Max - 14/15 yr old Maltese - kidney issues - debating continuation of Lysodren

[Janette]

Hello all,

glad I found everyone at "our" new home here.

For those that have been following Max's story, just wanted to let you know that Max has started on the maintenance dose of Lysodren (dosing at the low end of 25mg/kg/week, split into 2 doses).

I am happy :) to report that Max has not had a bad reaction to the Lysodren as far as I can tell. He's had 2 doses so far and the third is tonight (62.5 mg capsule per dose - which I had compounded).

I am relieved that we are through the first week. (I was worried about starting Max on the Lysodren, even at a maintenance dose).

For those unfamiliar with Max's story, we did NOT go through the loading phase because Max's cortisol levels are relatively low. He had been diagnosed as Atypical Cushings and we tried the Melatonin and Flaxseed oil with Lignans route for a year, but it didn't help. I do want to note, that I recently realized that I had been giving Max an extended release type Melatonin pill (had not been evident on the bottle, but found the info on the GNC website). This is NOT what I should have been doing, and I have since changed to another brand. I also was giving Max Flaxseed Oil with Lignans and have since changed to Flax Hulls.

I am continuing both the Melatonin and the Flax Hulls in conjunction with the Maintenance dose of Lysodren.

My plan is to retest with an ACTH stim test in 3 weeks, and we have our fingers and paws crossed that the cortisol levels come down. If not, then I imagine we will increase the dosage.

for reference, below is a recap of his most recent bloodwork:
_____________________________
March 27, 2009 adrenal panel from Univ of Tenn - baseline (baseline normal range) - post ACTH (post ACTH normal range)
Cortisol ng/ml - 22.1 (2.0 - 56.5) - 192.7 (70.6-151.2)
Androstenedione ng/ml - 3.1 (0.05-0.36) - 5.8 (0.24-2.90)
Estradiol pg/ml - 84.0 (23.1 - 65.1) - 91.4 (23.3 - 69.4)
Progesterone ng/ml - 0.11 (0.03 - 0.17) - 2.5 (0.22-1.45)
17 OH Progesterone ng/ml - 0.08 (0.08 - 0.22) - 1.77 (0.25 - 2.63)
Aldosterone pg/ml - 24.8 (11 - 139.9) - 238.7 (72.9 - 398.5)
Comments: these results indicate presense of increased adrenal activity. Values are increased as indicated. The disease has progressed since the last test. Consider items 1 through 5 on the treatment option sheet attached. Traditional Lysodren treatment is probably not needed at this time.
_____________________________

I wanted to say THANK YOU to everyone's input when I was trying to decide which treatment plan to follow.

Janette

[lulusmom]

Hi Janette.

I'm glad you found us and that Max is doing well on his maintenance dose of Lysodren. You are right the cortisol elevation is negligible which leads me to believe the real problem is the sex hormones, especially the estradiol. Changing to the standard Melatonin and Flax Hulls was an excellent decision and I hope that between the three treatments, you will finally start to see some improvements. It may take a bit of time so don't get discouraged because I think you are on the right path.

Glynda

[Squirt's Mom]

Hi Janette,

Sounds like a good plan and I hope you will start to see some real improvements in no time. The melatonin and lignans changes will help, too!

Hugs,
Leslie and the girls

[Bichonluver3]

I have had good luck with regular melatonin and flax hulls. Seems you are on the right track. Keep us updated and give Max a big hug!
Carrol

[Janette]

Hello,

I just wanted to give a quick update - re: Max

He's been on the Maintenance dose since my last posting, but we had worked our way up to Lysodren 62.5 mg three times a week.

Max now weighs 8.5 lbs.

The ASTM stim tests have varied, but the lowest has only been at 11 ug/dL post.

Just did one on March 18th and the results were 3.8 ug/dL pre and 28.1 ug/dL post. The 28.1 post result is the highest result since he started on the Lysodren, so it's obviously not working well.

I have decided to do a full loading on Max (which we never did do since we were hoping a maintenance dose would be sufficient). It won't be for a few weeks yet because I want to time it so I can take some time off from work to watch him.

Other events since I last posted:

Max had his spleen removed on Feb 2010 (ultrasound had shown a small nodule on it, which thankfully turned out to be benign.) As a benefit to having the spleen removed, Max seems more comfortable, with a less tight belly (I would assume that with the enlarged liver, it would be good to have some space freed up :) )

Max has a heart murmur (level 4) and is on spirolactone and enalapril for his heart.

I will post updates as they come.

Janette

[Squirt's Mom]

Hi Janette,

So sorry to hear that Max's cortisol is rising. When his spleen was removed, did they take the whole organ or only a portion? My Squirt also had a tumor but they left half her spleen. I was told it was a very slight possibility that the portion left could also develop a tumor so I wondered about Max's situation with his spleen.

If Squirt's cortisol started to rise even on maintenance, then I would be compelled to do an ultrasound before a load just to be sure there wasn't another tumor somewhere. Have you talked to your vet about this possibility?

That was a scary time with the spleen, huh? I understand! Between the time of learning about the tumor and the actual surgery, I was petrified it would rupture. Every time I picked her up my heart went up in my throat and breathing became difficult I was so scared of making it rupture! :eek: Then she had an acute pancreatic attack right after coming home and had to go back to the hospital for several more days. She is fine and dandy today, tho, and I am so grateful! I'm glad Max has that behind him - and YOU, too! ;):D

Let us know how things are going for him.

Hugs,
Leslie and the gang

[Janette]

Hi Leslie,

With Max, they removed his entire spleen.

