Need advice/guidance about liver/kidney/gallbladder issues

[Rhetts_mama]

Originally Posted by Ellie May

Please leave this vet. He is hurting your baby. Part of kidney disease treatment is phosphorus binding. He does not know what is up and needs to send you out.

We have specially trained sonographers here and I don't think they even go near the kidneys with a needle. Renal artery - hitting it bad news. You need an IMS. I'm going to go out on a limb here and say gallbladder sludge is the least of concerns with kidneys shutting down.

She has progressed beyond the point where your vet can help. She needs a specialist and she needs one now. Get your records and take her to the Emergency vet and get a referral from them today.

The problems you are describing now have progresses to an emergency level. These are not caused by sludge around the gallbladder.

[JuliannaB]

Sorry to hear about Bumble. I have no experience with anything you have posted, but dropping in to say I'm sending positive thoughts your way and really hope that you will get the right help in order to bring your Bumble back to himself... soon!

[Bumble]

Good evening, all! Thanks for all the information and support, and prayers for my little girl.

She spent today at the vet's office again on "four times maintenance" fluids, until the vet on staff today noticed that she had a 2/6 heart murmur, and upon xrays felt her heart was enlarged. Then he backed her off to 3 times maintenance fluids. I'm no longer comfortable with IV fluids at those rates, but more about that later.

This morning, after one day on fluids, her BUN dropped from 169 to 165, and her creatinine went from 2.5 to 2.2. Her phosphorous is down from "over 15" (off their charts) to 11.5. I insisted on a pancreatitis test, because this dog is a VERY good eater with an iron stomach, and the only time in her life that she's ever been sick to her stomach was a bout of pancreatitis from eating cat food many years ago. The CPLI (something like that?) test came back as a "strong positive" according to my regular vet, who was off today but called me from his home. He said that he and the on staff vet today had consulted about Bumble, and felt that all her bloodwork levels added together, along with enlarged liver, was most likely lymphoma (and even told me that the pancreatitis was probably from the lymphoma and not "true" pancreatitis). To be honest, I'm sick of hearing that word. It seems every time one of my pets has a mystery disease, it's "lymphoma" which has NEVER managed to be a definite diagnosis. The vet insisted that they needed a diagnosis to be sure, so they could figure out how to start treatment (chemo, etc.) and how advanced it is. Again, he pushed for the needle biopsy of her liver (not kidney, perhaps I misunderstood previously, but I made SURE it was liver only). Keep in mind there is no visible mass, just a generally enlarged, dense liver and high liver values. Also, the only enlarged lymph nodes she has are in her neck, and they've been enlarged since a particularly nasty infection/growth in her mouth in February this year. Against my better judgment, I allowed the biopsy of her liver. I was assured, many times, that she would be given propofol as a sedative, and told how safe it was, how quickly she would recover, etc. They ended up using butorphanol, I think he said, because of heart concerns. Also, to look for signs of metastasis (for this mysterious lymphoma), they wanted to do full body xrays. Okay, fine, I really have no problems with xrays. Apparently the xrays appear clean on first read, but they were also sent off for a radiologist to review.

The xrays DID show, however, that Bumble's heart is enlarged, larger than it was in xrays done back in February 2013. At that time we took her to a cardiologist who felt her heart was within normal limits considering her age and breed (he referred to her as a "barrel chested breed"). He did want to repeat the echocardiogram and EKG this fall, but one thing led to another with a cat who became sick and died in October, and now the entire month of December taken up with Bumble's illnesses, and we just haven't done it. Apparently this needs to be a priority in January, since the cardiologist only comes over from Gainesville once per month and I missed the visit in December already.

The on staff vet today, because of the murmur and the enlarged heart, was worried about stressing her heart and backed off on the amount of fluids. I know she probably SHOULD be on IV fluids for a few more days to bring her numbers down, but I just can't trust the vet to back off when he needs to. I told the tech this afternoon that I'm not bringing her back in for fluids tomorrow morning, and the vet could call me to discuss it when he's back in the office tomorrow. I anticipate an argument, to put it mildly. The straw that broke the camel's back, so to speak, was when the tech told me, at 5:00 p.m. tonight, that YESTERDAY Bumble seemed to have a couple of fainting/collapsing episodes while they were working with her. Nobody told me about this, and to my knowledge she has never ever EVER fainted or appeared to do so. I realize a lot of things could cause this, but in light of heart issues, I tend to think perhaps they were overstressing her little heart already.

