Our story

[karen-b]

A couple of years ago, we lost our almost 6 year old cocker Dora, to liver disease. She had gone in for a routine surgery and we lost her just over a month later. She had presented absolutely no outward signs, was fit and healthy, and loved life. A couple of weeks after the surgery, she seemed 'not quite right' so off to the vet we went. Blood test revealed her liver values were off the scale, and she was admitted to Langford referral hospital as an emergency. She had tests and it seemed she'd had liver disease for some time, she had less than  20% liver and that it was shrivelled and deformed. She was in hospital for a week, and they pretty much sent her home to spend what remaining time she had at home, and we lost her a week later. Devastated is an understatement, it destroyed us. 
We decided that we would have regular blood tests for our other three, Bailey, and Winnie and Myrtle who are Dora's daughters.
All have been fine, then in January the girls had pre op blood tests, and Myrtle's ALT was slightly elevated. We tested after a month to see if it was a blip, but it had gone up. She had Samylin and another test a month later, but it was still going up. Changed her to RC hepatic and continued with the Samylin, but still it went up. 
So we had an ultrasound, a bile acid stim test both showed nothing and then a biopsy. The biopsy revealed nothing sinister, but there was a lot of inflammation, and the diagnosis was immune mediated hepatitis. The internist at the lab recommended continuing with the Samylin and giving Destolit too, trying to avoid immune suppressants if possible. After a slight drop using this combo for a month it's is still climbing.
Now this week we have started cyclosporine (cyclavax) together with  Samylin and Destolit, and test again in a month.
This breed, or maybe this bloodline are obviously predisposed to this condition, as I think now in glorious hindsight that's what Dora had, and we hadn't known.
Winnie is fine, her  values and Bailey's values are perfectly normal.
I was told to expect vomiting and diarrhoea with Myrtle, she was a little sick after her first dose, but seems to be doing ok on the drug, but I know it's not a nice drug, and I want to support her body as much as possible while she is on it. Fingers crossed this stops her immune system attacking her liver and gives it a chance to recover.

[Jo CIMDA]

Hi and welcome

I am so sorry that you lost your Dora to IM hepatitis, and now you are having to deal with Myrtle with the same problem.  I fully sympathise because I had similar with my dogs, different AI diseases though.  It is a massive blow.

I do think that using an immunosuppressive drug like Cyclosporine, which is less harmful to the liver than the more commonly used immunosuppressive steroid prednisolone, is a good way forward, and it seems that Myrtle is tolerating it well.  I hope you will see some improvement in her soon.  Should for some reason Cyclosporine not agree with Myrtle then there is another drug that is considered to be less harmful to the liver than steroids and that is Mycophenolate Mofetil.  The liver support that you are giving is also very good.

As you have been very proactive and having regular blood tests on your dogs, then I hope that you have caught this early and that the immunosuppressive drug will halt further destruction of the liver and hopefully achieve remission.  The liver can regenerate too, so fingers crossed  the cyclosporine will give good results.

Jo

[karen-b]

Hi Jo, Thank you for your reply. You have made me feel a little more positive about the cyclosporine. I was worried sick when I read the contras on NOAH.

[Jo CIMDA]

Hi

When a dog has an autoimmune disease it has to be treated aggressively. The immune system has to be almost knocked out in order to stop the destruction - you have to take away the aggressor for the body to be allowed to heal and return to normal function. 

Dose and duration of treatment is vitally important to the outcome because the drugs that are used need to be potent, so you only give as much as you need to do the job and  for as little time as possible, but the duration and weaning down process is usually 4-6 months.   Langford should know the best protocol for Myrtle. Most AI diseases are treated with immunosuppressive dose of prednisolone but this drug is hard on the liver and would not be advisable when treating Myrtle but thankfully there are other immunosuppressive drugs these days that can have a good effect and bring the disease into remission. 

For an AI disease to develop there has to be a genetic predisposition but then it has to be 'triggered', so from this time on avoid using any thing that might  trigger a relapse and because you don't know the genetic status of Myrtle's siblings then you should also limit as much as you can, any potential triggers eg., vaccines, preventative flea and worm treatment etc.

Fingers crossed!

