Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Maggie's mixed results on 1st CBC

Maggie had her first CBC done yesterday (Thursday 3 November) since she started her Prednisone and Azathioprine treatments 13 days ago. Her results were mixed with a slight drop in hermatocrit but increase in reticulocytes. Two weeks ago: Hermatocrit: 25 Reticulocytes (measure of regeneration: 1.2% / a whole number of 48 Yesterday: Hermatocrit: 23 Reticulocytes: 2.9% / 85 So as my vet described, she is slowly starting to release immature RBCs (reticulocytes) into her general bloodstream. This is an improvement from two weeks ago when she was basically non-regenerative. She also attributed the slightly lower hermatocrit to the first week during which she was probably adjusting to her treatment. Also, her WBCs are up which indicate that the prednisone has taken affect. I am disappointed that her hermatocrit was lower, but overall encouraged that at least her bone marrow has started to release RBCs. Maggie's vet also offered to have the complete results emailed to me for the past 6 weeks. Otherwise, last night and this morning, Maggie has been a very chipper and active Lab. Not her usual self, but better than a week ago.

RobertN Superior

Robert, Do you know if these numbers on this test are listed as Absolute Reticulocyte? There is a math formula that is used to determine the actual effective value of regeneration that is dependent on the degree of anemia. A much lower HCT hematocrit or PCV packed cell volume (in the range of around 23 for instance which would be considered moderate anemia) requires a higher degree of regeneration than a HCT/PCV of a mild anemia (say around 35). So, thus, to "combat" the anemia, the body should be producing considerably more reticulocytes. In about 3-4 days these reticulocytes mature into working red blood cells, so you will see a jump in those numbers very soon. It will be a small number, but any increase at this point is significant. What you would like to see is for the next test to show an absolute reticulocyte value of more like 300,000! This would be considered appropriately responsive regeneration. And eventually the numbers of reticulocytes should drop down to a normal 1%, 60,000 once the HCT/PCV is around 37-38%. Does this make sense to you? I am short on time, but if you have questions and I will answer them later. my best patrice

Patrice NYS

Yes, I did not write it down in my notes, but I recall Maggie's vet saying that these numbers are Absolute Reticulocyte, which she described as a measure of regeneration. She seemed to be ok with the current blood test. Not ecstatic but not unhappy. She seems to think that the prednisone is "starting to work".

RobertN Superior

Maggie is also on Azanthioprine (50 mgs. EOD).

RobertN Superior

Patrice, I may have misunderstood my vet. She did say that Maggie went up from 1.2% to 2.9% I reread your reply and then did some independent research on my own. Maybe 45 and 85 was short hand for 45,000 and 85,000. IDK for certain. Hopefully the results will provide more clarity. We have another CBC in two weeks and I will look for improve reticulocyte value. Regardless, Maggie continues to do well, although she is more chipper on some days as opposed to others. Thanks so much. Robert and Maggie

RobertN Superior

Robert, I can understand your confusion. Think of it this way. A normal count for red blood cells is about 5.5 million. 1% of that would be about 50,000. The normal reticulocyte count (in a healthy human or dog) is around 60,000, or 1%. Obviously, this is counted by an automated laser and is estimated. It used to be viewed on a slide in a microscope, counted by sight in quadrants and estimated. Here is a page that explains the way they use a mathematical formula to determine if the amount of reticulocytes is adequately regenerative for the degree of anemia. http://ahdc.vet.cornell.edu/clinpath/modules/rbcmorph/cretic.htm Don't sweat trying to understand this too much, the automated analyzer does this now-a-days, but it does give you an excellent perspective on the ratios. If you can afford it, taking another CBC next week will probably result in a big surprise for you. It may show many more reticulocytes! She is chipper because she is getting better. She feels badly because the side effects of prednisone are horrible. The sooner you can decrease this safely, I repeat safely, the better off she will be. See the first three photos in these pictures of Chance. You can see what prednisone did to him after a summer on it and how he recovered a year later. http://www.flickr.com/photos/patricel/2857651904/in/set-72157602714279765/ Just for your future reference, aza is known to suppress bone marrow production of red blood cells at times. Keep this in mind if you seem to hit a wall with her improvements. my best patrice

Patrice NYS

Reticulocytes, broken down in greater detail. http://ahdc.vet.cornell.edu/clinpath/modules/hemogram/retic.htm

