This darling puppy had LS surgery on 6/27/13 and was released from the hospital the next day. Since then, he has continued to improve, except his appetite has been decreased. My dogs have all done well on the Royal Canin Hepatic prescription kibble, but Lucky stopped eating that about 3 weeks ago. Since then, he’s been on a home-cooked diet with some mashed RC Hepatic kibble and RenalCal liquid nutrition. He’s been getting his medication and supplements and six small meals a day.
He already seems ready to run around, but his activity has to be limited for at least another week-tough to do with a puppy! Today I started to decrease his aversion to the prescription kibble by saying “good boy†every time he looked at a piece of kibble, then every time he nudged it with his nose, then when he ate the piece. In the video, you can see that I’m tossing the kibble to him, trying to get him interested in a playful way, then rewarding him with “good boyâ€. This has worked really well, and even though he only ate 2 pieces of kibble for the first meal (on his own), by the second meal this amount was increased to 15 pieces. Still not enough for his daily requirements (so he still gets RenalCal) but hopefully he’s back on the right track to eating the kibble on his own.
The results of his liver biopsy should be back by the end of the week.
 Lucky after his big boy haircut on June 5
Lucky, now 9 months old and almost 9 pounds has finally shown enough improvement in his bloodwork result to be a good candidate for his liver shunt surgery. It’s been a long four months of medical management! When he arrived in Michigan near the end of February/13, he only weighed five pounds and his albumin was only 0.9 and total protein was only 1.2; there were other abnormalities which placed him at risk for seizures. Four months after medical management which included at least six small meals a day, medication and supplements (including pharmaceutical grade probiotics) repeated bloodwork results were a whopping 2.5 for albumin and 4.4 for total protein. Also, he’s no longer showing anemia with decreased RBC count, but his WBC is still high at 19.9.
He has needed to be on Clavamox because his WBC count increased every time the vet prescribed Amoxicillin (most of my foster dogs have done fine with only Amoxi). The other unusual symptom is that Lucky is unable to tolerate lactulose, one of the basic medications for controlling neurological symptoms associated with severe liver problems and also an aid to increasing protein tolerance. For some reason, his GI tract could not tolerate any lactulose and is not absorbing food normally.
In the past several weeks, he went from eating Royal Canin Hepatic kibble (soaked in distilled water) to eating canned LD, then home-cooked emals and finally when he refused to eat anything, he was syringe fed with RenalCal. After a few days of RenalCal only, he started to eat the home-cooked meals and in a few days I was able to add the RC Hepatic soaked kibble back in. He is such a sweet, bouncy dog that it’s hard to believe how sick he really is!
Please keep him in your thoughts and prayers this Thursday, June 27/13 for his surgery. RetroDoggyRescue is still in need of donations for his surgery because his medically fragile condition required much more veterinary care and supplements than is typical for a puppy with a liver shunt. Donations can be made directly at www.RetroDoggyRescue.com
http://youtu.be/c4d70I9vgYM  Duffy was only a few months old when he died, after liver shunt surgery on June 17, 2010. He was on medical management for 3 months and doubled his weight in that time (from two pounds to four); however, his bloodwork never stabilized.
Risk factors for post-surgery complications, including seizures and death, are very low albumin and chronically elevated WBC count and blood clotting abnormalities; Duffy had all three of these problems. Despite two blood transfusion prior to surgery and two resuscitation attempts after surgery, we lost him.
Duffy’s good friend Polly the dachshund died a year ago, almost to the day that Duffy died. Layla the yorkie who had LS surgery when she was almost 3 years old, died last month, only 3 years after her surgery. Harley, who’s not in the current video, was also 3 when he had LS surgery and died on May 20, 2013, five years after his LS surgery.
What happened to Duffy has resulted in our decision to not attempt liver shunt surgery with Augie, who has similarly unstable bloodwork. Augie will be four this August and has been with RetroDoggyRescue as my foster dog for over two years. I don’t think that we will have LS surgery done on adult dogs, especially those over two years old.
It’s very tough to lose these little guys so soon…
http://www.youtube.com/watch?v=hSN9oU85Jzc Although he seems healthy, this liver shunt pup is very medically fragile. Last week, after a few minutes of playtime, his gums turned white, he panted and almost passed out. He is doing much better this week!!
