Diabetes..?

Re: Diabetes..?

Stigen — Wed, 19 Mar 2014 12:54:05 GMT

[quote user="Martin Atkinson"]

[quote user="Stigen"] they sent me one journal that seemed to be more like a rant from a concerned vet who was writing about her discussion about diabetes with the owner. There was nothing about the initial exam,why the tests were done, or even the lab results. [/quote] Maybe a suggestion to them that you are reporting them to the RCVS for failing to keep adequate records may prove fruitful!!

Re. Laurence's comment on asking the client if they want to pay for further tests: I would suggest to the lab that they do the protein electrophoresis FOC as they cocked up the fructosamine test and could had catastrophically altered the outcome of your treatment protocol.

[/quote]I can`t really report them to the RCVS...I`m not practicing in th UK anymore, and we don`t have anything similar to it in Norway :)

I`m not sure if the lab will give me any flexibility on the 7€ owed to them,but will check.

Re: Diabetes..?

Andrew Kent — Mon, 17 Mar 2014 20:28:45 GMT

Worth asking about travel history as well, monoclonal gammopathies have been associated with some infectious diseases.

Re: Diabetes..?

Stigen — Mon, 17 Mar 2014 19:10:38 GMT

The reason for their initial encounter with the vets was that there was a small lump they wanted removed. The vet took some blood samples, and decided to do fructoseamine. I guess they might have found a slightly elevated glucose and then made that decision.
It is a 10 year old border collie mix.

I am seeing the dog back in a couple of days to recheck that the glucose level is remaining normal. I am certainly going to have a proper feel around this dog and see if anything stands out. I don`t know how far they would want to take the diagnostic process, but I know they`ll be devastated(and probably seek a 3rd. opinion) when I suggest it might be cancer...
I seriously doubt they would consider chemotheraphy...but the first challenge would be to actually find something on this dog. They failed to mention that lump to me last time I saw them...so I will certainly have a look at that, maybe consider an FNA.

Re: Diabetes..?

Laurence Webb — Mon, 17 Mar 2014 17:41:18 GMT

[quote user="Stigen"]

Total protein 105 g/l + 54-75

A/G-Quotient 0.23 . - 0.59-1.11

Albumin 18.5 % --- 47-59

alpha-Globulin 2.3 % - 9-15

beta-Globulin 5.1 % - 14-24

gamma-Globulin 74.1 % + 8-18

[/quote]So that makes Albumin 19.4g/l and Globilins 85.6g/l with a large gamma globulinaemia. I'd be thinking tumour, particularly a myeloma but lymphoma, granulomatous diseases etc possible. From internet reading some fructosamine assays are done on glycated albumin (so would be a little low in this instance) but others are done on any glycated amine, so the high globulins would cause the fructosamine elevation.

Has calcium been checked? Polydypsia caused by hypercalcaemia may have been the initial reason for blood testing.

I'd suggest the next step would be re-examination fo the dog to check all its lymph nodes, abdominal palpation and palpation of long bones for any signs of pain. Depending on findings aspirates and imaging checking ionised calcium would be appropriate.

Actually the next step is to try to get a better history - talk to the owners to find out why the blood tests were done at the other practice and demand comprehensive notes from the practice. Once you've done that explain to the owners the possible significance of the findings so far and see if they want to investigate further. If they were considering PTS rather that treatment of diabetes they may well not want to go to great lengths to get to the bottom of this either.

[quote user="Malcolm Ness"]???? Treat the dog, not the lab tests/if it isn't broken don't fix it.[/quote]2 independant high fructosamines, high total proteins and a protein electrophoresis would suggest that there is something amis with this dog rather than laboratory error but yes, it is for the owners to decide how far to persue this.

Re: Diabetes..?

mariette asselbergs — Mon, 17 Mar 2014 13:03:51 GMT

So can we get some more info about the dog? Breed, age, sex, neutered?, UK dog? weight/bcs? Do we think neoplasm possibility?

Hereditary something?

Mariette

Re: Diabetes..?

Stigen — Mon, 17 Mar 2014 09:30:41 GMT

So I did get the protein electrophoresis results today...and everything seems to be upside-down there;

Protein-electrophoresis:

Total protein 105 g/l + 54-75

A/G-Quotient 0.23 . - 0.59-1.11

Albumin 18.5 % --- 47-59

alpha-Globulin 2.3 % - 9-15

beta-Globulin 5.1 % - 14-24

gamma-Globulin 74.1 % + 8-18

Prevalent reasons for alteration of electrophoresis patterns:

hypoalbuminemia: e.g. protein-losing enteropathy or nephropathy,

hepatic disease or neoplasia.

polyclonal gammopathies:e.g. chronic inflammation, parasitosis, neo-

plasia, immune-mediated disorders

dog:frequently associated with ectoparasites or pyodermia (beta-and

gamma-fraction)

cat: frequently associated with FIP (gamma-fraction)

monoclonal gammopathies: e.g.multiple myeloma, lymphoma,

infrequently during infections

decreased gamma-globuline fraction:e.g.immuno suppression,

immuno deficiency

Not entirely sure where to go next. Probably ultrasound, but I`m not good enough to make many conclusion from that aparatus at the moment..

Re: Diabetes..?

Martin Atkinson — Fri, 14 Mar 2014 11:36:48 GMT

Re: Diabetes..?

Gillian Mostyn — Fri, 14 Mar 2014 08:34:11 GMT

Fair enough- just seems very odd!

As others have said, I would do nothing apart from checking some urine samples over the next few weeks.