Patrice NYS

Patrice, You are awesome! Thanks for taking the time to share your experience and provide your insight. My vet is very conservative and has expressed that even when we do get to the point where we can reduce the dosage of prednisone, (target of mid-upper 30s hermatocrit) it will be in small measures and very slow. I trust her implicitly and I truly performed due diligence in selecting her. Not only is she a very thorough and discerning professional, she is well networked with many relationships across the country. We send all Maggie's lab work to Colorado State University's Veterinary hospital and she is in constant consultation with an expert in internal medicine and hermatology. Prior to having the CBC results, and upon visual examination she said that Maggie looked "great... nice and pink". Chance's before and after photos are quite striking. I am alarmed by Maggie's muscle loss after just a little over 2 weeks. Does it ever hit a floor? I have been meaning to ask her about Azathioprine and bone marrow suppression. Maybe giving it to Maggie every other day is meant to mitigate any negative effects pertaining to her RBCs. Maggie enjoyed a medium rare bison burger mixed in with her dry kibble and some broccoli for dinner this evening. She trotted around the block with me and was very affectionate after dinner. Once her evening dose kicked in, she drank an entire bowl of water which I promptly refilled, then found a cool spot to lie down. She is exhibiting exactly what you describe, getting better but dealing the the nasty side effects associated with the prednisone. So I will continue to have faith but be a proactive partner in Maggie's treatment. Thanks again, Robert and Maggie

RobertN Superior

Robert, Prednisone is a wonder drug. It saves lives, not only dogs, but human lives as well. It is so easy, though, to grow to hate the side effects of it. And for this reason, human doctors and vets don't like to prescribe it long term. When human organ transplantation became more accessible, doctors knew that their patients would need some type of immunosuppressive for the life of the patient or they would reject the organ. At first they were using prednisone, but these patients often became very sick from the long term side effects. Researchers were tasked to find something else. One drug they discovered was cyclosporine. It is made from a fungus. It is unique because it seems to target just the elements of the immune system that cause the most havoc in autoimmune conditions, the T-cells. They sometime will stop listening to their original instructions and begin destroying "self" elements. They have been now found to contribute to many autoimmune conditions. And cyclosporine has found a market for many human autoimmune conditions. It was not long before veterinary medicine began to utilize this drug and you will find it for one use on your vet's shelf as Atopica, tested and approved for atopic allergies (those caused by inhaling allergens like pollen.) But it is often used for other canine autoimmune conditions. A popular use is as an ointment for a serious eye condition called conjunctivitis. I tell you this because this is the drug I used for Chance. When I contacted Dr. Dodds, Chance had been on prednisone only for over 2 months. He was not doing well, he had not made red blood cells or white blood cells in a long time. The prednisone was not working and the side effects were horrible. She explained to me that we needed to get him on another drug immediately so we could decrease the prednisone as quickly as possible. She wanted to use cyclosporine. At that time, the only source, we thought, was human meds and we could not find any in Rochester. But my vet offered up Atopica, dosed by dog weight and on her shelf. Dr. Dodds was delighted and so we started it. Within not quite 3-5 weeks he had became regenerative and I had been able to get the prednisone dose reduced significantly. He survived and by that fall was clinically nearly normal as far as his blood work went. But it took a long time to recover from the prednisone side effects. I wish I had contacted Dr. Dodds much sooner. We made him suffer needlessly. At one point his alkaline phosphatase was over 8600. The longer high dose prednisone is used, the more significant the side effects. It is not a normal body condition to be flooded with high amounts of cortisol. It is as though the body is in fight or flight 24/7. There isn't a body function that isn't impacted when this happens. This is called Iatrogenic Cushing's Disease. The adrenal glands sense they are not needed and shrivel. Removing the prednisone slowly is done to protect and wake up these glands that have been "sleeping" for a long time. The longer they are like this the harder it is to recover to normal. Dr. Dodds also prescribes azathioprine, but she is cognizant that this drug can suppress the bone marrow so she is very careful in non-regenerative cases. Chance's case was so intractable that she didn't want to use it for him for this reason. My greatest wish is if there could be nationwide accepted clinical protocols for diagnosis and treatment of these serious hematological autoimmune conditions. I see so many "flavors" of treatment on this forum. And owners sometimes have a day or two to understand the disease and all the complicated options they have to decide between. It can be overwhelming to them, and very disheartening. Owners who have been successful continue to come to this forum to help them, because we know that survival is possible, even with the most severe conditions. We are blessed that we have this open forum, un-moderated, and available around the world. my best patrice

Patrice NYS

This thread was discussed between 04/11/2011 and 08/11/2011

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