Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Relapse for Winston

It's been a while since I've posted - This process has became such a mental strain for me so I just read others, looking for successes. Winston was officially diagnosed with AIHA 8-2-09 but had been declining throughout July of last year. He underwent 4 blood transfusions and gamma guard infusions, the last of which was 12-31-09. He had been holding in the low 30's for a long time. I really thought Winston was over the worst of it and we'd dropped his pred by 1/3. He'd been stable for afew weeks when he came up with staph infections in some cuts. I don't know if he scratched himself or it was as simple as razor burn from the groomer - I'm just sick about it. He's dropped 10 points down to 21 in 4 weeks. He was on antibiotics for 2.5 weeks which cleared up the staph but he's slowly dropping and I'm just so down I almost called in sick to work today because I just didn't want to think about anyone elses drama.... I wanted to wallow in my own.... The Dr says there are no sphyrocytes (sp?) and he's highly regenerative...liver and kidneys appear ok. She's really scared me this last visit; talking about splenectomy? and adding a medication I cannot recall - started with an M and apparently is very very hard on his little body...worse than pred? Poor little thing started at 5.5lbs - the pred had gotten him up to 8.2. He was originally on 7.5mg, had dropped him back to 5 before the staph - we tried bumping back up to 7.5 but now he's at the highest level he's ever been. 10mg split morning and nite. Winston is taking 10 mg leflunamide once a day and 25mg cycloporine twice a day. I give him pet tinic, 5cc of folic acid and 3cc of liquid b12 as well as a teeny bit of pepcid. Dr. Locke says if he drops below 20 she wants to give him another gamma guard infusion. I cannot believe I'm going to have to make these decisions again. I called Dr. Dobbs office to get her opinion - she's out till late July... Any thoughts?

Lisa TX

Lisa, Oh dear. This is a tough thing to have happen. The unfortunate part of suppressing the immune system, esp with prednisone, is.... well.... you are suppressing its ability to fight off infections too. And that is what has happened. Staph bacteria are on all of us all the time. We easily fight it off without even knowing it exists. But when the immune system is being suppressed, it becomes an opportunistic bacteria. It takes over in a way that would not happen if there were enough of the protective white blood cells there to fight it. (There are several different kinds of white blood cells that do different jobs. Some of the T-cells are fighters that "lose" their memory of proper instructions and can be implicated in the destruction in AIHA.) Then your vet added another powerful drug, the antibiotic, to try to eliminate the staph and it gives a one/two punch to the good bacteria in the body. This is very hard on the body. I know when Chance was very non regenerative, he also was not making white blood cells. He had to be on one or another antibiotic for many many months. He developed staph several times. His life was always under threat of a serious infection. I have read quite a bit of Dr. Dodds literature and I know that infections are one of the causes that can "contribute to anemia." She would call that "Anemia of chronic disease." It is a very valid condition. You can read more here at Wiki: http://en.wikipedia.org/wiki/Anemia_of_chronic_disease Here is the introductory paragraph: "Anemia of chronic disease, increasingly referred to as "anemia of inflammation",is a form of anemia seen in chronic illness, e.g. from chronic infection, chronic immune activation, or malignancy. New discoveries suggest that the syndrome is likely largely the result of the body's production of hepcidin, a master regulator of human iron metabolism." This will go on to explain how this interferes with iron storage in the body and how that leads to poor response by the bone marrow. At least attempt to read this and bring the page with you to your vet and ask them to explain it to you. I would want to know a bit more about the "gamma guard infusions." There is a situation that sometimes vets will use a human gamma globulin shot to attempt to "boost" the immune system (that is having a hard time making its own gamma globulin). It also can help stop some of the destruction of platelets (in the spleen). Tests were done a few years back on a veterinary version of this for dogs but the results were ambivalent and they need to do more tests. So I wonder if this is a human or a canine gamma globulin shot? The risk of using a human version is that after the first shot, the dog's immune system can become sensitized to the "non-self" part of the human shot. This means that the dog's body possibly becomes primed to see that stuff again as an outside attacker. In some cases the dog's immune system begins to fight the shot if it sees it again. So that means there is now another element for the immune system to attack. So ask a few questions, do a little research to see what they are actually using and are the risks acceptable. If this were me, and I was in contact with Dr. Dodds, I know I would be actively pursing the infection issue to see if this is causing a systemic inflammatory condition in the body. I took a two day seminar with the vet in charge of nutrition at Cornell two years ago. He referred to inflammatory cytokines frequently as being implicated in all kinds of canine disease processes. And for every time he mentioned tumor necrosis factor and interluken he recommended the use of Omega 3 fatty acids, fish oil, as a way to decrease these. Fish oil may be contraindicated in a dog with a current bleeding issue. So it is always best to run anything like this by your vet. Tests can also be done to see if there is a problem with iron storage in the body. This is a digestive system test that measures blood levels of ferritin (iron). Testing the B12 and folic acid as a companion to this will help identify any contributing factors if there is an iron storage problem. B12 and folic acid are related to bone marrow production of RBC and are generally in the same test panel. I do hope that Dr. Dodds assistants can get your email to her while she is traveling so she can review it and send you a message. my best patrice

