Printable View
If your IMS can't find another vet with a BP machine you can purchase one online and have your IMS teach you on how to use it.
Here's a link to a couple I found: http://www.vmedtechnology.com/Vet-Dop.htm
http://www.petmap.com/
Oh Sharlene, I know how worried you will be about sweet Molly but I do hope you have a wonderful time visiting your sister.
Love and Hugs, Lori
Have a great time on your trip Sharlene. I know your thoughts will be home with Miss Molly at times, but I hope you can "escape" some of the time and have some fun. It will all be here when you get back. <3
Have fun in the sun Sharlene, if I was your vet I would be listening and reading every word you put down for them!! Be good if the had doggy cam so you could keep an eye on her yourself! They know you and Molly well so with this new BP issue I am sure they will be taking extra special care of her. xxxx
I'm back :)
Molly visited the IMS today and her BP was 150. Whoo hooo. She was almost a constant 180 last week. So this is an improvement. We just need to keep her at that range now. 150 shouldn't cause retinal bleeds and that is important!! We want to save as much of her sight as possible.
They want her switched to a renal diet soon though. We ran a recheck of blood work today. We also are doing a couple other tests, but everything seems to be pointing to kidneys being the underlying problem.
I admit to being emotionally exhausted and half the time feeling brain dead these days. You can't help worrying about them.
I don't know what is going on with my vet lately, but something sure seems to be. No follow up calls in regards to after care, didn't run requested tests while Molly was boarding (the IMS drew blood for those tests today along with the other things she wanted to do) No follow up on the renal diet or finding a local vet near me that can do the BP tests.
This is really not like my GP vet at all, so I'm a bit concerned and it just adds to the stress. Now my IMS said she is going to email some contacts about what would be the best food for molly. She is thinking a vegetarian food, or novel protein with SO index, wet might work best.
My head hurts sometimes trying to keep everything between molly and hubby straight. His surgery is scheduled for mid November.
That's my update on the muffin. :)
hugs
Sharlene and molly muffin
Wtg on the BP constant 150 we,ll take that. So it's pointing towards the kidneys, hopefully a new Noval diet will help.
So sorry your feeling emotionally drained and brain dead no wonder you have had so much to consend with recently between molly and your hubs. So have a huge HUG from me you are doing a fantastic job with both Molly, your hubs and work. I think sometimes you get overwhelmed with everything as its always on your mind day and night but remember to take 5 mins for yourself and regroup your thoughts.
Can you raise the concerns you have with your vet, see what's been going on and if you iron the problems out.
We are all here for you to lean on gawd we,ve all leaned on you often enough so feel free to lean and vent on us. Have another Hug
Oh Sharlene, I'm so glad Molly's blood pressure is down! All fingers crossed that this is just the beginning of a really positive trend. :)
With so much worry on your plate, I feel like a heel bringing up the subject of cortisol yet again. I promise this will be "it" and I'll try to let it go from now on. But in view of Molly's issues with blood pressure and protein loss, in good conscience, I feel a need to talk about the cortisol one more time. Molly's cortisol has been highly elevated for a good while, and I know your IMS is puzzled as to the cause -- for good reason. But it seems as though she just keeps sweeping it under the carpet. Regardless of cause, elevated cortisol can contribute to both hypertension and protein loss. Unless the cortisol is addressed, I'm not sure how you are going to get a totally satisfactory handle on these problems.
The normal reference range for this lab is 6.5 to 17.5 ug/dl. So since at least June of 2012, Molly's cortisol has been significantly elevated. I know your IMS commented on the fact that the cortisol had "gone down," but it seems to me that the difference between 36.75 and 34.5 could just be lab variation or normal daily variation. That does not seem like enough of a decrease to warrant believing that anything has significantly improved during these two years. I know there is a bit of the "chicken-and-the-egg" issue with all of this -- what came first, the high cortisol or the kidney issues? But with the recent onset of the hypertension and the lack of evidence of significant kidney dysfunction prior to 2012, it seems more likely to me that it was not her kidneys that caused Molly's elevated cortisol, but they are instead suffering as a result. At a minimum, the cortisol cannot be helping the problems that now exist. And so I can't help but wonder whether these new developments warrant more urgency in dealing with the dilemma of the cortisol.Quote:
ACTH (2 draws - this is due to the agent used by the vet) June 2012
Cor1 - Cortisol (base) 172 (30 - 300) 6.23 ug
Cor 21 - Cortisol (ACTH) - 1 hour 924 33.49 ug
Cor 22 - Cortisol (ACTH) - 2 hour 1014 36.75 ug
ACTH april 2014
Pre 29.5nmol range 2.1 - 58.8 1.06ug [corrected to 2.95 ug/dl]
1hr 283.1nmol range 65.0 - 174.6 10.26ug [corrected to 28.3 ug/dl]
2hr 345.6nmol range 65.0 - 174.6 12.52ug [corrected to 34.5 ug/dl
In the absence of Cushing's symptoms, I do understand the reservations about aggressive treatment beyond the melatonin and lignans that you are trying now. But it just seems to me as though Molly's cortisol is the elephant in the room that your IMS chooses not to address. I would flat-out ask her: with a cortisol level that has remained so highly elevated for this long and given the known impact of steroids on hypertension and kidney function, do you think we can satisfactorily control these issues in the absence of significantly lowering the cortisol in some manner?