While they were in there, they also biopsied the liver which had nodules (related to cushings I'm sure). Thankfully everything came back good news for us, and Max didn't have any unexpected difficulties with the surgery itself. :)

I was a nervous wreck having to make the decision and then waiting to hear the day of the surgery. Recuperation went well - even though Mother Nature decided to complicate our lives with TWO 20" plus snow storms the week when Max came home. :eek:

Poor Squirt, having a pancreatic attack right after her surgery. Misty, my other dog, seems to be prone to pancreatitis - she's been in the hospital because of it twice!!! So I know it can be scary. Glad to hear that Squirt is doing well now.

Janette

[lulusmom]

Hi Janette,

Just checking in on you and Max. How is Max doing today? Did you load him yet?

[Janette]

Hello,

Thank you for checking up and your timing is PERFECT. I was actually just doing some reading on ACTH stim results on the lower side.

I did load Max. We started last Wednesday, and he got 93.75 mg twice a day. (Max weighs 8.5 lbs). His last dose was yesterday (Sunday) morning. I stopped it because he was coughing some and then when I offered him a treat (just in case he had swallowed something wrong like people sometimes do :) ) he didn't take it. That is not Max. So I stopped it.

He had a ACTH stim this morning, and here are the results:

pre: 0.8 ug/dL
post: 1.1 ug/dL

I am glad that we have reached the end of the loading, but he is obviously at the very lower bound, and I am somewhat worried that he will drop a bit lower in the next day or two.

Do you think that is a concern as long as he is eating?

Re: the cough. Max does have a heart murmur (grade IV or V depending on which doctor we see) so I also had them do chest xrays today. No obvious fluid but perhaps a sign of some slight congestion. The regular vet gave me Furosemide 12.5 mg (a diuretic) - Max is to get 1/4 tablet every 12 hours. She has a call into Max's cardiac vet but hadn't heard back from him yet today. She said it's a low dose and a couple of doses wouldn't hurt him and she would rather err on the side of giving it to him for a couple of doses than not give it to him and have his heart start decompensating (I believe that is the word she used). The regular vet also has a call into the IMS we saw a couple of weeks ago but had not been able to make contact with her either. Tonight or tomorrow all of Max's vets should hopefully be able to talk and I know a bit more.

But Max hasn't had any coughing today that I have noticed and he is eating.

My immediate concern is that the post ASTM stim of 1.1 is too low considering his last Lysodren dose was 24 hours before the ASTM stim was done.

Thanks again for checking in on us.

Janette and Max

[lulusmom]

Hi Janette,

Yes that post stim number is low, especially considering the short time frame after the last dose. You need to keep a close eye on Max for signs that cortisol has dropped even lower. If his appetite remains off, that's a definite sign and you should give him a dose of prednisone and take him in to have his electrolytes checked. Your vet gave you Prednisone right?

Please check in with us and let us know how Max is doing over the next 24 hours.

Glynda

[Janette]

Glynda,

Yes, thank you, I do have Prednisone.

As of now, Max IS eating, which makes me feel somewhat okay (Although I think anxiousness is outweighing the okay feeling :().

I will watch him for sure.

Thanks again,
Janette

[Janette]

Just an update on Max:

He IS eating, so that is good. But I can tell his appetite is somewhat on the low side. He will eat his canned dog food, but I haven't seen him eat any of the dry dog food (which is always out for him) and he did not take a dog cookie (whereas he would normally want TWO [or more if he could get them] cookies).

He is a bit on the lethargic side I would say, but he does walk around, and did some sniffing/snuffling around when we were outside on the walk (which I was glad to see - that he was interested in his surroundings).

When I run my hand down his spine, he seems sensitive in certain spots - he has a bad back, so I am sure he is feeling some pain (which I know is to be expected with the lowering of the cortisol).

I contemplated whether or not to give him a dose of prednisone, but ultimately decided to hold off as long as he is still eating at the level he currently is. If his appetite gets worse I can always give him the prednisone....

Working under the assumption that he is in some pain, I gave him Tramadol. I think pain could also be an explanation for the lower appetite and not moving around too much. Hopefully I will see some improvement with the Tramadol.

I did ask the vet before I gave him the Tramadol and also checked that there would be no problem/interaction between the Tramadol and the prednisone in case I do decide to try a dose of prednisone. The vet said that would be okay.

I am hoping that Max feels better tomorrow than he does today. A little improvement bit by bit would be good.

Janette

[Janette]

another update:

I did decide to give him a prednisone - mainly to see if I would notice a marked improvement.

However, when I put the prednisone in his canned food (as I do all his meds), he wanted nothing to do with it. After tempting him with other types of food, Max finally swallowed the prednisone.

An hour or so later, I really couldn't say if I saw any change, so I started worrying more about electrolytes being out of whack.

I decided to take him to the emergency vet to get the electrolytes checked, and the good news is that they seem fine. Specifically:

Na: 159 mmmol/L (normal range is 144 - 160)
K: 4.2 mmol/L (normal range is 3.5 - 5.8)
CI: 114 mmol/L (normal range is 109 - 122)

All good news and will let me sleep better than I did last night......

Janette

[Casey's Mom]

A belated welcome to you from Casey and myself :) Once you are loaded it does get a lot easier. You seem to be on top of things and know what to look for which is great. Just so you know my dog has been on Lysodren for two years now and is doing just fine - it is a life saver.

[Harley PoMMom]

I am happy that Max's electrolytes are within the normal ranges.

