# Sticky  The Liver Shunt - Bile Acid Test Thread



## k/c mom

I'm starting this thread so we can have one place to discuss this very important issue of our beloved Maltese breed. If the thread ends up being informative enough, I'll ask Yung or Joe to pin it for us. 

Some of the posts in the other thread that is active on this topic today, but really in the wrong place, are so interesting... Maybe some should be copied and added in this thread, too.

Soooo, if you have information and opinions to share on the AMA Bile Acid Testing guidelines, Liver Shunt surgery, Protein C testing ... let's get it all here in one place.


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## uniquelovdolce

ok totally naive .. but what exactly does liver shunt mean?


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## bebybeck

Finnegans liver shunt is blood vessels bi-passing his liver, so the blood doesn't get cleaned of toxins and they get carried to the brain. He is taking meds so the toxins come out in his stools untill his surgery. There are different types of shunts and liver diseases though.


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## uniquelovdolce

thanks for the info , it gives me some insight , aww soo scary  i hope he does well in his surgery .. 

so let me ask u this , there are bile test that can determine this before?


bebybeck said:


> Finnegans liver shunt is blood vessels bi-passing his liver, so the blood doesn't get cleaned of toxins and they get carried to the brain. He is taking meds so the toxins come out in his stools untill his surgery. There are different types of shunts and liver diseases though.


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## allheart

Oh Sher, I'm so sorry, I had started a new thread as well on this topic. You can delete mine, and I will paste what I wrote on here. Thanks Sher. (I posted mine under everything else Maltese related, but yours is a much better place) Sorry for the confusion.

Here were my questions/comments:

I am sure there are countless threads here on this topic, so I hope it's okay to start a new one with some questions.

I never heard of liver shunt or bile acid testing until being a member of SM and still do not know much about it.

When I took Mia and Leo in for one of their early visits, I told my vet I wanted a bile acid test done. She looked so concerened and asked me WHY??? Are they showing any symptoms? She said they do not appear to be candidates for the testing and then we did have a discussion on this topic in reference to Mia and Leo. She felt the testing for them was unneccesary. I love my vet dearly and trusted and still trust her call on that. 

Anyway, my real questions/thoughts on this topic are:

1) If in the future, I would adopt (purchase) a pup from a True breeder, who has been breeding for years, knows their lines inside/out, upside down, I would possibly feel comfortable if they said no they do not test, as they know their lines. But would it be wise for me to offer to pay for the test anyway and what if they decline? I wouldn't think they would, but just wondering.

2) If a breeder with a smaller program does not bile test for the same reasons listed above, do I still ask for a bile acid test and what if they decline? I also wouldn't think they would, but I would offer to pay for it.

To be very honest, I am quite shy when speaking or asking questions of breeders, I admit, I sometimes feel like I'm probing, and I know I shouldn't feel that way, nor have I ever been made to feel that way, it's just my nature but once the conversation continues then I get a little more comfortable. The only thing I am not shy about, is that the True breeder, loves and completely cares and is attentive to every fur-baby in their care, the boys, the girls and the pups, all of them. That is my very first heartfelt requirement.

After reading recently on here about liver shunt, I think I would not want to adopt (purchase) a pup without having the testing done. Is that on the right track? 

I am so not ready to add a new addition, although I would love to, but I have my special two :wub::wub: and am still caring for my MIL, but who knows what the future holds and also I wish to learn more about this topic, in case I am ever in a position to help or advise someone else.

Thanks so much for taking the time to read this and for sharing your knowledge, it is much appreciated.


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## Ladysmom

k/c mom said:


> I'm starting this thread so we can have one place to discuss this very important issue of our beloved Maltese breed. If the thread ends up being informative enough, I'll ask Yung or Joe to pin it for us.
> 
> Some of the posts in the other thread that is active on this topic today, but really in the wrong place, are so interesting... Maybe some should be copied and added in this thread, too.
> 
> Soooo, if you have information and opinions to share on the AMA Bile Acid Testing guidelines, Liver Shunt surgery, Protein C testing ... let's get it all here in one place.



I hate to lose all the information, links and opinions that were already shared in the other thread. I think to try to copy and paste posts into this thread would not only be a lot of work, we would also loose the continuity and chronologically of the previous discussion.


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## The A Team

I know you are talking about maltese, but it's just as important to have yorkies tested. I'm not positive, but I believe they are even more supseptable to liver problems. 

Before I got Ava I had found a gorgeous little yorkie girl, she was 6 months old and 2 1/2 lbs, it wasn't the size as much as her sheer cuteness that attracted me. Anyway, I paid the breeder's vet to do a bile acid test as the breeder didn't think it was necessary. The numbers came back high enough that she would most likely have MVD. Not as bad as a shunt, and a special diet and supplements can keep their health in check. I passed on this pup and saved myself a ton of money having to buy food different from my other dogs. 

The liver shunt operation is a big deal. Ask Kodie's mom - Kodie had it done. And my friend Elaine's Kodie (a yorkie) had it done also - he still has seizures now and then...and it's been about 5 years now.


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## CloudClan

allheart said:


> Oh Sher, I'm so sorry, I had started a new thread as well on this topic. You can delete mine, and I will paste what I wrote on here. Thanks Sher. (I posted mine under everything else Maltese related, but yours is a much better place) Sorry for the confusion.
> 
> Here were my questions/comments:
> 
> I am sure there are countless threads here on this topic, so I hope it's okay to start a new one with some questions.
> 
> I never heard of liver shunt or bile acid testing until being a member of SM and still do not know much about it.
> 
> When I took Mia and Leo in for one of their early visits, I told my vet I wanted a bile acid test done. She looked so concerened and asked me WHY??? Are they showing any symptoms? She said they do not appear to be candidates for the testing and then we did have a discussion on this topic in reference to Mia and Leo. She felt the testing for them was unneccesary. I love my vet dearly and trusted and still trust her call on that.
> 
> Anyway, my real questions/thoughts on this topic are:
> 
> 1) If in the future, I would adopt (purchase) a pup from a True breeder, who has been breeding for years, knows their lines inside/out, upside down, I would possibly feel comfortable if they said no they do not test, as they know their lines. But would it be wise for me to offer to pay for the test anyway and what if they decline? I wouldn't think they would, but just wondering.
> 
> 2) If a breeder with a smaller program does not bile test for the same reasons listed above, do I still ask for a bile acid test and what if they decline? I also wouldn't think they would, but I would offer to pay for it.
> 
> To be very honest, I am quite shy when speaking or asking questions of breeders, I admit, I sometimes feel like I'm probing, and I know I shouldn't feel that way, nor have I ever been made to feel that way, it's just my nature but once the conversation continues then I get a little more comfortable. The only thing I am not shy about, is that the True breeder, loves and completely cares and is attentive to every fur-baby in their care, the boys, the girls and the pups, all of them. That is my very first heartfelt requirement.
> 
> After reading recently on here about liver shunt, I think I would not want to adopt (purchase) a pup without having the testing done. Is that on the right track?
> 
> I am so not ready to add a new addition, although I would love to, but I have my special two :wub::wub: and am still caring for my MIL, but who knows what the future holds and also I wish to learn more about this topic, in case I am ever in a position to help or advise someone else.
> 
> Thanks so much for taking the time to read this and for sharing your knowledge, it is much appreciated.


I posted this in the other thread (Christine's), but if it is to be deleted, I will repost it here: 
I am going to disagree with your vet. My own vets had a similar reaction. My friendships with knowledgeable people, and my participation in this forum are the reason I know about bile acid tests at all. Most General Practice vets do not know a lot about the test either. I know that the test I had done most recently, they had to look up the procedures in the books. (And here again is the reason that the information is not widely shared among breeders. Many of them rely on their own vets for their recommendations and those vets do not as a routine suggest BA testing). 

The truth is you do not need to test Mia and Leo. But the recommendation is to get it done to establish a baseline. 

The way I worded it with my vets is that it is a problem in the breed and I am following recommendations. 

As for buying from an Ethical Breeder, I think whether they test or not, they should be willing to answer your questions about BA to the extent of their ability. You and the breeder can agree to either have the test done before you take the pups home or soon after (at that 16 week age). 

I agree with you that it can be difficult to broach this subject, but I think you will find that an Ethical breeder's response should make you feel glad you asked. I know when I spoke with the two breeders I worked with most recently, I felt that awkwardness when I asked questions about LS and GME and other health issues. I did not want to sound like I was presuming their dogs were anything other than perfect healthy pups; however, the responses they gave me when we talked reassured me. I felt better about both breeders for having made that step forward with them and seeing how they responded to my questions.


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## CloudClan

The A Team said:


> I know you are talking about maltese, but it's just as important to have yorkies tested. I'm not positive, but I believe they are even more supseptable to liver problems.
> 
> Before I got Ava I had found a gorgeous little yorkie girl, she was 6 months old and 2 1/2 lbs, it wasn't the size as much as her sheer cuteness that attracted me. Anyway, I paid the breeder's vet to do a bile acid test as the breeder didn't think it was necessary. The numbers came back high enough that she would most likely have MVD. Not as bad as a shunt, and a special diet and supplements can keep their health in check. * I passed on this pup and saved myself a ton of money having to buy food different from my other dogs. *
> 
> The liver shunt operation is a big deal. Ask Kodie's mom - Kodie had it done. And my friend Elaine's Kodie (a yorkie) had it done also - he still has seizures now and then...and it's been about 5 years now.


This of course is your decision, and a personal one, but this is one thing that may be discouraging some breeders from testing. If pet owners react to MVD (a common problem in the breed 75-80% affected) in this way then it makes not knowing make more sense to some. 

I am not suggesting that you did this, but many buyers will learn of a result like this and move on to another breeder who does not test at all to purchase their pup. So they pass on the breeder who knows and discloses and move to a breeder who does not test and does not know. 

