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I have a dog who has been dealing with destructive

I have a young dog...
I have a young dog who has been dealing with destructive cholangitis for six months and by all veterinary estimates, should already be dead. Her liver values and bilirubin in her urine are off the charts. She's under care at a speciality hospital but we are currently traveling and have not been able to reach her internist. Her belly has recently gotten very swollen and we believe her liver disease is progressing. She had ascites drained previously and I think that's what this is. Several times her belly has swollen like this and then it goes away in a couple days. It's not subsiding this time, so I'm wondering if we could give her some lasix to assist with reducing the buildup. She's an 11 pound terrier mix, seven years old. We can get her to a specialty clinic on Thursday but I would like to try lasix to help in the meanwhile. Please advise on a dosage and any other advice. Thanks.
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Answered in 47 minutes by:
3/20/2018
Dr. Michael Salkin
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 35,469
Experience: University of California at Davis graduate veterinarian with 45 years of experience
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I believe you're correct. By the principle of Occam's Razor she's significantly hypoalbuminemic at this time and because the large molecule albumin is needed to keep fluid inside vessels and out of "third spaces" such as the abdominal cavity, you're now seeing ascites. Furosemide will be helpful until she can be attended to on Thursday. Dosing might be initiated at 0.5 mg/lb every 8-12 hours and doubled if you didn't see a positive response. Weighing her is a good gauge of how well she's excreting the fluid. Please respond with further questions or concerns if you wish.

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Customer reply replied 4 months ago
If she responds positively to Furosemide, would she still need to be seen on Thursday. She’s very complex and they’ve never seen her. If she responds well, would it be ok if we wait a couple weeks until we return home and she can see the specialist there?

Yes, furosemide isn't going to be completely effective. There may not be much more that can be done but I'd rather you were told that on Thursday than waiting for a comple of weeks during which she might completely fail. Please continue our conversation if you wish.

Dr. Michael Salkin
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 35,469
Experience: University of California at Davis graduate veterinarian with 45 years of experience
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Customer reply replied 4 months ago
How long will it take to see a change before we would double the dose?

Within the initial 24 hours. Weigh her now and again in 24 hours and please let me know what you find.

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Customer reply replied 4 months ago
Because she's only ~11 lbs, we couldn't get a consistent weight on her with our scale. So, we measured around her abdominal area. She's down an inch today, so it's definitely helping. And she's clearly more comfortable. Unfortunately, the speciality clinic we were planning to take her to on Thursday advised me today they can't see her until April. We can go in through emergency, but I'm not sure that's the best option. We've found two local vets who have ultrasound, so we're considering taking her to one of those. Is ultrasound what you believe she needs or would that even be necessary since the swelling is subsiding? Would bloodwork be more appropriate, or both? We had to take her to a rural vet in Texas on the way to Colorado from NC to confirm a UTI. The vet was clearly overwhelmed and she actually told us, in not such a great bedside manner, that Lexi should be dead already. That's why we were leaning towards going to the specialty facility, but I'm just not sure going through emergency is the best option. Please give me your thoughts.

I understand. That was a smart manner in which to determine efficacy. If I were to do anything, I would check her albumin level. If it's as low as I expect it is, considering her history it will be due to liver failure and at that point I don't see the value of an ultrasound other than confirming that her liver is sclerotic or cirrhotic and there isn't much we can about that. We're left with supportive care - dietary management, diuretic, drug therapy to increase protein tolerance in her GI tract. I never argue with having additional diagnostics performed and/or having a specialist attend to her but your expectations need to be tempered concerning how much can be done at this time.

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Customer reply replied 4 months ago
What drug therapy do you recommend to increase protein tolerance?
Customer reply replied 4 months ago
We've started her on metronidazole again because of a recent bout of diarrhea and are considering leaving her on it daily. We took her off because her primary care vet recommended doing so. Unfortunately, her primary care vet quit practicing recently without warning and she was who was handling her case most recently with occasional check ins with the internist. The internist is very difficult to reach as she's at a practice that is also overwhelmed with cases. So, it's made Lexi's care more difficult and mostly fall to us to determine what's best based on how's she's responded to various therapies since this began late last August.

Lactulose is the drug of choice. It alters bacterial metabolism so that less ammonia is generated and the risk of hepatic encephalopathy is then reduced. Metronidazole is a good choice but it needs to be given at a low dose of 3.4 mg/lb every 8-12 hours to avoid neurotoxicosis secondary to decreased hepatic metaolbism. I understand your logistical constraints.

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Customer reply replied 4 months ago
Thank you. Should we also leave her on a maintenance dose of lasix once the fluid is reduced more? Then adjust as her abdominal fluid level changes?

Yes, you should on both accounts.

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Customer reply replied 4 months ago
What should the maintenance dosage be? Or is that something we have to play with?

That's determined by trial and error. 0.5 mg/lb every 8-12 hours was an initial dose.

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Customer reply replied 4 months ago
Thanks for your help - again.

It's my pleasure.

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Hi Jeanette,
I'm just following up on our conversation about your pet. How is everything going?
Dr. Michael Salkin
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Customer reply replied 4 months ago
Hi. Lexi now has protein in her urine. She’s been licking at her vulva a lot and urinated in her sleep last night. Would it be prudent to start her on baytril for uti, or is that not likely without blood in her urine? I have baytril with me.

Proteinuria can be seen with an "active" sediment (increased numbers of red or white blood cell +/- casts) of a bacterial UTI but also in sterile urine due to a glomerulonephropathy. I wouldn't give any drugs unless absolutely necessary when a liver isn't functioning properly.

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Customer reply replied 4 months ago
What could we attribute the urinating in her sleep and licking her vulva to? Could her failing liver be the cause?

Many liver disorders cause polydipsia/polyuria (increased thirst/increased volume of urine). Overfilling incontinence, then, can arise; in other words, her bladder isn't used to accommodating such a large volume of urine and so the urine leak out of it. Urethral incompetence is another common cause of urinary incontinence. This describes weakness in the urethral musculature which then can't contain urine in the bladder.

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Customer reply replied 4 months ago
Would that cause her to lick her vulva?

Urine scalding

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