The prednisone, from my own prior use, is very bitter tasting. If you should ever have to give it again I would recommend wrapping the prednisone in some kind of lunch meat or cream cheese.

Keep up the great work and keep us posted! :)

Love and hugs,
Lori

[Janette]

Thanks for the welcomes and the good thoughts.

Also thanks for telling me that the prednisone is bitter tasting. That is good to know. I know that the Tramadol is bitter because Max often spits it out :)

I talked to the IMS this morning and she is suggesting I give Max prednisone for the next few days (3 days maximum) and see if he gets to feeling better. And then re-stim him on Monday evening and see where he is.

The current thinking is that, after the stim results come in, we would then start Max on the low end of the maintenance dose range by giving him 31.25 mg three times a week.

So that's the plan.....I will keep posting with updates.

Janette

[StarDeb55]

Janette, I have not posted to you previously. I did want to make sure that you were aware that you really should wait at least 24 hours after giving pred before having a stim done. The pred will read like cortisol on the stim, & give you falsely elevated results.

Debbie

[Janette]

My vet said to fast Max 12 hours prior to the ACTH stim test. They use IDEXX labs for the test results.

I am curious - does everyone else fast their dogs for 12 hours prior? I am Googling the topic and am having a tougher time than I thought finding an immediate consensus..

I am asking because Max has a 5pm stim test scheduled for tomorrow evening so it's very awkward timing if I have to fast him 12 hours. Ten hours would fit into our usual routine....

Janette

[StarDeb55]

My vet required a 12 hour fast on all stims, but told me that it had to be an absolute minimum of 10 hours, if I couldn't get my Harley to do 12. This is really a sample requirement of the lab performing the testing & not the vet.

Debbie

[BestBuddy]

Buddy was never fasted for his ACTH tests. He was diabetic so was fed and had insulin around 6am and tested about 10am.

I assume they made allowances for this in the testing. I was always reminded not to give a fatty meal before the test but Buddy was on a low fat diet so it was never an issue.

Jenny

[Harley PoMMom]

My boy, Harley, was never fasted for his ACTH stim tests. And according to Dr. Mark E. Peterson, a renown cushing's expert, a dog need not be fasted. You can read his blog article here: What's the Best Protocol for ACTH Stimulation Testing in Dogs and Cats?. (http://endocrinevet.blogspot.com/2011/03/whats-best-protocol-for-acth.html)

Love and hugs,
Lori

[lulusmom]

My first dog has been treating for six years and my second for over three years. You can only imagine how many acth stim tests we've done and I've never fasted my dogs. As a matter of fact, if a dog is treating with Vetoryl, you have to give the dog a small meal with their morning dose in order for the acth stimulation test to be meaningful.

[Janette]

Hi all,

I wanted to update everyone on Max. We had another ACTH stim this past Monday night and his results were pre: 1.6 ug/dL and post: 2.4 ug/dL.

Today I started Max on the first dose of a maintenance dose of 31.25 mg that he will get three times a week. Max weighs 8.5 lbs so that is on the low end of the maintenance dose range, but Max loaded very quickly so I feel more comfortable starting low.

I’ve been thinking some about Max’s most recent ultrasound results which mentioned a “nodule” in his left adrenal gland, and also some cysts in his kidneys. The IMS still considered pituitary dependent cushings to be much more likely since Max’s adrenal glands are both normal size. But I guess I am now sort of doing some second guessing…..:(

I think the adrenal nodule bothers me less than the kidney cysts. I say that because if Max’s high cortisol levels are actually caused by adrenal dependent cushings rather than pituitary dependent cushings, I would still treat with Lysodren (rather than elect surgery – due to Max’s heart issues). But I can't help but wonder about the kidneys... The IMS did a mini-renal panel and the results were normal. But I wonder if kidney cysts could raise cortisol levels. Has anyone ever heard anything relating kidney cysts to high cortisol levels?


In case it’s helpful, I’ve compiled the results of Max’s tests / exams from the past month or so.

Max’s Current Medications

Lasix (furosemide) – (for heart issues)
Amlodipine (for heart issues)
Enalapril (for heart issues)
Spirolactone (for heart issues)
Ursodiol (for gallbladder issues)
Lysodren (on maintenance dose now)
Tramadol (for pain relief of back issues, but not on a regular basis though)


3/18/11 ACTH STIM RESULTS

Pre: 3.8 ug/dl
Post: 28.1 ug/dl


3/18/11 BLOOD TEST RESULTS

Only listing HIGH or LOW results:

ALK. Phosphatase: 2263 HIGH (reference range 10 – 150 U/L)
ALT (SGPT): 130 HIGH (ref range 5 – 107 U/L)
TCO2 (Bicarbonate): 25 HIGH (ref range 17 – 24 mEq/L)
Potassium: 6.2 HIGH (ref range 4.0 – 5.6 mEq/L)
NA/K Ratio: 23 LOW (ref range 27 – 40)
Triglyceride: 157 HIGH (ref range 20 – 150 mg/dL)
Auto Platelet: 780 HIGH (ref range 164 – 510 THOUS./uL


4/5/11 ULTRASOUND

Findings: The hepatic parenchyma is diffusely mottled and relatively increased in echogenicity in comparison to the portal structures. A 0.97 cm, relatively hyperechoic, ovoid nodule is noted in the left side of the liver. Echogenic material is present within the gallbladder. Both adrenal glands are normal size and shape, however, a 0.6 cm, relatively hyperechoic nodule is seen in the caudal pole of the left adrenal gland. Multiple linear, relatively hyperechoic striations are seen within the mucousal layer of a segment of small intestine. Marked echogenic foci with distal acoustic shadowing is seen within both kidneys, bilaterally. Numerous nodules and cysts, ranging in size from 0.4-1.9 cm, are present within the kidneys, bilaterally. Some of these structures are anechoic and some are relatively hypoechoic. A hyperechoic focus is noted in the dependent portion of the urinary bladder. No other significant findings were seen.

