Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Opinions on removing spleen??

Toby is continuing to get weaker and started vomiting and having diahrrea yesterday. He recently started cyclosporine which could be causing this. He vomited again this morning and fell in the yard. I took him to the vet and found that his hematocrit had actually risen from 20 to 23 this week. She said she had talked to several vet friends who had good success with removing the spleen. If we decide to try it, she wants to do the surgery early next week. She wants to do this while his hematocrit is high enough to give us a chance. Any advice or comments regarding removing the spleen??? And, if poor Toby doesn't have enough problems.... I went home at lunch to take him outside and found him sitting on the floor shaking his head and licking his lips like crazy. At first I thought he had seizure. Upon closer inspection I realized that he had chewed on his blanket and had a large wad of thread stuck in his teeth. I was so relieved to find it and get it loose (which took some time) that I didn't stop to think that he could have swallowed some. That could be causing the vomiting, too, and could also be disasterous. Karen H.

Karen H. MO

Karen, I am so sorry to hear about Toby's problems. Some dogs do experience these kind of digestive problems with cyclosporine. If he is still on prednisone, that may account for some of the weakness that you are seeing as it will destroy muscle as one of it's side effects. Chance has had his spleen removed, not specifically for this reason your vet wants to, but for another reason at a time 2 months earlier than his diagnosis of anemia. I can explain to you the functions of the spleen and why your vet is considering this operation. Humans and dogs both have spleens. It is actually part of the lymphatic system and participates in immunity. However, it also plays a large role in the circulatory system as well. It's major day to day job is to take old worn out red blood cells and platelets, break them up and macrophages help the body recycle the materials in them. It does this by passing blood cells through very tortuous pathways that weave back and forth tightly in the spleen. The young healthy blood cells can navigate tight corners because they are supple. Older cells can't and they break apart. The average life span of a rbc is about 120 days. So this process occurs all the time as cells age. When the spleen is removed, this job falls to the liver, bone marrow (and possibly the kidneys) and they seem to do ok. Another function of the spleen to to produce B cells which develop into antibody producing plasma cells. A third function is to store blood and release it when there is a great demand for it. My vet says it is like an "instant transfusion." Dogs can store a lot of their blood in the spleen and may use this function to a greater degree than humans do. Imagine you are a sleeping dog in the wild and suddenly your alert ears hear a sound that indicates danger. The spleen has been holding a lot of blood in it during sleep. Suddenly strong muscles of the spleen squeeze it and release all this blood back into circulation so the dog can jump up to fight this enemy. Or, for most of us, it is the ability of a sleeping dog to reach the kitchen in a split second when they hear the cookie door open. Studies done on dogs have indicated that they can actually have anemic levels of circulating blood while they are asleep, something called nocturnal anemia. Most of the blood is in the spleen. This is important because it means that dogs can live ok without a spleen as far as the need for circulating blood goes. They will have a lower average packed cell volume or hematocrit, but they can function ok. Another function of the spleen in dogs is to destroy cells that contain blood parasites. Remember how I said that the pathways that the cells travel are very tortuous? If a cell has a blood parasite inside, it is not healthy and as it passes through the spleen it may break apart "spilling" the blood parasite. The body's immune system immediately comes and destroys the dangerous invader. It then mounts a systematic attack on these parasites by recognizing the antigen of the disease and developing antibodies to attack. Killer lymphatic t-cells are made by the body to attach to the blood cells that have these antigens on them identifying them as "not self." They hook on and destroy the blood cell with the bad thing inside. So if a dog is exposed to certain tick diseases, the immune system can sometimes mount an attack to this disease and possibly eliminate it in the early stages. A dog without a spleen has less of a chance at doing this properly and so they need special consideration when exposed to these certain tick diseases. What your vet has read in hematology textbooks is that the spleen can sometimes go crazy in this immune system function of destruction, not necessarily just for tick diseases. It can begin to see all the red blood cells as "not self." It mounts an attack to red blood cells and destroys them. So the spleen can be considered a "site of destruction" in some cases. This is autoimmune hemolytic anemia. Red blood cells are being destroyed. This is called hemolysis. "Lysing" or destroying heme.. red blood cells. Medical literature says that removing the spleen may possibly stop this process or slow it down. I think currently that it has not been decided if it is truly effective or not. Vets who are experienced in treating AIHA may have clinical experience that it is effective. There may be other vets who feel in their practice that it has not been effective. The veterinary hematology textbook I have indicates that it may not be as effective as once thought and at least should be considered a last step. The considerations you need to keep in mind with this surgery are the possible drawbacks of a major surgery when Toby is ill right now. Can he recover ok from a surgery like this? What are the risks of using anesthesia on a sick dog? What is the skill level of the vet doing the surgery and do they have instant access to blood transfusions that are properly matched to your dog? What is the vet's actual clinical experience with the efficacy of this surgery? If this were me I would also want to know what other causes of this destruction have actually been explored. In medical terminology they call this "ruling out" all causes. The removal of the spleen should probably be suggested after all other things have been ruled out. Chance is doing fine now without a spleen, as most dogs do. His pcv or hematocrit is always lower than most other dogs but that doesn't stop him from taking 3 hour walks. I think he sometimes gets a little more tired and has to lay down for a bit but he will get right back up again. We will always have to pay special attention to protecting him from certain tick diseases as he has less ability to fight them off himself. I hope that I have given you a complete but understandable look at what is involved in removing the spleen and that this will help you decide what to do. My best to you, Patrice

