HAC, Vetoryl and hypoalbumenaemia and PLN

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

ashvetenry — Fri, 14 Dec 2012 18:27:10 GMT

The thought is that the protein being filtered damages the kidneys further- therefore reducing levels reduces damage. I was advised this by one of the Small Animal internal medicine specialists at Idexx, and also in a previouis case I referred to Jane Eastwood, an RCVS SA medicine specialist at Willows Referral Centre. I am hestitating on the ACEi because of the Vetoryl datasheet statment about risk of suddne death when used concurrnelty with ACEi- felt if levels continue to fall then the potential benefits become much greater than the risks....

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

Kate Richardson — Fri, 14 Dec 2012 18:06:46 GMT

I would have thought you would want a higher protein diet rather than a low protein diet?? I have usually been advised to add protein in form of egg whites or cottage cheese in protein loss cases alongside regular monitoring of blood protein levels.- have ideas changed? I would start an ACE inhibitor now with UPCr at that level. My cases have shown improvements in UPCr level (ie reduction) with addition of an ACE-I. Albumin can get pretty low if developing slowly however before it causes any clinical problems such as oedema/effusion.

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

ashvetenry — Fri, 14 Dec 2012 17:39:13 GMT

Urine Pr:Cr ratio 3.3, no active sediment. BAST equivocla pre = 31.8 and post 44.7, with TBIL=1.4

Lab advises these results typical for a HAC dog but would expect would normalise when well controlled (tho no studies ever done to demonstrate this)

Have moved him onto a lowe rprotein diet (KD), started antithrombotci dose aspirin (0.5mg/kg SID) and started on Gomega- if ratio continues to go up and/or hypoalbumenaenia progresses I will risk starting an ACEi too.

Anyone have any other thoughts?

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

ashvetenry — Mon, 10 Dec 2012 13:16:08 GMT

BP = 140 (normal) awaiting Urine pr:cr ratio and deposit exam results + BAS results

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

ashvetenry — Fri, 07 Dec 2012 11:50:45 GMT

Thanks Kate, dog is on Monday- hopefully with a urine sample and for BP measurement and BAST.

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

Kate Richardson — Thu, 06 Dec 2012 18:02:28 GMT

I have had a few cases of HAC where have had good clinical control backed up by acth stim results, but have had persistent proteinuria. Ruled out UTIs etc. Haven't had one that developed significant hypoalbuminaemia though. Always suspected glomerular disease induced by the protein loss/other factors that developed before diagnosis and control of the HAC was achieved but only a theory, no scientific evidence to back this up.

Definitely echo measuring urine protein:creatinine ratios as you will have an objective marker for monitoring (rather than the number of + on a dipstick) with a concurrent sediment exam +/- culture. And +1 for checking BP as well

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

ashvetenry — Tue, 04 Dec 2012 12:01:10 GMT

Pre = 96, post = 121

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

Andrew Kent — Tue, 04 Dec 2012 11:45:01 GMT

A couple of thoughts: have you measured blood pressure? If the dog is persistently hypertensive then this could be a reason for persistence of the proteinuria. Can you post the figures for the most recent ACTH results? Andy

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

ashvetenry — Mon, 03 Dec 2012 23:18:03 GMT

[quote user="Christopher Saul"]

Urine sticks are at best semi-quantative; I would always advise a urine protein:Creatinine ratio from an external reference lab before calling it true proteinuria; it's also important to get a urine cytology to rule out a reactive sediment ( which can falsely elevate this ratio)

[/quote]

I will do that thank you- if his hypoalbumenaemia is not due to urinary loss however I cannot see a likely cause. His appetite is good, he is maintaining a constant weight and his stool is normal (ie PLE unlikely). ALKP and ALT are normal (ALT always has been), CHOL is just very slightly raised, as is UREA (7 if I recall) but CREA low normal. He seems too well to have hepatic insufficiency and his mentation has always been normal- hepatic encephalopathy seems very unlikely. I suppose a BAS test would still be a good idea also though?

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

Christopher Saul — Mon, 03 Dec 2012 21:12:54 GMT

[quote user="ashvetenry"]urine now has 3+ protein, with an SG of 1.050[/quote]

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

james herriot lied — Mon, 03 Dec 2012 18:44:02 GMT

Slightly daft question, but are you certain that the protein in the urine is albumin? Far and away the most likely, but perhaps worth checking.

I'm assuming liver function is showing OK also - any chance that previous symptoms could be linked to a hepatic encephalopathy? Again, unlikely, but possible. If you had a declining liver function in the face of vetoryl treatment, there might be issues with clearance.

I've had a patient on ACEi and vetoryl before - was monitored for K, but never actually seemed to be an issue. Doses of both were low in the range.

Re: HAC, Vetoryl and hypoalbumenaemia and PLN

Martin Atkinson — Mon, 03 Dec 2012 16:56:09 GMT

May be a case for the old fashioned method - mitotane.