(And now I've said my piece, and you can whip me with a wet noodle, and I promise that I truly will not bring it up again...:o :o :o).
Marianne
Go Molly. Go Molly!!!!
Sharlene, I would absolutely bring up your concerns to your vet. In light of the grievous error that Daisy's vet made, PLEASE talk to them. Don't hold back.
I'm glad that your IMS in on top of things though.
I would like to know exactly what is causing her Cortiaol to be high so that it can be remedied.
Hood luck to hubby!
The IMS is suppose to call me today if the lab results come in. I have constantly mentioned the cortisol factor but they seem unwilling to go anywhere with it with her not having classic symptoms. I am thinking to ask to start her on low trilostane to see if it would help. This is all so scary. What do you think?
Hugs
Sharlene and Molly muffin.
After opening up my big mouth, I don't know whether trilo is the way to go or not. But I guess what I'd be hoping for, first, is for the IMS to engage in a genuine conversation as to the significance of the cortisol. It's true that up to now, Molly had not exhibited any outward symptoms. But suddenly she's got two big issues that, as far as I know, are genuinely impacted by elevated cortisol.
I think we've got a quote somewhere from one of the Cushing's gurus stating that in otherwise outwardly asymptomatic dogs who test positive for Cushing's, hypertension and/or significant proteinuria is a sufficient trigger to start treatment. I'll try to look that up again. However, I do realize that the negative LDDS results really muddy the diagnostic waters for Molly and make her case ever so much more confusing.
With that in mind, I wonder if your IMS would be willing to ask some colleagues what they would do in this situation. I do not have the training to know the right answer. But boy, I bet our Molly could generate a lot of conversation at an endocrinology convention!
Bottom line, if your IMS still thinks the risk of intervening with the cortisol outweighs the benefits, then she's the expert. But I'm hoping she'll address the issue straight-on so you'll truly know what it is she is thinking is best, and why. And if she's in doubt herself, I'm hoping she'll bounce the question off some other specialists.
Marianne
P.S. Here's the quote. It comes from Dr. Peterson's blog, and as it turns out, it is in response to a question asked by our own Glynda!:
http://endocrinevet.blogspot.com/201...corticism.htmlQuote:
I am not a proponent of treating dogs with asymtomatic Cushing's disease, unless they have secondary hypertension or proteinuria.
I know what you mean Marianne. We've discussed it every visit. When the retinal bleeds and hypertension where discovered both her and I brought it up to the eye specialist who said she had not seen retinal bleeds caused by cushings. So, she didn't think that was the problem causing the hypertension, but that protein loss, could and would cause retinal bleeds. That is why they chose to go with treatment of the kidney first.
It is very frustrating! I want to do whatever is best for her, but it is hard to pin it down and yes that LDDS is causing the confusion I think as it is consistently negative.
Argggggh
Sharlene and molly muffin
Well, the eye specialist's response is rather puzzling! No, Cushing's wouldn't directly cause the bleed. And yes, hypertension is associated with renal disease. But Cushing's is also a known cause of secondary hypertension which, in turn, can cause hypertensive retinopathy. Here's a "human" blurb, but I assume the same is true for dogs:
Probably nobody can separate out one single cause of Molly's issues. The kidneys, hypertension, and elevated cortisol may all be intertwined. But it seems odd to me that the eye specialist would totally dismiss Cushing's from the picture. I mean, that is basically ignoring the known impact of elevated steroids on blood pressure. :confused:Quote:
The arteriosclerotic changes of hypertensive retinopathy are caused by chronically elevated blood pressure, defined as systolic greater than 140 mmHg and diastolic greater than 90 mmHg[2]. Hypertension is usually essential and not secondary to another disease process. Essential hypertension is a polygenic disease with multiple modifiable environmental factors contributing to the disease. However, secondary hypertension can develop in the setting of pheochromocytoma, primary hyperaldosteronism, cushing’s syndrome, renal parenchymal disease, renal vascular disease, coarctation of the aorta, obstructive sleep apnea, hyperparathyroidism, and hyperthyroidism.