The fact is that special diets are not required for all MVD dogs. Most live completely normal lives and never get sick from anything related to their liver.


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## k/c mom

allheart said:


> Oh Sher, I'm so sorry, I had started a new thread as well on this topic. You can delete mine, and I will paste what I wrote on here. Thanks Sher. (I posted mine under everything else Maltese related, but yours is a much better place) Sorry for the confusion.
> 
> Here were my questions/comments:
> 
> I am sure there are countless threads here on this topic, so I hope it's okay to start a new one with some questions.
> 
> I never heard of liver shunt or bile acid testing until being a member of SM and still do not know much about it.
> 
> When I took Mia and Leo in for one of their early visits, I told my vet I wanted a bile acid test done. She looked so concerened and asked me WHY??? Are they showing any symptoms? She said they do not appear to be candidates for the testing and then we did have a discussion on this topic in reference to Mia and Leo. She felt the testing for them was unneccesary. I love my vet dearly and trusted and still trust her call on that.
> 
> Anyway, my real questions/thoughts on this topic are:
> 
> 1) If in the future, I would adopt (purchase) a pup from a True breeder, who has been breeding for years, knows their lines inside/out, upside down, I would possibly feel comfortable if they said no they do not test, as they know their lines. But would it be wise for me to offer to pay for the test anyway and what if they decline? I wouldn't think they would, but just wondering.


Christine, I would never buy a Malt without the test .. now that I know about it! I got Claire from the type of breeder you describe in #1 and she paid for the Bile Acid test on Claire. I would have been glad to pay and would do so if the breeder didn't want to.


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## vjw

In the other thread where I mentioned that the University of Pennsylvania was doing metabolic urine testing for possible portosystemic shunts, I wasn't sure JMM and I were talking about the same urine test. I asked Dr. Urs Giger at UPENN a couple of questions about the test and here's his response:



Dear Joy,

our metabolic screening test is based upon metabolite studies in urine used for hereditary metabolic diseases. It may suggest a shunt but cannot diagnose a shunt. It cannot discover carriers but only affecteds and not specifically. It is not a DNA test and to the best of my knowledge there is no DNA test for portosystemic shunts.

By the way we are interested in hearing about Maltese who have eaten Chinese Chicken Jerky Treats and developed some kidney issues. We are working on characterizing this problem known as Fanconi Syndrome in the Maltese and a few other small breed dogs. Our metabolic screen is helpful for this purpose.

Sincerely
Urs Giger


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## MaryH

Hi Christine -- Thanks for asking some great questions. I can understand your vet's position given that most breeds do not have liver issues and therefore bile acid testing would only be done if a dog presented as "sick". Because of what I've learned about Maltese and liver issues, I would have had the bile acid testing done despite my vet's opinion. As Carina mentioned, having a baseline now when a pup is young and healthy could prove invaluable later in life. Baselines are so important in humans and are as important in animals.

In answering your questions, as a person looking to buy a pet, here's what I would do:

1. I, too, would not be uncomfortable if they are not testing puppies. I would ask that a bile acid test be done on the puppy I wanted to purchase and I would offer to cover the cost of the test (generally runs $125 to $150). If the breeder refused to test I would walk away.

2. Just because it's a smaller, lesser known breeder, I would not see it as a red flag that he/she is not routinely bile acid testing puppies. Again, I would ask that a bile acid test be done on the puppy I wanted to purchase and I would offer to cover the cost of the test. If the breeder refused to test I would walk away.

I don't like asking the tough questions, either. And I really don't like answering them. But they are questions that deserve to be asked and deserved to be answered.

Now, from a breeder perspective, running bile acid tests and disclosing results can be *pretty darn scary*. I do bile acid test all my puppies at or slightly before 16 wks. old. I do have an indepth conversation with every puppy buyer and potential puppy buyer about liver issues in our breed and how I personally am addressing those issues. I do provide a new owner with a complete health history including bile acid results, a printout of the Liver Shunt/MVD article on the AMA website, and an offer to speak directly with the new owner's vet should the vet have questions or concerns about the bile acid results. My fear is always that the new puppy owner is going to bring the puppy to their vet, the vet is going to look at the bile acid results, and the vet is going to say either "Your breeder must have produced liver shunt before and that's why she is testing puppies now." or "You have a very sick dog on your hands." The "sick dog" situation has happened to me. Did the vet read the info I gave the new puppy owner? Did the new puppy owner even share that info with the vet? Who knows. All I know is that I got a call from the new puppy owner saying she brought her puppy in for preanesthetic bloodwork prior to his neuter, the vet (who was not the "regular" vet of this puppy owner) drew the blood and then read through the file, got to the bile acid results, and said the puppy is very sick and should have a liver biopsy done. Luckily the owner remained calm, said that she would be calling me to discuss the situation, and then would continue the discussion with the vet after the bloodwork results were in. She called me, we talked again about bile acid testing and results and what it all means, I sent her more info, and offered again to speak directly with her vet. She called me three days later to let me know that the puppy's bloodwork was normal, she talked with her regular vet who agreed with me that there was no liver issue, and assured the puppy owner that he would have a discussion with the "other" vet about liver issues. And just so you all know, the bile acid results for this particular puppy was in the high 20s.

I think as buyers and as breeders we are trying to do the right thing. Open, honest discussion goes a long way toward that end. And discussion has to be a two-way street.


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## MaryH

uniquelovdolce said:


> thanks for the info , it gives me some insight , aww soo scary  i hope he does well in his surgery ..
> 
> so let me ask u this , there are bile test that can determine this before?


 
Liza, here's a link to the AMA Health pages: American Maltese Association Health Information

Once you get there, click on "Gastrointestinal" and then click on "Portosystemic Vascular Anomalies" to get to the writeup on liver shunt. It is a basic overview of Liver Shunt/MVD. The bile acid test can give you a very good idea if a puppy has a serious liver issue, further testing would then tell you what the issue is. Personally, if I was looking for a pet I would want to know that there is no shunt before I buy the puppy. If the puppy's results indicate MVD, but the puppy is at a good weight, normal activity level, bright eyed, etc., I would not be concerned about higher than normal bile acid values. Heck, my puppy will be in the same boat as most other Maltese!


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## bellaratamaltese

CloudClan said:


> This of course is your decision, and a personal one, but this is one thing that may be discouraging some breeders from testing. If pet owners react to MVD (a common problem in the breed 75-80% affected) in this way then it makes not knowing make more sense to some.
> 
> I am not suggesting that you did this, but many buyers will learn of a result like this and move on to another breeder who does not test at all to purchase their pup. So they pass on the breeder who knows and discloses and move to a breeder who does not test and does not know.
> 
> The fact is that special diets are not required for all MVD dogs. Most live completely normal lives and never get sick from anything related to their liver.


:goodpost:


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## Nikki's Mom

The percentage of Maltese who have asymptomatic MVD is pretty high, as I understand it, right?

What makes breeder Bile Acid Testing tricky is if a dog tests high, and it turns out that the dog has asymptomatic MVD, then the buyer might pass up an otherwise healthy dog. With the large percentage of MVD dogs, a person might pass up several great puppies.

I learned Nikki had MVD when she was 6 months old. If she'd been Bile Acid Tested at 4 months by the breeder, I still wouldn't have known whether it was a shunt or MVD, unless further, more expensive testing was done. So how far does testing go? If a potential buyer still wants a puppy that tests high on Bile Acid Test, does the breeder or the buyer pay for a protein C test, or an ultrasound, or a nuclear scintography? 

And what about those puppies who have tested high on bile acids but only have asymptomatic MVD and are perfect otherwise? What if nobody wants them? 

Just some things to think about and discuss. I have no answers, just thoughts.


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## The A Team

CloudClan said:


> This of course is your decision, and a personal one, but this is one thing that may be discouraging some breeders from testing. If pet owners react to MVD (a common problem in the breed 75-80% affected) in this way then it makes not knowing make more sense to some.
> 
> I am not suggesting that you did this, but many buyers will learn of a result like this and move on to another breeder who does not test at all to purchase their pup. So they pass on the breeder who knows and discloses and move to a breeder who does not test and does not know.
> 
> The fact is that special diets are not required for all MVD dogs. Most live completely normal lives and never get sick from anything related to their liver.


Carina, if I didn't already have three dogs here it wouldn't have mattered, but I see what Elaine goes through....three dogs with liver problems and two without. 

You're right, MVD isn't a big problem, but the size of my house is :blush:. And if I don't want to have to feed someone inside a crate...it's easier that they can all enjoy the same food. Plus Abbey is a thief....she thinks everyone else has something better than her. :HistericalSmiley:


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## k/c mom

Nikki's Mom said:


> The percentage of Maltese who have asymptomatic MVD is pretty high, as I understand it, right?
> 
> What makes breeder Bile Acid Testing tricky is if a dog tests high, and it turns out that the dog has asymptomatic MVD, then the buyer might pass up an otherwise healthy dog. With the large percentage of MVD dogs, a person might pass up several great puppies.
> 
> I learned Nikki had MVD when she was 6 months old. If she'd been Bile Acid Tested at 4 months by the breeder, I still wouldn't have known whether it was a shunt or MVD, unless further, more expensive testing was done. So how far does testing go? If a potential buyer still wants a puppy that tests high on Bile Acid Test, does the breeder or the buyer pay for a protein C test, or an ultrasound, or a nuclear scintography?
> 
> And what about those puppies who have tested high on bile acids but only have asymptomatic MVD and are perfect otherwise? What if nobody wants them?
> 
> Just some things to think about and discuss. I have no answers, just thoughts.


I was thinking the same thing. I think it really can be a tricky issue. It is not just a simple test with a black/white result.


