Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - To transfuse or not to transfuse

Maggie's (7 year old yellow Lab) last HCT, taken on Thursday, was 20. She is currently alert, able to sit up and walk slowly but has little or no stamina. When she needs to do a BM, she wants to go further away from my home and last night went down a small hill, came back slowly, taking a break on the way, and was really breathing heavily. She really strains but its soft, due to the Cyclosporine I believe. Otherwise, She eats, drinks and last night came to me for affection. She is sitting up and while her respiration is more rapid than normal, it is not unmaniginable. She is breathing through her nose. She is on 80 mg pred, 200 mg of cyclosporine which she started Friday night, and 50 mg of Azathioprine every other day plus Pepcid. We added the Cyclo on Friday because, while her reticulocytes are rising, they were not yet to the point where her hermatocrit had reversed and she is not feeling good. At the beginning of these 3.5 weeks of treatment, I was optimistic that we would not need to give her a transfusion. Now I am not so sure. 20 is pretty low, and that was 4 days ago, but many of her symptoms, including and especially the extreme muscle wasting, are due to the multitude of high doses of medications she is on. So in about 2.5 hours, she is going back to the animal hospital where the vet will perform a CBC. Please keep us in your prayers. I don't like the idea of transfusions and am still hoping we have time to turn the tide. I have faith that she is on the verge of a breakthrough, but am worried that if her HCT is too low, that a transfusion could trigger an immune response that sets us back. Maybe that's just my ignorance on her condition. Blessings to all two legged and 4 legged furry friends. Maggie and Robert

RobertN Superior

Robert, What you are thinking about is something called "transfusion trigger." I can tell you that this is not straightforward. There is no magic HCT number you reach that requires transfusing. This is the same for human medicine as it is for veterinary medicine. So, the skill of the attending clinical physician or vet contribute to this decision, along with the results of testing. They carefully evaluate the *symptoms* of the affects of anemia on the dog as well as the "signs" as presented by the CBC and chem screen. There is a good reason to avoid a transfusion if it is not currently medically needed. Do you remember my lengthy discussion about reticulocytes? To flesh that out, it is important to understand what triggers the increased manufacture of blood and what signals this to slow down to normal levels. I will try to simplify this, mostly because I am short on time, but if you have more questions, ask. Body cells need oxygen to produce energy. It is a complicated process that I won't describe, but think of it kind of like a chemical reaction.... When there isn't enough oxygen, the body cells "complain" to the body "hey, need more O2 down here now!" The body then stimulates the kidneys (yes the kidneys) to make a hormone that in turn stimulates the bone marrow to make more reticulocytes. The bone marrow will respond continuously (and with the proper amount required) to fill the need until the kidneys no longer signal this great need for oxygen (because the body cells stop complaining.) You can see that something like kidney disease can interfere with blood manufacture. If that hormone isn't being produced, then there is nothing to signal the bone marrow to make RBC. In humans they can receive injections of this hormone to jump start manufacture. Dogs can also receive this injection and I have known several dogs on this forum that had this done. But its very expensive and difficult to get for a dog. There is also a risk, since this is a human product, that the immune system will develop antigens to the hormone and create another round of autoimmune disease. So back to the bone marrow. You are dealing with non-regenerative or poorly regenerative bone marrow. So was my dog. We can assume since all testing has been done that we are dealing with purely autoimmune causes, common in dogs. First, you want to stop the destruction and you are doing that, by giving potent immunosuppressive drugs. BUT, you also WANT the bone marrow to start paying attention to the message from the kidneys and make more blood! You want those cells that are made to be strong and viable. Back to the transfusion. If you do a transfusion, it lessens the call for the kidneys to produce erythropoietin because the need for more oxygen has been met by the transfused RBC. Oops. This is where transfusions can backfire for dogs with bone marrow failure. It is like a suppression of the bone marrow. So the transfusion trigger for a dog with bone marrow failure can be a little different than for a dog that has active autoimmune hemolytic destruction going on in circulation. The decision, in my opinion, is dependent on how much you and your vet feel the low numbers are impacting on Maggie's condition. In other words, is she really feeling badly? I had Chance transfused when he reached a PCV of 18. He was trying to do his business and he was too weak to stand to do that. I could not bear to watch that. It was that simple. My vet agreed. The next complication with this is that dogs have many different blood types, vs humans. The cool thing about dogs is that their first transfusion is "free." In other words, they can take any type of canine blood and probably not have a transfusion reaction. This is great because most dogs usually only need a transfusion because they have been hit by a car. The subsequent transfusions must be done much more carefully. It is best to type and match the blood to avoid any negative transfusion reactions. Dr. Dodds' main business is producing large quantities of safe canine blood products for use around the US and Canada. She is an expert in blood transfusions. So if you do a transfusion now and then decide later you want to do another one, you must be much more careful. I am not trying to frighten you, only to get you to think these things through and talk with your vet about it. 20 is a low number but your description of how she is doing is pretty much the same as Chance was, slow but able to get around. If she can't do that BM then maybe this will be the reason you want to do a transfusion? I was glad I did the transfusion when I did and have no regrets, we ended up doing another one. But Dr. Dodds did talk with me about the possibility of it slowing down Chance's recovery. Luckily the cyclosporine didn't take long to work and once we were there, we did not consider them anymore. my best patrice