Here's another quote, this time from a veterinary paper on canine ocular disease:
http://c.ymcdn.com/sites/www.invma.o...%20DISEASE.pdfQuote:
Hypertension can be defined as systolic BP greater than 160mmHg. Hypertension is associated with renal disease, Cushing’s disease, pheochromocytoma, primary aldosteronism, hypothyroidism, and hyperthyroidism. Initial response to hypertension is constriction of retinal arterioles and with sustained high BP, occlusion and ischemic necrosis occurs of the blood vessel walls. This results in increased vascular permeability. Serous retinal exudates, hemorrhages, and edema occur due to the vascular permeability. In addition, tortuous retinal vessels and hyphema and vitreal hemorrhage can be seen. A blood pressure should be performed anytime there is bleeding in the eye. If the blood pressure can be controlled, then often retinal detachment and hemorrhage can be reversible and vision restored. Some permanent damage is likely..
I wonder if your IMS would even consider contacting Dr. Peterson and asking his opinion about Molly?
And I know this is probably overkill, but here's even a more comprehensive veterinary article, containing this summary statement:
Ocular Manifestations of Endocrine DiseaseQuote:
Ocular complications often are not considered among
the primary manifestations of HAC in small animals.
However, there is actually an extensive list of possible
ophthalmic consequences to the excessive levels of corticosteroids
present in this disorder. Some possible findings
vary, depending on the specific circumstances of the case
and the location of the primary causative lesion in the
adrenal glands or the pituitary. Conversely, systemic
hypertension and its repercussions are common regardless
of the site of the primary lesion, as are metabolic changes
associated with hyperlipidemia and lipoproteinemia.
Hyperadrenocorticism
(HAC,Cushing’s disease)
• Systemic hypertension
— Retinal hemorrhage
— Retinal detachment
— Hyphema
I am so sorry if I am overwhelming you with this stuff!!! But I know you're preparing to talk to the IMS and I'm just trying to arm you with as much info as possible. It makes it really hard since the eye specialist has already dismissed the cortisol as an issue. But I know you're wanting to do everything you can to preserve Molly's remaining eyesight. So I just don't want to overlook anything that is worth discussing further with your IMS while you have the opportunity to do so. :o
Well I sent a comment in to Dr. Peterson, referencing his response to Glynda. So lets see if he responds.
I hope my IMS will contact me today and I can ask her further about this. I don't know when Dr. Peterson will have a chance to respond, if he does.
Cross fingers.
I think there is enough evidence at this point that treatment with a low dose of trilostane should be considered. I'd want to start it once I return from Calgary, which will be Oct 13. I have another appt on Oc 16 with the IMS. I don't want to add anything new to the mix till then as I won't be around to monitor her and in addition to starting the benazepril.
We are currently not doing the lignams and melatonin, as I stopped those when this new situation occurred. I think I mentioned that on here, but it might have gotten loss in the muddle of the thread.
hugs
Sharlene and molly muffin
Bravo for writing to Dr. Peterson! :) Let's hope he responds!!
I'd like to throw out a few things for consideration. If its helpful, please use it, if not just ignore it. Cushing's is new to me but I'm an old hat at eye disease. My eye doctor is the Professor and Chairman of the Retinal and Vitreous Disease Dept. at Duke University which is the 4th rated Ophthalmology clinic in the USA.
When my eye disease began, the first thing EVERYONE (1 opthalmologist, 1 retina specialist, and 1 neuro-ophthalmologist) thought was that I had a pituitary tumor because the back of my eyes at the retina was consistent with tumor. No tumor was identified on MRI and after many more tests, it was found that I had a very rare autoimmune disease that is destroying my retina. What am I saying here? If Molly has indeed had a micro pituitary tumor, there is the possibility that it has grown and that could be cause of the retinal bleeds. Pressure in the brain causes pressure on the back of the eyes where the retina and optic nerve reside.