In the meantime, I have taken all your VERY GOOD advice and both located a replacement primary vet, and talked to a specialist who will let me self-refer. The bad news is that the holidays are going to cause quite a delay for both appointments. To get in with our choice of vet, because of Christmas holidays and everybody's work schedule, I can't get her in to see her new vet until December 30th, a week from Monday. I set that appointment already. The specialist's schedule also looks like December 30th or 31st will be my first chance to get an appointment. If I get a lymphoma diagnosis from this biopsy, then I'll get Bumble in to see the oncologist. Otherwise, I'll get her in with the internist. For now, I will probably treat the pup instead of the numbers, and unless she gets worse, delay any other treatment until the biopsy results are back.

My husband picked Bumble up from the vet's office this evening. I didn't tell him that the vet had said this morning he'd give us prescription I/D food for Bumble. It wasn't ready for her, and they didn't give her any food to take home. Turns out they also haven't fed her, so she had not eaten in over 48 hours. I got my hands on a case of I/D (thank you Petsmart, and gee I hope this is okay food for pancreatitis) on the way home, and I've fed her twice tonight, about two tablespoons worth each time. I'll give her a teeny bit more before bed, but so far no signs of nausea. She's tired tonight (hungover from the drugs they gave her around 2:30 p.m.), but overall seems much more alert than last night. She's followed us through the house, and was incredibly happy to see me put food down for her. Poor little girl was probably starving.

I don't think she's out of the woods yet, and unfortunately it's going to take a while to get her established with a new vet, an appropriate specialist, and to get those biopsy results back in and interpreted, but tonight I think I can sleep. Last night I stayed in the den with her, with the light on, and only dozed, waking up probably every 30 minutes or less to make sure she was still breathing. My poor husband was in tears when he kissed her goodnight last night, and told me he didn't think she would still be here this morning. She was THAT listless last night.

Thanks again for all the guidance and support. Knowing that some of you have dealt with these multiple-organ issues without it being a diagnosis of lymphoma is comforting to me. I wish we could all have perfectly healthy little ones, but since that just isn't possible, I'm really glad there are wonderful groups like this one who are supportive and helpful and willing to share their experiences!

Now if I can just get her stable and back to her old self, I can bore you all to tears with stories about how wonderful she is, and all the silly little things she does!!
Dana and Bumble

[wemple2]

Worried and praying...

[Scoobstersmom]

Dana, I am worried about Bumble as well. How soon will you get the results for lymphoma? I am praying for a negative result.


I understand your concern about 4 x maintenance fluids. That is a lot for a very small dog and could cause fluid backup leading to heart failure. Without that heavy fluid load, hopefully the heart issue will resolve on it's own.


Did the vet send you home with any kind of treatment plan? With a BUN and Phosphorous that high, I would be concerned about waiting until the 30th for any kind of treatment for the kidneys. Having dealt with kidney disease in my dog for the past 18 months, I am familiar with the treatment protocols. It seems that Bumble should be taking Pepcid or some kind of acid reducer, getting at least a maintenance amount (5-10 ml per pound of your dog's weight per day) of subcutaneous (under the skin) fluids, which you could administer at home, and a phosphorous binder such as aluminum hydroxide to try to bring the phosphorous down before it causes further damage to the kidneys. Diet should be very low fat (because of the pancreatitis) and low phosphorous diet.


How does Bumble's breath smell? Many dogs in kidney failure have a tinny, uremic smell to their breath, caused by the toxins building up in their system.


These are some things that it might be worthwhile to talk to your vet about while you're waiting for the appointment with the new vet.


It's fairly normal for a dog that has spent days in the hospital on fluids to come home feeling exhausted and lethargic. I would let her rest as much as she wants to right now.


Sending lots of prayers and positive thoughts for your little girl.