Patrice NYS

Dear Lisa, Dr. Dodds is out of the office but answering emails. Email her at the clinic and hopefully she will respond quickly. I wrote to her this morning about Chloe and she answered almost immediately. Thinking of you and Winston. Cheri

Cheri Maryland

Lisa, Email Dr Dodds ASAP, she will respond. Her email is: hemopet@hotmail.com Keep us posted. Furhugs, Ella

Ella Seattle

Thank you guys for letting me know Dr Dodd was responding to emails. I sent one off to Dr Dodd a few minutes ago and will keep my fingers crossed. Thank you all for your information. Patrice I need to read your info over again to make sure I understand it. As to the "systemic inflamatory condition" and needing to "pursue the infection issue further" are you suggesting though the course of antibiotics is completed, that the infection is still ongoing and he should still BE on antibiotics? The gamma guard infusion wasn't a shot. It was an IV drip that took 7 hours. Had to be given extremely slowly to prevent blood clot? I'll get more specific info on that though - It's been 6 months since the last one and I just cannot recall if the vet told me if it was human gamma globulin or canine. I'll also ask her about the Omega 3's. Thank you again - and I'll post again soon.

Lisa TX

Lisa, Anemia of chronic disease (or "anemia of inflammation") is not understood fully. If you read the wikipedia article you will see that some of the information is based on theories that researchers believe "may" be true. What they explain in one section is that when the body responds to inflammatory agents called cytokines there is a request for more white blood cells. White blood cells are made in the bone marrow, along with red blood cells and platelets. All three kinds of cells actually start from the same "precursor" cell type and as the cells mature they differentiate into one of these 3 types. Ideally, there should be a lot more red blood cells and only a small number of white blood cells and a lesser number of platelets. So if you have 1 million precursor cells and there is a request for many more white blood cells than normal (to fight bacteria), researchers theorize that there is a decreased number of red blood cells being made. This would be a cause for anemia (which is a condition of less red blood cells carrying hemoglobin). So one way to check for this may be to look at the results of a CBC complete blood count and examine the number and types of white blood cells. This is pretty easily done. From the quantity and types of white blood cells they can get a lot of information. The researchers tie this in with the idea of iron stores in the body. They think that if the body feels it is fighting bacteria it will try to keep iron away from the bacteria. Bacteria need iron to reproduce and live. To be successful, the body will try to reduce the iron available in general circulation and lock it up to keep it away from the bacteria. But the bone marrow needs that iron too so it can make red blood cells! Does this make any sense so far? You've got bad guys and good guys. Both sides need gas for their cars to keep going. The team leader of the good guys thinks that if he puts the gas away so that neither side can get to it, then it will help them defeat the bad guys. The problem is that not only does it make it hard for the bad guys (bacteria), it is making it really hard for the good guys to get around, in this case the bone marrow isn't making enough red blood cells to move oxygen around to the body cells. The iron is what helps build the red blood cells in the marrow. If this situation continues long enough, the good guys are going to suffer from this lack of iron and chronic anemia begins to develop. So back to Winston. He's been at this fight a very long time. Then he gets a bacterial infection. He has a hard time fighting it off because you have been suppressing his immune system with prednisone. The part of the body that initiates an attack on bacterial infections is saying "hey guys (white blood cells) get out there and do your stuff." The white blood cells say "hey boss, there aren't enough of us." "Well, let's make some more!" "Ok, we will. Red blood cells stand down while we take care of this problem." This is anemia of chronic disease, at least the way they theorize it works. Because the blood tests are no longer showing signs of autoimmune destruction, it is very possible this is what is happening. So, ask your vet about testing the iron levels (ferritin), the B12 levels and the folic acid levels. This is a blood test that is sent to a lab. This will help confirm or rule out if there is problem with iron storage, B12 and folic acid levels. It's not a cheap test, but it's not extremely expensive either. This will be testing the nutritional contribution to anemia. From these results they can determine a lot of things about how the body is processing these nutrients. They are essential to making red blood cells. Your vet may look a bit surprised when you ask, but I do believe they will see the importance of doing this test. I had them done with Chance when he was non-regenerative. In fact Chance had a severe deficiency of B12 and I began to give him B12 shots at home on a therapeutic schedule. This is why Dr. Dodds always talks about Pet-Tinic, it is an **iron and B vitamin supplement.** She is covering these bases right from the start! In addition, adding Omega 3 fatty acids to the diet will help significantly. Again, check with your vet before doing this. They may offer you a veterinary product called Welactin. This is a pump dispenser that helps you give the perfect dose. The Cornell vet advised us to use it for many different canine diseases. Here is some information about it: http://www.nutramaxlabs.com/Vet/Products/Welactin-for-Dogs.aspx You can go this route or use fish oil capsules. Your vet can help you determine the dosage. The Arthritis Foundation and The American Heart Association, among others, now recommend the use of Omega 3 fatty acids to reduce inflammation in the body. So Omega 3 fatty acids play an *Anti-inflammatory* role in the body. Omega 6 acids are *Inflammatory.* Many human diets and canine diets have an improper balance of too much Omega 6 to too little Omega 3. There should be MORE Omega 3 than Omega 6. So, check the white blood cell count, check the iron, B12 and Folic acid levels and add some source of Omega 3 fatty acids. I would not necessarily want to use more antibiotics, this is your vet's decision and is dependent on the results of the blood tests they do. I found GammaGuard on the internet, it is a human plasma product administered to human patients who have a primary immunodeficiency (have trouble protecting their body against infection). There are some risks when using it in humans and I can imagine that this product has not been officially tested for veterinary use. However, many human drugs are used in veterinary care that have not been officially tested. It is an accepted practice and the pluses and minuses are generally known by those vets using them. I truly believe your vet is hesitating and is considering this carefully. Any vet that is willing to spend 7 hours doing an infusion is definitely on your side. My vet spent a whole day obtaining donor blood, learning everything she needed to know about matching it and administering it and then spent 4 hours on July 4th, 2007 giving Chance a transfusion. She is extraordinary. I think your vet may be similar. my best patrice