As part of my treatment for severe inflammation in the vitrious fluid, chorid tissues and retina area of the eye, I was put on high doses of steroids by mouth and steroid injections in the eyeball. As a result of that, I developed cataracts and glaucoma. Even after the steroid shots and higher doses of steroids were discontinued, the glaucoma (eye pressure) and cataracts remain. Proof positive that high cortisol, natural or synthetic causes eye damage. I have also had to be put on blood pressure medicine because of the continued steroid use which has created the elevated BP
In thinking about the pituitary tumor possibility, maybe low dose Lysodren would make better sense since it actually shrinks the tumor. At least a short course of it may be more beneficial, and then you could always switch to Vetoryl.
I know you are worried sick about Molly and with the hubby's surgery coming up as well, you are probably about at the end of your rope. I'm praying for good answers for you and a good treatment plan so Miss Muffin can retain her sight and kidney function and live many more happy years. I know she brings you and the hubby so much joy. I also understand the "disconnect" with your regular GP vet. Mine did the same thing and as much as I love and respect him, I moved Dixie to someone else who has been very on top of things with regard to her Cushing's. You have a lot to think about, but I think if you will address 1 problem at a time and get 1 answer at a time, you will move thru your list of concerns and get to that place where you can sigh a breath of relief again. (((((SHARLENE)))))
Wow, Suzie, it sounds like you have had more than your share of eyeball adventures! :o
That is all really interesting information. If Sharlene were to start treatment, I've also thought about low-dose Lysodren for Molly, too, since UTK feels that treatment is safe for dogs who have even normal cortisol levels but elevations in other adrenal hormones (which Molly has, too, in addition to the elevated cortisol). Lysodren does not shrink a pituitary tumor, but a small percentage of adrenal tumors do physically respond to the drug, alongside the cells of the adrenal cortex. We do know that Molly has an adrenal nodule of some sort, so who knows, maybe the Lysodren would have an effect on it.
If there are issues of kidney function beyond proteinuria, that may be another reason why Lysodren might be a better choice, too. I'm not sure about that, though -- maybe some of our Lysodren experts will know more about Lysodren and kidney function.
Marianne
So, blood work is all good.
We will repeat the ACTH on Oct 16 and see where that stands. The 2012 ultrasound showed change in the kidney, so she said it is hard to know if the kidneys came first or the cortisol came first. I shared my concerns of the cortisol contributing to the kidney protein loss, which caused the hypertension, which caused the retinal bleeds. Since that was our first ACTH and LDDS has been negative since 2010, she doesn't think a repeat of an LDDS would do any good as Molly flatlines it every time. She said, depending on what that tells us, we can look at at 1mg/1kg dose of trilostane, but that she wouldn't do lysodren based on what she knows of molly's medical history. That we also don't want molly in any pain and that a bit higher cortisol would help that. In 2012, she had one kidney stone (it must have been on the report but I don't remember it being a factor in anything, I thought it was a bladder stone maybe?) small and unobstructed. Now she has two and they are unobstructed at this time too.
She doesn't think the cortisol is high enough to have caused the problems in mollys kidneys but thinks that the kidneys might have started the cortisol going up, although that isn't a definite, just us throwing ideas back and forth at each other. Either way, likely we will go with low trilostane and see how molly reacts to that and stop it if she appears to be in any pain from the kidneys, etc. She'll be calling me next week, once we get the lepo test results back and we hear back from the nutritionist on food options.
I'm so tired. My brain is a fog. :( The internet here at the house isn't the greatest for some reason today. Have a call in about that too. And I have to get ready to go to the funeral home for a visitation as my friends dad passed away.
We are hoping hope that molly's BP stays down and we can keep this controlled. Whatever it takes to do so, we'll do.
Wow, you have had a lot of experience with eye issues and steroids Suzie! I mentioned all of these things inclucing Dr. Peterson's thoughts to the IMS. She said these are all valid concerns and that we'll do our best to figure it out and get it all under control. She doesn't think there is a macro tumor involved, she said the clinical signs and neurological signs aren't there for that in molly.
so address the protein loss, doing that, get her on food, working on that, get the cortisol checked, doing that the 16th, start on trilostane (based on results of acth), BP, so far down, so working on that too.
