pu/pd and hypoproteinaemia

Re: pu/pd and hypoproteinaemia

Kate Dawes — Fri, 16 Jul 2010 21:16:58 GMT

[quote user="Michael Woodhouse"]How are you measuring albumin?[/quote]

The latest albumin was done in house, but the first sample (last wk) was checked with our outside lab to confirm and they got the same result, so am assuming this is correct.

The latest is the owners have decided they can't afford an ultrasound and "will leave it a few weeks"............she doesn't seem to be that ill at present, but might be by then!

Re: pu/pd and hypoproteinaemia

Michael Woodhouse — Fri, 16 Jul 2010 20:47:47 GMT

[quote user="Kate Dawes"]Albumin yesterday was similar to before (18).[/quote]

How are you measuring albumin? Our Vettest was playing silly buggers at one point giving everything a low albumin with everything else WNL. How are you measuring this, have you done a recent QC if done in house? Compare total protein with total dissolved solids on a refractometer?

We had to send our analyser to Holland to be mended!

Re: pu/pd and hypoproteinaemia

Kate Dawes — Thu, 15 Jul 2010 15:02:18 GMT

Just a quick update for anyone that is interested.

BA stim done yesterday - pre and post prandial BA well within normal range.

So seem to have ruled out hepatic and renal dz as cause for the hypoproteinaemia. Am getting even more stuck now.............am planning on booking in for full abdo ultrasound early next week I guess GI disease is still a possibility though no vomiting or diarrhoea. Albumin yesterday was similar to before (18).

Re: pu/pd and hypoproteinaemia

Vikki Halliday LLB — Tue, 13 Jul 2010 23:15:31 GMT

[quote user="Kate Dawes"]

[quote user="Vikki Halliday"]I have seen a progressive proteinuria possibly due to secondary glomerulonephritis,[/quote] I think we have ruled out proteinuria in this case as UPC normal, so would you expect this degree of hypoproteinaemia from a pyo?

[/quote]

Sorry missed that one!

Re: pu/pd and hypoproteinaemia

Kate Richardson — Tue, 13 Jul 2010 20:18:11 GMT

Just saw ths post after my last comment- end stage liver disease often does present as 'acute' onset once the final piece of functional liver gives up the ghost as well

Re: pu/pd and hypoproteinaemia

Kate Richardson — Tue, 13 Jul 2010 20:15:11 GMT

Low proteins- think reduced intake, reduced production or increased loss. What was the liver size on xray? Agree if UPC normal not urine loss. Which leaves GIT loss, and will not necessarily have GI signs such as vom/diarrhoea although inappetance can be a GI sign. Normal liver enzymes does not rule out liver if there is minimal functional liver tissue. So BAST important and if considering surgery, check clotting times first.

Re: pu/pd and hypoproteinaemia

Kate Dawes — Tue, 13 Jul 2010 20:08:19 GMT

Seen again today, 24hr water intake confirms significant polydipsia, urine samples from different times of day consistently hyposthenuric (1.004), still no vaginal discharge or temperature and still 'not quite right', appetite about half of usual. Owner is convinced this has come on suddenly rather than something that has been brewing for a while.

Booked in for BA stim and to reck albumin/total protein tomorrow, am off on hols next week , so unfortunately will have to pass it on to someone else then, probably for a full ultrasound if nothing else has come to light.

Re: pu/pd and hypoproteinaemia

Kate Dawes — Tue, 13 Jul 2010 07:34:40 GMT

[quote user="Vikki Halliday"]If funds are limited, why not spay to "rule out"? [/quote]

As Rob said, seems a bit of a major step with no real evidence, and wouldn't be cheap either. I would also have concerns re the low albumin level, though I do appreciate as someone else has said that an entire female of this age "probably has a pyo until proven otherwise"

I'm seeing her again today, and am hoping somethings changed that will give me more of a clue - If she has developed a vaginal discharge and a temperature then I'll actually be quite pleased!

Thanks for everyone's input, will keep you posted

Re: pu/pd and hypoproteinaemia

ilanit — Tue, 13 Jul 2010 06:33:26 GMT

[quote user="Martin Atkinson"]If the urine is so dilute could it still be a protein losing nephropathy even with normal UPC ratio? You say urine dipstick was normal but what was the actual protein level? [/quote]

Isn't that why you check the ratio with creatinin rather than the absolute value of protein? So you correct for the influence of dilution (spg), But I could be wrong

Re: pu/pd and hypoproteinaemia

Rob Loxley — Mon, 12 Jul 2010 23:07:22 GMT

[quote user="Vikki Halliday"]If funds are limited, why not spay to "rule out"? [/quote]

Well, you asked:
Bit of a sledgehammer?
Wouldn't necessarily fancy the GA of the dog with an undiagnosed shunt - the last (known) shunt dog we referred for spaying as it developed a pyo never returned home, but I digress.
Would also be reluctant to do surgery on a hypoproteinemic dog on a punt as healing may be impaired and postop complications won't help the budget.
I'd also be reluctant to go for speculative surgery on a dog who's presented just 'not quite herself', doesn't sound like she's a surgical emergency at the moment.

What was the calcium level?
If you run one, let us know what the BAST shows, and then maybe the results of further imaging when other staff are back, might get closer to a diagnosis.

Re: pu/pd and hypoproteinaemia

Vikki Halliday LLB — Mon, 12 Jul 2010 22:51:06 GMT

I'd still consider a grumbling low level pyo, and not necessarily one you could pick up on xray or poor quality U/S. I have seen a progressive proteinuria possibly due to secondary glomerulonephritis, and I have also seen endometriosis that would have taken a very detailled scan and experienced ultrasonographer to pick up.