Patrice NYS

Patrice, Thanks for your response. Maggie is currently checked in at an overnight emergency hospital receiving a transfusion. She was definitely showing the clinical signs that my vet warned of. Her PCV was 17. She's had trouble breathing and needed oxygen. But you want the good news? Her reticulocyte count now suggests that her bone marrow is fully responding to the anemia. 9.1% Absolute value 188 (bottom regenerative range my vet said is 110-150). So her bone marrow, as my vet said, is now responsive. My vet was a bit guarded at first but more optimistic after speaking with the internal medicine specialist who says Maggie is finally in the ballpark of where we want her, we just ran into a timing issue. So I am positive, knowing full well that there are still risks and no certainties. BTW, Maggie was typed and is receiving matching donor blood. My vet knows of Dr. Dodds and speaks of her as the preeminent expert in this field. The hospital is also treating Maggie for blood clots (aspirin, herparin) in case they are contributing to her trouble breathing and also to protect her during and following the transfusion. They were impressed with her reticulocyte count but also cautioned me that sometimes blood transfusions trigger an immediate immunity response and the transfusion does not take. But the idea is clear. Give Maggie time until we finally get full necessary immune suppression and let those reticulocytes take off. Fortunately, Maggie started her Cyclosporine dosing last Friday and they let me give her tonight's dose. They said that they'd give her the prednisone tonight so she shouldn't be off track in her medication. I had a feeling that this was the week for big improvements, but that timing was of the essence. Hopefully the transfusion giving her more time is what help turns the tide. Thanks so much. Maggie and Robert

RobertN Superior

Roller coaster evening. Working vet calls to let me know Maggie's breathing still strained even though much less than before. Thinks its caused by blood clots. He is worried, mentions the option of putting her on a ventilator, says her condition is very guarded and I may need to keep that into account when spending this much. But tests come back negative for clots, however there is some swelling around the heart. Gives her oxygen and she starts getting much better. She has a heart murmur. Upon viewing ultra sound, there is fluid around the heart. Vet can't reach cardiologist but says one injection of diurectic will help without harming her and the specialist agrees. The vet has gone from being very concerned to now being very encouraged. Maggie in the meantime is getting stronger. He said the PCV was better and her clinical signs are much better and she looks very strong, albeit with oxygen. He still suggests a cardiac echo when the cardiologist comes in tomorrow morning. He says its now likely this can be treated and I can bring my dog home but says he will let me know if she declines. Tells me in the meantime to get some rest. RIGHT! I know that the standard protocol for treating IMHA includes some very harsh drug/steroid therapy. Any way the Prednisone is contributing to Maggie's heart issues?

RobertN Superior

Robert, I hope all goes well. Transfusions can also jumpstart RBC production. But expect her PCV to at first stabilize. I know that if you google prednisone side effects most sites offer a straightforward list. Cookie went blind when she was on high dose prednisone but after we decreased it that went away. I'm sure they were related but that's not a known side effect. So just because it's not on the list, doesn't mean they it isn't caused by the prednisone. I have looked at a list of human prednisone side effects which does include eye and heart side effects so this is more reason to believe that it is drug caused. Here is the list if you would like to take a look http://www.webmd.com/drugs/mono-9383-PREDNISONE+-+ORAL.aspx?drugid=6007&drugname=prednisone+oral&pagenumber=6 Also my suggestions for when she comes home: Limit activity, if she can't be trusted to go out without wandering then take her out on a leash. Feed her bland food (rice, chicken, fish, eggs, cottage cheese, pumpkin, I/D food), so the digestive system can have a break. When my dog turned up chicken, eggs, and cottage cheese I started using tripe to mix with the rice and that too worked well. Is she on pet tinic or another vitamin? A dose of vitamins might help her feel better.