Conclusions:
1. Mottled hepatic parenchyma with increased echogenicity and generalized hepatomegaly. Endocrinopathy, such as hyperadrenocorticism, is the most likely differential diagnosis. Chronic hepatic inflammation with nodular regeneration or neoplasia, such as hepatocellular carcinoma, are less likely.
2. Left adrenal nodule. Differential diagnoses include adrenal adenoma, myelolipoma or pheochromocytoma.
3. Probable bilateral polycystic kidney disease with bilateral dystrophic renal mineralization. Renal neoplasia, such as cyst adenocarcinoma, is an unlikely differential diagnosis.
4. Cystic calculus.


4/5/11 exam with IMS (Internal Medicine Specialist)

Diagnostic Tests:
• Abdominal ultrasound – normal sized adrenal glands (left one has a small nodule), VERY small cysolith (1 mm); cysts in the kidneys
• Systolic blood pressure – 195mmHg (stressed)
• Urinalysis
[comment by Janette: the only thing identified as HIGH or LOW was the Specific Gravity: 1.010 (LOW) (reference range 1.015 – 1.050). There were no crystals and the pH was 6.0 (reference range 5.5 – 7.0)]
• Urine culture / sensitivity
[comment by Janette: the Urine MIC Culture showed no growth after 24 hours and no growth present after 48 hours]
• Mini-renal profile
[comment by Janette: none of the results were identified as HIGH or LOW, and they checked the following: Total Protein, Albumin, Globulin, Albumin/Globulin Ratio, Urea Nitrogen, Creatinine, Phosphorus, Glucose, Calcium, Sodium, Potassium, the Na/K Ratio was 27 (no reference range given), and Chloride
• 3 view thoracic radiographs (due to crackles ausculted) – no evidence of pulmonary edema (official report pending)


4/13/11 Start date - Max was Loaded using Lysodren for 4.5 days (Max weighs 8.5 lbs, and he got 93.75 mg twice a day


4/18/11 ACTH STIM RESULTS

Pre: 0.8 ug/dl
Post: 1.1 ug/dl


4/20/11 Electrolytes checked

Na: 159 mmmol/L (normal range is 144 - 160)
K: 4.2 mmol/L (normal range is 3.5 - 5.8)
CI: 114 mmol/L (normal range is 109 - 122)


4/21/11 - Cardiac Vet Echocardiogram

• Progressive now advanced degenerative valve disease
• Moderately large mitral regurgitation
• Mild to moderate tricuspid regurgitation
• Mild aortic insufficiency
• Progressive severe left atrial enlargement
• Progressive moderate left ventricular dilation > stable
• Maintained contractility > stable
• Mild systemic hypertension > some signs of high BP on today’s echo
• History of Cushing’s disease > was atypical > now elevated cortisol levels > was loading Lysodren but started coughing stopped eating > rechecked cortisol levels were low
• Mild increase lobar pattern right caudal lung lobe > rule out mild heart failure, airway disease, pulmonary thromboembolism
• Progressive now moderate pulmonary hypertension > rule out secondary to advanced mitral valve disease, secondary to airway disease
• Mild pericardial effusion > unexpected finding > rule out atypical presentation of heart failure, secondary to left atrial tear (my worry), pericarditis, occult neoplasia
• One episode of stumbling/falling over / couldn’t walk > rule out cardiac (arrhythmia, poor cardiac output), neurologic, vasovagal / neurally mediated > no recent episodes
• Change in bark > rule out throat issue – improved with time
• Hind limb paresis / weakness > rule out disk disease, peripheral neuropathy, myopathy associated with Cushing’s disease


4/19/11 – 4/22/11 - For these days, I gave Max prednisone (1/4 tablet of a 5 mg tablet)


4/25/11 ACTH STIM RESULTS

Pre: 1.6 ug/dl
Post: 2.4 ug/dl


4/29/11 - started Max on a Maintenance dose of Lysodren: 31.25 mg that he will get three times a week

[Janette]

Hi,

Just another update on Max - we had another ACTH stim this past Friday and his results were pre: 2.4 ug/dL and post: 11.3 ug/dL.

So obviously being on the low end of the maintenance dose range is not working. (Max is now 8 lbs and is getting Lysodren: 31.25 mg three times a week).

I am contemplating doing a "mini-load" of maybe 2 days (since he loaded quickly in 4 1/2 days last time) and then changing to a higher maintenance dose. I've got a phone call into my vet to discuss the options.

If anyone has any thoughts on a possible approach, I would be glad to hear any ideas.

Thank you,
Janette

[lulusmom]

I think your plan to do a mini load is a good one and I suspect your vet will probably agree. Your experience is a perfect example of how difficult it is to figure out an appropriate maintenance dose. The original loading dose and subsequent maintenance dose were textbook and based on the law of averages, you shouldn't be facing a reload but dang it, sometimes our dogs don't read the book and follow directions. :D

I think your vet is probably correct in thinking that Max has pituitary based disease. A dog with an adrenal tumor rarely, if ever, has normal sized adrenals and an adrenal tumor is highly resistant to lysodren which requires much higher doses and usually longer loading times. With Max loading well before the average 5 to 8 days, I personally don't think he has an adrenal tumor. Of course, if he does have an adrenal tumor, surgery can be a cure so if that is something you would be open to, you can do further diagnostics to make that determination.

