Hypoalbuninaemia

Re: Hypoalbuninaemia

Christopher Saul — Thu, 18 Nov 2010 23:52:48 GMT

Good stuff.

There are anecdotal reports of glutamine supplementation helping with lymphangiectasia, though I cannot find a dose for you I'm sorry. Any biopsy results?

How is she this evening?

Re: Hypoalbuninaemia

Utlendigur — Thu, 18 Nov 2010 23:48:02 GMT

See first post - already did - just waited to take the bloods on Saturday am first so it didn't interfere with the results (I did actually request folate, cobalamin etc as well as the haematology and urine but missed it off the post - brain not working while I was typing) . She's due her next injection on Saturday

Re: Hypoalbuninaemia

Christopher Saul — Thu, 18 Nov 2010 23:23:20 GMT

[quote user="Utlendigur"]Folate and cobalamin are low.[/quote]

You need to supplement the B12

Re: Hypoalbuninaemia

Andre Escudeiro-Vieites — Tue, 16 Nov 2010 23:27:09 GMT

My "gut" feeling is still lymphangiectasia, but hopefully the biopsies will tell us more. I had cases that responded to prednisolone, but the worrying problem as said before is the hypercougulable state.

I have recently gone through a long problem with my dog and it does make you think a lot about what the clients you are seeing every day feel.

Good luck!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Re: Hypoalbuninaemia

Christopher Saul — Tue, 16 Nov 2010 20:38:30 GMT

Thought it sounded more like PLE. You've had a horrid time, sounds like you have more than your fair share to deal with, but I'm sure I speak for us all on here in having everything crossed for you.

Please keep us updated

Chris

Re: Hypoalbuninaemia

Utlendigur — Tue, 16 Nov 2010 19:58:26 GMT

I had a bit of a nightmare trip over there - very early start, diverted to my parents house with some shopping and managed to drop a tub of tomato soup on the floor, got lost, almost ran into the back of an idiot who decided to treat a 60mph slip road as a give way - so I arrived somewhat soup-splattered, late and frazzled....

It looks like she's got PLE - most likely IBD and/or lymphangiectasia (biopsies pending) - rather than renal loss or liver disease (pupd might have been driven by hypovolaemia). There was minimal protein in the urine although prot:creat ratio was 1.0. Albumin and globulins low (are machine was struggling to read them). Folate and cobalamin are low. Haematology relatively ok - haemoconcentration and mild inflammation. Still some other bloods to come back. She's a bit brighter although still quite ascitic and has lost quite a bit of muscle. For now she's on low fat diet, antibiotic and preds while we wait for the biopsies.

Thanks again for all the help and suggestions

Re: Hypoalbuninaemia

Alex Allen — Mon, 15 Nov 2010 12:05:07 GMT

Good luck for today.

A little leftfield but worth checking faeces for Parvo - run PCR as antigen test maybe unreliable at this stage. Would still check even in vaccinated animals. If villous damage significant could have produced the massive protein loss described. Also dehydration, neutropaenia on your smear etc.

How are the WBCs doing?

Re: Hypoalbuninaemia

Michael Woodhouse — Mon, 15 Nov 2010 00:04:31 GMT

[quote user="Christopher Saul"](Michael, how did you do the smilie?)[/quote]

Google search and then 'insert media'

Gives you any number

Re: Hypoalbuninaemia

Christopher Saul — Sun, 14 Nov 2010 23:25:26 GMT

OK I'm glad you've got her into a referral centre.... I've got everything crossed for you. I'll keep checking on here in case I can be of any help, though if you've got her referred best let the specialists do their thing

(Michael, how did you do the smilie?)

Re: Hypoalbuninaemia

Utlendigur — Sun, 14 Nov 2010 22:08:05 GMT

In some ways she seemed a bit better - no D+ for 24hrs, pupd has reduced (urine SG 1.027) this morning even with iv fluids and keen to go for a walk, but she has now stopped eating, developed an uncomfortable abdomen and become more depressed through today (even allowing for the vetergesic) so she is going for referral tomorrow (tried for today but the same problem as before with weekends - specialist not available). I did xray and ultrasound her last night but not ideal single handed. Abdomen just ground glass appearance with a few narrow streaks of gas shadows in guts, so there didn't look to be any dilated loops/gravel signs etc. Liver didn't look enlarged. Chest had a tiny amount of pleural effusion but the heart looked normal. I'm a beginner at ultrasound so fairly unrewarding - guts had good/overactive peristalsis + but I couldn't really assess wall thickness. Couldn't get a good view of the liver as she hates clippers so the clip was minimal, stomach + food in the way and she kept curling up or running off. There didn't look to be a large volume of acsites - which explains why I could only get a few blebs of fluid (I'm not usually that useless) - not enough for SG or cytology but it did look just like water. Thanks for all the advice . I'll let you know what happens but I'm not expecting a good prognosis at the moment.

I love the smilie can we add it to the list?

Re: Hypoalbuninaemia

Michael Woodhouse — Sun, 14 Nov 2010 20:21:50 GMT

[quote user="Utlendigur"](we could do with a highly stressed, tearing hair out smilie)[/quote]

Ah - something I can help with

Glad your dog is getting better.

Re: Hypoalbuninaemia

Christopher Saul — Sat, 13 Nov 2010 20:52:29 GMT

Ah well I'm glad she's getting a bit better, that's the main thing. You could ring the lab on monday to request a single point bile acids which although is not as good as a stim would give you some idea of what the liver's doing.

