Hi,
I have 11 year old Irish Setter boy named Harry.
For a few years, Harry has had proteinuria (urine protein creatinine ratio of 1.6-2.8) - we have been controlling this with low protein diet (Natural Balance Reduced Calorie Formula). His blood pressure is normal. His kidney values so far have been normal. No protein deficiency in the blood numbers.
I just wanted to point out that the mild proteinuria can be caused from strenuous exercise so with Harry being a trail running dog, this may be normal for him. I would be more concerned if his urine specific gravity was low. Do you have copies of urine tests and if so, what was the USG and PH?
Harry's routine blood panel in December showed slightly elevated Alk Phosphatase (208). His T4 was a low, but additional test (free T4?) ruled out hypothyroidism. We started Harry on Denamarin. Harry has had unusual hunger, so our vet and I debated Cushing's. Despite his age, Harry is still a very active and fit dog, being able to go on hours of trail runs. We decided to just monitor him closely.
Early February, Harry had a non-recurring episode of vomiting. A blood test for pancreatis was negative. Blood chemistry showed even more elevated Alk Phosphatase (280) and ALT (128). Ultrasound done by a radiologist showed everything normal, including liver, stomach, gall blader, kidneys, testicles (Harry is intact). Some gas in his stomach. He has not had any vomiting since, so we attributed to one-time gasteritis.
A follow-up blood test in early April showed even more elevation in Alk Phos (480!) and ALT (140).
Believe me, 480 Alk Phos is not that high for a cushdog. We've actually seen numbers in the thousands. To touch on Harry's intact status, the gonads are at the top of the list of body tissue where you can find estradiol so this can be contributing to the elevations you see on the UTK panel.
We did a tick panel, lepto and U Tennessee Adrenal Panel test. Tick was a very slight positive on Rocky Mountain Spotted Fever. Lepto was negative, and U Tennessee Adrenal Panel came back hyperestrinism.
I'm not sure of the significance of a very slight positive on Rocky Mountain Spotted Fever would be. I know that you can see elevated cholesterol, Alk Phos and Alt with this condition so am wondering what your vet had to say about this.
Cortisol - Normal, Baseline (9.5 vs range of 2.5-56.7), Post (107 range of 70.8-108.5).
Androstenedione- Normal, Baseline (2.97 vs range of 0.21-4.26), Post (3.67 range of 0.68-7.92).
Estradiol - Abnormal, Baseline (105.3 vs range of 30.5-66.6), Post (98.9 range of 30.0-65.6).
Progesterons- Normal, Baseline (0.10 vs range of 0.03-0.40), Post (1.0 range of 0.55-1.70).
17 OH Progesterone - Abnormal, Baseline (0.52 vs range of 0.08-0.84), Post (3.31 range of 0.37-2.87).
Aldosterone - Normal, Baseline (50.4 vs range of 11-139.9), Post (196.5 range of 72.9-398.5).
Other than hunger and begging Harry has not had any other symptoms. Some hair loss around his anal area (hair fell off when he has some skin rashes there a few months ago, has not grown back much). He has had some plant material embedded around his toes and got infected (due to thinnern skin? But then he is a trail running dog).
Our vet does not think that we need to pursue additional diagnostics to dig deeper into liver (biopsy or bile acid test). She thinks that Harry's estrogen elevation is significant, and this could cause vacuolar hepatopathy that could elevate enzymes. She also thinks hypothyroidism is still a possibility given many Irish Setters are prone to this.
Hyperestrinism can cause vacuolar hepatopathy but this is usually apparent on abdominal ultrasound and Harry's liver appeared to be normal. I assume that the adrenal glands were also normal? PU/PD (excessive drinking and peeing) is also the norm in most dogs with this condition so with Harry lacking this symptom, I think your vet's thinking that hypothyroidism shouldn't be ruled out just yet is understandable. In my opinion, Harry seems to have more lab abnormalities and physical symptoms consistent with hypothyroidism and until you absolutely rule it out, there's no way to tell which condition is causing the symptoms. Can you post the results of the Free T4 test that was done?
For now, she is recommending melatonin and flaxseed hulls.
Now, I also belong to a Yahoo Cushing's board, and the prevailing thought on that board seems to be that there is no such thing as Atypical Cushing's and that melatonin / flaxseed do not really work.
Atypical cushing's, also known as pseudo or occult cushing's, does exist. More than a few reknown endocrinologists use these tags when defining a dog that has clinical signs and blood chemistry indicative of cushing's yet circulating serum cortisol levels are normal on the LDDS and acth stimulation tests. I'm therefore not sure why the folks at ccac feel that atypical cushing's does not exist. It may be because it's a highly controversial subject and the veterinary medical community seems to be split as to whether or not it's truly the elevated sex hormones that are at the root of the problem.
It is known that efficacy for melatonin and flaxseed treatment is slow and low in comparison to the conventional treatment used for typical cushing's; however, we have seen some good results here.
I wanted to get your opinion on this issue and understand how to deal with this issue.
I was also told that U Tennessee Adrenal Panel often results in elevated estrogen due to collection / testing method problems. Is Harry's estrogen even elevated?
I've personally never heard about problems in collection methods skewing test results but this can easily be clarified by Dr. Oliver at UTK. FYI, estradiol is an estrogen.
Are there any other procedures I should follow?
I think you should follow your vet's plan of action and I also agree with Lori that your vet should contact Dr. Oliver to discuss Harry's case. It doesn't cost a cent and Dr. Oliver may have some sound recommendations based on Harry's full medical history presented by your vet.
As you can tell, I am very very confused and would appreciate any help.
I understand how confusing all of this is and everybody has their own opinion based on their own experience and research. It took me a very long time after my first cushdog was diagnosed to get my arms around the disease and I didn't form my own opinions about anything for months. Try to catch your breath and go easy on yourself. We're here to help you in any way we can and I promise that the more you learn, the more unconfused you will become.
Harry's Mom
California