Glynda

[Janette]

Hello,
It's been a while since I've posted. Maxwell is now approx 14/15 years old. Maxwell has been on maintenance doses of Lysodren with some mini loads to keep his values in the target range. The most recent of which were Jan 13th and 14th, 2012 (a 2 day mini load), and then a one day mini load on Feb 4th, 2012. I think the Feb 4th one was a mistake on my part - but I had skipped a few maint doses and wanted to make sure Max's cortisol levels didn't climb too high. I think I should have totally stopped the Lysodren a couple of weeks ago. My main concern is that Max has been having a low appetite for about three weeks now.

HOWEVER I have now stopped giving Max Lysodren (as of this past Saturday).

On January 23rd, he was obviously not wanting to eat (not even treats) so I took him into the vet for a check up. At that point I was more concerned that he might be having some back pain and not wanting to eat (Max has a history of back pain, and had surgery for a ruptured disk in April 2008), and I also was concerned that maybe his cortisol levels were low (Max has Cushings and is being treated with Lysodren). We did an ACTH stim test (the results came in the next day: Pre: 3.2 ug/dl and Post: 6.2 ug/dl - so too low cortisol levels didn't appear to be the case), and the vet examined Max and he seemed to be a little protective of his neck so we tried a few days of an anti-inflammatory (meloxicam) in case he was suffering disc pain.

A week later Max still wasn't eating well so I took him in for more blood work and a urinalysis, the results of which I have included at the end of this post.

After the blood test results came in, the vet also suggested doing an abdominal ultrasound to see what else might be going on. The ultrasound was done on 2/3/12 and noted multiple cysts in the kidneys. I have included the ultrasound report at the end of this post.

The vet's assumption was that Max's kidneys are functioning less and less well, and that this is leading to his lack of appetite.

The last thing I would like to point out is that this past Saturday morning Max refused to eat anything (no chicken, no hotdogs, no eggs). He had also thrown up a little the night before and had diarrhea as well - all of which was very worrisome to me. I placed a call into the vet and while I was waiting for her to be able to call me back I did some web research re: kidney disease, and came
across something that mentioned a low NA/K ratio could indicate Addisons, and that all of a sudden made me realize that maybe I was being side tracked by the kidney issues - when maybe it WAS low cortisol levels. So I gave Max a "rescue dose" of prednisolone. When the vet called me back she had said she had also been wondering if it was the cortisol levels and she agreed that giving the prednisolone was a good thing. She also prescribed something for the diarrhea,
which I went to pick up from the vet (taking Max and Misty along for the car ride). When we got back home, Max actually ate some chicken (yeahhh!!) - so I am of the opinion that the prednisolone helped him feel better.

I gave him another dose of the prednisolone the next day, and have stopped giving him any Lysodren (maintenance dose) for the treatment of his Cushings.

So...... the low appetite problem still remains an issue. For about the past week, he has been only eating people food for the most part. Initially (three weeks ago) I could mix some chicken up with his dog food (prescription diet: Royal Canin Urinary S/O to prevent formation of bladder stones which he had surgery to remove back in Nov 2006), and Max would eat the dog food along with the chicken. Then it progressed to where he wouldn't eat the Royal Canin Urinary S/O but he would eat some other dog food (he did okay with Canidae for a few days), and now he won't eat the Canidae anymore either. Chicken breasts so far have been something he will eat but I worry that soon he will refuse that as well.

Last note: the vet did prescribe Mirtazapine as an appetite stimulant and I gave Max 2 doses of it initially. However I couldn't notice an appreciable increase in his appetite, and I did notice that he seemed a bit more wobbly in his hind end (which is already pretty wobbly - I think as a combination of his back surgery and the cushings reduction in muscle mass) so the vet had suggested maybe stopping it and seeing if his appetite got worse. After this Saturday morning not eating issue I decided to start Max back on the Mirtazapine, and he had his first dose on Sunday. The vet said to give it to Max every other day, so he was supposed to get another dose this morning but I forgot to give it. I apparently haven't worked the Mirtazapine into Max's pill regimen sucessfully yet (I have listed all of Max's medications as part of my signature line below).


Max's kidney blood test results don't seem to be too bad based on what I've researched so far, and I posted a similar post on the yahoo K9Kidneys forum/list and a few of the moderators there also said that Max's kidney values don't look too bad (in terms of chronic kidney failure) and they were of the opinion that I should look at Max's Cushing meds and also perhaps Max being Addisonian now. <-- However Max's last stim test was at a post 6.2 so I assumed that his cortisol levels were not the cause of his low appetite.

My plan is to stop the Lysodren for a few weeks at least and see if Max's appetite returns.

I would be appreciative of any opinions and/or suggestions as to what I could try next - either in terms of additional vet tests and/or supplements/foods to try with Max.