Patrice NYS

Patrice, you've outdone yourself again!!! Thank doG we got you here! That's gotta be THE BEST description of Anemia of chronic disease I've read to date. You definetely got a way with words! You sure you don't wanna be a vet? Hugs to Lisa and Winston. Johnny & Tessy

Johnny

Johnny, Thanks. It was tough to get it down to something that is understandable, but it is really too long. If I had a week, I could shorten it. <VBG> Yes, I have thought about going back to college for at least a vet tech. But I am older and have two full careers behind me at this point. If I did go back to college, I would get maybe 10 years in that career before I would have to age out of the system. Vet techs don't have a clear path to becoming vets either. It's a very difficult program. I do encourage high school students to get into it though. It is still an excellent career path. my best patrice

Patrice NYS

You Guys are so Fantastic. Patrice - I'm so grateful to you for describing it so thoroughly. I read the wiki on Anemia of Chronic Disease and thought I was watching a Charlie Brown in the classroom when the teacher spoke and the words came out "WHA..WHA..WHA". OK - so instead of the white cells killing the red cells, you are suggesting the white cells are multiplying to fight off the infection and the red cells are slowing down because the body perceives the other is more important at that time. The body is shutting off the iron supply totally in a pre-emptive effort to starve the bacteria but now neither the bone marrow or the bacteria are getting any iron. That would mean the increased prednisone is all for nothing if there's no red blood cell destruction going on. The appropriate response would then be to go back to fighting the infection.... not specifically the anemia. I am going to re-start the antibiotics today even though Winston's Vet thought it wasn't necessary to continue last Wednesday - I just think it may have been too soon and I can't see that it would hurt anything. I'm going to check on the Probiotics and the Omega 3 today (not to be given at the same time as the antibiotics - Thanks Johnny) I keep waffling on taking him to a local Vet to draw blood to send out to Dr Dodds lab or wait until Wednesday for his scheduled appointment. I'm worried that he seems to be weaker today. I may drive him up there sooner anyway but if that's the case, I just know she'll want to do the gammaglobulin infusion and I won't say no. Thanks again ya'll. Lisa and Winston

Lisa TX

This thread was discussed between 09/07/2010 and 10/07/2010

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