Lucky’s liver shunt surgery that had been scheduled for May 30 had to be postponed due to his worsening bloodwork results. Although his symptoms are largely controlled, he is medically fragile and relies on 24/7 care with proper nutrition, supplements and medication to keep him alive. His liver is really not functioning at all (post bile acids of 260) and he also probably has a protein-losing enteropathy which prevents him from absorbing food normally. His albumin (liver protein) has gotten as low as 1.0 but is currently up to 2.0. His total protein has been as low as 1.2 but is currently up to 3.6-both are still very low; however, they have increased in the past couple of weeks.
Lucky has been rescheduled for surgery on June 27, 2013 and hopefully will remain medically stable until then. Please donate towards his care, as RetroDoggyRescue has spent at least $ 1300 to date and we currently do not have enough money for his liver shunt surgery.
https://www.youcaring.com/saveluckysliver
The adorable Lucky is doing better! Lucky has been with me for 8 weeks and his bloodwork has finally started to improve. In February, his albumin and total protein were so low that he developed edema underneath his chin and around his lymph nodes. In March he had another crisis and developed ascites (fluid retention in his abdomen due to severe liver problems). I’ve never fostered a dog whose albumin and total protein were so low, at their lowest points, only 1.0 and 1.2.  Low normal is 2.5 for albumin and 5 for total protein. He also had elevated in his liver enzymes and white blood cell count as well as low red blood cell counts.
March 10, 2013
This sweet bichon-poo puppy has been with me for two weeks. After the first week, Lucky had full panel bloodwork done and his results were very concerning! He had critically low albumin (0.9) and Total Protein (2.0) and BUN was only 3. Lucky only weighed 5 lbs. 5 oz when he was flown in by Pilots N Paws but gained 8 ozs in one week. He was eating consistently and I was trying to gradually increase his protein without causing symptoms; however, he’s sensitive to protein because he has a large liver shunt (almost 8mm on the ultrasound). Too much protein caused a noticeable increase in growling and rough play with the other dogs. Neurological symptoms secondary to severe liver problems are called hepatic encephalopathy and include aggression.
The second week he was here, his appetite decreased. The amount of protein a dog with a liver shunt can eat depends on several factors and needs to be adjusted up or down based on a dog’s weight, hunger level, bloodwork results and symptoms. Puppies have higher protein/nutritional requirements than adult dogs, but those with a liver shunt often cannot handle the amount of protein required to grow. There’s a balancing act between giving as much protein as Lucky can handle without causing symptoms. There’s some evidence that indicates that hepatic encephalopathy causes permanent brain changes.
In general, research indicates that dogs should get 2 grams of protein per kg. of their weight, per day, if they have neurological symptoms. I decreased Lucky’s protein amount but by Thursday he was eating less than I was giving him and I had to give PediaSure Vanilla for added nutrition and to keep him hydrated. Friday afternoon, Lucky had swelling under his jaw on both sides and I was worried that he had a worsening infection or autoimmune problem. So off we went to Wilson Veterinary Hospital.
The vet examined Lucky and did in house bloodwork. Bloodwork results were similar to the ones done just five days before; however, Total Protein was slightly up to 2.8 , albumin 0.9,  WBC count was slightly higher, and RBC counts were slightly lower. Lucky had lost 1.5 oz in a few days. Dr. Kirby thought that the swelling under Lucky’s jaw was edema secondary to his low protein/ albumin levels. He recommended continuing his Amoxicillin and Lactulose. I was relieved that Lucky’s problems were related to his liver shunt and not a secondary issue and that he didn’t require a transfusion.
I had to syringe feed Lucky all of Saturday, using a combination of two Nestle Nutrition liquid diets. NutriHep is formulated for people with severe liver disease and hepatic encephalopathy and RenalCal is for people with kidney disease. Due to the swelling under his jaw line and neck, Lucky had to have low sodium foods so the PediaSure could not be continued. I also tried giving him Hills LD canned.  He had one good BM in the morning but continued to be lethargic.