Diana and Scooby

[Bumble]

I wanted to keep Bumble on fluids today, and maybe tomorrow, depending on how her numbers are coming down. However, when the on site vet yesterday said she had been on 4x maintenance fluids even after I was told she would be dropped to 3x maintenance at lunchtime the day before, I became too afraid of hospitalizing her with her vet for fluids. I'm afraid he'll TELL me she is getting fewer fluids, but he'll do what he thinks is right anyway.


No treatment plan was given, and they even "forgot" to give her any food to take home yesterday. She did eat the ID last night, and again this morning. As far as I know she kept the food down. She's still not herself this morning, obviously not feeling well, but she's alert and when I left the house she got off her bed and moved to a spot in the room where she could stand and watch me until I walked out the door. I feel terrible having to leave her alone today, but it'll only be for 4 hours at a time.


As for phosphorous binders, that was the FIRST thing I asked when he told me her numbers were too high to register on their equipment. He said that they used to be heavily favored when he came through school (he's only in his early 40s), but now "they" feel binders don't work, so he doesn't use them. I've had CRF kitties before, and I've never heard of a vet that refused binders and said they didn't work, particularly if kitty had obviously elevated numbers.


I have a sneaking suspicion we'll end up at the ER vet tonight or this weekend, getting updated bloodwork and perhaps having her hospitalized for fluids. I truly don't have the money for all this, and the ER vet doesn't allow payments. Everything must be up front with them. I'm worried I'm going to run out of money completely before we get her stable and comfortable.


It's after 9:00 a.m. here and I'm really surprised the vet hasn't even called me to see how Bumble is, and to discuss why I didn't drop her off. I really do wish I could trust him to keep her on maintenance or 2x maintenance ONLY fluids today, plus keep giving her the IV antibiotics and rerun her bloodwork tonight. I guess I'll call him shortly if I haven't heard anything before then. This is just so nerve-wracking!


Dana and Bumble

[Scoobstersmom]

Dana I'm glad you're switching vets, and yours doesn't sound very easy to work with but since you can't get in to the other one for a week or more, I am going to suggest that you ask about doing sub q fluids at home this week. That way you control how much fluid she gets. Standard maintenance dose is between 5-15 ml of fluid per pound of body weight per day. With Bumble having a heart condition you would probably need to be on the low end of the range, but it is very easy to do and a lot less expensive too. I've been doing daily fluids with my little guy for months now and it has kept his numbers right at the normal range and he doesn't even mind them. We have a routine, and if I'm a little late he'll jump up on the bed, bark and remind me! For him it is attention time, hop up on the bed and cuddle in a big warm towel time, and he also appreciates the treat he gets ONLY after fluids. He weighs 11 pounds and it takes me less than five minutes to give him the fluids.


As for the phosphorous binder, some vets are difficult about owners making suggestions, but I have never ran into one that would refuse a binder to a dog with a phosphorous over 10. That's crazy. My vet actually suggested I use the Aluminum Hydroxide powder from thrivingpets.com because it's cheap and very concentrated. And it works. It also doesn't require a prescription. In the beginning I read a little about aluminum toxicity and worried about it, but then read more and am convinced it's ok for my dog. He's 15 and I only give him a very little bit to keep his phos in check. Even thought the high end of normal for phos is 6.6, my vet likes to see it between 4 and 5 for a dog in renal failure and less than 1/8th of a teaspoon per day with his big meal keeps his in that range. He has kidney, liver and gall bladder issues as well as chronic pancreatitis, so a little bit of the binder is the least of my worries!


Let us know how Bumble is doing when you get home.


Diana and Scooby

[Bumble]

Quick update and MAYBE some good news!


Biopsy results are back. No sign of lymphoma. Also, the full body xrays were read by the radiologist, and he sees NO signs of lesions or growths or anything like that. Vet now believes it's NOT lymphoma. YAY!


The biopsy DOES show inflammatory process in her liver, and some kind of finding (I couldn't even understand what he said) that meant red blood cells are being made in her LIVER and not just in her bone marrow. Vet said that's an unusual finding, doesn't know why it's happening, but it shouldn't be.


