Molly, 13 yr, shih tzu - lhasa aspo - Molly has passed

Hi AngelToto,

In 2010, molly had her first LDDS test due to thinking that she had cushings. Since they have have continued to suspect cushings and retest her but it has consistently been negative. I joined the forum, when the vet was positive she had cushings and I needed to find further information about the disease and possible treatment options and diagnostic options. Since then I think I have spent some time every day, other than being away on vacations, thinking, breathing, canine cushings. Knowledge is always the key. The more you learn, the better you can work with your vet team and be an advocate for your furbaby.

That is what brought me here, and that is what keeps me here. I cannot imagine where we would be today if this forum did not exist. If I can help others who are walking the same path to become more knowledgable about cushings and to be a full member of their pets treatment, then that is a worthy endeavor.

:)
Sharlene and molly muffin

Well I did say I would post her liver results didn't I. I've had some time to look them over and think about them a bit too. So, I'll post the last UPC's and liver, LDDS test:

UPC .06 May 30 2014
specific gravity 1.040
ph 5.5
protein .3 (1+)


UPC 1.1 June 26, 2014
specific gravity 1.045
ph 5.5
protein 3.0 (3+)
Ca 70 (1+)
WBC 3 - 5 hpf (1+)
crystals numerous

VET THINKS THIS SAMPLE went bad in transit, as the in house urinalysis was clear, but even in house
it looks like the protein is still on the high side. So this too I'll want rechecked.

LDDS June 26, 2014
base 100 nmol (range 30 - 300) = 3.62 uh
4 hour <27.59 = < 1.ug
8 hour 29 = 1.05ug

interpretation under <40nmol at 8 hour, their result - she is a normal dog without cushings

Liver Panel June 26, 2014

A/G Ratio 1.96 (range .60 - 1.90)
Albumin 44.4 (26.0 - 44.0)
ALP 1136 (4 - 141)
ALT 225 (6 - 118)
Gamma GT 12.0 (0.0 - 7.0)

Now, my thoughts. Yes, the vet thinks the sample might have gone bad during transit due to the comment of crystals too numerous to count, when they saw none in house. However, just a note, protein is high in both in house and in the lab on the urinalysis.

The ALT is going up at an alarming rate. It went from 162 in Dec 2013 to 225 in June 2015, 6 months. That is not good in my mind. Does this appear to be indicative of liver disease to you guys?
I have concerns about the protein going up so much in the urine sample and we will be retesting that in 2 - 3 weeks.

At this point I am not as concerned about a functioning adrenal tumor, with the LDDS being negative on that front. They seem to all think that if that was a functional one secreting cortisol, then she wouldn't be negative on the LDDS as most dogs with adrenal tumors secreting cannot suppress, 4 or 8 hours.

I do have some concerns that taking off of the SO food, might not have been so smart. As you can see, she isn't drinking and is very concentrated at 1.045 now.

So, am I worried, yes I am very worried about her liver. I know that haven't seen any nodules on the ultrasound but something is going on with her. If she has some sort of liver disease, then would that account for the ACTH being high?

Should I go forward with the flax hulls and melatonin, which the IMS wanted to see if bringing down the sex hormones would help the liver values? I'm leaning towards going forward with that. It won't hurt her I shouldn't think and we need something to help. I will be ordering the stuff you used for Hamish MC, for a liver supplement, I think the sam-e has to be included in this treatment.

Should I start them both at the same time? I'm thinking it matters less at the moment whether we know if it is the flax/melatonin or the sam-e if we can get that ALT down some.

okay, that is my thoughts for now.

hugs all,
Sharlene and molly muffin

Big hugs Sharlene. You know that I don't understand any of it, so sending hugs instead! :p

Check on the COOLING MATS thread that I posted on EVERYTHING ELSE. You will crack up! Consider the source! :D:D

I saw, I admired, I commented! You are fabulous!
hugs back atcha,
Sharlene and molly muffin

Hey Sharlene, yes I would also be tempted to try the melatonin and flax seeds. I think like you, it is not going to do any harm. I think they have mentioned a liver biopsy in the past? What do your vets think about proceeding with that? I also would go with the liver supplement now too.

RE UPC I would retest again, so we can see the trends or if there was in fact a problem with the transporting. No need for treatment unless it goes >2.0. So she is a way off that for now thank goodness. I always see UPC go up if Flynny's liver tests are off. So hopefully if we get the liver working a bit more efficiently with the meds then UPC will go down again too. x

Yup, I would go ahead start the lignans/melatonin and liver support supplements, too. And like Trish, I guess I would be wondering about a liver biopsy, too.

