Use of diuretics with ascites due to PLE

RE: Use of diuretics with ascites due to PLE

Andrew Kent — Thu, 25 Jul 2019 09:16:56 GMT

[quote user="Aine Seavers"]I would still like an U/S of the HEART of this dog.[/quote]

Agree cardiac disease would be an important differential for ascites although the liver enzymes make me favour a hepatic cause.

[quote user="roger wilkinson"]

Anybody tried stem cells for PLE (as per abstracts below)?

there were 3 hypoalbuminaemic dogs in that small series and in those dogs mean alb increased from 21 to 31 after a single iv infusion of stem cells. No long term follow up reported.

[/quote]

Hadn't considered this but clearly an interesting area. And in those reports this was stem cells from a donor rather than from the dogs so wouldn't even need to harvest...

[quote user="Kate Richardson"]

[quote user="Thomas Johnson"]

[quote user="David Mills"]There is a theory that draining ascites will cause hypoproteinaemia, but I've never really understood that or seen it. It does seem to improve the dogs demeanour markedly though. [/quote]

I've often wondered about this as well, surely the protein in the ascitic fluid is already 'lost' from circulation, and I assume that draining off the fluid doesn't significantly increase the development of further fluid.

[/quote]

Agree, had one little dog with restrictive pericarditis (I think from memory) with ascites and we used to drain her abdomen every 1-2 weeks. Used to insert a large bore catheter and then she would just stand there until the flow stopped, then would literally bounce of the table and run around happily for a week or so until the fluid started to build up again, then her owner would bring her in again. Drained anything up to a litre often, on 1 or 2 occasions more. Info I had at the time was there was a risk of circulatory collapse, but it never happened.

[/quote]

Yeah we sometimes do resort to drainage if everything else fails although I have seen some dogs with severe chronic wasting due to very frequent drainage - although guess with PLE patients many of them can lose weight for other reasons.

In general we tend to see a reasonable response initially to medical therapy for portal hypertension so would favour that first - and often if the ascites is becoming unresponsive to medical treatment the dogs are fairly unwell with the primary liver disease at that point but there are always exceptions.

Definitely an option in the right cases...

Andy

RE: Use of diuretics with ascites due to PLE

Roger Wilkinson — Wed, 24 Jul 2019 08:52:00 GMT

...also an interesting issue! Apparently in people R CHF is one of commonest causes of PLE. There's a nice article of a PLE case cured by heart transplant. And since restrictive pericarditis is a consideration they don't always have obvious chamber dilation

RE: Use of diuretics with ascites due to PLE

Aine Seavers — Sun, 21 Jul 2019 01:16:35 GMT

Agree with all re drainage-we use extra large bore catheters but what ever works. I would still like an U/S of the HEART of this dog.

RE: Use of diuretics with ascites due to PLE

Sarah Keir — Sat, 20 Jul 2019 11:44:08 GMT

I have used cow rumen trochars too - good way to get a large amount off relatively quickly then a little suture to close, done under local only.

RE: Use of diuretics with ascites due to PLE

Kate Richardson — Fri, 19 Jul 2019 14:50:19 GMT

[quote user="Thomas Johnson"]

[/quote]

RE: Use of diuretics with ascites due to PLE

Thomas Johnson — Fri, 19 Jul 2019 12:05:38 GMT

RE: Use of diuretics with ascites due to PLE

Anthony Dennison — Thu, 18 Jul 2019 17:04:51 GMT

[quote user="Anthony Dennison"]I took about 60ml off on Friday - completely clear, SG 1.015. Just spoken to the owner and fluid leaked out from the centesis site for the following 48 hours until pressure had reduced to the point it wasn't being forced out. [/quote]

Dog kind of did this by himself last week after I didn't want to take too much off... dribbled until the pressure dropped and the hole sealed over!

RE: Use of diuretics with ascites due to PLE

Roger Wilkinson — Thu, 18 Jul 2019 16:51:19 GMT

That's an interesting issue. I've also seen ascites drained repeatedly in canine patients with tense ascites (usually either R CHF e.g. with PAH as per David or portal hypertension due to chronic liver disease). Plenty of theoretical warnings against this in the literature. In people the big issue associated with high volume paracentesis appears to be paracentesis-induced circulatory dysfunction leading to faster reaccumulation of ascites, hyponatremia, renal impairment, and shorter survival. For that reason it seems that giving IV albumin is mandatory (in human medicine). But obviously that's not so straightforward for us.... And maybe paracentesis-induced cardiovascular dysfunction isn't such a problem for dogs???