Sincerely,
Janette & Maxwell (Maltese, 8 lbs, 14/15 years old, kidneys with cysts, Cushings [Atypical at first, then seemed to change to Typical], Heart Murmur, history of back pain) in Frederick, MD
Max's medications: for cardiac issues - enalapril, spirolactone, amlodipine, furosemide, aspirin; and for prevention of bladder stones he is taking Ursodiol; for treatment of Cushings - Lysodren (although have currently stopped until his appetite gets better); for lack of appetite: famotadine and starting Mirtazapine


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Superchem
Format:
Description - Date 1/6/2012 - Date 1/30/2012 - (Ref Range)
Glucose - 105 - 93 - (60 - 125 mg/dL)
Bun - 33 - 57 - (7 - 27 mg/dL)
Creatnine - 1.4 - 1.8 - (0.4 - 1.8 mg/dL)
TotProtein - 6.6 - 7.2 - (5.1 - 7.8 g/dL)
Albumin - 3.3 - 3.5 - (2.5 - 4.0 g/dL)
TotBillirub - 0.2 - 0.2 - (0.0 - 0.4 mg/dL)
AlkPhos - 1010 - 1060 - (10-150 U/L)
ALT - 313 - 144 - (5 - 107 U/L)
AST - 68 - 38 - (5 - 55 U/L)
CK - 118 - 76 - (10 - 200 U/L)
GGT - 10 - 5 - (0 - 14 U/L)
Cholesterol - 193 - 188 - (112 - 328 mg/dL)
Calcium - 10.2 - 10.9 - (8.2 - 12.4 mg/dL)
Phosphorus - 4.5 - 4.9 - (2.1 - 6.3 mg/dL)
Sodium - 143 - 149 - (141 - 156 mEq/L)
potassium - 5.6 - 5.7 - (4.0 - 5.6 Meq/L)
chloride - 100 - 105 - (105 - 115 mEq/L)
Albumin/Globulin ratio - 1.0 - 0.9 - (0.6 - 1.6)
BUN/Creatinine ratio - 23.6 - 31.7 - (no ref range provided)
Globulin - 3.3 - 3.7 - (2.1 - 4.5 g/dL)
tc02-bicar - 25 - 29 - (17 - 24 mEq/L)
NA/K ratio - 26 - 26 - (27 – 40)

----------------------------------------------------------------------------------------------------------

CBC
Format:
Description - Date 1/6/2012 - Date 1/30/2012 - (Ref Range)
Hemoglobin - 12.6 - 13 - (12 - 18 g/dL)
Hematocrit - 37.2 - 39.9 - (37 - 55 %)
WBC - 7.4 - 9.5 - (5.7 - 16.3 K/uL)
RBC - 5.96 - 6.17 - (5.5 - 8.5 M/uL)
MCV - 62 - 65 - (60 - 77 fL)
MCH - 21.1 - 21.1 - (19.5 - 26.0 pg)
MCHC - 33.9 - 32.6 - (32 - 36 g/dL)
Platelet Count - 837 - 759 - (164 - 510 K/uL)
Remarks - Slide reviewed microscopically. No parasites seen.
Neutrophils - 58 - 61 - (60-77 %)
Lymphocytes - 25 - 23 - (12-30 %)
Monocytes - 10 - 11 - (3-10 %)
Eosinophils - 7 - 5 - (2-10 %)
Basophils - 0 - 0 - (0-1 %)
Absolute Neutrophils - 4282 - 5795 - (3000 - 11500 /uL)
Absolute Lymphocytes - 1850 - 2185 - (1000 - 4800 /uL)
Absolute Monocytes - 740 - 1045 - (150 - 1350 /uL)
Absolute Eosinophils - 518 - 475 - (100 - 1250 /uL)
Absolute Basophils - 0 - 0 - (0 - 100 /uL)


----------------------------------------------------------------------------------------------------------

URINALYSIS
Date : 1/30/2012
Description - Test Result - (Ref Range)
Collection Method - Free-Catch
PH - 5.5 - (5.5-7.0)
Specific Gravity - 1.016 - (1.015-1.050)
Appearance - Hazy - (Clear)
Color - Yellow
Protein - Negative - (Neg)
Glucose - Negative - (Neg)
Ketone - Negative - (Neg)
Bilirubin - Negative - (Neg to 1+)
Blood - Negative - (Neg)
WBC - 2 - 5 - (0-5 HPF)
RBC - None Seen - (0-5 HPF)
Bacteria - None Seen - (None)
EPI CELL - 1 + (1-2) - (0 )
Mucous - None Seen - (None - 2+)
WBC Casts - None Seen

----------------------------------------------------------------------------------------------------------


URINE CULTURE & SUSCEPTIBILITY
Date: 2/3/2012
Source: Urine
Status: Final
Completed Culture Results No Aerobic Growth

----------------------------------------------------------------------------------------------------------


ACTH STIMULATION

Format:
Description - Date 1/6/2012 - Date 1/23/2012 - (Ref Range)
Pre-ACTH Cortisol - 2.4 ug/dL - 3.2 ug/dL - (1 - 5 ug/dL)
Post- ACTH Cortisol - 12.4 ug/dL - 6.2 ug/dL - (1 - 5 ug/dL)

----------------------------------------------------------------------------------------------------------


ULTRASOUND
Date: Feb 3, 2012
HISTORY: Rule out an neoplasia
PROCEDURE: Abdominal ultrasound

FINDINGS:
Both kidneys are irregular and enlarged secondary to large anechoic round cysts measuring up to 3.7 cm x 3.1 cm (left renal cortex) and 0.6 cm x 0.7 cm (right cortex). The visible renal cortex is hyperechoic with decreased corticomedullary distinction. The liver is homogenous with normal echogenicity and size. The gallbladder is moderately enlarged with no abnomalities detected. The common bile duct and pancreas is not visible. The adrenal glands measure within normal limits with normal morphology. The gastrointestinal tract is unremarkable with normal wall thickness and retention of layering. The urinary bladder is collapsed with no obvious abnormalities detected. There is no evidence of lymphadenopathy or peritoneal effusion. The remainder of the visible abdominal study is within normal limits.