But this is the thing, Molly has had highly elevated cortisol for a long time now, regardless of the LDDS results. I know this may be really unorthodox, but I am still wondering whether it wouldn't be prudent to get the cortisol level down significantly regardless of the cause (I'm still beating the drum for the maintenance Lyso...). I know we're stuck with the chicken vs. the egg dilemma, but all those lab abnormalities could be the result of chronic elevated cortisol, which we know Molly has from the repeatedly high ACTHs. And the ACTH has stayed consistent throughout time, even while the liver values have been worsening. This is what prompts me to think that it is the cortisol affecting the liver rather than vice versa.

Would you consider sending an email to Dr. Bruyette, just to see what his take would be on a dog with Molly's profile (+ACTHs, -LDDSs, adrenal tumor on ultrasound, lab abnormalities but no overt symptoms)? She is indeed such a puzzle, but he's seen so many Cushdogs through the years that maybe he's faced something similar. Just a thought...

Marianne

Hi Sharlene,

I don't see liver disease in those numbers. I see the classic pattern that we see in both typical and atypical cushing's. The ALT has gone up but it is still a tad less than a two fold increase. Albumin is low in dogs with primary liver disease and Molly's is a tiny bit high, which is not a concern. I think starting treatment for atypical cushing's is a great idea and I also agree with Marianne that you might consider adding a maintenance dose of Lysodren. Liver biopsies are not benign and I personally would not consent to one based on the results you posted. That's my two cents worth.

I, too, think that adding the melatonin and lignans would be a good plan, though it can take up to 6 months for improvements to be seen with this treatment. So if this were me, I would begin the melatonin/lignans and in 6 months retest the liver values and if no improvement is seen than I would consider adding a maintenance dose of Lysodren.

Hugs, Lori

Thank you all so much.

I agree and my IMS agrees that the liver biopsy isn't benign and her concern is the cortisol being high when it would be done and possibly bleeding, so they won't do that unless something shows on the ultrasound that is indicative that there is a specific problem with the liver itself. Thank you for that addition Glynda!

Marianne, the reason the IMS didn't go with lysodren maintenance dose right now is that she is wary of using lysodren in a dog with no symptoms. Even atypical you usually have symptoms and molly just doesn't. Specifically with the not eating all her food all the time and lack of drinking water. All things that she would expect to see and she says this makes it difficult even with maintenance dosage of lysodren. It could become an option though if the lignan and melatonin don't do anything.

She said that even in a dog who say has pituitary cushings and tests negative on the LDDS, she wouldn't expect it to be consistently negative as molly's has been. She thinks that is very strange for a cushing dog. I don't know myself, I mentioned that there is that 5% who test negative and she said, yes, but they normally Do have symptoms and because medication is started follow up LDDS usually isn't done, you switch to the ACTH. That for it just consistently through years be negative is what is strange. Hence, we seem to never get that positive diagnosis of cushings. I went back through every test and found the very first LDDS was done in 2010. This makes 4 years now *sigh* perplexing to me anyway.

So, I ordered the S Adenosyl 100, as I want to get that sam-e involved in her liver and I'm switching her over to Dasequin with MSM for joint support.

I just now after all day of looking have Finally found a place to order HMR lignans which seems to have better results than the flax hulls and melatonin.
It just seems to be impossible to find in Canada, but this place does have a canadian outlet to get it direct from, so I plan to get that ordered tonight and get her started, as soon as they all come in.

I appreciate the feedback. We'll retest the UPC in a couple weeks. She'll be having a follow up ultrasound at some point, in the next couple months. (postponing a bit to wait and see if these options make a difference in both her liver values and what we see on the ultrasound, but they need time to work)

I'm glad you don't think it is liver disease, but a result of the high cortisol, which while that isn't good either, is at least more treatable I hope.

I wonder, if it is possible that molly does have pituitary cushings. If so why no symptoms and why does she suppress on the LDDS all this time. We wouldn't have even thought of treating her if she hadn't had that ACTH because I didn't fast her once and then the ultrasound thanks you guys. It is just all baffling and blows my mind after all the years I've been living breathing cushings now on the forum. So weird.

hugs
Sharlene and molly muffin