RE: Use of diuretics with ascites due to PLE

David Mills — Thu, 18 Jul 2019 14:57:32 GMT

I remember managing a dog with ascites due to pulmonary hypertension that we used to drain every few months. Small stab incision and poke a survical suction tip into the abdomen, normally 2 to 3L out in 10 minutes.

There is a theory that draining ascites will cause hypoproteinaemia, but I've never really understood that or seen it. It does seem to improve the dogs demeanour markedly though.

RE: Use of diuretics with ascites due to PLE

Anthony Dennison — Thu, 18 Jul 2019 10:26:21 GMT

Thanks Andy, will see how we get on.

RE: Use of diuretics with ascites due to PLE

Andrew Kent — Wed, 17 Jul 2019 13:55:02 GMT

Hi Anthony,

[quote user="Anthony Dennison"] I wonder if there was initially severe IBD and PLE (Albumin was under 15 2 years ago) but then this is a secondary complication, possibly from chronic steroid use or the other things we've tried?[/quote]

Unusual to see it directly associated with chronic inflammatory gut disease - most commonly a sequel to chronic hepatitis so could be unrelated.

[quote user="Anthony Dennison"]I've just been looking at papers to try and look for treatment options, but there doesn't seem to be much effective work out there. He's on a low dose of prednisolone at the moment so I'll look at tapering that off and stopping it, spironolactone has been restarted. BAST seems to be the next step diagnostically?[/quote]

Portal hypertension with ascites can, unfortunately, have a pretty grim prognosis in many cases. Often that depends on the underlying cause so, if the fluid can be reduced, liver biopsy is worth considering.

I tend to start with spironolactone alone as there is some experimental evidence suggesting anti-fibrotic activity. The same may be true with telmisartan but that would be a less common choice in this setting.

Many dogs will have a good response to spironolactone initially so hopefully that will be the case here.

Andy

RE: Use of diuretics with ascites due to PLE

Anthony Dennison — Mon, 15 Jul 2019 11:49:31 GMT

[quote user="Andrew Kent"]have you analysed the fluid?[/quote]

I took about 60ml off on Friday - completely clear, SG 1.015. Just spoken to the owner and fluid leaked out from the centesis site for the following 48 hours until pressure had reduced to the point it wasn't being forced out.

RE: Use of diuretics with ascites due to PLE

Anthony Dennison — Mon, 15 Jul 2019 11:03:11 GMT

[quote user="Andrew Kent"]

Hi Anthony

it would be unusual to see ascites with an albumin of 17 (usually has to be below 15) although there are some exceptions.

Also the ALT is higher than the ALP which would be atypical for just a steroid hepatopathy. I would worry the ascites may be due to portal hypertension from liver disease.

have you analysed the fluid?

Andy

[/quote]

Hi Andy,

Now you've mentioned portal hypertension, it all makes sense with hindsight! There definitely was thickened intestines initially and he definitely did improve on treatment initially but has then since deteriorated. I wonder if there was initially severe IBD and PLE (Albumin was under 15 2 years ago) but then this is a secondary complication, possibly from chronic steroid use or the other things we've tried?

I've just been looking at papers to try and look for treatment options, but there doesn't seem to be much effective work out there. He's on a low dose of prednisolone at the moment so I'll look at tapering that off and stopping it, spironolactone has been restarted. BAST seems to be the next step diagnostically?

Given how chronic everything is there is obviously some long term RAAS activation. Would ACE inhibitors be of any use - could possible use Cardalis off licence as a single tablet for both benazepril and spironolactone. I've read about beta blockers too but they don't seem to be particularly effective in dogs - has anyone had any success using these?

RE: Use of diuretics with ascites due to PLE

Roger Wilkinson — Sat, 13 Jul 2019 18:44:11 GMT

Anybody tried stem cells for PLE (as per abstracts below)?

there were 3 hypoalbuminaemic dogs in that small series and in those dogs mean alb increased from 21 to 31 after a single iv infusion of stem cells. No long term follow up reported.