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## jmm

I've had 3 MVD Maltese, 1 of whom was sick with concurrent liver issues....none required special diet for the liver. Jonathan is 11 1/2 years old and has never had special diet or medications. A symptomatic MVD is an exception to the rule - an unusual occurrence. Back in the day when Jonathan was diagnosed it was liver biopsies. Today we have non-invasive tests like Protein C which only require a blood draw. I would not hesitate to purchase a Maltese with MVD. Nor would I look down upon a breeder who was breeding MVD dogs with the goal of better test results. Phenotype-to-phenotype is how we reduce hip dysplasia in big dogs...no reason not to respect the same principles with our liver dogs (plus this approach has been successful in other breeds).


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## Tanner's Mom

Tanner is an asymptomatic MVD dog. When I had the preanesthesia bloodwork done before his neuter, his ALT was in the high 300's. He was not neutered that day. Later, I had an ultrasound done (lucky for me the vet who did it trained under Dr. Center at Cornell), and she didn't see a shunt but recommended a biopsy which was done 4 years ago. Because I didn't get a definitive dx from the biopsy, I sent the tissue sample to Dr. Center & best we could determine, Tanner has MVD. I take him in 2 or 3 times a year for blood work & his ALT has ranged from a low of 129 to a high of 500. 

I feed Tanner low protein canned food, i.e., 8% or less, & mix a few pieces of whatever kibbles the others are eating. He doesn't know what beef is, he only eats chickens. Also, he gets 1/4 tab of Marin daily. I tried Denosyl and he wouldn't touch them no matter how they were disguised. Feeding him a different food from the others really hasn't been a problem.

When I had his bile acids done, they were in the low 40's. 

Tanner is now 6 years old. He weighs 8#s (he was a BYB boy) and is a happy, active, little boy. At one point, I was hoping to have him til he was 5; now he's 6 and I think/hope he'll be around a long, long time.


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## Nikki's Mom

Nikki's blood work has been perfect for over 2 years, and she'll be 3 in November. Her ALT numbers returned to normal about 6 months after her liver biopsy/MVD diagnosis, and they have been that way ever since.

She does not eat a special low-protein diet. She has no symptoms, and the vet thinks she is in perfect health. 

What if I'd changed my mind about buying her, or returned her, just because of her bile acid test result? What a shame!


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## MaryH

I bile acid test puppies for three reasons: (1) so that I know what I am producing; (2) so that I know I am not selling a puppy with a liver shunt; and (3) so that if a puppy has higher than normal bile acid results I am the person who explains to the buyer what that all means. If a buyer chooses to walk away from the puppy that is their right. But I'd rather be the person to break the news and explain and educate rather than have a buyer find out from a vet, a friend, or someone on the internet who may have far less breed specific knowledge than me. Just me ... I don't like bad surprises and will try to avoid them if at all possible. And to me the worst surprise of all would be to sell a puppy with a liver shunt, especially when there IS a non-invasive, reasonably inexpensive test known as a bile acid test that will tell me what I need to know beforehand so that I am not selling heartbreak.


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## Nikki's Mom

MaryH said:


> I bile acid test puppies for three reasons: (1) so that I know what I am producing; (2) so that I know I am not selling a puppy with a liver shunt; and (3) so that if a puppy has higher than normal bile acid results I am the person who explains to the buyer what that all means. If a buyer chooses to walk away from the puppy is their right. But I'd rather be the person to break the news and explain and educate rather than have a buyer find out from a vet, a friend, or someone on the internet who may have far less breed specific knowledge than me. Just me ... I don't like bad surprises and will try to avoid them if at all possible. And to me the worst surprise of all would be to sell a puppy with a liver shunt, especially when there IS a non-invasive, reasonably inexpensive test known as a bile acid test that will tell me what I need to know beforehand so that I am not selling heartbreak.



I understand, as I don't like surprises either. What I am concerned about is this: Since not every high BA test number means a shunt, things get complicated. May I ask: What is the next step if a puppy has a high BA number, and the buyer thinks they may still want the dog? Does the breeder do further testing themselves, or do they sell the dog and let the owner decide what to do next?


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## Ladysmom

MaryH said:


> I bile acid test puppies for three reasons: (1) so that I know what I am producing; (2) so that I know I am not selling a puppy with a liver shunt; and (3) so that if a puppy has higher than normal bile acid results I am the person who explains to the buyer what that all means. If a buyer chooses to walk away from the puppy is their right. But I'd rather be the person to break the news and explain and educate rather than have a buyer find out from a vet, a friend, or someone on the internet who may have far less breed specific knowledge than me. Just me ... I don't like bad surprises and will try to avoid them if at all possible. And to me the worst surprise of all would be to sell a puppy with a liver shunt, especially when there IS a non-invasive, reasonably inexpensive test known as a bile acid test that will tell me what I need to know beforehand so that I am not selling heartbreak.


Excellent post, Mary. :thumbsup:

Since Maltese have been identified by Dr. Center as one of the breeds highly affected by liver disease, there is just no good reason IMO for not having a BAT done on a puppy prior to its sale. Being afraid of the results is certainly not a good reason. To me, it is similar to being in a high risk group for AIDS and not getting a test to see if you are HIV positive out of fear.

Even if a potential buyer backs away from a sale based upon the results of the BAT, isn't that better than having a upset owner find out her puppy has MVD or a liver shunt a few months later and that her breeder could have had this simple, inexpensive test done prior to the sale? That can really damage a breeder's reputation.


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## allheart

CloudClan said:


> I posted this in the other thread (Christine's), but if it is to be deleted, I will repost it here:
> I am going to disagree with your vet. My own vets had a similar reaction. My friendships with knowledgeable people, and my participation in this forum are the reason I know about bile acid tests at all. Most General Practice vets do not know a lot about the test either. I know that the test I had done most recently, they had to look up the procedures in the books. (And here again is the reason that the information is not widely shared among breeders. Many of them rely on their own vets for their recommendations and those vets do not as a routine suggest BA testing).
> 
> The truth is you do not need to test Mia and Leo. But the recommendation is to get it done to establish a baseline.
> 
> The way I worded it with my vets is that it is a problem in the breed and I am following recommendations.
> 
> As for buying from an Ethical Breeder, I think whether they test or not, they should be willing to answer your questions about BA to the extent of their ability. You and the breeder can agree to either have the test done before you take the pups home or soon after (at that 16 week age).
> 
> I agree with you that it can be difficult to broach this subject, but I think you will find that an Ethical breeder's response should make you feel glad you asked. I know when I spoke with the two breeders I worked with most recently, I felt that awkwardness when I asked questions about LS and GME and other health issues. I did not want to sound like I was presuming their dogs were anything other than perfect healthy pups; however, the responses they gave me when we talked reassured me. I felt better about both breeders for having made that step forward with them and seeing how they responded to my questions.


Mary H and Carina THANK YOU so much for all that knowledge that you shared. I appreciate it so much. My vet actually knew about bile acid test, but was shocked at my asking, as though I spotted a problem with Mia and Leo. Almost like, why would I put them through that sort of look, when they were symptom free. But both of you and all of you sharing your experinces and knowledge have helped so much. I like the way you worded it to the vet Carina, that makes complete sense.

Suzan you bring up great points as well. Knowing how I am, and this may sound crazy, but regardless of the outcome of the test, I don't think I could walk away or turn the pup away, actually I know I wouldn't be able to, but I would be darn glad to know upfront, what to do and what to expect.

Thank you all so much for your valuable input.


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## k/c mom

Ladysmom said:


> Excellent post, Mary. :thumbsup:
> 
> Since Maltese have been identified by Dr. Center as one of the breeds highly affected by liver disease, there is just no good reason IMO for not having a BAT done on a puppy prior to its sale. Being afraid of the results is certainly not a good reason. To me, it is similar to being in a high risk group for AIDS and not getting a test to see if you are HIV positive out of fear.
> 
> Even if a potential buyer backs away from a sale based upon the results of the BAT, isn't that better than having a upset owner find out her puppy has MVD or a liver shunt a few months later and that her breeder could have had this simple, inexpensive test done prior to the sale? That can really damage a breeder's reputation.


Marj, great points! I do wonder how it would be with a breeder who was not a good communicator and a buyer who had never heard of liver issues in Malts. I think it may take someone who is good with words and who can adequately explain the situation .. especially in a phone call or email when the buyer is in another town. 

For some reason I had just thought of the test and that was that but really I think there is more to it if the results are not good or borderline.


----------



## MaryH

Nikki's Mom said:


> I understand, as I don't like surprises either. What I am concerned about is this: Since not every high BA test number means a shunt, things get complicated. May I ask: What is the next step if a puppy has a high BA number, and the buyer thinks they may still want the dog? Does the breeder do further testing themselves, or do they sell the dog and let the owner decide what to do next?