Patrice NYS

Patrice, thank you so much. I appreciate the thorough explanation. The surgery would be a last resort. My vet feels we are at that point. I've always wanted to try everything possible, but I have to be realistic, too. The skin infection that he developed last month has not healed properly, and that's on the back of his neck. The vet mentioned that she had Oxyglobin on hand in the event that he needed a transfusion. It seems like I've read bad things about that??? When Chance was so weak and layed down in the middle of the road, did he ever stumble and fall? Or did he just get too tired to walk? Toby has fallen several times lately. I know the prednisone is causing this. I'm just wondering if it's actually possible for him to regain his muscle and strength?? Thanks again, Karen H.

Karen H. MO

Karen, Chance was just very weak from anemia at that point and did not fall down, but rather laid down. But he was weak enough at many times to stumble a bit. The muscle mass goes very quickly. His legs were just a collection of bones and ligaments. Please review the first three photos of Chance in his flickr set to see how bad he looked in the summer of 2007 and how he looks now to understand that the muscle does come back. His rear legs will never be the same strength. I encourage him to walk as much as he can handle. http://www.flickr.com/photos/patricel/sets/72157602714279765/ Here is a clip from Dr. Dodd's protocol: "*Do not use Cytoxin, Oxyglobin - studies show a decreased survival rate with these drugs." If you need a transfusion here is what she says about that: "Transfusions: a. Better to transfuse sooner than later. b. Transfuse if PCV<15% or ( >12% if reduction if PCV is not peracute). c. Use Packed Red Blood Cells (best) or Fresh Whole Blood. d. True universal donor (DEA 4) is best as you usually can't type or cross-match due to auto agglutination." We were lucky that our vet's donor dog was a good match for Chance so we had a source of fresh whole blood at all times. We had the blood of both dogs cross matched BEFORE we needed to. If your vet is looking for a safe source of blood to purchase, Dr. Dodd's organization is in the business of providing donor blood nearly world wide. www.hemopet.org. An email or phone call would provide all the information she would need to determine if they have a source of blood for Toby. patrice

Patrice NYS

Patrice, Chance is gorgeous! The sweater you made for him is beautiful, too. I love schnauzers. We've had three miniature schnauzers over the last 28 years. We have one now that will be 14 next month. She acts like a puppy compared to poor Toby. Thanks for the suggestion regarding contacting Dr. Dodds for a blood transfusion. I hadn't thought of that. Toby has had one unmatched transfusion already so the next one must be matched. I was told that if he needed another transfusion we would have to go to an emergency clinic about 2 hrs. away. Maybe if we can determine his blood type now, before we need it, I could have it shipped to my vet?? That's definitely something to look into. Thanks again, Karen H.

Karen H. MO

Oh, yes, please make sure that you either have blood typed ahead of time or consult with Hemopet about safe donor blood. There are approximately 11 different typings for canine blood. Dr. Dodds maintains safe, universal donor blood. She is very proud of this part of her organization. Her goal is to have blood bank locations around the world. p

Patrice NYS

Why does Dr. Dodd not recomment the use of Cytoxin?

Sue K PA

Sue, I am not sure exactly what her reasoning is. I can certainly guess at it and do some research about it. In my text Schalm's Veterinary Hematology there is this reference to cyclophosphamide: Pages 187-188 "The immunosuppressive agent cyclophosphamide is known to cause bone marrow suppression in dogs and cats." On Joanne's treatment page she lists this information about it: "Another potent drug used in the treatment of autoimmune hemolytic anemia is cyclophosphamide sold under the brand name Cytoxan. Cytoxan may be used in cases with severe hemolysis and agglutination. The usual manner in which Cytoxan is given is daily for 4 consecutive days per week, stop for 3 days and then repeat. Because of the potential for development of serious adverse effects, Cytoxan should only be used in patients who can be adequately and regularly monitored. Primary adverse effects in animals associated with Cytoxan are bone marrow suppression, gastroenterocolotis (nausea, vomiting, diarrhea) alopecia (hair loss) and hemorrhagic cystitis." So from what I am reading, it can have significant negative side effects. If you have a dog that is marginally non-regenerative and needs transfusing perhaps there are better choices than this drug. patrice

Patrice n

When I first started doing the Meisha's Hope Web site, (10+ years ago) Cytoxan was the second drug used in the treatment of AIHA/IMHA after pred. I saw very few dogs on cyclosporine and if they did use cyclosporine they used Sandimmmune. I now see very few dogs now on Cytoxan and more vets using cyclosporine (either Neoral or atopica). I think most vets feel that cyclosporine just works better then cytoxan. I do still see lots of dogs on Azathioprine (Imuran). In info I received from Dr. Dodds years ago, she said she preferred Cyclosporine (at that time,Sandimmune) over Cytoxan (cyclophosphamide) so I think she has not changed her thinking on this issue. Bottom line, I think vets just feel Cyclosporine works better and has less side effects then Cytoxan (cyclophosphamide)

Joanne MN

This thread was discussed between 06/12/2008 and 08/12/2008

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