It's technically easy enough to do if you thought circs justify and owners aware of the uncertainty involved. For example if you were considering liver biopsy then could harvest fat under same GA. Culture takes 2-3 weeks and reintroduce them via IV infusion.

might be effective for either IBD or chronic hepatopathy:)

best wishes

Roger

Vet J. 2015 Dec;206(3):391-7. doi: 10.1016/j.tvjl.2015.07.023. Epub 2015 Jul 23.
Safety and efficacy of allogeneic adipose tissue-derived mesenchymal stem cells for treatment of dogs with inflammatory bowel disease: Endoscopic and histological outcomes.
Pérez-Merino EM1, Usón-Casaús JM2, Duque-Carrasco J3, Zaragoza-Bayle C2, Mariñas-Pardo L4, Hermida-Prieto M4, Vilafranca-Compte M5, Barrera-Chacón R2, Gualtieri M6.
Author information
Abstract
Systemic administration of mesenchymal stem cells (MSCs) has been shown to be safe and efficacious in humans with Crohn's disease. The aim of this study was to evaluate the safety of an intravenous (IV) infusion of adipose tissue-derived mesenchymal stem cells (ASCs) and to assess macroscopic and histological effects in the digestive tract of dogs with inflammatory bowel disease (IBD). Eleven dogs with confirmed IBD received a single ASC infusion (2 × 10(6) cells/kg bodyweight). Full digestive endoscopic evaluation was performed pre-treatment and between 90 and 120 days post-treatment with mucosal changes being assessed using a fit-for-purpose endoscopic scale. Endoscopic biopsies from each digestive section were evaluated histologically according to the World Small Animal Veterinary Association (WSAVA) Gastrointestinal Standardization Group criteria. The pre- and post-treatment canine IBD endoscopic index (CIBDEI) and histological score (HS) were calculated and compared using the Wilcoxon test. Remission was defined as a reduction of >75% of the CIBDEI and HS compared with pre-treatment. No acute reactions to ASC infusion or side effects were reported in any dog. Significant differences between pre- and post-treatment were found in both the CIBDEI (P = 0.004) and HS (P = 0.004). Endoscopic remission occurred in 4/11 dogs with the remaining dogs showing decreased CIBDEI (44.8% to 73.3%). Histological remission was not achieved in any dog, with an average reduction of the pre-treatment HS of 27.2%. In conclusion, a single IV infusion of allogeneic ASCs improved gastrointestinal lesions as assessed macroscopically and slightly reduced gastrointestinal inflammation as evaluated by histopathology in dogs with IBD.

Vet J. 2015 Dec;206(3):385-90. doi: 10.1016/j.tvjl.2015.08.003. Epub 2015 Aug 7.
Safety and efficacy of allogeneic adipose tissue-derived mesenchymal stem cells for treatment of dogs with inflammatory bowel disease: Clinical and laboratory outcomes.
Pérez-Merino EM1, Usón-Casaús JM2, Zaragoza-Bayle C2, Duque-Carrasco J3, Mariñas-Pardo L4, Hermida-Prieto M4, Barrera-Chacón R2, Gualtieri M5.
Author information
Abstract
Mesenchymal stem cells (MSCs) have shown immunomodulatory and anti-inflammatory effects in experimental colitis, and promising clinical results have been obtained in humans with Crohn's disease and ulcerative colitis. The aim of this study was to determine the safety and feasibility of adipose tissue-derived MSC (ASC) therapy in dogs with inflammatory bowel disease (IBD). Eleven dogs with confirmed IBD received one ASC intravascular (IV) infusion (2 × 10(6) cells/kg bodyweight). The outcome measures were clinical response based on percentage reduction of the validated Clinical Inflammatory Bowel Disease Activity Index (CIBDAI) and Canine Chronic Enteropathy Clinical Activity Index (CCECAI), as well as normalisation of C-reactive protein (CRP), albumin, folate and cobalamin serum concentrations at day 42 post-treatment. The Wilcoxon test was used to compare variables before and after treatment. No acute reaction to ASC infusion and no side effects were reported during follow-up in any dog. Six weeks post-treatment, the CIBDAI and CCECAI decreased significantly and albumin, cobalamin and folate concentrations increased substantially. Differences in CRP concentrations pre- and post-treatment were not significant (P = 0.050). Clinical remission (defined by a reduction of initial CIBDAI and CCECAI >75%) occurred in 9/11 dogs at day 42. The two remaining dogs showed a partial response with reduction percentages of 69.2% and 71.4%. In conclusion, a single IV infusion of allogeneic ASCs was well tolerated and appeared to produce clinical benefits in dogs with severe IBD.