If funds are limited, why not spay to "rule out"?

Re: pu/pd and hypoproteinaemia

Kate Dawes — Mon, 12 Jul 2010 20:12:39 GMT

sorry haven't quite got the hang of the quote thing - not sure how I managed to do it twice

Re: pu/pd and hypoproteinaemia

Kate Dawes — Mon, 12 Jul 2010 20:11:19 GMT

[quote user="Martin Atkinson"]f the urine is so dilute could it still be a protein losing nephropathy even with normal UPC ratio? You say urine dipstick was normal but what was the actual protein level?[/quote]

External lab urinalysis - can't remember exact protein level, but I'm sure it was within normal limits[quote user="Martin Atkinson"] If the urine is so dilute could it still be a protein losing nephropathy even with normal UPC ratio? You say urine dipstick was normal but what was the actual protein level?[/quote]

Think it needs a better brain than mine too unfortunately

Re: pu/pd and hypoproteinaemia

Martin Atkinson — Mon, 12 Jul 2010 19:19:36 GMT

Older dogs can get 'aquired' shunts due to secondary liver disease. Also can get some older dogs with HAC Cushings disease with normal liver enzymes, PU/PD is sometimes the only reliable symptom, so low dose dex is IMO more reliable than ACTH for diagnosis in these cases. You need to eliminate these potential problems from enquiries anyway. If the urine is so dilute could it still be a protein losing nephropathy even with normal UPC ratio? You say urine dipstick was normal but what was the actual protein level? Probably need a better brain than mine on this one. Maybe its the one in a million true diabetes insipidus!

Re: pu/pd and hypoproteinaemia

Kate Dawes — Mon, 12 Jul 2010 17:52:33 GMT

[quote user="Martin Atkinson"]I'd be thinking porto-systemic shunt so bile acids would be next[/quote]

She is 10 tho - wouldn't you have expected a shunt to show up earlier? Agree that I probably need to do bile acids as next step tho

No neuro signs.

Re: pu/pd and hypoproteinaemia

Martin Atkinson — Mon, 12 Jul 2010 17:40:07 GMT

I'd be thinking porto-systemic shunt so bile acids would be next - any neurological/mentition symptoms? If that draws a blank low dex suppression test rather than ACTH is marginally cheaper.

Re: pu/pd and hypoproteinaemia

Kate Dawes — Mon, 12 Jul 2010 16:37:58 GMT

Thanks - all opinions gratefully received on this one! Have double checked there is no D+ (tho owners aren't the brightest), but insist her stools are solid.

Calcium is actually slightly low - 1.95 (2.15-2.95), but am assuming this is 2ry to the low protein. Agree a full abdominal ultrasound would be nice, but our chief ultrasonographer is away til next wk, and the rest of us are pretty useless with an ultrasound probe. (I would like to think I would have picked up a pyo, but did have to x ray to double check

Glucose is also on the low end of normal (3.3) so I guess that could support end stage liver disease as well. Liver looked normal size on x ray.

Re: pu/pd and hypoproteinaemia

ilanit — Mon, 12 Jul 2010 16:30:00 GMT

I would do a bile acid stim first to exclude (or not) liver involvement. Normal enzymes don't exclude (end stage) liver disease, although you would have expected a longer hx of vague symptoms.

Would PLE be a possibility? There's no diarrhoea, but I think that's not always present. The PU/PD could be neoplastic (did you check calcium?): intestinal lymposarcoma.

An abd U/S would be nice to check thickness of intestines and liver, kidney etc.

An intact older female with polyuria has pyometra until proven otherwise :), but I agree that nothing supports this. And for a pyometra to cause that amount of protein loss, you would imagine a very high leuco count and it would be visible on X-ray/US

Just some thoughts... hope it helps

Re: pu/pd and hypoproteinaemia

emerald — Mon, 12 Jul 2010 15:55:40 GMT

Sorry I thought she was 3years old! Misread!! So Addisons prob lot less likely anyway.

I would consider as next steps BAST test and ACTH stim.

Re: pu/pd and hypoproteinaemia

Kate Dawes — Mon, 12 Jul 2010 15:54:08 GMT

Sounds like it is a possibility then. My other issue is that she isn't insured and the owners don't have loads of money to spend, so am trying to prioritise any further diagnostics

Re: pu/pd and hypoproteinaemia

emerald — Mon, 12 Jul 2010 15:52:09 GMT

Couldnt remember why exactly, just looked it up in BSAVA book, apparantly can get moderate - severe hypoalb, exact pathogenesis unknown, linked to Gi haemorrhage, impaired intestinal absorption of nutrients, and impaired albumin synthesis.

Just with the low SG and gen CS's may be a DDx? Interesting!

Re: pu/pd and hypoproteinaemia

Kate Dawes — Mon, 12 Jul 2010 15:41:29 GMT

Na/K normal, (which I know doesn't rule out), but how can that cause hypoproteinaemia?

She otherwise seems pretty well at the moment (just 'not quite right' according to the owners). Am still slightly worried this could be an as yet undiscovered pyo, but presumably if it is she won't remain well for very much longer......! Am seeing her again tomorrow, so trying to formulate some sort of logical plan, but not having much sucess.

Re: pu/pd and hypoproteinaemia

emerald — Mon, 12 Jul 2010 15:28:09 GMT

How about Addisons?