For me, the answer depends on the puppy itself. So now I'll share my whole story and hope that I don't lose you part way through. I got my first brood bitch hopeful in August 2006 as a 12 wk. old puppy before I knew much about liver shunt, MVD or bile acid testing. In October 2006 a breeder friend (the breeder of my Ch. male) had a puppy returned to her because it was diagnosed with a liver shunt. I knew of Dr. Center because of a rescue dog I had taken in in 2004 with a liver shunt. That dog's shunt was surgically repaired at Angell Animal Medical Center in Boston by a vet who years earlier was a colleague of Dr. Sharon Center at Cornell. He consulted with her while treating Mack, our rescue liver shunt dog. I also knew of Dr. Center's expertise with liver issues thanks to Jackie (JMM) who had been consulting with Dr. Center about her beloved little dog Mikey. So when my friend's puppy was returned for a supposed liver shunt I offered to contact Dr. Center. Dr. Center immediately contacted my friend and there started my education on liver issues. In November 2006 my friend and I drove to Cornell with all of her dogs plus two of mine, my 4-1/2 yr. old Ch. male and my 5-1/2 mo. old female. Brigid, the puppy with the alleged liver shunt did not, in fact, have a shunt. She had very high bile acid values (>100), but after a second ultrasound, a Protein C test, and a cholorectal scintigraphy she was diagnosed with asymptomatic MVD. She ultimately was spayed, placed in a pet home with a Cornell Vet School employee, eats a normal diet, is on no medication, and is at the Vet School on a regular basis, not because she is sick but because she gets to go to work with her human mom. My male has normal bile acid values (<5/18). My female has higher than normal bile acid values (11/68). What a bittersweet moment ... a normal male and abnormal female. My first question was "Is it safe to spay her?" knowing that it's the liver that processes out the anesthesia. The response I got from Dr. Center was "Why would you spay her? She is a normal, healthy, bright, active puppy at a good weight, does not have chronic episodes of diarrhea or vomiting, has normal CBC results, has no neurological issues. You should do exactly what you planned to do. Let her grow up and so long as she remains healthy breed her to your normal male. If you cull everything out of your breed with higher than normal bile acid values you will seriously compromise the gene pool. Bile acid test all puppies and do not sell anything with breeding rights for at least two generations." I asked about having a Protein C test done and was told that I could if I wanted to but that the Protein C test was going to tell me what I already knew just by observation ... I have a healthy asymptomatic MVD dog. She grew up, has always been healthy, has had regular wellness exams, and has been bred twice. Her first litter, sired by my male, produced a singleton girl with normal bile acid values. Her second litter, sired by a different male who also had normal bile acid values, produced 3 boys and 1 girl, two of whom have normal bile acid results, one had just slightly higher than normal values (high 20s), and one with what I consider higher values (low 60s). None of the puppies had Protein C tests done as I felt it was not necessary ... they were all happy, healthy, active puppies and are now happy, healthy, active dogs. If I felt that any of the puppies was not quite "right" I would have done a Protein C test without hesitation. When I sell my puppies, I provide the new owner with a complete health history. I spend a great deal of time discussing liver issues and sharing my knowledge. Should the owner want a Protein C test done, unless the puppy is exhibiting signs of symptomatic MVD, then I believe it is the owner's responsibility to pay for any further testing. If the puppy starts showing chronic symptoms of MVD, then I would offer to have my vet do a Protein C test and I would pay for the testing. Should the Protein C test results indicate that further testing should be done then I would also pay for that so long as I have the vet or vet school of my choosing do the testing. I have spoken at length with more than a couple of breeders who have in their lifetime produced a liver shunt puppy. They have all confirmed to me that they knew by 8-9 wks of age that something was not quite right with the puppy and therefore held on to it until it was of an age where further testing would provide more insightful results. I know my puppies because I spend every free waking moment with them from birth to 16 wks. I would know if something was not quite right and would never dream of withholding necessary diagnostic testing. I hope this helps to answer your questions and feel free to keep the dialogue going.


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## Nikki's Mom

MaryH said:


> For me, the answer depends on the puppy itself. So now I'll share my whole story and hope that I don't lose you part way through. I got my first brood bitch hopeful in August 2006 as a 12 wk. old puppy before I knew much about liver shunt, MVD or bile acid testing. In October 2006 a breeder friend (the breeder of my Ch. male) had a puppy returned to her because it was diagnosed with a liver shunt. I knew of Dr. Center because of a rescue dog I had taken in in 2004 with a liver shunt. That dog's shunt was surgically repaired at Angell Animal Medical Center in Boston by a vet who years earlier was a colleague of Dr. Sharon Center at Cornell. He consulted with her while treating Mack, our rescue liver shunt dog. I also knew of Dr. Center's expertise with liver issues thanks to Jackie (JMM) who had been consulting with Dr. Center about her beloved little dog Mikey. So when my friend's puppy was returned for a supposed liver shunt I offered to contact Dr. Center. Dr. Center immediately contacted my friend and there started my education on liver issues. In November 2006 my friend and I drove to Cornell with all of her dogs plus two of mine, my 4-1/2 yr. old Ch. male and my 5-1/2 mo. old female. Brigid, the puppy with the alleged liver shunt did not, in fact, have a shunt. She had very high bile acid values (>100), but after a second ultrasound, a Protein C test, and a cholorectal scintigraphy she was diagnosed with asymptomatic MVD. She ultimately was spayed, placed in a pet home with a Cornell Vet School employee, eats a normal diet, is on no medication, and is at the Vet School on a regular basis, not because she is sick but because she gets to go to work with her human mom. My male has normal bile acid values (<5/18). My female has higher than normal bile acid values (11/68). What a bittersweet moment ... a normal male and abnormal female. My first question was "Is it safe to spay her?" knowing that it's the liver that processes out the anesthesia. The response I got from Dr. Center was "Why would you spay her? She is a normal, healthy, bright, active puppy at a good weight, does not have chronic episodes of diarrhea or vomiting, has normal CBC results, has no neurological issues. You should do exactly what you planned to do. Let her grow up and so long as she remains healthy breed her to your normal male. If you cull everything out of your breed with higher than normal bile acid values you will seriously compromise the gene pool. Bile acid test all puppies and do not sell anything with breeding rights for at least two generations." I asked about having a Protein C test done and was told that I could if I wanted to but that the Protein C test was going to tell me what I already knew just by observation ... I have a healthy asymptomatic MVD dog. She grew up, has always been healthy, has had regular wellness exams, and has been bred twice. Her first litter, sired by my male, produced a singleton girl with normal bile acid values. Her second litter, sired by a different male who also had normal bile acid values, produced 3 boys and 1 girl, two of whom have normal bile acid results, one had just slightly higher than normal values (high 20s), and one with what I consider higher values (low 60s). None of the puppies had Protein C tests done as I felt it was not necessary ... they were all happy, healthy, active puppies and are now happy, healthy, active dogs. If I felt that any of the puppies was not quite "right" I would have done a Protein C test without hesitation. When I sell my puppies, I provide the new owner with a complete health history. I spend a great deal of time discussing liver issues and sharing my knowledge. Should the owner want a Protein C test done, unless the puppy is exhibiting signs of symptomatic MVD, then I believe it is the owner's responsibility to pay for any further testing. If the puppy starts showing chronic symptoms of MVD, then I would offer to have my vet do a Protein C test and I would pay for the testing. Should the Protein C test results indicate that further testing should be done then I would also pay for that so long as I have the vet or vet school of my choosing do the testing. I have spoken at length with more than a couple of breeders who have in their lifetime produced a liver shunt puppy. They have all confirmed to me that they knew by 8-9 wks of age that something was not quite right with the puppy and therefore held on to it until it was of an age where further testing would provide more insightful results. I know my puppies because I spend every free waking moment with them from birth to 16 wks. I would know if something was not quite right and would never dream of withholding necessary diagnostic testing. I hope this helps to answer your questions and feel free to keep the dialogue going.


Thanks so much for taking the time out to explain this. It does help very much. Knowing what I know now, I am not concerned about asymptomatic MVD and don't consider it to be a huge issue. I just wanted some clarification because there are others who are new to this issue, and I don't want them to be frightened away from a wonderful pup they may be considering. Thank you.


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## CloudClan

I want to thank MaryH and Jackie (JMM) for sharing their hard won knowledge with us. I should point out that Mary is in large part responsible for much of the information that is out there within the AMA on this issue. 

I also want to make this point. At SM we have benefited from the wealth of information they have shared. Many breeders do not have as much access to these two ladies as we do here on this forum. 

It is one of the great things about SM that we should value. 



Nikki's Mom said:


> Thanks so much for taking the time out to explain this. It does help very much. Knowing what I know now, I am not concerned about asymptomatic MVD and don't consider it to be a huge issue. I just wanted some clarification because there are others who are new to this issue, and I don't want them to be frightened away from a wonderful pup they may be considering. Thank you.


Thank you Suzan for making this point. This is one of the things that often worries me when Bile Acid tests are brought up. Though we have a lot of knowledge here, there are many people who are "afraid" of owning a dog with elevated numbers. As MaryH pointed out in her personal story, and you pointed out in yours, MVD is not something that should have people run away in terror. Obviously, it would be better if our breed did not have this problem as it is related to the much scarier liver shunts, but for most pet owners MVD will never be a true cause for concern.


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## jmm

It will always be at the forefront of my thoughts just why I learned about shunts and MVD in Maltese. When my first dogs were diagnosed, MVD was still a relatively new diagnosis. Nobody was able to tell me what would happen to my dogs until we ended up on a 6+ hour drive for some last miracle. 
Dr. Center told me I had to understand what was wrong in order to understand how to help my dog. Down I sat at the microscopes with a couple of vet students and a resident. Dr. Center took Mikey's picture the first time we visited. She said she saved all of them. I was still shocked to hear years later on one of Mary's visits that Dr. Center remembered my Mikey Man. 
Mikey was a *rare *case. We lost him at just 5 years of age. Unfortunately, his lines produced other dogs who died of their shunts or required chronic medical care. 
Mikey's lesson to me was not to run from another MVD dog...but to realize how *RARE *sick MVD dogs are. And that the sick ones usually have some concurrent condition. And yes, I purchased another pup with MVD who is normal, happy, and healthy. 
Mikey, my "original" Dust Mop with Drive


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## Ladysmom

jmm said:


> It will always be at the forefront of my thoughts just why I learned about shunts and MVD in Maltese. When my first dogs were diagnosed, MVD was still a relatively new diagnosis. Nobody was able to tell me what would happen to my dogs until we ended up on a 6+ hour drive for some last miracle.
> Dr. Center told me I had to understand what was wrong in order to understand how to help my dog. Down I sat at the microscopes with a couple of vet students and a resident. Dr. Center took Mikey's picture the first time we visited. She said she saved all of them. I was still shocked to hear years later on one of Mary's visits that Dr. Center remembered my Mikey Man.
> Mikey was a *rare *case. We lost him at just 5 years of age. Unfortunately, his lines produced other dogs who died of their shunts or required chronic medical care.
> Mikey's lesson to me was not to run from another MVD dog...but to realize how *RARE *sick MVD dogs are. And that the sick ones usually have some concurrent condition. And yes, I purchased another pup with MVD who is normal, happy, and healthy.
> Mikey, my "original" Dust Mop with Drive


I remember following Mikey's story on other forums. Thank you and others who have helped to shine the light on liver disease in Maltese.