RE: Use of diuretics with ascites due to PLE

Andrew Kent — Sat, 13 Jul 2019 13:56:15 GMT

Hi Anthony

it would be unusual to see ascites with an albumin of 17 (usually has to be below 15) although there are some exceptions.

Also the ALT is higher than the ALP which would be atypical for just a steroid hepatopathy. I would worry the ascites may be due to portal hypertension from liver disease.

have you analysed the fluid?

Andy

RE: Use of diuretics with ascites due to PLE

Anthony Dennison — Sat, 13 Jul 2019 12:26:05 GMT

Bloods taken yesterday:

Test Result Alert Units Reference Range

*Red cells 6.17 10^12/L 5.39 - 8.70

Full Blood Count
*Haemoglobin 13.8 g/dL 13.4 - 20.7
*Hct 0.423 l/L 0.383 - 0.565
*MCV 68.6 fL 59.0 - 76.0
*MCH 22.4 pg 21.9 - 26.1
*MCHC 32.6 g/dL 32.6 - 39.2
*Absolute retic. count 96.9 10^9/L <= 110.0

*Reticulocyte 24.4 pg 22.3 - 29.6
Haemoglobin
*White Cells 24.4 High 10^9/L 4.9 - 17.6
*Neutrophils (Absolute) 20.25 High 10^9/L 2.94 - 12.67
*Neutrophils 83 %
*Lymphocytes (Absolute) 2.20 10^9/L 1.06 - 4.95
*Lymphocytes 9 %
*Monocytes (Absolute) 1.71 High 10^9/L 0.13 - 1.15

*Monocytes 7 %
*Eosinophils (Absolute) 0.24 10^9/L 0.07 - 1.49
*Eosinophils 1 %
*Platelet count 796 High 10^9/L 143 - 448
*Analyser ID Results generated by SYSMEX XT2000
(67683)

*Morphological No morphological abnormalities detected
Assessment : in red blood cells and there is no
increase in polychromasia.
No abnormal white cells seen.
Mature neutrophilia.
Blood film suggests platelet numbers are
increased.
Platelet clumps are seen. Platelet
count should be considered the minimum
value.

347845904	1	Catalyst DX	BUN				0.0-0.0
347845901	2	Catalyst_Dx	ALB	=	17	g/L	22.0-39.0
347845894	3	Catalyst_Dx	ALB/GLOB	=	0.6
347845895	4	Catalyst_Dx	ALKP	=	103	U/L	23.0-212.0
347845892	5	Catalyst_Dx	ALT	=	508	U/L	10.0-125.0
347845891	6	Catalyst_Dx	AMYL	=	1055	U/L	500.0-1500.0
347845896	7	Catalyst_Dx	BUN/CREA	=	16
347845907	8	Catalyst_Dx	CA	=	1.97	mmol/L	1.98-3.0
347845906	9	Catalyst_Dx	CHOL	=	2.16	mmol/L	2.84-8.26
347845909	10	Catalyst_Dx	Cl	=	116	mmol/L	109.0-122.0
347845898	11	Catalyst_Dx	CREA	=	69	Î¼mol/L	44.0-159.0
347845899	12	Catalyst_Dx	GGT	=	3	U/L	0.0-11.0
347845903	13	Catalyst_Dx	GLOB	=	28	g/L	25.0-45.0
347845897	14	Catalyst_Dx	GLU	=	5.94	mmol/L	3.89-7.95
347845910	15	Catalyst_Dx	K	=	3.6	mmol/L	3.5-5.8
347845893	16	Catalyst_Dx	LIPA	=	306	U/L	200.0-1800.0
347845908	17	Catalyst_Dx	Na	=	150	mmol/L	144.0-160.0
347845911	18	Catalyst_Dx	Na/K	=	42
347845913	19	Catalyst_Dx	Osm Calc	=	296	mmol/kg
347845902	20	Catalyst_Dx	PHOS	=	1.05	mmol/L	0.81-2.2
347845900	21	Catalyst_Dx	TBIL	<	< 2	Î¼mol/L	0.0-15.0
347845905	22	Catalyst_Dx	TP	=	45	g/L	52.0-82.0
347845912	23	Catalyst_Dx	UREA	=	4.7	mmol/L	2.5-9.6

Owner had found an iron supplementation online but on Thursday the dog started passing dark, frank blood from his rectum. Couldn't feel any polyps at all, so wondered whether the supplement could be causing local irritation. Still really hypoproteinaemic. Ultrasound scan was very difficult due to the amount of ascites present. Intestines appeared normal thickness, couldn't clearly visualise the liver because it was quite small and hidden right under the ribcage due to the ascites, but no nodules seen on it.