CONCLUSION:
Bilateral renal cysts, much greater on the left side. Chronic renal changes are detected. No other abnormalities detected.

----------------------------------------------------------------------------------------------------------
--

[Cyn719]

Janette and Maxwell

Thanks for the update and his present history. So sorry Maxwell is not feeling well. You know the members here will be by to help you soon. Hang in there.....we are all here for you.

Hugs xoxo

[Harley PoMMom]

The rule of thumb is if a dog is not acting like him/herself than the Cushing medicine should be stopped. So I do agree with your decision of stopping the Lysodren.

The Yahoo K9kidney forum has a great bunch of people that are very knowledgeable about kidney disease so I am happy that you are joined there.

When a dog has Cushing's and then a kidney issue arises it is a catch 22 situation as to whether to continue treatment. Whatever decision you make we will be here to lend moral support.

Is Max losing protein in his urine? Has an UPC been done?

Sending loving hugs,
Lori

[Janette]

Is Max losing protein in his urine? Has an UPC been done?



Lori,

Hmmm, re: losing protein - the urinalysis said protein "negative" so I assume that means he is not losing protein......(???) Do you think that is a correct assumption?

re: the UPC being done? Googling UPC I think you are asking about a urine protein:creatinine ratio test? No, that test has not been done.
Do you think it would be worth having done?

Janette

[Harley PoMMom]

Sometimes an urinalysis will not detect protein-loss. If a kidney issue is being contemplated, an UPC (Urine Protein:Creatinine Ratio) test should be performed because this test will detect the smallest amount of protein-loss.

[labblab]

Janette, I see my reply is starting a new page. Be sure and check back at the bottom of the preceding page, because Lori answered your question about the UCR.

As for your fears about Max having Addisonian issues, I believe I'd go ahead and repeat a chem panel that includes his sodium and potassium levels. If they are normal or nearly-normal, I'd feel less worried that his problems are being caused by the Cushing's treatment. And at that point, I think that whether or not to reinstitute the Lysodren becomes a judgement call between you and your vet. It does become a balancing act, doesn't it? You don't want to do anything to suppress Max's appetite further and as we know, higher levels of cortisol do help ease certain kinds of problems. But I don't know whether elevated cortisol might actually accelerate the kidney damage. I would definitely want your vet's input as to that question. And Lori may have some additional feedback about that, as well.

Marianne

[lulusmom]

Hi Janette,

I would keep an eye on those kidney values because Max is on a battery of heart meds, a lot of which do make the kidneys very fragile plus, he has what appears to be progressive cystic kidney issues which can cause renal failure by itself. I have a Maltese, Jasper, who is also on several heart meds, including large doses of Lasix so I worry about the impact on his kidneys too. He's becoming pickier and pickier about his food and I am becoming more nervous, so I understand your concerns.

The diuretics Max is taking commonly cause a mild increase in potassium levels and I believe it's this increase that caused the low NA/K ratio you are worried about. Dogs with Addison's usually have much lower ratios and higher calcium levels, so in my layperson's opinion, you probably aren't dealing with Addison's. The one thing that jumped out at me was the increase in in ALT and AST on the 1/6 blood chemistry. These liver enzymes dropped considerably on the next blood chemistry done on 1/30. I don't believe cushing's caused these elevations so I'm wondering if perhaps Max had an active infection when the 1/6 bloodwork was done. What was going on with Max when you had that bloodwork done? Dehydration can cause elevations in BUN and creatinine. Was Max eating and drinking normally? Any vomiting or diarrhea before the bloodwork?

Glynda

[Janette]

Lori, Marianne, and Glynda,

Thank you for all of your responses to me. Sorry for the late reply, we (me, Max and Misty) had gone up to visit my family in NY over the long weekend.

Thanks for the input on the UPC and retesting the electrolytes.

This weekend Max actually ate a few bites of his dry dog food, and today he ate some wet dog food (not his usual - I tried Wellness Lamb with Sweet Potatoes, and Max liked it) so I feel better about Max than I have in what seems like quite a while...

Re: the blood work and high liver values on 1/6 - there was nothing going on with Max that I noticed. I had it run just because I was taking him in for a ACTH stim and I asked the vet if it would be good just to get some blood work done as well. She said that it would be good to do given Max's age and health issues, so I went ahead and had the blood work done. I don't remember specifics but at that point I hadn't been concerned about his eating, and I don't remember any occasions of vomiting or diarrhea.

The vet had mentioned the high ALT to me at that time and the plan had been to retest in a month or so.

Glynda, thanks for pointing out the fact that diuretics tend to increase the potassium levels slightly. It makes sense because I had noticed the trend to the lower NA/K ratios when looking back at his past tests as well.

Since entering into this new "not eating much" era, I have asked the vet how often I should be having Max's blood tests run, and she suggested that (assuming nothing came up to necessitate earlier testing) I rerun blood work at the end of February. I expect we are on track to do that (as well as an ACTH stim) and then I will talk to his regular vet as well as his cardiac vet as to the necessity/pros/cons of continuing all of his medications.

I will not restart Max on the Lysodren until we run the blood work again, and maybe not even then.

Thanks again,
Janette

[Janette]

First, I have a request for the moderators - would it be possible to change the title of my Thread to something more relevant? Maybe: Max - 14/15 yr old Maltese - kidney issues - debating continuation of Lysodren treatment.

I just wanted to give an update on Maxwell:

Max has not been getting any lysodren since 2/11/12. I stopped it because he has been not eating well at all.

