Dealing with PLN after surgery

RE: Dealing with PLN after surgery

Andrew Kent — Tue, 28 Feb 2017 18:08:45 GMT

Yup - sounds like it was probably beyond help by the time it was with you and always tricky taking on a case that has had other treatment elsewhere, especially with limited history.

Thanks for letting us know the outcome!

Andy

RE: Dealing with PLN after surgery

Anthony Dennison — Tue, 28 Feb 2017 17:59:41 GMT

PTS this evening unfortunately. Shame that I inherited the case halfway through, we threw everything we had at her but looks like it was too late by that point.

RE: Dealing with PLN after surgery

Andrew Kent — Tue, 28 Feb 2017 17:54:14 GMT

It certainly doesn't sound good - the failure to see any improvement of the azotaemia and the probable nephrotic syndrome are both worrying findings.

Do let us know what the owners decide to do.

Andy

RE: Dealing with PLN after surgery

Anthony Dennison — Tue, 28 Feb 2017 16:25:57 GMT

BG normal. Dog is vaccinated, seemed to miss about 18 months then just another booster came up. Glucose was normal on bloods and always has been.

Dog is looking really crap atm, has pitting oedema ventrally and all the way up her legs, Albumin has dropped back down to 14, PCV dropped from 20% to 17.1%, no improvement in the azotaemia (Creatinine 532 this afternoon). She's also started regurgitating anything we get down her, so feeding tubes are out of the question at the moment.

Inactive urine sediment, dog has been on antibiotics since Saturday night so not much point in doing a urine culture.

Unsure about toxicity, that would be the next step. We're having conversations with the owner this afternoon about prognosis and see what they are wanting to do.

Thanks for all the advice and help Andy, much appreciated.

RE: Dealing with PLN after surgery

Andrew Kent — Tue, 28 Feb 2017 15:36:55 GMT

Hi Anthony,

Is the blood glucose normal? Looks like there was glucosuria and ketonuria initially so would make sure we have excluded a hyperglycaemic cause (i.e. DKA).

Otherwise supports severe tubular disease - any possibility of leptospirosis, toxicity (eg Jerky treats), pyelonephritis etc?

Andy

RE: Dealing with PLN after surgery

Anthony Dennison — Tue, 28 Feb 2017 13:31:00 GMT

Thanks Andrew. Finally got the notes from the original vets, has had long term 'heat suppresion' using a drug called promone, but was given delvosterone December 2016 as the last one.

History from prev vet is pretty sketchy, limited notes and all hand written in the standard vet scrawl! Initially presented 19/2, suspect pancreatitis, it says 'TP+', which I'm not sure what that means. Still 'TP+' on 20/2, I think bloods were taken on this day, we've got the printout of them dated 21/2, then they are written in the notes on 23/2, once again '?pancreatitis?, USG 1.025, prot++, gluc+, ketones+, conscious xray taken, 'quality poor (wriggling)'

24/2: '?pyometra?' had xrays 'NAD', abdo scan which showed 'large gall bladder only', went to exlap, 'enlarged cystic mucus filled womb => SPAY'

'25/2: post-op check, again handwritten notes hard to read here, 'V+, bit spaced out'.

BP today with us was 160mmHg, USG 1.010, Gluc++, pH 6.5, UPC >9.76 still.

Unfortunately I don't think the prognosis is looking good.

RE: Dealing with PLN after surgery

Andrew Kent — Tue, 28 Feb 2017 12:01:41 GMT

Hi Anthony,

I would not biopsy right now - this is only likely to be useful in a clinically stable dog and it would be difficult to interpret otherwise. Renal biopsies should be assessed through the renal standardisation scheme, require careful sampling/submission and tend to take a month to get results so this dog will be dead or better before you benefit from the biopsy.

I agree things sound pretty grim with this dog but it's difficult to know how much is chronic (ie a PLN) and how much is acute (due to the pyo/surgery/sepsis). So I think reviewing what your bloods are doing and your urine output sounds sensible.

Unfortunately this dog is quite severely azotaemic which makes treatment of the PLN difficult as we will drop the glomerular pressures with those drugs and could worsen the azotaemia. The flip side of that in this dog is that the proteins are concerningly low - although this could be a combination of things (PLN, inflammation, inappetence).

If you are seeing progression of the azotaemia then I agree that the prognosis for this dog may be quite poor.

Andy

RE: Dealing with PLN after surgery

Anthony Dennison — Tue, 28 Feb 2017 10:24:48 GMT

[quote user="Andrew Kent"]Generally I only use immunosuppressant medications in dogs who have had a renal biopsy and there is a suggestion on that of likely immune-mediated aetiology, or if biopsy is declined as a last ditch effort if things are going badly.[/quote]

Would you recommend a renal biopsy at the moment, considering that clinically she's not looking great?

RE: Dealing with PLN after surgery

Anthony Dennison — Tue, 28 Feb 2017 09:49:51 GMT

[quote user="Andrew Kent"]So the first line in most cases will always be 'conventional' therapy - ACEi/ARB, fatty acid supplementation, dietary modification, anti-thrombotics.[/quote]

Thanks for that link, I'll read through that later.

Fatty accid supplementation - would Viacutan be ok for this or would you recommend anything else? Dog is pretty nauseous at the moment, currently on metoclop BID but I'm considering switching it to a CRI alongside the daily maropitant.

Annoyingly as the dog presented 10.30pm on a Sat night with a haemoabdomen I didn't think quickly enough to catheterise her under the GA for the ex-lap to monitor urine output, and now I'm supervising it remotely from my branch so haven't seen the dog since Sunday, relying on pestering my colleagues for all the information and then coming up with plans!

Kidneys on ultrasound scan yesterday are around 6cm long so not enlarged, but the cortex does look thickened.

Plan is to get a urine sample today to recheck UPC and send off to Idexx for culture. How long could this go on for before we need to make a decision re: prognosis? She's looking pretty awful according to the vets that are with her.

RE: Dealing with PLN after surgery

Andrew Kent — Tue, 28 Feb 2017 09:29:13 GMT

Hi Anthony,

Tricky case!

Generally I only use immunosuppressant medications in dogs who have had a renal biopsy and there is a suggestion on that of likely immune-mediated aetiology, or if biopsy is declined as a last ditch effort if things are going badly.

So the first line in most cases will always be 'conventional' therapy - ACEi/ARB, fatty acid supplementation, dietary modification, anti-thrombotics.

In your case the recent inflammatory disease also complicates matters and I would definitely wait and see what happens with the dog and UPC before considering further meds.

There is a useful JVIM edition from a few years ago that covers lots of this including what treatments are useful in dogs without a histopathological diagnosis:

http://onlinelibrary.wiley.com/doi/10.1111/jvim.2013.27.issue-s1/issuetoc

Andy

RE: Dealing with PLN after surgery

Nicola Cole — Mon, 27 Feb 2017 22:13:50 GMT

The only case I've seen of PLN was maintained on just benazepril, amlodipine (and I think initially flouroquinolones but not 100% on this) with no immunosuppressive drugs. The dog was referred for imaging after presented with polydipsia, massively swollen abdomen (tapped) and initial bloods showed very low albumin (it was a good few years ago and we didn't have a scanner so sent to see if an underlying cause to the PLN present )-came back from referral on the above drugs and lived at least another 2 years. n=1 so I'm sure there'll be more useful comments along soon!