been a week since all this has happened with my foster. She's still hanging in there, not worse, but not much better. We did a liver panel blood re test this past week and her levels are all down, still above normal range by 1500 and so, but not at 4500 as before.

We have a lepto test being done at Cornell, we have a coagulation test being done at a vet lab. Should have results tomorrow.

She went for an ultrasound today, liver is a bit small but otherwise very healthy. She has Pancreatitis. Her Kidneys- the pelvis in both is dilated. This could be due to her fluids or it could be kidney disease. Another urinalysis was run and her specific gravity is very low, yet another sign of kidney disease/failure. The vet thinks that the liver enzymes was a rare infection somewhere in her body.

We repeated her chest rad today and her lungs are not in great shape. They were 100 percent clear prior to starting her heartworm treatment and now they are cloudy and granuloma all over, possibly from heartworm dying or rare chance she has cancer. Films are being sent to Cornell tomorrow. Going to do a bile acid test as well. (bilirubin very high in urine and blood)

My vet is doing lots of research and talking with some other vets to get a plan for her. Keeping her on the IV fluids for pancreatitis.

Hopefully we will get more answers soon! Feel free to chime in if you have thoughts!
 

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Re: Elevated Liver Enzymes UPDATE

Has a full tick panel been run? I had a great experience with the Cornell serology lab when my girl was diagnosed with disease from the lyme vaccine.

doxy without the pred? I would definitely try the doxy alone if it hasn't been tried yet.

a number of folks on the tick list have had pancreatitis along with tick disease -- in some dogs it appears correlated.

OOPS, reread about the doxy w/o pred......any positive response to that? Tick dose is 5 mg/lb BID. Many vets use half that.
 
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