Hannah's progress report

Hannah continues to have some health issues. Her liver status has improved since starting the Denamarin two weeks ago and that is good news. Her kidney values have gotten worse and that is disturbing. Our vet has recommended starting her on Actigall (ursodiol) to give her liver more help so we are doing that, continuing the other medications. Hannah will like that the Actigall needs to be given with a "fatty meal" so she will be getting cheese, peanut butter or 2 teaspoons of flax oil with her evening meal. In three weeks, we will do a liver function test.

Below are all of the high blood chemistry as of June 18

Urea Nitrogen	38	(6-25)
Creatinine	2.1	(0.5-1.6)
Alkaline Phosphatase	2108	(5-131)
ALT (SGPT)	505	(12-118)

Hannah's BUN was normal as of her tests June 4 (25) but was high on June 3 (29). Her creatinine was 1.9 on June 3, 2.0 on June 4 and has increased to 2.1 on her latest test. Both her akaline phosphatase and her ALT have improved. I made a few tables below to show her progression.

	Alkaline Phosphatase (5-131)	ALT (SGPT) (12-118)
June 3	2821	1901
June 4	3107	1932
June 18	2108	505

	BUN (6-25)	creatinine (0.5-1.6)
June 3	29	1.0
June 4	25	2.0
June 18	38	2.1

We also need to make some decisions about her Cushings (hypoadrenocorticism) . It is important to have her liver and kidneys functioning well before we can move forward on that. I am trying to take the "What Would Hannah Do" approach to this.

• Hannah does not want to be in pain (who does)
• Hannah does not want to take pills (but she has to take some regardless because of pain meds)

Treatment options:

• Keep Hannah comfy (pain meds)
• Treat the Cushings (Lysodren + pain meds) -- Trilosane is out because it's lots of pills and our vet said that given Hannah's clear desire to not have pills, a twice a day medication would probably not be the best choice. Our vet said repeatedly that Lysodren is chemotherapy and that it is a derivative of DDT. The literature on this is pretty scary too. This treatment option would most likely result in a prednisone prescription.
• Treat the Cushings aggressively. Surgery (adrenalectomy) might be a good option but she would still have to take pills even with surgery so it does not solve the pill problem and it is a risky undertaking since the adrenal gland is so close to the aorta. The adrenal gland is located between the aorta, the renal artery and vein, which are the sole blood supply to
  the kidney, and the phrenicoabdominal artery. In fact, the more I have looked into this, the less I feel that this is a good option. According to the Textbook of Veterinary Internal Medicine, "Approximately 50% of dogs develop severe postoperative complications, including pancreatitis, pneumonia, pulmonary thromboembolism, acute renal failure, sepsis, and hypoadrenocorticism due to insufficient steroid levels." We know that she has a tumor because it showed up on ultrasound but we don't know if it is malignant or benign because it is not easy to determine if an adrenal mass is malignant or benign before surgical removal and histopathologic evaluation. If the tumor is benign, surgical removal is a cure but if it is malignant, surgery may help for a while but is not a cure. I have read that while only approximately 15% of canine Cushing's syndrome patients have adrenal tumors, half of these patients will have benign tumor and half will have malignant tumors.

Unfortunately, from what I have read, this comment from The Animal Health Clinic is a good summary from: "Dogs with ADH caused by a benign tumor have a good prognosis whereas the prognosis is guarded with the malignant form (adenocarcinoma)."

I will continue to do some research and thinking this weekend, discuss it with DH and meet with our vet sometime in the next week or so to come up with a treatment plan for The Brown One.