I’m happy to report that Lucky actually lapped up the liquid diet on his own this morning (Sunday) and ate a few pieces of his prescription kibble (Royal Canin Hepatic). The swelling under his neck has significantly decreased, although there is still some mild swelling around the lymph nodes under his jaw. He’s getting probiotics and liver support supplements as well as six+ small meals. Hopefully he will continue to eat and gain weight so that he will be stable for liver shunt surgery.
http://youtu.be/f8j_y-pb4sY The Homies!  Lucky (mini /5 pounds) my foster dog for RetroDoggyRescue; Louie (medium sized/13 pounds) my 14 year old bichon and Chico (large/20 pounds), my 13 year old bichon-poodle mix boy. Party time!
Lucky is a 5.5 pound, 5 month old bichon-poo who has been diagnosed with a liver shunt. His ultrasound showed a shunt that’s almost 8 mm in diameter and his bloodwork has problems which are consistent with a shunt as well. Even at his young age, he already has bladder stones, which are likely some form of urate. He has elevated liver enzymes, low albumin, low cholesterol, low BUN and very elevated bile acids (post around 250). Due to the cost of surgery and time required for medical management, his owners reluctantly surrendered him to rescue.
Lucky was flown in by Pilots n Paws from MN to MI! Liz Pederson http://protecting-paws.org/about was instrumental in coordinating his transport and contacting me to foster him. RetroDoggyRescue, whose director is Connie Kramer, is committed to getting him liver shunt surgery if he is a candidate. Funds will have to be raised and donations can be made online at: www.RetroDoggyRescue.com  Donations.
Andrew/ Lucky’s transport was his first one for Pilots n Paws
http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/130502.htm
Clara is eating on her own and up to about 2.5 grams of protein per kg. of her weight (she may be more than six lbs., five oz.). This is about 18 pieces of the RC Hepatic kibble at each of her six meals, with additional boiled carrots and fresh romaine lettuce. She is able to hold her head up when walking now and does not have neurological symptoms, although her sense of smell still seems to be gone. It’s great to have her eating again and not have to syringe a liquid diet into her. Her eyes seem a lot clearer as well. Due to her severe liver issues, I’ve been using Nutren 1.5 and Nutrahep liquid diets for humans, as the fat is easier to metabolize (medium chain triglycerides). Additionally, the Nutrahep is much lower in sodium than the PediaSure Sidekicks/Vanilla Shake with fiber. Low sodium helps to prevent fluid build up in the abdomen secondary to liver disease (ascites).
Additional supplements are Vet-Zimes V1 pancreatic enzymes, which are from a vegetarian source, continued higher doses of thiamine, increased psyllium husk as a source of fiber and Zinc Supreme (rather than plain zinc glycinate). Additional medications are LDN (low dose naltrexone) for hepatic encephalopathy and her probable liver cancer. Dr. G has been using LDN for a variety of autoimmune problems; Clara’s was originally prescribed by Dr. Loren Weaver, her chiropractic/acupuncturist. There’s an online support group for pets. LDN:http://health.groups.yahoo.com/group/LDN_4_Pets/
My liver disease dogs have not been able to tolerate the usual recommended dose of LDN because it’s metabolized in the liver; however, I feel that they’re still getting some benefits from it even at about 1/10 of the usual dosage.
Clara is going back to the vet for repeat bloodwork in a few days.
It was really tough seeing her like that and I thought that I might lose her. It’s one thing to have lethargy as a symptom of hepatic encephalopathy (HE), but the head pressing and “yowling†were terrible and she seemed to be in pain. She had restlessness that kept her walking aimlessly through the house and her vision was impaired. Her pupils did not react to light and stayed dilated. Vet put her on an antibiotic and low dose prednisolone syrup and I was syringing Pediasure into her with a syringe because she wasn’t eating. I increased her probiotics for liver and kidney support and her other supplements. She had also been diagnosed with early renal disease and tended to get dehydrated. http://www.heska.com/Products/Renal-HealthScreen/ERD-HealthScreen.aspx Perking up for a few days, she had repeat bloodwork a week later that showed normal WBC count-amoxicillin dosage and prednisolone dosages were reduced. Despite improved bloodwork, her symptoms increased-another symptoms of HE that she has had in the past is “air licking†and she was till lethargic and unable to hold her head up when walking. Clara had subQ fluids on January 9 but symtpoms still did not improve.
