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post #1 of 9 (permalink) Old 10-17-2019, 09:39 PM Thread Starter
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Possible liver shunt problem

Hello all
My 8 month old Havanese has an ALT level of 354 which indicates liver issues . We are headed to a specialist Monday. Please share any and all info on procedures I.e. ultrasound, bile acid testing and nutrition. Any information would be gratefully accepted . We bought our dog from a very reputable breeder. She was the smallest puppy in a litter of two. We took her home weighing 3.5 pounds. Her liver was tested as a puppy and was normal. At spaying it was elevated and we were advised to repeat testing in 6 weeks. We did repeat the tests and she was up to 354 and normal is 118. Her BUN level is also elevated which could indicate a kidney problem. We are heartbroken and the irony is our last dog , a Yorkie , had a liver shunt. He had many years of health issues. We chose a Havanese because of their good health history .
Please help me with any info you may have !!!
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post #2 of 9 (permalink) Old 10-18-2019, 07:07 AM
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I am sorry that your puppy is having these health issues. I can only imagine how stressed and worried you must be. I hope another member may have some advice for you. At the very least, this forum has a lot of caring members that are here to give you moral support if you need it.



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post #3 of 9 (permalink) Old 10-18-2019, 09:49 AM
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I do not have any personal experience, but I do know that it is something that can happen in Havanese. The only advice I can give you is to stay in close communication with your breeder through this. You will be in our thoughts and prayers!


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post #4 of 9 (permalink) Old 10-19-2019, 11:26 AM
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I am so sorry that you are havving to go through this. I had a similar experience as yours with my first hav. He was asymptomatic but had elevated BAT and ALT for his entire life. Btw, he lived 11 wonderful years and passed from heart failure. When the vet raised the possiblity of a liver shunt because of his small size and the labs were abnormal, I was a so worried for quite some time. I consulted a vet at a teaching hospital in TN who specialized in micro and macro shunts ( Dr. Tobias). After many discussions with my vet, breeder andspecialists, I decided only to have the ultrasound done (essentially normal, which did not exclude MVD). Weighing all optionsa nd knowing how traumatic the liver biopsy could be, I decided to take a watchful waiting approach. His ALT remained chronically elevated, slightly waxing and waning over the years. Keeping his teeth extra clean with regular cleanings also seemed to help. An elevated BUN can simply mean the pup is dehydrated when the blood is drawn. My havs have never been great at drinking enough water and always seem to have marginally elevated BUN on their labs. I stopped worrying about that years ago. Since you have been through this with your yorkie, I hope it give you strength to know even if the labs are abnormal, they can still live long happy lives. After all of that, I decided to become less fixated on the labs and just tried to watch my pup to see how he seemed to be doing (which was just fine). I hope that helps a little.



Dr. Tobias sent me this in back in 2009:

Accuracy of unltrasonography depends on the radiolgist or internist. Some specialists are 95-100% accurate and others are less. We use transplenic scintigraphy here to rule out shunting when we suspect MVD from congenital portal hypoplasia (CPH).

MVD/CPH is the most common cause of increased bile acids in clinically normal dogs with normal chem panels. A diagnosis would require ruling out a shunt (since PSS results in the same histologic liver changes) and then obtaining a piece of liver large enough to include at least 5 portal triads. This may require a minimally invasive approach (mini-lap or lalparoscopy), since we often do not get enough tissue on needle/trucut biopsies to be certain of a microvascular anomaly, and because that approach is less dangerous than ultrasound guided biopsy in a small breed dog with a small liver.

No one knows about diet change. No one has compared long term outcome of dogs with CPH/MVD that are on regular and protein restricted diets. At the very least, I wouldn't give any extra protein, puppy chow, or performance diets. No need to stress the liver.

With CPH/MVD, bile acids will always be high and they do not correlate with severity of disease. Better indicators are albumin, BUN, total protein, urine specific gravity, and urine sediment (for urate crystals and infection). Yearly lab work unless clinical signs occur.