Jo

[karen-b]

For an AI disease to develop there has to be a genetic predisposition but then it has to be 'triggered', so from this time on avoid using any thing that might  trigger a relapse and because you don't know the genetic status of Myrtle's siblings then you should also limit as much as you can, any potential triggers eg., vaccines, preventative flea and worm treatment etc.

Fingers crossed!

Jo

Thank you.
Both girls had only one puppy shot at 16 weeks, no lepto, no chemical preventives, we wormcount every 6 months, all raw fed, the pups were weaned onto raw. We did everything right, and they lead pretty much identical lives, so we find it really strange that Myrtle has developed this and Winnie hasn't. I am just glad we decided to have regular blood tests, and this was flagged up with hopefully enough time to either put it right, or mitigate any damage.
I have been racking my brains to think of any trigger that Myrtle encountered and Winnie didn't though I don't suppose we will ever really know.
I have contacted the families that their litter mates went to, forewarned is forearmed.

She has tolerated it so well, I'm actually worried that maybe she isn't getting enough! Still great appetite, a bit sick after the first dose, but fine since, firm poos.  How quickly would you see a reduction the ALT value if the drug is working. The vet wants to test after four weeks, but I'm leaning toward two.

[Jo CIMDA]

Hi

You couldn't have done any more than you have.   All pups in a litter will inherit a different mix  of genes from their mother and father, so it could be that the genes that your other two have inherited will not reach the threshold that would make them an 'affected'.  If they don't go on to develop an AI disease it is likely that they may just be 'carriers' .  It is such a complicated mode of inheritance, with multiple genes involved, that even the top professors do not understand it fully and this is why we don't have DNA tests for AI disease.   They thought when the canine genome was discovered that they would have DNA tests to complicated, polygenic diseases within 18 months (that was quoted to me by a Prof) but of course it is much more complicated than they first thought.  All you can do is to carry on keeping them as natural as possible.

If Myrtle is tolerating the drug well, then this is good news.  It can take a while for the liver enzymes to start reducing, and all dogs are different. As long as Myrtle doesn't get stressed by the vets then often an interim blood test is a good thing and it should indicate if things are going in the right direction, and if they are then you will get some peace from that.  You don't have to go to a specialist for that, your own vet can take the blood and liaise with the specialist.

Jo

[karen-b]

Hi, it's been a little while now, so I thought I'd update.
Myrtle seemed to be doing well on the cyclosporine, the ALT level was dropping steadily, and when it reached just over 200, the vet suggested reducing the daily dose to every other day and test again in 6 weeks. She is still having the Samylin.
We tested yesterday and it's gone up again to 640. To make things awkward, our regular vet is off for two weeks, so between us, the covering vet, nurse and me decided the best course of action would be to go back to a daily dose and talk with our vet when he returns.
I was really hoping this would have knocked out and reset things, like a defibrilator for the immune system.
What are peoples experience of this? Are liver issues like this fixable, or is it likely that she'll have to be on immune suppressants for life.
We've kind of kept her in a bubble, not wanting her to come into contact with any viruses, cuts and scratches. We walk in areas where there aren't many dogs, we are missing Agility, so she is missing out on mixing and playing with other dogs, though at least she has her sister Winnie and our other boy Bailey. Am I going to far?
If its a lifetime thing, we obviously want to give her the best quality of life and experiences, weighed against the need to reduce the risks of a compromised immune system. Because we have been giving her a cooked fresh diet, she is missing out on bones, and has developed a bit of plaque/tartar. She has had a couple of minor skin infections, and I'm told these are a typical side effect. I understand the meds hopefully prevent further damage to her liver, but at what cost in the future. I understand it reduces T cells, but don't they help fight potential cancer sells?
I am so worried, and feeling really deflated after things seemed to be going well.

[Jo CIMDA]

Hi

I am sorry that you feel so deflated.  Now that Myrtle has gone back on to a daily dose of cyclosporine, it will be interesting to see when you test again what effect it has had.  I don't have much experience of hepatic immune disease, as it is not one of the more common AI diseases, so I did some research and I shall quote from the book Clinical Immunology of the Dog and Cat by Michael J Day.  This is under the heading Immune mediated hepatic disease, chronic hepatitis in the dog.    In addition to the usual immunosuppresant drugs it mentions:

