Elevated ALT and bilirubin.

Misha had ALT in the 200s in February. Now it is in the 500s with a very mildly elevated bilirubin. He has been on tylan since January. It is possible for tylan to artificially elevate ALT so we are stopping the tylan and rechecking blood in 2 weeks. Any thoughts?

I have all these terrible thoughts of what it could be

What is Misha's age and health history? What is his diet? Any other meds or supplements taken? Concurrent health issues? Why specifically was he on long term Tylan? Any other abnormalities on his bloodwork? What is his albumin? Do you have a copy of the blood chemistry report? Was the blood chemistry done on a fast? (Most accurate results are when blood is pulled after a fast, just as with humans.) Any problem with the serum such as lipemia or hemolysis? (That can artificially raise certain values, and the lab will report lipemia or hemolysis on the lab report.)

I'd probably be more concerned about the bilirubin mild elevation. Have you discussed with your vet giving liver supplements such as milk thistle (silymarin) and SAM-e - vet products such as denamarin, denosyl or human equivalent products? Those supplements (as well as liver-friendly diet) can be quite beneficial for the liver.

More reading about blood tests, etc.:

http://www.dogaware.com/health/tests.html

Pat

P.S. Where are you in Ohio? Anywhere near Columbus?

What is Misha's age and health history? Misha turns 14 on August 1st. He has well-compensated MVD with no symptoms or need for medication (checked Feb 2010). He's been pretty healthy most of his life other than progressive deafness starting at age 5. He also has chronic bronchitis (diagnosed via lung flush procedure) so he coughs sometimes. In Feb he had a dental and they noticed his eyes looked off - vets have not called it dry eye to me, but it is being treated as such. In November, December and January he presented with diarrhea. Antibiotics were given and diarrhea recurred as soon as medication stopped (campylobacter and clostridium). The vet decided to use Tylan until re-evaluation in summer. Oh, he also has "twitching" and I've asked every vet I've been to about it with no diagnosis. He just twitches for a moment and then continues on.

I do not have a copy of his bloodwork, but they did not indicate any other values out of range. He was not fasted.

If bloodwork is still off, then vet recommends bile acid test and ultrasound.

Misha is on a liver friendly homecooked diet designed by a nutritionist (Cat Lane). She does diets according to NRC guidelines.

Neither vet nor nutritionist want to start liver supplementation until a diagnosis is made (via bloodwork, bile acid test, ultrasound, etc.)

Pat - your link leads to many broken links so no useful info about bloodwork :-(

Also I am in Columbus and frequent the OSU vet hospital (go for yearly dentals, heart check and eyes).

Ah, all very good answers! I was hoping that you were familiar with OSU vet school - a fantastic place. So you have access to all the specialists that you will ever need. (My brother and his family live in Columbus.)

The plans laid out by vet are very sound - retest in two weeks (I would try to get an appt. early in the morning and fast Misha from the night before to get more accurate results), and then if values still abnormal do bile acids test and then an ultrasound. I do know several senior dogs on long-term tylan, and I've heard of no ill effects from this. Diet is good and it won't hurt to wait the two weeks for retest before starting liver supplements. I have had several and know of some other geriatric dogs that had elevated liver enzymes and no reason was ever found and there were never any symptoms of disease. But in those cases, I believe that bilirubin was normal.

It's wonderful that you have vets who can differentiate between lung disease and heart disease as that often is not the case with a coughing cardiac patient (many vets just assume cough is due to heart failure, but concomitant heart and lung/airway disease is common). And I too have dentals done on geriatric dogs as I believe that dental/periodontal health is important for the oldies. It sounds as if you and your vet team have a good handle on what is going on, a good track record, and a good plan.

Sorry about those links - I'll see if I can find some helpful links that work and repost.

Pat

I'll be very curious to follow your progress with Misha as I am also currently dealing with an elevated ALT with Jake. What I find interesting is that I never would have known anything was going on had we not had pre-dental bloodwork done. Jake tested at 149 in Feburary '09, I started him on milk thistle, re-tested after 8 weeks and it was back to normal. He then tested at 150 February '10, I put him back on milk thistle, re-tested 4 months later, results returned at 317, he is now on denamarin and a 3 week course of clavamoxx. All other test results normal. From reading Pat's post I believe I will make sure to fast Jake before re-testing at the end of the antibiotic course.

Hoping you get normal results with your next bloodwork.

I'm considering rerunning bloodwork and having the bile acid test in the same day. From the scant bit I've read about tests, the level of bile acid is variable and the fasting and postprandial tests give a much better indication of liver function than fasting alone would.

I'm also torn on whether I should get the ultrasound at OSU or his regular vet clinic. OSU is twice the cost, but they might be better. Thinking (worrying) ahead. Suggestions?

In any case, I'll keep updating everyone.