We use scintigraphy here because it's easy and inexpensive, and we have seen dogs with shunts that have normal chemistry panels and mildly increased bile acids. So, for my own dog, I would do a transplenic scintigraphy. If it was normal, I'd probably leave it at that. Denamarin now comes in chewable tablets that have better absorption. Again, research has not been done in dogs with CPH/MVD to determine if it makes a difference, but its contents (milk thistle and SAM-e) have been shown to improve liver function. Owner preference.

No idea about long term prognosis. We tested 139 healthy Yorkies and found that 2/3's had increased bile acids. Most likely this condition is present in the majority of Yorkies, Maltese, and Havanese, so most will live normal lifespans.
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post #5 of 9 (permalink) Old 10-19-2019, 12:44 PM
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Oh I'm so sorry to hear this. Please keep us updated. We all pray that all goes well. I don't know anything about liver shunts so I can't offer any past experiences.



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post #6 of 9 (permalink) Old 10-20-2019, 06:30 PM
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Quote:
Originally Posted by nwhavmom View Post
I am so sorry that you are havving to go through this. I had a similar experience as yours with my first hav. He was asymptomatic but had elevated BAT and ALT for his entire life. Btw, he lived 11 wonderful years and passed from heart failure. When the vet raised the possiblity of a liver shunt because of his small size and the labs were abnormal, I was a so worried for quite some time. I consulted a vet at a teaching hospital in TN who specialized in micro and macro shunts ( Dr. Tobias). After many discussions with my vet, breeder andspecialists, I decided only to have the ultrasound done (essentially normal, which did not exclude MVD). Weighing all optionsa nd knowing how traumatic the liver biopsy could be, I decided to take a watchful waiting approach. His ALT remained chronically elevated, slightly waxing and waning over the years. Keeping his teeth extra clean with regular cleanings also seemed to help. An elevated BUN can simply mean the pup is dehydrated when the blood is drawn. My havs have never been great at drinking enough water and always seem to have marginally elevated BUN on their labs. I stopped worrying about that years ago. Since you have been through this with your yorkie, I hope it give you strength to know even if the labs are abnormal, they can still live long happy lives. After all of that, I decided to become less fixated on the labs and just tried to watch my pup to see how he seemed to be doing (which was just fine). I hope that helps a little.



Dr. Tobias sent me this in back in 2009:

Accuracy of unltrasonography depends on the radiolgist or internist. Some specialists are 95-100% accurate and others are less. We use transplenic scintigraphy here to rule out shunting when we suspect MVD from congenital portal hypoplasia (CPH).

MVD/CPH is the most common cause of increased bile acids in clinically normal dogs with normal chem panels. A diagnosis would require ruling out a shunt (since PSS results in the same histologic liver changes) and then obtaining a piece of liver large enough to include at least 5 portal triads. This may require a minimally invasive approach (mini-lap or lalparoscopy), since we often do not get enough tissue on needle/trucut biopsies to be certain of a microvascular anomaly, and because that approach is less dangerous than ultrasound guided biopsy in a small breed dog with a small liver.

No one knows about diet change. No one has compared long term outcome of dogs with CPH/MVD that are on regular and protein restricted diets. At the very least, I wouldn't give any extra protein, puppy chow, or performance diets. No need to stress the liver.

With CPH/MVD, bile acids will always be high and they do not correlate with severity of disease. Better indicators are albumin, BUN, total protein, urine specific gravity, and urine sediment (for urate crystals and infection). Yearly lab work unless clinical signs occur.

We use scintigraphy here because it's easy and inexpensive, and we have seen dogs with shunts that have normal chemistry panels and mildly increased bile acids. So, for my own dog, I would do a transplenic scintigraphy. If it was normal, I'd probably leave it at that. Denamarin now comes in chewable tablets that have better absorption. Again, research has not been done in dogs with CPH/MVD to determine if it makes a difference, but its contents (milk thistle and SAM-e) have been shown to improve liver function. Owner preference.