Re: Diabetes..?

Laurence Webb — Thu, 13 Mar 2014 22:59:15 GMT

[quote user="Stigen"]I asked the to do a protein electrophoresis,including acute phase proteins...hopefully something useful will come from that...I still have`nt talked to the owners. [/quote]

Is the lab doing it free of charge? I'd talk to the owner before racking up increased fees for them (or the boss to see if he wants to indulge your concern out of his/her pocket!)

Re: Diabetes..?

Malcolm Ness — Thu, 13 Mar 2014 22:38:57 GMT

[quote user="Stigen"]the dog is perfectly fine! [/quote]

[quote user="Stigen"]Any suggestions[/quote]

???? Treat the dog, not the lab tests/if it isn't broken don't fix it.

Re: Diabetes..?

Stigen — Thu, 13 Mar 2014 22:21:21 GMT

I know I am working at a disadvantage without the history, but everything was done in the right form. the clinic was notified, and I asked them to send me the history. they sent me one journal that seemed to be more like a rant from a concerned vet who was writing about her discussion about diabetes with the owner. There was nothing about the initial exam,why the tests were done, or even the lab results. They told me this was all the history they have. I guess I could keep nagging...but hoping to be able to find something on my own too. I talked to the lab. They had problems believing their own fructoseamine result so they tested it again today. The new results has now gone from 1100 to 550 , which is better,but still high.
I asked the to do a protein electrophoresis,including acute phase proteins...hopefully something useful will come from that...I still have`nt talked to the owners.

Re: Diabetes..?

Gillian Mostyn — Thu, 13 Mar 2014 22:02:11 GMT

[quote user="Stigen"]I did not get a proper clinical history from the other clinic.[/quote]

Why? We wouldn't give a second opinion without notifying the original vet, and getting a clinical history, as per our CofPC:

Taking over a colleague’s case

5.4 Although both veterinary surgeon and client have freedom of choice, in the interests of the welfare of the animals involved, a veterinary surgeon should not knowingly take over a colleague's case without informing the colleague in question and obtaining a clinical history.

5.5 When an animal is initially presented, a veterinary surgeon should ask whether the animal is already receiving veterinary attention or treatment and, if so, when it was last seen; then, contact the original veterinary surgeon for a case history. It should be made clear to the client that this is necessary in the interests of the patient. If the client refuses to provide information, the case should be declined.

The history will certainly be relevant in this case as no one does routine fructosamine tests! There MUST have been something in the history or examination that prompted it - and you can't really give a second opinion without knowing what it was! You never know- it might help to explain the strange blood results

Re: Diabetes..?

Martin Atkinson — Thu, 13 Mar 2014 19:25:35 GMT

[quote user="Stigen"]They were at a diffewrent clinic that measured fructoseamine and found it to be very high. They were told that the dog has diabetes and needs treatment. [/quote] I can't imagine any circumstances where a vet would randomly perform fructosamine without a suspicious hyperglycaemia! You need a proper history - your diagnosis is potentially compromised without. Ditto reservations on how the blood was stored prior to testing for glucose and although I'll admit the stuff about fructosamine being potentially high in hyperalbuminaemia was new to me, I agree that an albumin and globulin count is necessary and protein electropheresis would be useful.

Re: Diabetes..?

Laurence Webb — Wed, 12 Mar 2014 12:56:25 GMT

As Andrew said, fructosamine is effectively albumin with some sugar attached. It will go up if the level of glucose in the blood increases or if the albumin increases.

Given the hyperproteinaemia I would recheck the glucose and protein levels including albumin. Depending if it is albumin or globulin increased I would check out they thyroid or run serum protein electrophoresis in case there is a myeloma.

Re: Diabetes..?

Andrew Kent — Wed, 12 Mar 2014 12:35:46 GMT

Dysproteinemias do affect fructosamine independently of blood glucose, so there are correction formulas to try to account for this, but they are variably reliable. Fructosamine also relies on a normal half life of albumin so if you have conditions that extend the albumin half life (hypothyroidism is the classic for this) then fructosamine can increase (though I think normally mildly).

The correction formula for canine fructosamine that is talked about is:

Corrected fructosamine = observed fructosamine x (median albumin in healthy dogs / observed albumin).

So the dog doesn't look and doesn't sound diabetic, so I would look for other things - why is the dog hyperproteinaemic? and could it be hypothyroid? Might also be worth rechecking the electrolytes as borderline hyperkalaemic.

Andy

Re: Diabetes..?

Yantha Smyth — Wed, 12 Mar 2014 11:50:27 GMT

That does sound strange. Strange also to check a fructosamine level in a normoglycaemic dog with no compatible symptoms. I wonder if it could be in any way related to the very high TP levels? I can't remember but is it bound to albumin?

Re: Diabetes..?

Nicola Lawlor — Wed, 12 Mar 2014 11:17:25 GMT

How soon was the sample processed for glucose and what anti-coag did you use? Is there a chance this glucose was high at the time of sampling but due to sample storage the glucose has decreased over time. This may explain the anomaly between the fructosamine and glucose readings. Perhaps worth a spot check on a glucometer if there is any doubt about that, or a urine sample also likely to be pretty revealing too as already suggested.

Re: Diabetes..?

Thomas Johnson — Wed, 12 Mar 2014 11:02:10 GMT

It does seem unlikely that the dog is diabetic if it is showing no clinical signs, but that fructosamine is very high. Would it be useful to do a blood glucose curve? Or get the owners to collect urine every morning for a week?