He now thinks, based on everything he sees from the biopsy results, that she has chronic active hepatitis. He also now believes the "strong positive" test result for pancreatitis.


Around 1:00 p.m. I checked her back into the hospital (I had kept her home this morning) for fluids and IV antibiotics ONLY. He said the treatment for chronic active hepatitis is steroids, and that her kidneys are "in bad shape" and he's afraid that the steroids will shut down her kidneys. He said there's "no good decision" in her treatment course now. I will be doing lots of research tonight.


For now, fluids, IV antibiotics, tonight we start her back on ursodiol, she's on prescription I/D canned food, and tomorrow morning we'll re-run full blood panels to see where her kidney, liver and anemia numbers are (she's anemic, too, but until today, he didn't want to treat that, either....).


She's got a long road ahead of her to get well, if that's even possible, but MAYBE we finally have a diagnosis and I can figure out how to treat her. She's obviously weak, but she's feeling at least a little better because her personality is coming back. If she wants to be held, that's fine, but when she wants down, she wants DOWN NOW, and that's how she was acting this morning. Snuggle time is on her schedule only.


Dana and Bumble

[JuliannaB]

My bad typing 'him' when it should have read 'her'.
So much concern over your little one. Glad to hear that it isn't cancer though. Hope that you find out more good news, or at least some news that can help her. Sending more positive thoughts your way.

[Scoobstersmom]

Dana, that is awesome news about the lymphoma. Your vet is right in that the kidneys are a much bigger problem than the liver. The liver is a pretty amazing organ that can regenerate over time. And CAH is not always treated with steroids. (My dog has a diagnosis of CAH, has not had steroids and his liver numbers have dropped almost back into the normal range over a year's time.) The kidneys are a whole different ballgame and once they lose function you can't get it back. So you need to do everything possible right now to protect her remaining kidney function and to make it easier for her kidneys to work effectively.


Yes, it's a long road. It seems your dog has exactly the same diagnosis as mine. Kidney disease, hepatitis, pancreatitis. We're not sure about the gall bladder. Nothing has ever shown on a scan, but adding ursodial saved his life. I am sending lots of positive thoughts and prayers for your baby!


Diana and Scooby

[ladyjane]

Prayers for Bumble.

[ladyjane]

BTW I have a pup with renal issues and she also had hepatitis. She was hospitalized and treated and is now doing very well. I again recommend a board certified internist...oh...I see you have one. IF you explain how sick she is, they should get her in before the 30th. Is it a 24 hour facility?

What I have found is that they don't start reaching out for all sorts of things...they get right to the bottom of things and it does not go on and on .... usually within days I have an answer with my sick pups. Here is Olivia's thread:

http://www.yorkietalk.com/forums/sic...phropathy.html

[Bumble]

Originally Posted by Scoobstersmom

(My dog has a diagnosis of CAH, has not had steroids and his liver numbers have dropped almost back into the normal range over a year's time.) ... It seems your dog has exactly the same diagnosis as mine. Kidney disease, hepatitis, pancreatitis. We're not sure about the gall bladder. Nothing has ever shown on a scan, but adding ursodial saved his life. I am sending lots of positive thoughts and prayers for your baby!


Diana and Scooby

My vet loves the word "aggressive" and wants to "aggressively" treat this CAH now. He was even initially stressed that I refused to start the steroids today, even though he keeps making it sound like the steroids have a better-than-average chance of destroying her kidneys (doesn't sound like a win to me!). He agreed to wait until tomorrow, after I insisted that we need to know where her kidney values are first, to make that steroid decision. Can you tell me exactly what drugs/protocol was used for your Scooby? I tried going through the forums but can't seem to figure everything out.

Bumble is back on the ursodiol as of tonight, which seemed to be helping her gallbladder issues, anyway. She had been on Denamarin (SAM-E and milk thistle, I believe?) for a month or so, and will probably be going back on that tomorrow or the next day.

My problem with getting her in to see the specialist is the holidays. The specialist works at the emergency vet, but only sees patients by appointments on Monday through Thursday. Unfortunately, she's out ALL next week and not back in the office until the 30th. I just called them again to make sure I understood that correctly.