All of these things should help us to keep molly, as she is at least currently for awhile. She plays, she walks, she loves her treats, even her medicine treats, so step by step.
hugs and thanks everyone
Sharlene and molly muffin
Marianne, thanks for clearing up my mistakes about Lysodren. I'm showing my lack of Cushing's knowledge. ;) I'm glad you understood where I was going with that thought. Yes, my eye adventures have been quite amazing. Much, much more than I ever wanted to experience, but I'm not completely blind yet, so they are hanging in there. I actually have an apt. at Duke tomorrow. Yuk.
Sharlene, I'm glad you got to talk to the IMS and wrote Dr. Peterson. It will be interesting hear what he has to say and it sounds like you have a starting plan in place. Try to get some rest.
Hi Sharlene, I am sorry you have so much on your plate. Hugs and love to you, hubby and sweet Molly. I have no words of wisdom, just our experience. Our ophthalmologist never saw evidence of high blood pressure in Zoe's eyes despite the IMS's claim she had high BP. Whenever he checked her BP it was not elevated. When the IMS would check it - it was higher. What the ophthalmologist did say was that with all of Zoe's eye issues, maintaining her cortisol at a lower level was important.
Zoe started out without the classic Cushings symptoms, even in her blood work. Dr. Peterson told me not all Cush pups will have the elevations we normally see. Her main problems were skin/coat issues. Dr.Peterson felt her cortisol was too high for a maintenance dose of Lysodren to work and that her IBD would not tolerate the higher Lysodren doses of a load. He opted for starting at a low dose of Trilostane.
I think if it were me, I would ask if a maintenance dose of Lysodren would hurt Molly and how and if her cortisol is not sky high, perhaps a maintenance dose would be enough to bring it down. Dr. Oliver did tell me he had dogs that did respond to a maintenance dose without a load.
Deciding when to start treatment and which treatment can be overwhelming. We all do the best we can and we listen to the experts and go with our gut.
So go with your gut, sweetie.
love you.
My 2 cents worth - I would choose the Lyso maintenance over Trilo any day if that is the route I decided to go were Molly mine. I would probably go ahead and keep the melatonin and lignans treatment along with it as recommended by UTK. BUT you know I'm partial to Lyso. ;)
Jeepers, if that LDDS went up even a wee bit it would help clarify the course of action for Molly. Hopefully Dr Peterson will get back with some advice, or maybe even you could try Dr Bryette as some have had replies from him.
Sorry your local vet appears to have dropped the ball a little, that is surprising as she has always been so receptive. Hopefully that gets sorted out soon xxx
Dr. Peterson has responded:
Spoke with my vet today, who called me. I think she was just busy, but she has looked into food and ordered omega 3 for me, which I already received from the IMS, but I have now another bottle that I can pick up later.Quote:
Dr. Mark E. Peterson said...
If your vet has done the proper testing for Cushing's (ACTH Stimulation, LDDST, and urine cortisol:creatinine ratios) and it is positive, then I would start treatment. If the tests are normal, then the "complications of Cushing's" you are talking about are likely secondary to another problem.
The ALT and AP are not specific tests for Cushing's, and the finding of large adrenal glands could be due to nonadrenal illness (such as primary kidney disease).
My vet is not on board with treating for cushings as she doesn't think now that cushings is the main culprit or that the cortisol is constantly high, and her worry is that we could make her cortisol go to low.
Both IMS and vet have discarded lysodren as a choice, going with trilostane.
I think both the IMS and vet seem to think that the kidney disease is primary and the cortisol is secondary to that. I am not so sure, but don't know what the best option is. At the moment, I want to know what the cortisol is now and see if it has changed in either direction, up or down. Although I've been told that it might have gone higher in response to the advancement of kidney disease.
If she has cushings and constant high cortisol, I'd think we would want to bring it down a bit and the IMS does seem to be thinking that but wants the ACTH first, as do I.
This is so frustrating.
hugs
sharlene and molly muffin
Well, phooey on Dr. Peterson for missing the central issue: your vets have done the proper testing and the results are contradictory! Don't know whether it would be worth following up with another question to him, seeking that specific clarification: your dog has had significantly elevated ACTH tests two years apart, but two negative LDDS tests within that same timeframe. Of the two tests, the ACTH is supposed to be the most "specific" to Cushing's, so what gives??