Thursday morning, Max was acting lethargic and not eating (his appetite is low anyway, but Thursday it was non-existant and had diarrhea. He did eat some chicken that evening, but the diarrhea continued. Thursday PM I gave him a dose of metronidazole for the diarrhea.

Friday (yesterday, 3/2/12) I took Max in for bloodwork and a stim.

AFTER the stim test, before I received the results, I went home and gave Max a dose of prednisolone - sort of a "just in case" type deal.

This morning he was noticeably more peppy and was relatively eager to eat some hotdogs and chicken.

In my mind I attributed it to the prednisolone and half expected that his stim results would show he was low. BUT that turned out not to be the case - with the ACTH stim was pre 1.9 ug/dL and post 6.8 ug/dL.

HOWEVER - his kidney values have gotten worse - his BUN has doubled from a month ago (BUN at 118 mg/dL) and his phosphorus is high now to at 7.2 mg/dL. All the results are listed out below.

The vet is lowering his dose of furosemide (diuretic, will be halving his current dosage), and has started him on Epakitin Powder as a phosphorus binder.

I will have to decide whether or not to slowly start Max back on a Maintenance dose of Lysodren. The only reason I would do so is because lower cortisol levels would be better for Max's heart. But I worry about having to make his kidneys do more work.

Think good thoughts for us,
Janette and Max


ACTH STIMULATION
Format:
Description - Date 3/3/2012 - (Ref Range)
Pre-ACTH Cortisol - 1.9 ug/dL - (1 - 5 ug/dL)
Post- ACTH Cortisol - 6.8 ug/dL - (1 - 5 ug/dL)

AMC Chemistry Panel
Format:
Description - Date 3/2/2012 - (Ref Range)
Glucose - 112 - (60 - 125 mg/dL)
Bun - 118 - (7 - 27 mg/dL)
Creatnine - 2.2 - (0.4 - 1.8 mg/dL)
TotProtein - 7.3 - (5.1 - 7.8 g/dL)
Albumin - 3.6 - (2.5 - 4.0 g/dL)
TotBillirub - 0.1 - (0.0 - 0.4 mg/dL)
AlkPhos - 561 - (10-150 U/L)
ALT - 187 - (5 - 107 U/L)
AST - 54 - (5 - 55 U/L)
CK - 139 - (10 - 200 U/L)
GGT - 7 - (0 - 14 U/L)
Cholesterol - 191 - (112 - 328 mg/dL)
Calcium - 11.2 - (8.2 - 12.4 mg/dL)
Phosphorus - 7.2 - (2.1 - 6.3 mg/dL)
Sodium - 142 - (141 - 156 mEq/L)
potassium - 5.1 - (4.0 - 5.6 Meq/L)
chloride - 102 - (105 - 115 mEq/L)
Albumin/Globulin ratio - 1.0 - (0.6 - 1.6)
BUN/Creatinine ratio - 53.6 - (says High, but no ref range provided)
Globulin - 3.7 - (2.1 - 4.5 g/dL)
tc02-bicar - 21 - (17 - 24 mEq/L)
NA/K ratio - 28 - (27 – 40)

----------------------------------------------------------------------------------------------------------

CBC
Format:
Description - Date 3/3/2012 - (Ref Range)
Hemoglobin - 12.7 - (12 - 18 g/dL)
Hematocrit - 37.5 - (37 - 55 %)
WBC - 8.9 - (5.7 - 16.3 K/uL)
RBC - 6.02 - (5.5 - 8.5 M/uL)
MCV - 62 - (60 - 77 fL)
MCH - 21.1 - (19.5 - 26.0 pg)
MCHC - 33.9 - (32 - 36 g/dL)
Platelet Count - 868 - (164 - 510 K/uL)
Remarks - Slide reviewed microscopically.
Neutrophils - 54 - (60-77 %)
Lymphocytes - 26 - (12-30 %)
Monocytes - 16 - (3-10 %)
Eosinophils - 4 - (2-10 %)
Basophils - 0 - (0-1 %)
Absolute Neutrophils - 4806 - (3000 - 11500 /uL)
Absolute Lymphocytes - 2314 - (1000 - 4800 /uL)
Absolute Monocytes - 1424 - (150 - 1350 /uL)
Absolute Eosinophils - 356 - (100 - 1250 /uL)
Absolute Basophils - 0 - (0 - 100 /uL)

[Harley PoMMom]

First, I have a request for the moderators - would it be possible to change the title of my Thread to something more relevant? Maybe: Max - 14/15 yr old Maltese - kidney issues - debating continuation of Lysodren treatment.



Your Thread title has been changed. ;):)

So sorry to hear about Max's kidney problems, getting him a phosphorus binder is a great idea.

Elevated phosphorus levels can make a dog nauseated so getting that down with the binder will hopefully make Max's appetite greater.

I see that Max's calcium levels are within normal limits, which is good news because calcium is bound to phosphate in clumps, and then the blood level of calcium goes down. This stimulates the parathyroid gland to produce more PTH, which releases calcium and phosphate from bones into the blood.

Timing is important when taking phosphate binders. Phosphate binders must be taken with meals, otherwise they do not work.

Although the therapeutic ranges for a dog being treated with Lysodren are between 1-5 ug/dl, Max might benefit with letting this run a bit higher.

Please do keep us updated and keeping you both in my thoughts and prayers.

Love and hugs,
Lori

[lulusmom]

Hi Janette,

Lori has covered all the bases, so just wanted to let you know that I'm keeping an eye out for your updates and that you're both in my thoughts and prayers.

Hugs,
Glynda