January 10th/13, she was seen by Dr. Loren Weaver for a chiropractic/acupuncture appointment. Her gums were tacky and she could barely stand up. We drove right from Northville to Flat Rock, Mi, for an appointment with Dr. L. Greear of Cahill Veterinary Clinic. I had made an appointment for two of my foster dogs, but instead took Clara and only one of my senior fosters, Alfie.
Poor Clara actually fell down while walking on the clinic floor. I left her with Dr. Greear-she had repeat bloodwork and was put on IV fluids – PlasmaLyte with added B and C vitamins. She also had an xray (which showed lots of gas) and an ultrasound. Her liver on the US was enlarged with several bright spots, which Dr. G diagnosed as cancer. Another shock, as most liver shunt dogs tend to get cirrhosis. Her RBC count was still down and calcium was high. I opted not to have the bloodwork to check for cancer, since it was unlikely she would survive any cancer treatment in this conditon. http://www.oncopetdiagnostics.com/
Clara seemed to have perked up a little and was more alert and I brought her home with a port in her leg so that I could administerd the IV fluids at home.
IV fluids
She had a repeat visit on Sat, Jan 12/13 and it was found that Clara again had a urinary tract infection so her antibiotic was changed to Clavamox. On Monday, her port was removed. Clara had still been lethargic at home despite the fluids, syringing Pediasure and the oral Barium that Dr. G had prescribed for her constipation. She was waking up in the middle of the night and it was very stressful not knowing whether she would make it through any given day. My grandmother had just died on Jan 5/13 and my nerves were already raw from losing her (ironically to gall bladder/liver pancreas disease). Dogs with liver disease need at least double the amount of B vitamins and Clara had been getting extra B vitamins in some of her supplements; however, thiamine deficiency can also cause neurological symtpoms.I thought it was worth a try to increase thiamine at higher dosages (since she was no longer getting B vitamins by IV). My use of supplements, especially probiotics, has already been discussed in other blogs. VSL3 is very important in reducing ammonia and liver inflammation and Renadyl gets rid of excess nitrogen and ammonia produced by the kidneys
Thiamine Deficiency
http://www.dsm.com/en_US/html/dnpna/anh_comp_vit_b1_def.htm
Also, from Dr. S. Center’s article, “Nutrional Support for dogs and cats with hepatobiliary diseaseâ€.
†Of particular concern is adequacy of thiamine (vitamin B-1), which relies on intracellular activation and hepatic storage. Thiamine is an essential coenzyme in intermediate carbohydrate metabolism, functioning as a coenzyme in the pentose-phosphate pathway (transketolase) and tricarboxylic acid cycle (pyruvate decarboxylase and α-ketoglutarate). Deficiency induces a syndrome known as Wernicke‘s encephalopathy, which is easily avoided by supplementation with a balanced vitamin formula (Reuler et al. 1985). Clinical signs are attributed to impaired cerebral energy metabolism and synaptic transmission, which can be potentiated by glucose administration without vitamin repletion. Clinical signs are inconsistent and confusing, and resemble HE. Cats may be more susceptible than dogs to thiamine deficiency. Affected cats develop ventral neck flexion, dilated, poorly responsive pupils and sluggish postural corrections (Jubb et al. 1956). In dogs with experimentally created thiamine deficiency, abrupt onset of neurologic signs (depression, vestibular signs, profound muscle weakness, exaggerated spinal reflexes, head ventroflexion, and deficits in supporting reflexes and menace response) terminated in death within 1 wk (Read and Harrington 1981). As in humans, Wernicke‘s encephalopathy is a clinical diagnosis and should be treated if suspected because response to vitamin supplementation is acute and dramatic. Treatment requires parenteral thiamine administration with an empirical dose; dogs and cats are each given 100 mg once or twice daily.â€
Clara seems to be responding to the liquid thiamine! She is starting to hold her head up above her shoulders and definitely can see better. Her appetite has improved, although constipation is still an issue for her.
Holding her head up a little
Another vet visit tomorrow with Dr. Greear at Cahill Veterinary Hospital. Hopefully the positive changes will continue until then!