I wonder what leads your vet to conclude that Molly's cortisol is not consistently high when she has had two significantly elevated ACTH tests fully two years apart? What evidence does she have of a normal cortisol? I worry a bit about her because I think I remember her making reference to Molly's basal cortisol as being normal as though that had diagnostic significance for Cushing's, which it does not. Plus, as is the case with maintenance Lysodren for "Atypical" cases, there are situations when trilostane is prescribed for dogs with even normal cortisol (including Alopecia X, I believe).Quote:
My vet is not on board with treating for cushings as she doesn't think now that cushings is the main culprit or that the cortisol is constantly high, and her worry is that we could make her cortisol go to low.
I also have been puzzling in my own mind about the notion that it is a kidney problem that has been elevating Molly's cortisol all along. I know it is written everywhere that other, nonadrenal illness can elevate cortisol, and Dr. Peterson mentions primary kidney disease as a possible cause of swollen adrenals as do your vets. But I've been trying to figure out exactly what the connection would be. In doing some searching, I came across this article relating to humans. And if anything, it seems as though the worry being investigated relates more to the reverse -- that human patients experiencing renal failure might need glucocorticoid supplementation. At any rate, here's the study's conclusion (one warning, though, this is an older 1998 study, so more recent research may be different):
http://martinclodi.at/downloads/25-r...nts-with-c.pdfQuote:
It is surprising that neither changes of cortisol metabolism due to renal insufficiency, the effects of uremic toxins on the HPAaxis, nor the modalityof renal replacement therapy alters cortisol response to ACTH in patients with end-stage renal failure. Thus, in general, glucocorticoid replacement therapy in CRF patients does not appear to be necessary under everyday circumstances and only a minority of patients migh benefit from glucocorticoids in stressful situations, such as major surgery...
In summary, the low-dose ACTH [stimulation] test elicited a normal adrenal response in a well-selected group of patients with CRF [chronic renal failure] who were receiving hemodialysis or CAPD. This finding suggests that neither renal insufficiency itself nor the modality of renal replacement therapy has a major implication on adrenal function.
I sure am not trying to be Miss-Smarty-Pants, acting like I know more than Dr. Peterson and your vets (although I'm afraid that's exactly how I'm coming across! :o :o :o). And even though it may seem otherwise, I also don't know whether trilo is the right way to go. But I definitely think it's worth it to perform another ACTH to see where Molly stands now. If it is still high, then maybe your IMS would be willing to garner some additional opinions among her colleagues about Molly's very perplexing situation.
Just for the heck of it, would you mind if I sent Dr. Bruyette an email asking his thoughts about a situation like Molly's?
No my vet never mentioned a normal pre cortisol level. Thank god she wasn't of that mind. I don't know why she doesn't think the cortisol is consistently high but it has to do with not testing positive on the LDDS. It didn't make sense to me since they are two different test.
3 LDDS in last couple years. Two last year.
They are all worried that if it isn't cortisol that we will send her low but I think we have to try. Maybe we will know more after the next ACTH test? I hope anyhow.
She still doesn't have the appetite or drinking urinating of a Cush dog. Skin and hair fine. It is all the internal organs being affected in her case. :(. Which is bad.
I think we Have to try something but I am the only one advocating it. Now I have to check the urinalysis reports as my vet didn't think she had oxalate sones and I am sure that I had read she did. I want to add potassium citrate to any food we use and they think potassium could be a problem as it is an issue with renal function.
Some days they drive me nuts. No I don't mind if you email dr. B. I wish that Dr. P had addressed that the test were done and it is the contradiction between them that is the problem. No UC:CR has been done. I am thinking of that too.
Thanks Marianne
Addy you are such a sweetheart. I so remember Zoe eye problems. Cortisol. Bp. Proteinuria all are issues for the eyes.
Hugs
Sharlene and Molly muffin.
Well, I sent off an email this afternoon to Dr. Bruyette listing the specifics of Molly's original presentation (elevated ALKP and pot belly but no other external symptoms), her contradictory LDDS and ACTH testing history, and also included the same current summary you had written to Dr. Peterson, including continuing lack of outward symptoms. Within a half-hour (on a Saturday afternoon!), I already got a response back. Here it is:
So another opinion to consider as we await the next ACTH test...Quote:
Hi. It not uncommon to have discordance between the test results and given the whole picture I think the dog has PDH and I would treat. It may help with the blood pressure and proteinuria.