Mikey will always be the face of liver disease to me. A brave and exceptional boy who captured all our hearts.

Do you still have that picture of Mikey in his pumpkin costume?


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## tamizami

awww, jackie, i love seeing pictures of your mikey man. thank you and mary and carina for all of your insight, we are so lucky to have you here on SM.

my experience with 2 MVD dogs was that they had very high bile acid values (>130). at the time of their bile acid tests, they also had elevated ALTs, but for the last 18 months stuart's ALTs have been in the normal range. i am not afraid of an MVD dog and i don't make any assumptions based on the bile acid numbers.

sooooo, when i think about BATs being recommended at 16 weeks by Dr. Center, and so many maltese having high BATs, why wouldn't it be more prudent (and less invasive) if breeders just did Protein C tests??? new owners can get the BAT at 16 weeks or older for a baseline, but at least the breeder has pretty much ruled out a liver shunt before placing the puppy.


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## MaryH

tamizami said:


> sooooo, when i think about BATs being recommended at 16 weeks by Dr. Center, and so many maltese having high BATs, why wouldn't it be more prudent (and less invasive) if breeders just did Protein C tests??? new owners can get the BAT at 16 weeks or older for a baseline, but at least the breeder has pretty much ruled out a liver shunt before placing the puppy.


The Protein C test was never intended to be a stand alone diagnostic test for liver function; instead when used in conjunction with bile acid testing it helps to differentiate between PSVA and MVD in dogs whose bile acid results are abnormal. The majority of dogs with confirmed MVD also show high Protein C activity whereas dogs with confirmed PSVA show low Protein C activity. Protein C activity on its own does not tell anyone what liver function is and could be high or low for any other number of reasons. It's more like a law of averages scenario -- if bile acids are X and Protein C is Y, then we can reasonably conclude with an accuracy of about 95% that this dog is diagnosed with Z. If I were selling a puppy I would never feel comfortable saying that the puppy does not have serious liver issues based solely on a Protein C test. If I were buying a puppy I would never feel assured that there were no serious liver issues based solely on a Protein C test. If a puppy is tested at 12 wks. and has higher than normal bile acid values chances are at 16 wks. it is still going to have higher than normal bile acid values. If at 12 wks. a puppy has sky high bile acid values at least the breeder is aware and can cancel or postpone a sale until further testing is done.


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## edelweiss

This thread is excellent---makes me excited to be on the SM forum! Thanks to Mary & others who take time to share their knowledge w/us.
As mentioned earlier 18 yrs. ago I had a seriously ill dog, Kirby, w/shunting. I knew very early on that something was wrong, but after seeing numerous vets in Europe I finally took him to the US where he was diagnosed at Colorado State vet school. He was operated, was on meds for seizures his entire life (phenabarb), had a consistently low protein diet and lived to be an old man! He did have some health issues throughout his life---but he was a tough little fighter and always won---until we finally had to put him to rest---by then he was also blind and deaf. Oh, but so loved!
We still miss him and that was almost 18 yrs. ago now.
One question I have been thinking about? Is it possible that the high-protein dog foods that we love to feed our dogs contribute to this predisposition? Any thoughts here?


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## Nikki's Mom

edelweiss said:


> This thread is excellent---makes me excited to be on the SM forum! Thanks to Mary & others who take time to share their knowledge w/us.
> As mentioned earlier 18 yrs. ago I had a seriously ill dog, Kirby, w/shunting. I knew very early on that something was wrong, but after seeing numerous vets in Europe I finally took him to the US where he was diagnosed at Colorado State vet school. He was operated, was on meds for seizures his entire life (phenabarb), had a consistently low protein diet and lived to be an old man! He did have some health issues throughout his life---but he was a tough little fighter and always won---until we finally had to put him to rest---by then he was also blind and deaf. Oh, but so loved!
> We still miss him and that was almost 18 yrs. ago now.
> One question I have been thinking about? Is it possible that the high-protein dog foods that we love to feed our dogs contribute to this predisposition? Any thoughts here?



Good question.

I am no medical expert at all, but IMO, I don't think that food has much to do with the genetic aspect of a liver shunt. 

IMO, the fear of high protein food, in general, is overblown - IF you feed your dog *high-quality* protein, and IF you provide enough water. 

I am much more suspect of the QUALITY of the protein and QUALITY of the fats in commercial dog foods, than protein itself. I may be wrong, but I don't think that there have been any studies done on hereditary liver shunts and diet. If anyone is aware of one, then please let us know. 

BTW, Nikki has been eating a good amount of protein since I started home cooking for her, and her liver values are normal. She doesn't have a shunt, though, just MVD.


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## edelweiss

I would agree Susan, but I am thinking long-term---say generations back? We know that what we feed our dogs, or what people eat does make a difference in how healthy the next generation is, and the next, and the next. . . . (you get the idea ). 
Kirby and I were in a study done by the U. of CO. way back then---it had already been determined that a large degree of small breed dogs are genetically liable for liver issues. 
I am aware that this is a different issue but in South Africa more babies are born w/primary liver cancer than any country in the world and it is suspected that this is loosely connected w/FAS (fetal alcohol syndrome)----over time. Just wondering about consumption/environment/etc. over the l o n g haul! 
'Thrilled your Nikki is doing so very well!


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## Nikki's Mom

Oops, double post.


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## Nikki's Mom

I hate to open up a can of worms here, but I also think that the reason why liver disease in small dogs is so common might just be due to a generation of over-vaccinating with the same exact dose that a Great Dane receives.


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## Nikki's Mom

edelweiss said:


> I would agree Susan, but I am thinking long-term---say generations back? We know that what we feed our dogs, or what people eat does make a difference in how healthy the next generation is, and the next, and the next. . . . (you get the idea ).
> Kirby and I were in a study done by the U. of CO. way back then---it had already been determined that a large degree of small breed dogs are genetically liable for liver issues.
> I am aware that this is a different issue but in South Africa more babies are born w/primary liver cancer than any country in the world and it is suspected that this is loosely connected w/FAS (fetal alcohol syndrome)----over time. Just wondering about consumption/environment/etc. over the l o n g haul!
> 'Thrilled your Nikki is doing so very well!


Yes, agreed. I still don't think it isn't high protein, per se, that is causing a lot of issues. I think it is poor quality protein, chemically-laden, rancid fats, and poor quality vitamin mixes from China (hate to single out one country, but that's where 99% of vitamins are from) in dog foods that are causing disease in dogs. 

I would imagine the same could be said for humans, too, regarding processed people food.


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## Ladysmom

Nikki's Mom said:


> Good question.
> 
> I am no medical expert at all, but IMO, I don't think that food has much to do with the genetic aspect of a liver shunt.


I agree, Suzan. 

May I suggest we stick to the topic of liver shunts and bile acids in this thread so Sher doesn't haven't to start yet another thread because this one went off topic, too? LOL


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## Ladysmom

Since this subject just came up in another thread, I guess it's a good time to bring it up here. Many vets are under the misconception that fasting is required before a bile acids test. *That is inaccurate.
*
_"It is no longer recommended to fast for 12 hours before first collection or meal."
_
http://www.ytca.org/health_CenterQue...xpress2010.pdf

"Dogs DO NOT need to be fasted for 12-hours to conduct this test."

PSVA and MVD Research Summary


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## Ladysmom

tamizami said:


> awww, jackie, i love seeing pictures of your mikey man. thank you and mary and carina for all of your insight, we are so lucky to have you here on SM.
> 
> my experience with 2 MVD dogs was that they had very high bile acid values (>130). at the time of their bile acid tests, they also had elevated ALTs, but for the last 18 months stuart's ALTs have been in the normal range. i am not afraid of an MVD dog and i don't make any assumptions based on the bile acid numbers.
> 
> sooooo, when i think about BATs being recommended at 16 weeks by Dr. Center, and so many maltese having high BATs, why wouldn't it be more prudent (and less invasive) if breeders just did Protein C tests??? new owners can get the BAT at 16 weeks or older for a baseline, but at least the breeder has pretty much ruled out a liver shunt before placing the puppy.


Dr. Karen Tobias' research at U of T has raised some questions about the accuracy of the Protein C test:


_*Protein C Test*_
_by_
_Dr. Karen Tobias_






Question: How good is the Protein C test?


Answer: We're re-evaluating the Protein C test here at UT. In the original Cornell paper, normal dogs had Protein C activity between about 70% and 130%; 95% of dogs with MVD/CPH (microvascular dysplasia secondary to congenital portal hypoplasia) had protein C's in that range; and 88% of dogs with shunts dogs had Protein C's below 70%. Most dogs with liver failure had low numbers. Dogs with other liver diseases fell in the normal or abnormal range. So, the test is not completely accurate and should be coupled with other tests to be sure there's a shunt. Currently our dogs with MVD/CPH have very low Protein Cs and we don't know if it is the way we are running our test or whether we are seeing dogs with MVD/CPH that are much more severely affected.

www.yorkieangelpatrol.com/*ProteinCTest*.doc


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## MaryH

Sandi and Susan, thanks for raising such good questions. Certainly provides some food for thought ... no pun intended. While we know that environmental factors play into genetics over time in humans as well as animals, I have heard nothing about diet or vaccinations playing a part in the genetics behind the vascular issues in our dogs. Maltese are a very very old breed, around long before vaccinations and commercially processed food. And liver shunt is not new either. It may not have had a "real name" 40 years ago and diagnostics were not what they are now but liver shunt was around. It's thought now that "Fading Puppy Syndrome" (unexplained death of puppies from birth to 3 weeks old or so) might actually be puppies with liver shunt. Necropsies that have been performed on puppies that young were generally inconclusive as to cause of death. There is also the theory that one of the reasons why Maltese have such small litters is that puppies with shunts die in utero and are resorbed.