Monet Sammamish

Maggie update. Packed Cell volume has positively responded to the transfusion (up from 17 and holding steady at 27!). She is now being treated for a blood clot that the vet believes will resolve. The idea is to prevent new blood clots while her current clot breaks up. Vet is confident that she will recover but she currently needs oxygen, treatment and continued hospitalization until the clot resolves. The idea is that the blood clot is an acute event and that Maggie, once the clot breaks up enough and is released, will need anti-platelet coagulation medication for the next month. I asked the emergency vet if this will impact Maggie's continued immuno-suppression. Maggie is responding well to the Prednisone/Aza/Cyclosporine and finally regenerative so I don't want to set this back. The emergency vet promised me that this is a separate issue and will confer and work with my vet. So things are looking good. Nothing is certain, but the vet is confident that Maggie will be able to soon come home, feeling better with a manageable treatment. Maggie and Robert 15, Nov. 2011.

RobertN Superior

Robert, I am sorry for the awful night. Transfusions are lengthy procedures that require lots of hands on and attention to detail. Even with that, there can be issues. Inappropriate clotting is a complication that requires great skill to treat. It is good to hear that they have gotten her past that. If you would like to read about this, you can research DIC disseminated intravascular coagulation. Anytime a transfusion is given, it is administered with a lot of fluid. The body cannot process that much fluid all at once. It needs to "set it aside" in the interstitial tissues so that the kidneys can process it at a steady rate. Around the heart and the abdomen are common places where the fluid will go. Yes, it is accepted practice to give a shot of something like lasix to help blow off some of that fluid. Chance developed a murmur in the years following, after he had recovered from his non-regenerative anemia. I suspected the prolonged use of prednisone, combined with the seriously low PCV he had for so long contributed to this. Eventually it worsened and he also developed an atrial fibrillation. He was seen by a veterinary cardiac specialist and we were able to prolong his life, with quality, for much longer than the specialist expected. I read somewhere that an insignificant murmur can develop during treatment for AIHA/IMHA. I don't have the reference handy and I don't have the time to look today. But I also seem to remember that they can diminish after recovery. A murmur can occur when the mitral valve does not seal properly and allows regurgitation of blood back into the chamber. It can be caused by a thickening of the valve tissue. However, there can also be innocent murmurs that cause no problems at all. There are probably as many degrees of murmurs as there are people and dogs. Many people go through life with an innocent murmur and never even know it. Their doctor does not feel it is significant. At this point I would not worry too much. While the doppler is a great test, and I have seen them done several times, I would advise you ask a lot of questions before you decide to have one done right now. Maggie is very ill right now and any kind of testing like this can be stressful. It's not invasive, but there is a lot of handling. Make sure they are doing things to make her comfortable and then revisit the testing later when she if feeling better. Again, I am very happy that they have added cyclosporine to the treatment so they can begin to drop that high dosage of prednisone. I have seen the damage it did to my dog and I wish that no one has to go through what he did. It is a great acute care drug, but for long term immuno-suppression there are better choices. Please try to remember how good Chance looked a year later. It can happen. my best patrice