I am currently leaning towards refusing the steroid treatments until I can get an appointment with the specialist, and praying that I won't lose my little girl in the meantime, by being overly cautious and afraid to make a decision. It just seems like kidney support is okay (fluids), antibiotics are great, ursodiol is fine, and Denamarin is probably fine. She doesn't feel great, though, and in fact just threw up everything she ate and drank tonight. My husband is afraid that waiting over a week to start treatment when she's already sick and has been so sick for a week is a really bad idea (I tend to think that, too, but I am SO afraid the steroids will kill her).

If her kidneys are compromised, and her heart MAY be, it seems like steroids are a bad idea. My fear is that this is something that's doing real and immediate damage to her liver, and that if I don't control it with steroids now, maybe she won't make it through this.

Thank you so much for all the information and support. I can't tell you all how much it means to me!

Now for the "Silly Bumble story of the day": My husband thinks the most unusual thing about Bumble is that we never heard her bark, not ONCE, until she was probably a year old and there was a space shuttle launch which shook the windows. She barked, once, at the rattling windows in the middle of the night. After that, she didn't bark again until she was around 3 years old. At that time, my dad came to visit and we had to put a mattress in the living room for him to sleep on. In the middle of the night, Bumble wandered through the house and found a strange item (mattress) taking up the entire living room floor, with a strange man on it. I guess she forgot he was visiting. As she got onto the mattress to check things out, he reached out to pet her, startled her, and she bounced off the mattress and began barking loudly. After that, she has never shut up. Okay, that's not entirely accurate. She barks when we come home, barks for food and snacks and medicine treats (she is hypothyroid and gets meds twice a day), and has been known to bark at the cat when she gets in a weird spot where Bumble thinks the kitty shouldn't be. However, overall, she's still a VERY quiet yorkie! My dad of course thinks it's GREAT that he "taught" her how to bark, and frequently threatens to come teach her new tricks!

Thanks again for the prayers, and for letting me run all these ideas past you! Best wishes to all of you and your little furbabies!
Dana and Bumble

[Scoobstersmom]

Dana, do you know what Bumble's liver numbers are? CAH is sort of a catch all diagnosis for liver disease and means there is an inflammatory or infectious process or both going on in the liver. Lots of dogs have a slightly enlarged liver and a dx of CAH. That's a big improvement over cirrhosis and CAH, which means parts of the liver have shrank and gotten hard and will not regenerate. If there is an infectious process (bacterial) going on in the liver it needs to be treated with antibiotics - often amoxicillin - which your vet is doing. Hepatitis is chronic and is mostly just managed. The liver numbers can drop quickly, but more often it is a slow process taking months, and in the meantime you're managing the condition with pulsed antibiotics, ursodial (not only for gall bladder, it is an awesome antioxidant for the liver), denamarin and other supplements, and diet and watching to make sure the numbers are decreasing instead of increasing. Many dogs live for years with chronic liver disease and just managing the symptoms. Some times hepatitis is treated with steroids (or becoming more common now - atopica - which is an immune suppressant) but both can be very damaging to the kidneys so I'm shocked your vet would want to treat with steroids at this point.


It took several months for my Scooby's liver numbers to show a significant decrease and about nine months before they were mostly in the normal range. Even after 17 months, Scooby still has an elevated ALKP, but ALKP is not liver specific, so may just be a response to the inflammatory process in his digestive system. He does not have any symptoms of liver disease now, but his numbers will jump when he has a pancreas flare.


An acute case of pancreatitis can elevate both the liver and kidney numbers so you really need to get the pancreas under control before you have a baseline on the liver and kidneys. The pancreatitis is probably what is causing Bumble the most discomfort as it is very painful. There isn't a magic medicine to fix the pancreas so treatment is mostly supportive care. Fluids, pain meds, rest the pancreas by fasting until the diarrhea and/or vomiting is resolved, and then slowly reintroduce a very bland and low fat diet, tiny amounts frequently and increase the amount slowly as tolerated. It can take days or weeks to get back to eating regular meals, and once a dog has had an acute case of pancreatitis they are more likely to relapse so that means feeding the low fat diet from now on. Some vets add an antibiotic but that is mostly to prevent a secondary infection, and some vets treat pancreatitis with steroids but that is dangerous territory for a dog in renal failure.