No idea about long term prognosis. We tested 139 healthy Yorkies and found that 2/3's had increased bile acids. Most likely this condition is present in the majority of Yorkies, Maltese, and Havanese, so most will live normal lifespans.
Wow, this is really interesting, and comforting information. Thank you for passing it along! Do you mind me passing it along to a couple of breeder friends outside this group?


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post #7 of 9 (permalink) Old 10-20-2019, 06:58 PM
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Of course- but please note that the email Dr. Tobias sent me was from 2009. She is still on staff at U of TN and is an expert on this subject. I still appreciate her willingness to help me at that time. If you google her name, you can find several articles she has written on this CPH/MVD (see below). I also have quite a bit of info via my breeder from that time. He was on the [email protected] groups trying to reach out to other breeders as well. As difficult as this entity can be, once you realize that pups can often live with it and still have a good life, you can learn to navigate the waters a little better. Milk thistle and SAM-e did not help my pup and we discontinued it. Over time, I also learned to stop chasing the lab value and just became a close observer of my baby to make sure he was doing ok. Sometimes, there is no perfect answer.I am careful to not put my pups through any procedure that ultimately may not change the outcome. I did appreciate every day with him maybe a little more. In the end, it was his mitral regurgitation /CHF that ultimately facilitated his transition, not his MVD. He was a brilliant star that shined extra bright for a little less time. But I was still blessed to spend 11 amazing years with him <3

http://www.dvm360.com/karen-m-tobias-dvm-ms-dacvs
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post #8 of 9 (permalink) Old 10-20-2019, 07:20 PM
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I'm so sorry to hear about your ailing puppy.
My previous dog got very sick following sedation for a dental cleaning. Many of his liver enzymes were elevated(very). Then a few months later, he had to have surgery for bladder stones. He was quite sick following the surgery. This time, his liver enzymes were off the charts high. My vet had never seen a dog with worse bloodwork that survived. The prediction was very bad and I did not want to sedate him for further testing. I redid the bloodwork a week later and it was still bad.
My vet felt that he had cancer (probably bile duct) and would not survive for more than a week. His only suggestion was to try the Denamarin. I used the pills for 30 days. Bloodwork had improved quite a bit, he was improving. 30 more days of Denamarin and better. This very sick young man lived to be 15 years old,about 6 years from when this all started.
I hope you find some answers and get some good news.
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post #9 of 9 (permalink) Old 10-20-2019, 08:23 PM
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Quote:
Originally Posted by nwhavmom View Post
Of course- but please note that the email Dr. Tobias sent me was from 2009. She is still on staff at U of TN and is an expert on this subject. I still appreciate her willingness to help me at that time. If you google her name, you can find several articles she has written on this CPH/MVD (see below). I also have quite a bit of info via my breeder from that time. He was on the [email protected] groups trying to reach out to other breeders as well. As difficult as this entity can be, once you realize that pups can often live with it and still have a good life, you can learn to navigate the waters a little better. Milk thistle and SAM-e did not help my pup and we discontinued it. Over time, I also learned to stop chasing the lab value and just became a close observer of my baby to make sure he was doing ok. Sometimes, there is no perfect answer.I am careful to not put my pups through any procedure that ultimately may not change the outcome. I did appreciate every day with him maybe a little more. In the end, it was his mitral regurgitation /CHF that ultimately facilitated his transition, not his MVD. He was a brilliant star that shined extra bright for a little less time. But I was still blessed to spend 11 amazing years with him <3

http://www.dvm360.com/karen-m-tobias-dvm-ms-dacvs
I did note that your info was from 2009, and that it would be worth looking for newer info too. But this is still VERY heartening information. I also love the way you handled life with your guy. It seems like a wonderful way to live with it!


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