Dave
Yes, Dr. B is amazing with the speed of his replies. :p He responded to me right away too, but it wasn't the news I really wanted to validate.:o His recommendation is what was used to partner his vet with his consulting neurosurgeon. Someone who I couldn't afford to see on a regular basis because she was over the top expensive, but consulted daily for me anyway. This is a doctor who lectures all over the world in neurosurgery and still took the time to monitor Buddy for nothing. There are doctors out there who really care about our pups and are willing to help, even when they aren't getting paid. :p
I am so sorry that all of this is so darn complicated.Molly has been doing so well for so long without heavy duty Cushing's meds. I understand your reluctance to start on them.:o I'm not so sure I would want to do it either, particularly if you're not sure whether she needs them or not. :confused: I wish I could be of some help.
Big gentle hugs to you, hubby and out little diva,
Hi Sharlene, hoping that you and hubs and Molly are having a peaceful Sunday and that you can push all the worry in a drawer for now. You've got a very reasonable plan in place and in my book, just figuring out the plan is half the battle won! ;) :)
Sending lazy Sunday afternoon hugs your way,
Marianne
We are definitely being lazy. Just haven't been home much to do so as much as I'd like. Lol. All the errands from being away last weekend and then away next weekend too. All things we already had flights and plans for prior to this coming up with Molly. The high bp and sight thing.
Yes I think we will get the ACTH and if that is still high, then start trilostane at 1mg/1kg. Ratio. Which would be around 8mg so have to have it compounded.
Let's see what that is.
Thanks for checking in on us.
Hugs
Sharlene and Molly muffin.
i hope everything works out fine for you and molly.
when is molly's acth test?
luckily she is still feeling fine.
strong girl!
I'm pretty sure that Calcium citrate can be used in place of potassium citrate.
Hugs to you and sweet Molly, Lori
Ahh ha! I was thinking there was another I'd read about. That is it! Thanks Lori.
I will mention to my vet
Hugs
Sharlene and Molly muffin
Hi Sharlene,
I haven't been around posting lately, but I've been following your posts about Molly very carefully. I am so sorry for everything that has been happening, I understand how frustrated you must feel. I keep meaning to chime in, and just haven't had a chance get my thoughts together to post. So happy to see all the information that Marianne, Lori and others have been providing.
I just have a quick minute now to post because it's the middle of the night and I need to get back to bed, but wanted to let you know about the food that you asked about on our thread.
The renal diet that Jasper was started on after being diagnosed with Protein Losing Nephropathy was Royal Canin Renal MP Modified. This is considered a moderate protein restricted diet rather than a low-protein diet. The other Royal Canin renal diet is called Renal LP Modified. That is the low-protein version and more protein restricted, the MP is what you want. Science Diet makes a renal diet also, I believe it's called K/D. We did try Jasper on that initially but he didn't like it and I had a lot of trouble getting him to eat it. Plus it was more protein restricted which I didn't like. After researching quite a bit, and with help from folks here, I asked my vet about the Royal Canin. Their prescription foods seem to have better ingredients than Hills, although none of them are wonderful as foods go. And I know there are others on the forum that will not recommend any of the prescription diets and feel very negatively about them. However, my vet insisted that Jasper needed to have that at the time, so that is what we went with.
He is no longer on the renal diet because his triglycerides got sky-high (he has hyperlipidemia also), so we now have to have him on a prescription low-fat diet. He is getting Royal Canin G.I. low-fat right now. Unfortunately, it was a trade-off for us. We had to get the triglycerides down, so I couldn't keep him on the moderately restricted protein diet for his kidneys. So far it hasn't seemed to affect the protein level in his urine significantly.
The other thing I wanted to make sure I mentioned right now is that in addition to the Benazepril, Molly needs to be taking fish oil daily. That is an extremely important component in treatment for PLN.
Sharlene, I will try to be back on the forum tomorrow night after I get home from work and post a little more. Again, I am so sorry with all that you and Molly are going through right now, and also about your hubby. I will try to help with whatever I can regarding the PLN, I have done a lot of reading on that.
Big hugs,
Tina and Jasper xo
Sharlene, I'm so glad Tina is having a chance to talk with you about the food options! Here's a link we all found helpful back when Jasper was first diagnosed with PLN:
http://dogaware.com/health/kidneyprescription.html
It's an article by Mary Strauss with a comparative chart of commercial renal foods and other helpful info. I confess that it is confusing to fairly compare the actual protein content among the foods on the chart, because there is a big difference between "as fed" and "dry matter" basis and "per 1000 calories," the latter number not being included in the chart and perhaps it is the most important comparison of all. But there is still a lot of helpful info there, and if you click on any food, you'll be taken directly to it's website.