If Bumble is dealing with nausea or acid buildup, your vet can prescribe medications for that. Most dogs in renal failure take Pepcid or some other acid reducer, and sometimes need Reglan or Cerenia to get past a bout of nausea.


The kidney disease is a big problem because kidneys are non-regenerative and the disease is progressive. Once kidney function is lost it's permanent, so the goal - again - management of the disease - is to slow the progression as much as possible for as long as possible. That phosphorous level really needs to come down as soon as possible to prevent further damage to the kidneys and other organs. IV fluids will help but your dog really needs to be on a phosphorous binder. Fluids - either IV or subcutaneous - will also help to decrease the BUN and flush out toxins and help the remaining kidney tissue to function better. Bumble will need to be on a quality protein - low phosphorous diet for maintenance and management of the kidney disease. There are several supplements you can add to help the kidneys function and slow progression of the disease. You want to keep treating with fluids to get those numbers as low as possible, and then maintain them for as long as you can with the sub q fluids, diet and supplements.


Anemia can be caused by advanced kidney disease, or it can be caused by a bleed (which is often also caused by kidney disease as uremia is very acidic and can cause ulcers in the mouth, stomach or intestines). Your vet will need to determine whether the anemia is regenerative or non regenerative. ie is the anemia a result of the body not making the red blood cells and caused by the advanced kidney disease, or is the anemia regenerative and caused by an ulcer? The treatments are different for the different types of anemia.


Your Bumble has a lot going on in her little body right now, and if she recovers it will be a long road back, but it is possible. In August-September of 2012, we were right were you are right now and the vet only gave Scooby a 50/50 chance to make it through the acute phase. It's been about 17 months now and he is doing well. He still has liver disease, still has kidney disease, still has occasional flare-ups from his pancreas. We manage all of his conditions with diet, supplements, blood pressure medication, ursodial, metronidazole, occasional pulses of amoxicillin, and daily sub q fluids at home. His numbers are all mostly in the normal range because of the treatment protocol we follow. He eats, is active and playful and feels good about 95% of the time with an occasional bad day when his tummy is acting up. For a 15 year old dog, I guess that's about as good as it can get.


I hope this helps a little, and maybe gives you a little hope. Not all dogs follow the same course and your Bumble may have different things going on, but hang in there and just keep staying the course. Sending lots of prayers and positive thoughts.


Diana and Scooby

[Scoobstersmom]

My husband is afraid that waiting over a week to start treatment when she's already sick and has been so sick for a week is a really bad idea (I tend to think that, too, but I am SO afraid the steroids will kill her).


----------------
By the way, Dana, I just wanted to add that you are NOT waiting a week to start treatment. You are doing many appropriate things to help her. Fluids, antibiotics, ursodial, denamarin - that is all appropriate treatment for liver disease. The pancreas just has to heal on it's own, and the fluids will help. I would not push her to eat, especially if she's vomiting. If anything you can try a very small amount of over-cooked and very mushy rice or boiled white potato (no skin) pureed in a blender and fed by syringe. Give her just 5 ml and see if she holds that down. If she does, give her another 5 ml an hour or two later. And continue that through the day. If she's holding that down tomorrow, you can add a little baby meat chicken to the puree and increase the amount a little but keep feeding her the very small amounts frequently. She won't starve in a day or two and it will give her pancreas a chance to heal. Just make sure she stays well hydrated. The one thing you need to do is get your vet on board with treating her kidneys. Giving fluids and getting the phosphorous down and feeding a low phosphorous diet are the best things you can do for her kidneys. If she were mine and I did not see a huge and significant drop in the phosphorous by today, I would be pushing to add a phosphorous binder. Since the vet's office is probably closed on Sunday, I would also see about bringing her home with sub q fluids that you can give yourself at home.


Let us know what the numbers are today.


All the best,


Diana and Scooby