I'll check this thread regularly to see how you're getting on.Have you got a spg/ total protein and looked at a slide of the ascitic fluid?

I do hope your parents are ok, best of luck with everything

Re: Hypoalbuninaemia

Utlendigur — Sat, 13 Nov 2010 20:03:30 GMT

Bloods and urine are already in the post (unfortunately didn't get them off before the last post on Fri) with a request for most of the above (except BA stim). We're still on the steep part of the learning curve with ultrasound. I wish I had xrayed her but time/staff pressures were against it, especially if it became a barium study, and I suspected I would just see an ascitic abdomen. I was considering referring her today but she seemed a bit better. Unfortunately the nearest referral centres are over an hour away and I've had problems previously referring things at weekends (http://www.vetsurgeon.org/forums/p/3985/11016.aspx#11016) but that is looking the likeliest option - also juggling the needs of two elderly parents due out of hospital (we could do with a highly stressed, tearing hair out smilie) doesn't help.

Re: Hypoalbuninaemia

Christopher Saul — Sat, 13 Nov 2010 17:02:48 GMT

Even better, can you get her to a referral centre?

Re: Hypoalbuninaemia

Christopher Saul — Sat, 13 Nov 2010 17:00:11 GMT

I do think imaging, most importantly abdo ultrasound and chest x ray would be useful if you can; US would certainly add information regarding intestinal wall thickness and you can have a look to see if there's any intussusception etc, as well as looking for other intra-abdominal pathology.

I'd do an URGENT external laboratory request for TLI, PLI, as well as bile acid stimulation B12/folate, urinalysis (prot:creat) and fluid analysis from the ascitic fluid. My gut feeling is protein losing enteropathy but given PUPD could stll be a glomerulo-neprhopathy so really need the prot creat ratio as a matter of urgency. Have you looked at the fluid under microscope and got an SpG?

Re: Hypoalbuninaemia

Utlendigur — Sat, 13 Nov 2010 16:27:53 GMT

Thanks for the replies. Oops I forgot to mention abdomenocentesis (was trying to condense the post as much as possible) - although noticeable because she's a slim dog, I couldn't get much on a tap, but it looked like transudate. She also has no abdominal pain, no vomiting since single episode on Weds and the mild pyrexia (102.8F) resolved during yesterday. Amylase was normal in-house (we don't have the snap tests). PCV was normal this morning and the ascites has reduced a little so I have stopped the fluids for now. She is still pupd though - so initially I was thinking enteric loss but now not sure. I have got some frozen plasma from our local Vets Now (thanks for the suggestion, I wasn't aware how easy it was to get hold of). I haven't xrayed or scanned as yet as no time/staff yesterday and didn't seem surgical. Thanks again

Re: Hypoalbuninaemia

Christopher Saul — Sat, 13 Nov 2010 13:10:43 GMT

I'm basically just going to reiterate Andy's thoughts here, he's pretty much spot on but here's my musings anyway.....

Generally speaking, hypoalbuminaemia is down to one of the following: malassimilation/malnutrition (Doesn't fit with the history in this case), hepatic disease, renal disease, GI disease, or 3rd spacing/peritonitis.

My first thought with this case is could there be a septic peritonitis going on? Could you get a quick abdominocentesis and have a look at the fluid - is it turbid etc, look at a smear of it under microscope - if neutrophils prob septic.

My next thought would poss be lymphangietasia or some other severe protein losing enteropathy. Otherwise - good plan with the urine protein creat ratio... it's a must to eliminate renal protein loss. a Bile acid stimulation may be useful to eliminate hepatic disease.

Plasma is certainly a good idea with regards clotting factors/ DIC/ peritonitis, however Iv'e found it fairly unrewarding for imroving plasma oncotic pressure; I tend to use venofundin as my colloid of first choice for that purpose.

I would always stress the risk of thromboemloism with these cases too. Heparin is of questionable use in these cases because this works by potentiating antithrombin, which is about the same molecular weight as albumin and hence antithrombin is also low in hypoalbuminaemic patients; hence Andy's suggestion of plasma may be a good one.

Hope this helps, good luck

Chris

Re: Hypoalbuninaemia

Andrew Kent — Sat, 13 Nov 2010 11:14:04 GMT

Sorry to hear about your dog.

A few of my thoughts - agree need to decide on site of protein loss so urinalysis a good idea. It would also be worth tapping her abdomen to find the nature of the fluid present - if you are suspicious of something like pancreatitis then an amylase/lipase on the abdominal fluid can be useful. Equally can run lactate/glucose levels if cytology of the fluid suggests peritonitis. I find most of these can be run in house when needed at the weekend.

I think I would add acute pancreatitis to the list of possibilities - do you have snap cPLI tests - that may add something useful to the diagnostics though obviously they can elevate with 'other' causes of pancreatic inflammation.

If the albumin continues to drop I would be considering the use of fresh frozen plasma (or even human albumin if very low) which will also be of benefit if an acute pancreatitis or any risk of DIC etc. If you do no keep this at the practice you can get it delivered pretty quickly from pet blood bank or sometimes collect from Vets Now (or another local practice).

Imaging could also be fairly important - abdo rads and scan in case possibility of septic peritonitis.

For me most important next step would be abdominocentesis for cytology and analysis.

Andy