I love it when someone asks questions like yours because it keeps us all thinking and learning and, as always, discoveries start with someone thinking.


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## CrystalAndZoe

I just want to say thank you for this thread. I can't believe how fortunate we are to have people that are so knowledgeable here and are willing to spend their free time sharing that knowledge with us. Jackie, Carina and Mary are invaluable and I am very grateful to and for them. 

I had been under the misconception as well that you needed to feed an asymptomatic MVD dog a special diet. Mary has selflessly spent hours on the phone with me calming my fears and answering my questions. When I adopted Jett, his levels were all perfect and have been with each CBC. However again I was unaware that you could still have an asymptomatic MVD dog with perfect ALT and AST levels and the BA test would be high. Had I known, I would have had a BA test performed for a baseline. After talking with Mary, she has calmed this overly worrier down and advised me that at this time it really isn't necessary to do a BA test. We suspect that Jett is also asymptomatic MVD. But now that I know that, if ever he should get sick and a BA Test is done and his level is high, it most likely always has been. 

So after reading about the Protein C test, just for clarification for those whose vet may say that the next step in testing after a CBC would be a Protein C, a Protein C Test is only indicated after the BA test comes back high and is used to help determine if we are dealing with MVD or PSVA, correct? Sorry but I'm not familiar with the acronym PSVA. What is that?

So if a breeder is really spending the kind of time with the puppies that they should be to fully evaluate them, (in other words does not have an outrageously high # of dogs in their breeding program and too many litters at one time) and you can usually tell by 8 or 9 weeks of age that a puppy is not quite right and are suspecting shunt, then how is it that a reputable breeder sells a dog at 12 + weeks of age with liver shunt? Can a LS puppy not show signs until an older age? Now I'm not saying that just because a breeder has had a puppy with LS they are not a reputable breeder. They can only do so much to try to ensure the healthiest puppies. I am no longer fearful of anyone getting a puppy knowing they have asymptomatic MVD, but just hate the heartache of someone getting a puppy with LS. So even if a breeder is not doing BA tests on their puppies, they should be able to tell if there is something not quite right (suspecting LS) before 12 weeks, correct?


Edited to add...OOPS!! Just went to the link on the AMA website Mary posted and now know what PSVA is. ::blushing a LOT right now::


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## Nikki's Mom

Others can correct me if I am wrong, but I believe that some liver shunts can be acquired over time.


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## tamizami

MaryH said:


> The Protein C test was never intended to be a stand alone diagnostic test for liver function; instead when used in conjunction with bile acid testing it helps to differentiate between PSVA and MVD in dogs whose bile acid results are abnormal. The majority of dogs with confirmed MVD also show high Protein C activity whereas dogs with confirmed PSVA show low Protein C activity. Protein C activity on its own does not tell anyone what liver function is and could be high or low for any other number of reasons. It's more like a law of averages scenario -- if bile acids are X and Protein C is Y, then we can reasonably conclude with an accuracy of about 95% that this dog is diagnosed with Z. If I were selling a puppy I would never feel comfortable saying that the puppy does not have serious liver issues based solely on a Protein C test. If I were buying a puppy I would never feel assured that there were no serious liver issues based solely on a Protein C test. If a puppy is tested at 12 wks. and has higher than normal bile acid values chances are at 16 wks. it is still going to have higher than normal bile acid values. If at 12 wks. a puppy has sky high bile acid values at least the breeder is aware and can cancel or postpone a sale until further testing is done.


now i am a little confused: why would you test a 12 week old puppy when the recommendation from dr. center is 16 weeks? also, what testing would you recommend next if a 16 week old puppy has high bile acids?

also, i am not suggesting that a puppy owner shouldn't have a baseline BAT done at 16 weeks or a little older, they should along with a CBC and other wellness check when they get their puppy and before any vaccines are administered.


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## Ladysmom

tamizami said:


> now i am a little confused: why would you test a 12 week old puppy when the recommendation from dr. center is 16 weeks? also, what testing would you recommend next if a 16 week old puppy has high bile acids?
> 
> also, i am not suggesting that a puppy owner shouldn't have a baseline BAT done at 16 weeks or a little older, they should along with a CBC and other wellness check when they get their puppy and before any vaccines are administered.


Tami, Dr. Center's revised protocol is to have a second BAT at six months. I would assume that would be a failsafe for puppies who had a BAT done a little earlier or puppies whose organs develop a little more slowly.

http://www.ytca.org/health_CenterQuestionsExpress2010.pdf

Dr. Center has always stressed the importance of having a BAT before the puppy goes to her new home.


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## Ladysmom

Nikki's Mom said:


> Others can correct me if I am wrong, but I believe that some liver shunts can be acquired over time.


You're right.
*
Multiple small shunts ("acquired portosystemic shunts") form because of severe liver disease such as cirrhosis.*

Portosystemic Shunts FAQ

Congenital portosystemic shunts are most common in Maltese, though.


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## CrystalAndZoe

Ladysmom said:


> Tami, Dr. Center's revised protocol is to have a second BAT at six months. I would assume that would be a failsafe for puppies who had a BAT done a little earlier or puppies whose organs develop a little more slowly.
> 
> http://www.ytca.org/health_CenterQuestionsExpress2010.pdf
> 
> Dr. Center has always stressed the importance of having a BAT before the puppy goes to her new home.



I'm pretty sure my understanding of Dr. Center's revised protocol of having another BA Test at 6 months is for those who are breeding and considering using that puppy in their breeding program. I don't think that is for the pet owner. I think she is recommending a BA test for the pet owner (if the breeder hasn't done it, soon after 16 weeks for a base line only. It does not need to be redone after 6 months.


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## Ladysmom

Crystal&Zoe said:


> I'm pretty sure my understanding of Dr. Center's revised protocol of having another BA Test at 6 months is for those who are breeding and considering using that puppy in their breeding program. I don't think that is for the pet owner. I think she is recommending a BA test for the pet owner (if the breeder hasn't done it, soon after 16 weeks for a base line only. It does not need to be redone after 6 months.


Hmmm....I don't see where Dr. Center makes that distinction at her YTCA seminar last October.

_3. What is the best age to have a puppy/dog bile acid tested?_

16 weeks and again at 6 months.

Are you referring to another study or article?

Maybe MaryH has attended one of her recent seminars and can clarify.


----------



## CrystalAndZoe

Ladysmom said:


> You're right.
> *
> Multiple small shunts ("acquired portosystemic shunts") form because of severe liver disease such as cirrhosis.*
> 
> Portosystemic Shunts FAQ
> 
> Congenital portosystemic shunts are most common in Maltese, though.


So acquired portosystemic shunts from something like cirrhosis would be in an older dog? Not a puppy under 12 months?


----------



## CrystalAndZoe

Ladysmom said:


> Hmmm....I don't see where Dr. Center makes that distinction at her YTCA seminar last October.
> 
> _3. What is the best age to have a puppy/dog bile acid tested?_
> 
> 16 weeks and again at 6 months.
> 
> Are you referring to another study or article?
> 
> Maybe MaryH has attended one of her recent seminars and can clarify.


I got that from Mary H's post in the other thread.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
* Quote:
Originally Posted by **Ladysmom  
*_*Dr. Center has been recommending for years that all puppies have a bile acids test before going to their new homes. If all breeders were doing this routinely, it would save new owners a lot of heartache and expense.
* 
*2: The best approach to avoid "over diagnosis" is to test bile acids in young dogs of highly affected breeds (at 4 mths of age) while they are clinically healthy and before they are adopted into pet homes**. Highly affected breeds include: Yorkshire Terrier, Cairn Terrier, Maltese, Tibetan Spaniels as well as many other "terrier" type breeds (Miniature Schnauzer, Lhasa Apso, Shih Tzu, Dachshund, Bichon Frise, Pekingese, Toy and Miniature Poodles, and Havanese and others). *
_ _
Dr. Center has recently revised her protocol and now recommends a BAT be done at 16 weeks and again at six months.

http://www.ytca.org/health_CenterQue...xpress2010.pdf_


~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 
Quote:
Originally Posted by *Cosy*  
_While that's all well and good, most pups are sold at three months, not four months. Something has to give here. The AMA needs to adjust the age if we are ever to get a grip on this awful disease._

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
_*
We all need to remember before putting out certain info that we should know the context in which the advice was given. The better time to run a bile acid test is when the puppy is a bit older, at or after 16 wks. But we have also been advised that testing a younger puppy, say at 12 wks., is better than not testing at all. The advice about testing again at 6 mos. or after was advice given to BREEDERS regarding dogs that they are considering keeping for BREEDING PURPOSES. This was never meant for puppies who were tested at an appropriate age and placed on a spay/neuter contract.