For instance, here's the webpage for Royal Canin's moderately reduced protein foods. To show why I'm confused a bit about the comparisons, from their webpage it looks like the dry version has a bit higher protein while Mary's chart makes it appear that the wet version does. But either way, there is a lot of helpful info to look over.
http://web.archive.org/web/201011270...P+Modified.pdf
Marianne
That makes my head spin trying to sort out all that stuff. It looks like though that protein restriction can actually have adverse effects even. The key seems to be the low phosphorus in the food, not the protein. Interesting.
I definitely need to forward this one on to my IMS for her to review too.
Tina, that is one of the things that was mentioned, that every low protein, has a high fat content it seems, and that isn't good! So that causes me some concerns too, along with whether a low protein that is in fact too low, could cause protein malnourishment, especially in a dog caught early.
thanks Marianne!
hugs
Sharlene and molly muffin
Hey Sharlene, no, I don't think you are not looking for a low protein diet in Molly's situation but instead only mild/moderate protein restriction. But when a dog is persistantly leaking significant protein in the urine, you are looking at more than just phosphorous alone. The situation differs depending on the specific renal issues and abnormalities.
MarianneQuote:
Remember that low protein is unnecessary and even harmful unless your dog is uremic, but low phosphorus is advisable. Moderate protein reduction may be required if your dog has proteinuria (significant protein in the urine).
Here's a quote with a more extensive explanation that seems more relevant to Molly's situation. It comes from a really great IDEXX roundtable discussion on Proteinuria and Renal Disease.
https://www.idexx.com/pdf/en_us/smal...ound-table.pdf
Quote:
Metzger: How about the nonclinical, non-azotemic animal with persistent proteinuria? If I have a senior patient with persistent proteinuria, should I initiate a renal diet?
Sanderson: Yes, there are some indications for renal diets in the nonazotemic proteinuric patient. If you have a choice between early-stage renal diets, which tend to have a little more protein, and advanced-stage diets, go with the early-stage diet in the beginning. The benefits are the omega-3 fatty acids and the protein itself. You want to keep up with what they’re losing, but you don’t want to give them so much that more and more protein is leaked into the kidneys and causes damage. Mild dietary protein restriction is warranted in those cases. Renal diets are indicated in both chronic renal failure and glomerular disease.
Moderate protein, got it.
Look at this:
These are commercial foods.
http://www.dogfoodadvisor.com/best-d...ein-dog-foods/
I compared the technical of Fromms Adult mature classic
http://frommfamily.com/products/clas...ical-analysis/
With renal mp
http://www.royalcanin.ca/index.php/V...mulas/Renal-MP
looks about the same, except that Fromms, has lower fat content, while Renal MP has higher fat content, which can cause other problems.
Sharlene
Couldn't get the from a food. Grabbed the blue buffalo life protection senior and a can of natural balance vegetarian
Sharlene. Stop gap merhod
Sharlene, if I'm reading the analysis lists correctly, the Fromm's has significantly more protein than the Royal Canin.
Fromm's: 6.6 grams of protein per 100 kcal
Royal Canin: 3.9 grams of protein per 100 kcal (listed on the chart as 39 grams per 1000 kcal)
And the fat doesn't seem hugely different:
Fromm's: 3.5 grams of fat per 100 kcal
Royal Canin: 3.8 grams of fat per 100 kcal (listed on the chart as 38 grams per 1000 kcal)
But these charts are so darn confusing, so maybe I'm missing something...
Plus, I just looked at that DogFoodAdvisor list and I'm afraid they haven't made any effort to quantify or justify what they mean by "low protein." I mean, it just looks like they've arbitrarily picked as their criteria: "They must contain no more than 23% dry matter protein." From the article, I have no idea where they got that number or what they're basing it on. Plus, dry matter analysis isn't the most direct comparison, I don't think, because the actual amount of protein consumed will depend on how much food you'll actually feed your dog each day, and that varies depending on the calorie count comparison.
Plus, the article acknowledges that it made no attempt to analyse phosphorous.
I totally agree that it will be great if you can find a food with better ingredients than the the prescription diets. That's what I did with Peg when I hunted out a low-fat food for her. But unless I'm goofing up the anaysis, I think the prescription reduced protein foods are probably lower in protein content than most of the foods on this list.
Maybe Tina will have more experience with this.