In this pic she was wearing a Thundershirt, which I have found helpful for dogs with some neurological problems.
Top 10 Myths About Liver Disease
1) Home-cooked food is better than commercial prescription food for all dogs.
I’ve had great success by doing the following: Feeding prescription Royal Canin Hepatic kibble. While home-cooking is an option, it’s not a good one for dogs that are unstable medically (eg. Those with neurological symptoms). It’s just too difficult to control protein grams and other nutrients. Even for an asymptomatic dog with elevated bile acids, a home-cooked meal should be formulated for an individual dog and will require more monitoring in terms of bloodwork to make sure that requirements for protein and other nutrients are met.
2) Dogs must eat high protein food if their albumin is low, especially meat.
There is a fine balance between giving a dog enough protein to prevent muscle wasting and giving too much and causing symptoms (which may not be apparent the same day or even for a couple of weeks). My principle has been to “start low and increase slowly†in terms of protein grams until that balance is met. Any type of meat will cause more symptoms and toxin build up than vegetarian food; especially organ meats, red meat and turkey.
3) Dogs should not get dairy, soy products or corn.
Dairy and soy are much more easily metabolized by the liver than any type of fish or meat. Only about 1.5 % of dogs are allergic to corn. While corn should not be the first ingredient in any food, it does provide a variety of amino acids. Many of my dogs have been on PediaSure Vanilla (with or without added fiber) if they are anorexic, won’t eat on their own or their digestive systems can’t tolerate the RC Hepatic.
4) It’s OK if a dog with liver disease doesn’t eat for 12+ hours; fasting will cleanse their systems.
Fasting dogs with severe liver disease can cause a dangerous drop in albumin, and then result in ascites (fluid in the abdomen). The only dogs that may need to be fasted are those with pancreatitis, and it’s likely that if the have liver disease and pancreatitis they will be in a vet hospital on an IV.
5) Dogs should get their minerals from real food eg. nutritional yeast.
Nutritional yeast is extremely high in purines and not recommended for any dogs with liver disease. Purines result from food metabolism and high purine foods increase uric acid, which will cause toxins to build up. Urate bladder or kidney stones or even neurological symptoms may occur.
6) It’s OK to feed raw food to dogs with liver disease.
Dogs with liver disease are also prone to immune system problems, so giving anything raw can expose them to infections from salmonella that their systems will not be able to fight off. Even raw veggies and fruit are tougher to metabolize and not recommended. Any fruit given should be partially pulverized to aid in digestion.
7) Natural foods that heal the liver should be given eg. beans, peas, pumpkin ,raisins, garlic, pineapple.
Beans and peas are high in purines and should be avoided. Pumpkin is high in copper so is not recommended. Raisins can cause kidney damage. Garlic can cause hemolytic anemia (even in low doses in a dog with a liver disease). Pineapple contains bromelain which is often used in digestive enzymes, but may be a problem for dogs with liver disease as it is high in manganese. Furthermore, any dogs with calcium oxalate crystals in their urine, kidney stones or those that have been identified as having high copper levels should avoid food high in vitamin C.
8) Any supplement or dog product labeled “Natural†is safe to give .
There is very little oversight in terms of pet products! Natural does not mean safe! A product that you buy may contain numerous ingredients that are not listed as ingredients or have unsafe “inert†ingredients. I remember calling a company about a “Natural†flea/tick shampoo that had about 4 ingredients listed on the label. This shampoo actually had about an addition 20+ ingredients that were not on the label, including antibacterial and antifungal ingredients.
9) Fiber is good for all dogs with liver disease.
While fiber is important for most dogs because it increases their tolerance for protein and can help control intestinal bacteria that contribute to neurological symptoms, dogs with small intestinal problems are an exception to this rule.
10) If your dog isn’t eating, it’s OK to feed them anything they will eat.
I’ve heard this one a million times. Dogs with liver disease frequently have anorexia and will not eat on their own. It’s our responsibility as owners to give them the proper food, even if it has to be syringed or force fed. Frequently a dog will eat a new food on their own once or twice, but then will get nauseous and refuse to eat it again; either because it’s the wrong type of protein, or too much has been given per meal.
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