AMA cannot mandate testing, let alone the timing for it. I do keep my puppies until they are 16 wks. old and I do bile acid test all of them before they leave my house. THAT MAKES ME A BIT OF A CONTROL FREAK BUT DOES NOT NECESSARILY MAKE ME A BETTER BREEDER THAN SOMEONE WHO DOES NOT TEST THEIR PUPPIES. I don't have the benefit of 20 years' worth of breeding experience behind me so I cannot say "I've bred for X years and have never produced a shunt." I am relatively new to breeding, I don't have the luxury of several generations of related dogs to work with, so consequently I use the only tool I have available to me ... the bile acid test. I know and highly respect certain breeders who do not test every puppy. But they DO test all of their breeding stock, they have been breeding for years, and they will absolutely test a puppy if the purchaser wants the puppy tested before the purchase takes place. Responsibility is a two-way street, especially here on this forum where there is probably more good breed-specific info on liver issues than you will find anywhere else on the internet. Buyers as much as breeders should be wanting bile acid testing done on their potential new bundle of joy.*_


----------



## MaryH

tamizami said:


> now i am a little confused: why would you test a 12 week old puppy when the recommendation from dr. center is 16 weeks? also, what testing would you recommend next if a 16 week old puppy has high bile acids?
> 
> also, i am not suggesting that a puppy owner shouldn't have a baseline BAT done at 16 weeks or a little older, they should along with a CBC and other wellness check when they get their puppy and before any vaccines are administered.


What Dr. Center said to us at her seminar at the NJ National was that the preferred time for testing is 16 wks. BUT if a puppy is being sold at 12 wks. it is still better to test then than not at all. One is likely to get a more accurate bile acid value on a more mature liver. BUT, if a breeder is going to sell a puppy at 12 wks. of age it is still better to test then than not to test at all.

An example -- As a rule, I keep my puppies until I can test at 16 wks. old. However, I am selling a puppy to someone who lives out of state and will be vacationing here in my area when the puppy is 12 wks. old. Personally, I'd rather place the puppy at 12 wks. knowing it will fly home in the cabin of the plane rather than wait 4 more wks. and ship the puppy as cargo. So I'm going to test that puppy at 12 wks. If, say, I get a bile acid value of 40 and by all appearances the puppy is healthy, well, not a huge concern as I'm placing the puppy in a pet home. Waiting to test at 16 wks. or even at 6 mos. I might have gotten the same value, a bit lower, or a bit higher but generally there are not huge swings. But what if the bile acid value is 150 at 12 wks? I'd be postponing the sale until the puppy is more mature to get a more accurate value which would help me to decide whether or not to pursue further testing. If the puppy was one that I was thinking of keeping for breeding I would wait to test a mature liver. The variation at an older age might be one more factor in deciding whether I keep that puppy as a future hopeful in my breeding program. There are a number of good reasons why breeders sell puppies at 12 wks. old and I still think it is better to test then to try to avoid surprise or heartbreak.

At whatever age, if a puppy has extremely high bile acid values (greater than 100) I personally would do a Protein C test next. If a puppy has moderately high bile acid values (50-99) I would think about doing a Protein C test after taking into consideration other factors ... weight, activity level, occurrences of diahrrea and/or vomiting, behavior after meals, neurological symptoms, etc.


----------



## MaryH

Ladysmom said:


> Hmmm....I don't see where Dr. Center makes that distinction at her YTCA seminar last October.
> 
> _3. What is the best age to have a puppy/dog bile acid tested?_
> 
> 16 weeks and again at 6 months.
> 
> Are you referring to another study or article?
> 
> Maybe MaryH has attended one of her recent seminars and can clarify.


 
:smilie_tischkante: I'm losing my patience ... :smilie_tischkante:

What you keep referencing (and putting your own spin on) is a synopsis of a seminar given to breeders for breeders. Nowhere in that synopsis is there discussion about pets. I can't spend any more time explaining this because my head is starting to hurt.


----------



## CloudClan

Crystal&Zoe said:


> I just want to say thank you for this thread. I can't believe how fortunate we are to have people that are so knowledgeable here and are willing to spend their free time sharing that knowledge with us. Jackie, Carina and Mary are invaluable and I am very grateful to and for them.
> ...
> So if a breeder is really spending the kind of time with the puppies that they should be to fully evaluate them, (in other words does not have an outrageously high # of dogs in their breeding program and too many litters at one time) and you can usually tell by 8 or 9 weeks of age that a puppy is not quite right and are suspecting shunt, then how is it that a reputable breeder sells a dog at 12 + weeks of age with liver shunt? Can a LS puppy not show signs until an older age? Now I'm not saying that just because a breeder has had a puppy with LS they are not a reputable breeder. They can only do so much to try to ensure the healthiest puppies. I am no longer fearful of anyone getting a puppy knowing they have asymptomatic MVD, but just hate the heartache of someone getting a puppy with LS. So even if a breeder is not doing BA tests on their puppies, they should be able to tell if there is something not quite right (suspecting LS) before 12 weeks, correct?


Thank you Crystal, but I would not know anything about this if it were not for the knowledge shared by MaryH and Jackie. Even what I have learned from my vet has ultimately been insignificant or incomparable/incompatible with their expertise. 

I think Mary answered the rest of your questions, but on the topic of what a breeder may or may not recognize I would say that it is true that often there are signs and if breeders do not spend enough time with their dogs they may miss them, but it is a very case by case situation and that would not be true all the time. Yes, a puppy may not display clear signs until an older age. 

In the case of Finnegan and Rocco, one thing that might raise a red flag for me is the dramatic difference in size. A 2 pound pup and a 6 pound pup in the same litter can certainly happen, but any 2 pound pup would cause me grave concern that something might not be quite right. 



tamizami said:


> now i am a little confused: why would you test a 12 week old puppy when the recommendation from dr. center is 16 weeks? also, what testing would you recommend next if a 16 week old puppy has high bile acids?
> 
> also, i am not suggesting that a puppy owner shouldn't have a baseline BAT done at 16 weeks or a little older, they should along with a CBC and other wellness check when they get their puppy and before any vaccines are administered.


I think the main reason that a pup might be tested at 12 weeks is the issue of the age when most breeders release their puppies. Frankly, waiting until 16 weeks is not something many breeders or pet owners want to do, for a variety of reasons. So then you are left with the question of should the test be done at 12 weeks before the pup leaves home, or at 16 once the family has already bonded with the pup. 

I personally would be willing to take home a 12 week old pup and test at 16. But that is part of the individual discussion and decisions that each breeder and buyer must go through. 




Crystal&Zoe said:


> I'm pretty sure my understanding of Dr. Center's revised protocol of having another BA Test at 6 months is for those who are breeding and considering using that puppy in their breeding program. I don't think that is for the pet owner. I think she is recommending a BA test for the pet owner (if the breeder hasn't done it, soon after 16 weeks for a base line only. It does not need to be redone after 6 months.


As Mary has said, this was in a presentation to Breeders. So Dr. Center's recommendations targeted them. It does not need to be redone for pets at 6 months.


----------



## Ladysmom

Crystal&Zoe said:


> I got that from Mary H's post in the other thread.
> 
> 
> _*
> We all need to remember before putting out certain info that we should know the context in which the advice was given. The better time to run a bile acid test is when the puppy is a bit older, at or after 16 wks. But we have also been advised that testing a younger puppy, say at 12 wks., is better than not testing at all. The advice about testing again at 6 mos. or after was advice given to BREEDERS regarding dogs that they are considering keeping for BREEDING PURPOSES. This was never meant for puppies who were tested at an appropriate age and placed on a spay/neuter contract.
> 
> *_


That seems to contradict what I have read from Dr. Center. This is Dr. Center's most current bile acids protocol linked on the Yorkshire Terrier Club of America website. The recommendation to test again at six months is included in the basic protocol with no qualifications for dogs used for breeding. 

http://www.ytca.org/health_biletestproced.doc-1.pdf

The YTCA website is a great source of up to date information on liver shunts since the breed is so highly affected by them. Yorkies are 36 times more likely to be born with a shunt than all other breeds combined.

There are copies of a recent letter from Dr. Center to the club updating the results of her research study, too.


----------



## CrystalAndZoe

CloudClan said:


> In the case of Finnegan and Rocco, one thing that might raise a red flag for me is the dramatic difference in size. A 2 pound pup and a 6 pound pup in the same litter can certainly happen, but any 2 pound pup would cause me grave concern that something might not be quite right.


That's what I was thinking. Yet another reason why I don't understand why people are truly wanting teeny tiny ones and the runts of the litter. No a teeny tiny does not automatically indicate LS, but I always worry when someone announces they have a new baby and it's extremely small.



Ladysmom said:


> That seems to contradict what I have read from Dr. Center. This is Dr. Center's most current bile acids protocol linked on the Yorkshire Terrier Club of America website. The recommendation to test again at six months is included in the basic protocol with no qualifications for dogs used for breeding.
> 
> http://www.ytca.org/health_biletestproced.doc-1.pdf
> 
> The YTCA website is a great source of up to date information on liver shunts since the breed is so highly affected by them. Yorkies are 36 times more likely to be born with a shunt than all other breeds combined.
> 
> There are copies of a recent letter from Dr. Center to the club updating the results of her research study, too.


Seriously? Marj are you not seeing the above posts by Mary H and Carina?


----------



## Ladysmom

Crystal&Zoe said:


> Seriously? Marj are you not seeing the above posts by Mary H and Carina?


Crystal, I have read the posts by Mary and Carina. Again, they seem to contradict the current protocol verbatim from Dr. Center posted on the YTCA website.

I am not trying to be argumentative. With all due respect to Mary and Carina, I personally would prefer to follow a protocol set out by Dr. Center herself rather than someone else's interpretation of it.

I suggest we agree to disagree on this one and move on.


----------



## CloudClan

Ladysmom said:


> Crystal, I have read the posts by Mary and Carina. Again, they seem to contradict the current protocol verbatim from Dr. Center posted on the YTCA website.
> 
> I am not trying to be argumentative. With all due respect to Mary and Carina, I personally would prefer to follow a protocol set out by Dr. Center herself rather than someone else's interpretation of it.
> 
> I suggest we agree to disagree on this one and move on.