RE: Use of diuretics with ascites due to PLE

Anthony Dennison — Tue, 02 Jul 2019 09:59:47 GMT

[quote user="Aine Seavers"]The age of this dog is not clear[/quote]

Dog is now 8 years old

[quote user="Aine Seavers"]U/S of heart and/or intestines.[/quote]

Did do as part of the original work up and intestines were so thickened (1.2cm in places if I remember0

RE: Use of diuretics with ascites due to PLE

Aine Seavers — Tue, 02 Jul 2019 00:17:35 GMT

Just an additional thought-if doing bloods etc, can you get an U/S of heart and/or intestines. The age of this dog is not clear so always good to keep stand alone issues in mind and not get tunnel vision.

Glad to hear the food is cooked as less allergenic if cooked and less risk of infection when on preds and compromised intestinal barrier.

Whilst I like z/d for my derm cases, I still find I/D far better for malabsorptive cases so consider that as a plan D if begins to have issues with diet he is now on.

Interesting paper on the negative effect on B vit from probiotics-maybe include that in your bloods-not sure if you need special handling there-here vial transported wrapped in tinfoil etc and analysed very quickly.

Here we use the Extreme Krause Muzzles-an open boxed plastic muzzle dogs can pant and drink and walk in but harder to snatch food etc. I wish like the in-clinic use muzzles they came in attractive colours and some bling so that the visual narrative on the muzzle changed and it looked part of the 'clothing' range available for dogs. We have fancy leads,collars, harness, boots, hats, coats, in a dazzling array-it would be nice to see muzzles equally as attractive to overcome owner reluctance to use.

RE: Use of diuretics with ascites due to PLE

Andrew Kent — Mon, 01 Jul 2019 20:17:03 GMT

[quote user="Anthony Dennison"]

I'm using the wrong words quite regularly at the moment - 3 week old baby at home and I'm still adjusting to the new levels of sleep deprivation!

[/quote]

Congratulations! I know that feeling well - hope you are all soon settled into a new routine and enjoy it! The tiny phase disappears before you know it and you soon find yourself trying to potty train a strong minded toddler which is currently my life!

RE: Use of diuretics with ascites due to PLE

Anthony Dennison — Mon, 01 Jul 2019 17:18:41 GMT

[quote user="Andrew Kent"]I would encourage him to cook whatever he is feeding if possible.[/quote]

Yes, sorry I used the wrong terminology. It's not raw food, it is cooked but just comes in a loaf like some raw diets.

I'm using the wrong words quite regularly at the moment - 3 week old baby at home and I'm still adjusting to the new levels of sleep deprivation!

RE: Use of diuretics with ascites due to PLE

Andrew Kent — Mon, 01 Jul 2019 14:15:53 GMT

[quote user="Anthony Dennison"]I used chlorambucil initially with the preds when he first got really ill. If anything it made him worse and he was better on preds alone.[/quote]

Ciclosporin would be an alternative then.

[quote user="Anthony Dennison"]Owner definitely won't go back on to a commercial prescription hydrolysed diet, and I'm happy with it at the moment - previously if changes were made he goes really loose. One of the big problems at the moment is the neighbour feeds bread to the birds which is then dropped in the owners garden...[/quote]

Scavenging can certainly be problematic - again maybe discuss about a muzzle when out and about - I know a lot of owners are resistant to that but have had a few cases do very well with that simple measure.

I would encourage him to cook whatever he is feeding if possible.

Andy

RE: Use of diuretics with ascites due to PLE

Anthony Dennison — Mon, 01 Jul 2019 13:34:13 GMT

Thanks Andy, will get him booked in for bloods.

[quote user="Andrew Kent"]If it is related to low proteins then I would add a second immunosuppressant, such as chlorambucil or ciclosporin[/quote]

I used chlorambucil initially with the preds when he first got really ill. If anything it made him worse and he was better on preds alone.