Patrice NYS

Sending our prayers and we hope Maggie can come home soon. Cheryl & Ginger

Cheryl and Ginger

2nd night of Maggie's stay at the hospital sees her more pink, less labored respiration, regaining her appetite, and taking longer walks when away from the oxygen. Plus, her post transfusion PCV held steady tonight, dropping to 25 from a high of 27 at 3 am yesterday morning. The only thing is that she is penned up in the oxygen chamber and doing the prednisone pant. They are waiting until tomorrow to give her the Cyclosporine dose in order to let her food settle. A mentioned that while I am aware that we need to be focused on the current crisis, that if she seems well enough, the cyclosporine is what has brought her back to being regenerative. The daytime vet is very positive about Maggie's progress and told me so. The tech taking care of her tonight said that Maggie has more stamina outside of the oxygen which demonstrates that her clot is starting to break up. The night time emergency vet, on the other hand, decided to give me a lecture of the money I'm spending and the fact that nothing is guaranteed. It was though he was trying to get me to give a price on Maggie's life. He complained about his colleagues saying that no one else ever has this conversation. That being said, he even admitted that Maggie looks and acts better but still calls her condition "guarded". I visited her and got her to eat a decent portion for the first time. She no longer wants to eat rice because, as I believe - and the night time vet agrees, she has an adverse association with the rice because that's what I fed her when she was hypoxic. The night time vet who gave me that lecture said it was a "huge" - meaning very positive - development that she is eating. Plus, she is keeping her food down. Hopeful that I can bring her home tomorrow. Otherwise, we are looking at another $1,600 in care the following evening. Glad I have VPI. Maggie and Robert

RobertN Superior

Continued prayers for Maggie! Blessings, Cindi & Tori

Cindi FL

Sounds like Maggie (and you) have been through quite the roller coaster thus far! I sure hope you get to bring her home soon. She'll likely heal faster at home in a stress free environment. Have you considered adding CoQ10 as a supplement daily? I'll keep you both in my thoughts and prayers! Johnny, Tessy & Sadie

Johnny

Robert, Hopefully all the positives you hear from the daytime Vets helps you shut out the negative stuff from the night vet. I think once you start down this road you are fully aware of what a tight rope you walk and need to be able to hang on to anything good that happens. Hopefully your girl will be home with you soon. Sending healing thoughts to you both. Penny

Penny Lytle Creek

Robert, You strike me as someone who is intelligent and well-spoken. I am sure in person you are even more self-assured than you can present in a forum post. I think vets are used to having some clients who are not confident of what they are doing and want to know "how much is this going to cost?" And I think many people decide they cannot afford more than $x. I am sure vets think about this all the time when they are treating their patients, "how much is this family going to be willing to spend?" And so they come up with treatment suggestions that appeal to this cost cutting apprehension. When they are faced with a client who seems to be willing to spend a large sum on treatment, they are probably worried that the owner may not be able to pay the bill. Or alternatively, they think that the owner must not understand what is happening. I believe you understand enough at this point to know what you are facing and what you want to do. If you were clueless about the seriousness of this condition, it might be appropriate for a vet to say something to you, but that is not the case. I can pointedly say I have no regrets at the amount of money I spent or the length of treatment that Chance had to go through. As long as he was not in great pain, both my husband and I agreed, we would continue with the treatment. If he began to suffer, I promised it would be time. I spent many many hours sleeping on the floor with him and many hours at the vets waiting for test results and treatments. I was with him through the whole thing, start to finish. I also understand and embrace those owners who cannot continue for long complicated treatments for financial, commitment or emotional reasons. There is no wrong choice here. An informed decision is the only thing that is of importance. This vet's bedside manner needs some improvement, but his passion probably comes from personal experience. Thank him for his opinion and move on. Conserve your energy for Maggie. We support you in whatever you decide to do. my best patrice

Patrice NYS

Maggie has been steadily improving, her respiration, appetite and strength are all improving, and the hope is that she can come home today. While the hospital vets continue to work to keep her immuno suppressed, their main focus is dealing with the now fading crisis. All indications are that the blood clot is slowly resolving as her tolerance outside the oxygen chamber increases. We are expecting even good enough results that she may well come home later today! I did receive a dreaded overnight call, she has some built up fluid around the abdomen that the night time vet (a different one) tapped and treated with lasix. The feeling is that it is a bit of congestive heart failure from acute pulmonary hypertension which is being treated and will heal. However, they will do a repeat echo later this morning to verify. I'd rather not have gotten this call, but it does not necessarily set her back. I just really want to bring her home, healthy and stable. I have created a little fund raiser for her, to help allay some of the costs with some decent response. My plan is to see this through, get her well, which we are doing. She is still eating and sleeping and responds more to affection and is much more active when taken out for walks to relieve herself and see how she responds to being outside the oxygen. So, she is on the right track! Please keep you fingers crossed that this fluid is not a big deal and won't keep her from coming home. Maggie and Robert

RobertN Superior

This thread was discussed between 14/11/2011 and 17/11/2011

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