'Ursodeoxycholic acid (UDCA 15mg/kg every 24 hours) is a hydrophilic bile salt that is of benefit in stimulating bile flow in cholestasis and excluding naturally-occurring, toxic, hydrophobic bile acids.  However, it also has some immunomodulatory effect, at least in part through the inhibition of expression of MHC class II.  (note: these are the genes involved in AI disease)   

Hydrophobic bile acids accumulate in cholestasis and perpetuate hepatocyte membrane damage through their detergent action.  Oxidative free radicals released in inflammation are also involved in the perpetuation of chronic liver damage, and are the rational basis for the use of anti-oxidants in chronic liver disease.    Vitamins C and E, silymarin and s-adenosyl L-methionine (SAMe) have all been reported to be beneficial, although Vitamin C is contraindicated if hepatocyte damage is associated with copper accumulation because of an interaction with the copper, reducing it to a more toxic valency.'

Some breeds have copper associated hepatitis.

When your vet returns, it might be worth you discussing this quote with him and seeing if further supplements could be added to Myrtle's regimen.

Don't think about the reduction in T cells because if it wasn't for the immunosuppressant drugs Myrtle would be very poorly indeed.  I don't know the prognosis of immune mediated hepatic disease, and I don't have any anecdotal references that I can share either, but even though she is missing out on certain activities at the moment, as long as she has a quality to her life and is not very poorly then you are doing the right thing and I am hoping that she will achieve remission and she can get back to doing all those things that she loves.

Carry on doing what you are doing, and when your vet comes back you can discuss things like supplements and even changing to a different drug or perhaps introducing another immunosuppressant drug alongside the cyclosporine.

Jo

[karen-b]

Hi Jo,

Thank you so much for your reply.
Myrtle was on Destolit (Ursodeoxycholic acid) for a couple of months along side the Samylin and the Cyclavance. The biopsy didn't show any sign of copper storage disease, though I know that its just a small sample of the liver that is biopsied. Even so, we adopted that thought and fed her food with low copper, and bottled filtered water.
I'm just thinking now that maybe we should have kept her on the full dose till her ALT levels had been at a normal level for maybe a month. But then again, what to I know.

My new worry over the weekend is her skin break outs, she's had a few minor skin infections, which I know are a side effect, and we've managed to deal with with Peptivet.
On Saturday morning, we noticed another, but this is different. It's only come up over the last day or two. It looks like a boil about the size of a thumbnail,  and the surrounding skin his hard and swollen. The 'spot' itself is obviously very sore to touch, but isn't hampering her movement. I've clipped the area, and washed it with hibiscrub solution. I didnt know whether to try and express it, or leave well alone. It looks to me like it needs antibiotics, but I know that some antibiotics are contra'd against cyclosprine, and can cause renal failure.
I'm going to speak to the covering vet today, but in my regular vet's absence, I'm not sure he will know what to do.
Do you know if there are any topical antibacterial or antibiotics creams or that could be used?

Thank you again for taking the time to research and reply. x

[Catherine]

Is it possible to put a photo of it on the site? Whereabouts on her is it and is she trying to nibble it?

There is Fuciderm (Isaderm) but the sore/lump really needs to be identified first.

[karen-b]

Thank you Catherine.
I've tried to upload photos, but it says the file is too large. I'm at work, so cant used photobucket or anything like that.
I caught her licking around the area, but not the actual spot, it's just too sore.
She wont lie on it either, preferring to lie on her other side.
The image doesn't really show how swollen the area is around it.
We are going to the vet at 4.30 today, to hopefully try and identify it.
I can't wait for my regular vet to get back.

[Catherine]

Hopefully your vet will know. I have experienced various skin problems with my dogs, some when they were on steroids so I know how difficult it can be. Keeping her from even licking around the area and keeping it clean etc. is a problem and so some sort of medical head "cone" or body covering may be necessary. Is it on her trunk or leg or...?

[karen-b]

https://www.flickr.com/photos/194850470@N05/shares/17Eq02

I managed to set up Flickr on my phone.

[Catherine]

It is like an indentation but swollen around it. Did it happen suddenly? Has she any other ones? I think it could be a sort of pyoderma that has swollen for some reason, infection maybe? Is the swollen surrounding hard or squishy?

[karen-b]

Its not really an indentation, the pinkish area is the lump itself, with a little red mark in the middle, and the surrounding area is swollen and hard. It's difficult to show it properly on a 2d photo
I thought bite or sting at first, but I'm pretty sure its not.