[quote user="Andrew Kent"]Without wishing to stir too much of a hornets nest - what other diets have you tried?[/quote]

Tried RC Anallergenic and Hills Z/D Ultra, didn't make a massive difference, dog was still quite ill on it and was quite cost prohibitive for minimal improvement. Initially was on boiled kangaroo mince with butternut squash, which he improved on but then Iceland stopped stocking the meat he was on. His stool consistency has been the best it's been on the food he is now (can't remember exactly, possibly Arden Grange or Nature's Diet?). Owner has done a lot of his own research and supplements with cooked vegetables too. In the early days he wanted to try lots of different foods to find the right mix or add in addition CHO source, so we'd do it for a few days then wait to see if there was a reaction for each individual food.

Owner definitely won't go back on to a commercial prescription hydrolysed diet, and I'm happy with it at the moment - previously if changes were made he goes really loose. One of the big problems at the moment is the neighbour feeds bread to the birds which is then dropped in the owners garden...

RE: Use of diuretics with ascites due to PLE

Andrew Kent — Mon, 01 Jul 2019 12:56:40 GMT

Hi Anthony,

I think it would be sensible to do some blood work as we really want to check that the ascites is related to the protein levels - if not then we might need to consider other mechanisms (such as portal hypertension).

If it is related to low proteins then I would add a second immunosuppressant, such as chlorambucil or ciclosporin.

[quote user="Anthony Dennison"]hypoallergenic BARF diet with added gourd family veg as a CHO source intermittently.[/quote]

Without wishing to stir too much of a hornets nest - what other diets have you tried? Many of the raw diets described as hypoallergenic are not truly that - ie they are often not novel/single source protein so we may be able to improve on it. I am also concerned about feeding raw diets to immunosuppressed patients.

[quote user="Anthony Dennison"]I was convinced the dog was going to die or need euthanasing 2 years ago so I'm amazed he's still going, would quite like to keep him so! Owner is well aware he probably won't ever be 100% normal again but happy to keep going as we're going. [/quote]

Certainly sounds like he has done well considering this - but hopefully we can improve him further.

Andy

RE: Use of diuretics with ascites due to PLE

Anthony Dennison — Mon, 01 Jul 2019 11:06:34 GMT

[quote user="robloxley"]What is the final diagnosis - lymphangectasia and IBD would have quite different management, for instance?[/quote]

IBD

[quote user="robloxley"]Have you tried spironolactone[/quote]

Yes, was on it alongside the furosemide for a bit, not a huge difference.

[quote user="Aine Seavers"]Optimise the diet but remember that when dogs become resistant to oral furosemide, they still respond to the furosemide injection for many months after.[/quote]

That's interesting - I suspect the owner would be happy to inject if we looked down that route.

[quote user="Andrew Kent"]i am generally not a fan of diuretics in PLE cases as they are typically not very effective and end up with a dehydrated dog with electrolyte abnormalities. [/quote]

That's what I thought, especially as the furosemide isn't making a difference so I'd prefer to try something different or not at all.

[quote user="Andrew Kent"]Do you have a recent protein level?[/quote]

Haven't taken bloods for a while because when discussing it with the owner, we're both not sure if it would really change the treatment protocol. Probably worth repeating though, bit poor of me.

[quote user="Andrew Kent"]And does this dog take any medications currently[/quote]

Currently on 3mg/kg furosemide once daily and 0.75mg/kg prednisolone once daily. Managed well with diet, probiotic supplements and fed on a hypoallergenic BARF diet with added gourd family veg as a CHO source intermittently.

I was convinced the dog was going to die or need euthanasing 2 years ago so I'm amazed he's still going, would quite like to keep him so! Owner is well aware he probably won't ever be 100% normal again but happy to keep going as we're going.

RE: Use of diuretics with ascites due to PLE

Andrew Kent — Sun, 30 Jun 2019 09:30:02 GMT

Hi Anthony

i am generally not a fan of diuretics in PLE cases as they are typically not very effective and end up with a dehydrated dog with electrolyte abnormalities.

As others have said the key to managing the ascites is to manage the protein levels which means managing the underlying disease.

if that is associated with scavenging then it would be sensible to walk the dog with a muzzle.

Do you have a recent protein level? And does this dog take any medications currently?

Andy