Just have a second, and I'll update later today, but I attended three sessions on liver at the AVMA convention - one on diagnostics - specifically what to do in the presence of elevated liver enzymes, one on hepatic disease, and the last was called "emerging liver diseases that you should know about." Presenter was David Twedt, bd. cert internist and US liver guru. He was a great speaker and a really nice guy.

You can read more here:

http://veterinarymedicine.dvm360.com/vetmed/author/authorInfo.jsp?id=48140

I'll review my notes and post later very basics of what he said, but the bottom line is that two weeks is too short an interval to learn anything meaningful - drugs stay in the liver for a very long time so re-test should be more like 6-8 weeks. He also recommended starting the liver support stuff in the interim. I'll write more later.

By the way, everyone bookmark the dvm360 website - lots of good info there, AND you can print stuff and discuss with your vet since this is info for vets versus just something that some yahoo (like Pat B) wrote in an internet pet forum. When talking with your vet about something you read on the internet, they are much more receptive to actual vet material.

Pat

P.S. Misha and Jake are two of the reasons that I attended these sessions!

Pat said:

P.S. Misha and Jake are two of the reasons that I attended these sessions!

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And we love you for that Pat :lotsaluv:

Thanks for the link to the articles. Will give them a read later today.

I picked up a copy of Misha's bloodwork. In addition to the ALT/bilirubin, his RBCs were at low at 5.05M/ul (ref range 5.5-8.5). His albumin is normal midrange. Perhaps low RBC and elevated hemoglobin are signs of some sort of anemia?

Thanks for all the information Pat. I've been going through it. Unfortunately, it seems like the bloodwork is not indicative of anything but a general problem and I have to worry and wait for more tests.

I found this site for bloodwork info: http://home.gci.net/~divs/disease/lab_tests.html#cbc

Also, his blood tests say ALB/GL = 1.0 but there are no units indicated or reference range so I can't tell anything from it.

Finally, he has been exposed to a dog with hookworms for the past 3 weeks. Said dog is a rescue and vetted OK, but when new mom took him to the vet he showed hookworm.

I looked up and read everything from the link. It looks like Dr. Twedt says, "A rational wait period for re-evaluation is 4-6 weeks giving consideration to the half-life of liver enzymes and the time needed for recovery from an acute occult hepatic injury. ". Next Friday is officially 4 weeks, and I don't think I can handle the stress of waiting any longer. Vets are only testing ALT, bilirubin and RBCs. If ALT/bilirubin levels have not dropped, we move to the bile acid test.

I talked to my vet who said the pharmacist indicated that 2-3 weeks should be enough time for the Tylan to clear. Vet also said that clearance is not clear cut and can be different based on the individual animals status. I hope waiting the extra 2 weeks (4 total weeks as above) has not caused anything terrible to progress.

Shoot, I forgot to ask the vet if the 2% cyclosporin eye drops could be affecting the liver...

Just wanted to let you know I'm thinking about you out here. We are going in next week after a 3 week round of antibiotics and a 4 week round of denamarin to see if Jake's ALT levels have dropped. Hoping the best for both of us :hug:

Thanks for checking in on us Cathy. Does Jake have a thread too?

I've had what I hope is wonderful news. My vet was out when I called for results but they said ALT is at 105, RBC's are either slightly low or low normal and bilirubin is back in normal range. I made sure he was fasted 12 hours before the test. My vet should call me tomorrow or Monday to discuss. I am so relieved that his ALT has dropped so much. Hope it was just the Tylan after all.

I suppose his liver friendly diet could be a major factor too, but whatever it was the results look much better

That is excellent news!!! I've been waiting to see if you've heard anything.

The liver is such a strange organ. It's just so complicated to figure out what the tests mean and how the various elevations work in conjunction. The one relieving thing I've been reading is that there is rarely urgency. When my vet and Dr. Dodds both said to re-test in 6-8 weeks I took some comfort in that. The downside is that by the time you are seeing actual physical symptoms of liver distress it's usually too far gone to be able to do much.

Does Jake have a thread too?

Click to expand...

No....I just joined onto yours :-D:-D

Jake's ALT came back at 79.....on his birthday...what a great birthday present! i*no:No clue what did the "trick"....antibiotics or denamarin....or maybe the fasting. Interesting that the his February results were elevated but the most recent ones elevated so much higher but that was not a fasting blood test. Makes me wonder how much the fasting has to do with it. But I had read a lot of good things about denamarin. We are going to do one more month of it and re-test again. I am thinking I will keep him on some kind of liver support, something along the lines of milk thistle in combination with SAMe (basically the same ingredients in Denamarin). Am still researching it a bit.

Sounds like Misha is in great shape now and his liver is a-okay. Let's hope it stays that way :d*g:

Well, it's been 6 weeks since Misha went off the Tylan and he's started with the diarrhea again. Lucky for me, we are on a holiday weekend and I will have to take him to an e-vet instead of his regular vet :-( He is also supposed to be my ring bearer next Sunday. Wish us luck that we get everything cleared quickly.

I think the Tylan artifically elevates liver enzymes so I'm hoping he can go back on it long term.