Marj, 

I think the point you are missing is that you are taking it out of context. The context in which those recommendations were given was when Dr. Center was speaking to breeders. 

If it were your own decisions regarding your own pets then I would not be concerned and happy to move on and agree to disagree as you say. It is not a big deal to run a BA test again. However, when you post here that this should be done on all pets at 6 months I think you need to understand that you could be costing people collectively a small fortune.


----------



## Ladysmom

CloudClan said:


> Marj,
> 
> I think the point you are missing is that you are taking it out of context. The context in which those recommendations were given was when Dr. Center was speaking to breeders.


Could someone please show me where in Dr. Center's most current bile acid protocol it says anything about it being only for puppies being used for breeding? Or has any qualifications?

This was not taken from a seminar. It is a pinned link on the YTCA website, Health Committee section, entitled *Bile Acid Testing:* Optimal Conditions on Dr. Center's letterhead.

http://www.ytca.org/health_biletestproced.doc-1.pdf


----------



## k/c mom

Ladysmom said:


> Could someone please show me where in Dr. Center's most current bile acid protocol it says anything about it being only for puppies being used for breeding? Or has any qualifications?
> 
> This was not taken from a seminar. It is a pinned link on the YTCA website, Health Committee section, entitled *Bile Acid Testing:* Optimal Conditions on Dr. Center's letterhead.
> 
> http://www.ytca.org/health_biletestproced.doc-1.pdf


This link is great. It explains everything so simply and in such a straightforward way. 

I do hate to see this thread get bogged down on one point but there is nothing in this link at all about breeding stock, etc. The way it is written, it sounds like this is general advice. So this makes for confusion regarding whether the information just wasn't written with all of the details included or if indeed she is recommending a 2nd test for all at 6 months.

Copied & Pasted from the link above. Written by Dr. Center:
Additional Information; 
*It is no longer recommended to fast a dog for 12 hours before first collection or meal. The same size and type of meal that the dog normally eats is what should be used for the meal. 
*Test puppies at 16 weeks and again at 6 months. Dogs > 4 years of age can have other liver problems that will affect the Bile Acid test. 
*If the dog is stuffed or if the dog is frightened the test result can possibly be skewed. 
*The draw can be done one day pre feeding, then the dog can be taken home and fed and another draw done 2 hours post-feeding. It is not imperative it be done the same day.


----------



## Cosy

Marj, the Dr. Center header info was sent to YTCA. This is the yorkie club of America and I believe it was directed to the club, which consists primarily of breeders. Thus, it is pinned by the YTCA. This is my understanding.


----------



## tamizami

CloudClan said:


> I personally would be willing to take home a 12 week old pup and test at 16. But that is part of the individual discussion and decisions that each breeder and buyer must go through.


thanks carina, i agree, i am willing to take home a 12 week old and then test the puppy at 16 weeks or older to be sure to get an accurate reading. and its important to me to feel this way about a breeder in order for me to get a pup from them. that is all part of the mutual interview process. 

mary, thanks for your explanation, too!


----------



## princessre

I'm learning alot from this thread- thanks to everyone!!

I got both Casanova and Bijou at 6 months. I had Casanova tested at 8 months, and Bijou tested at 6 months (as part of the initial vet checkup.) Both tests came back normal. But since some shunts can be acquired later in life, should I repeat the bile acid test at some later time to be sure that they have not acquired a shunt later? Or what signs would indicate a shunt, if, God forbid, they did acquire one later?


----------



## Nikki's Mom

princessre said:


> I'm learning alot from this thread- thanks to everyone!!
> 
> I got both Casanova and Bijou at 6 months. I had Casanova tested at 8 months, and Bijou tested at 6 months (as part of the initial vet checkup.) Both tests came back normal. But since some shunts can be acquired later in life, should I repeat the bile acid test at some later time to be sure that they have not acquired a shunt later? Or what signs would indicate a shunt, if, God forbid, they did acquire one later?



I'm no expert, but I just have a complete blood panel done on Nikki once a year. If the ALT (Liver enzyme) level remains in the normal range, I don't see any reason to do another BA test.


----------



## MaryH

princessre said:


> I'm learning alot from this thread- thanks to everyone!!
> 
> I got both Casanova and Bijou at 6 months. I had Casanova tested at 8 months, and Bijou tested at 6 months (as part of the initial vet checkup.) Both tests came back normal. But since some shunts can be acquired later in life, should I repeat the bile acid test at some later time to be sure that they have not acquired a shunt later? Or what signs would indicate a shunt, if, God forbid, they did acquire one later?


Generally dogs who acquire shunts later in life develop an intrahepatic shunt or multiple microscopic intrahepatic shunts. For the most part these shunts happen in dogs who don't start off with a healthy liver, have concurrent liver issues (read Jackie's post #29 in this thread and follow the link to her webpage about Mikey), or are afflicted with some other liver disease like hepatitis later in life. I do not do repeat bile acid tests on my dogs but would if they were sick and based on CBC results and/or physical symptoms my vet thought that there might be something going on with liver issues.


----------



## jmm

Mary is right on with acquired shunts. In my experience, I have seen them after an injury/assault on the liver, concurrent with another liver disease (cirrhosis), or following a shunt repair when the liver couldn't handle the newly given load so creates new shunts to relieve the pressure. When dealing with acquired shunts, the dog is having another issue going on (so your dog would likely be sick due to this other problem).


----------



## 3Maltmom

Nikki's Mom said:


> *What if nobody wants them? *
> 
> .


 
They end up at my house ~ :HistericalSmiley:

I Love YOU, my friend. :grouphug:


----------



## Nikki's Mom

3Maltmom said:


> They end up at my house ~ :HistericalSmiley:
> 
> I Love YOU, my friend. :grouphug:



:HistericalSmiley::grouphug:


----------



## newlove

Is there special food I can buy to keep my new baby from getting this? I have heard they can have liver problems but guess I never knew how serious.


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## MTC

I know this thread is old, but I wanted to thank everyone for posting this information. We just got our wonderful Maltese, Chloe, about 4 weeks ago when she was just 12 weeks. Our breeder gave us the results of a BAT that was done around 11 weeks and the results were 1 pre /30 post. We took Chloe to our vet the first week we had her and he thought she should be retested at 16 weeks because he thought 30 was high. The retest was this past Tuesday. We got the results tonight and they were 1.2 pre and 70.9 post. He had indicated that it was probably a shunt and that we need to immediately go to Hills LD food to try to manage the shunt. He was concerned about putting her under for her spay surgery in a few months and wanted to make sure she gets on the Hills LD immediately.

Now, I am glad that I found this site because it has absolutely helped to calm our nerves and educate us on the shunt and MVD topic. However, it is still alarming to us that she went from a 30 to 70.9 in just over 4 weeks. I know that 70.9 isn’t too alarming in and of itself, but is the increase in just 4 weeks an area of concern?

Unfortunately, the breeder did not explain shunts or MVD to us in detail as Mary H would have :angry::angry::angry:, she just said that levels >100 are an area for concern, but since she was 30 she was fine. So naturally we didn’t think anything of the BAT results. When we bought her we went with a reputable breeder that had Champion lines to try to minimize some of the predisposed health risks. You can only imagine my disappointment when the vet said that it is a shunt and we need to be prepared for her to be sick. It’s all a little shocking since we have only had her for four weeks. She doesn’t display any symptoms that I can tell so it makes it even harder to understand.

I mentioned MVD to the vet and he kind of blew it off… I am not sold that he knew what it was. What I do know is that I am close enough to UPenn should I need a second opinion. Any thoughts or opinions on her levels would be appreciated.
Thanks in advance!


----------



## k/c mom

MTC said:


> I know this thread is old, but I wanted to thank everyone for posting this information. We just got our wonderful Maltese, Chloe, about 4 weeks ago when she was just 12 weeks. Our breeder gave us the results of a BAT that was done around 11 weeks and the results were 1 pre /30 post. We took Chloe to our vet the first week we had her and he thought she should be retested at 16 weeks because he thought 30 was high. The retest was this past Tuesday. We got the results tonight and they were 1.2 pre and 70.9 post. He had indicated that it was probably a shunt and that we need to immediately go to Hills LD food to try to manage the shunt. He was concerned about putting her under for her spay surgery in a few months and wanted to make sure she gets on the Hills LD immediately.
> 
> Now, I am glad that I found this site because it has absolutely helped to calm our nerves and educate us on the shunt and MVD topic. However, it is still alarming to us that she went from a 30 to 70.9 in just over 4 weeks. I know that 70.9 isn’t too alarming in and of itself, but is the increase in just 4 weeks an area of concern?
> 
> Unfortunately, the breeder did not explain shunts or MVD to us in detail as Mary H would have :angry::angry::angry:, she just said that levels >100 are an area for concern, but since she was 30 she was fine. So naturally we didn’t think anything of the BAT results. When we bought her we went with a reputable breeder that had Champion lines to try to minimize some of the predisposed health risks. You can only imagine my disappointment when the vet said that it is a shunt and we need to be prepared for her to be sick. It’s all a little shocking since we have only had her for four weeks. She doesn’t display any symptoms that I can tell so it makes it even harder to understand.
> 
> I mentioned MVD to the vet and he kind of blew it off… I am not sold that he knew what it was. What I do know is that I am close enough to UPenn should I need a second opinion. Any thoughts or opinions on her levels would be appreciated.
> Thanks in advance!


Oh, gosh, I can imagine your panic based on what your vet is telling you but don't panic yet!!! You may want to start a new thread if you don't get responses in this one. I would absolutely take her to U of Penn, especially since you say it is close to where you live. It seems to me that your vet is jumping the gun in saying she has a shunt, but I'll let the experts give their thoughts. I assume you told the breeder all this ? If not, I surely would.

Did you read what MaryH said in an earlier post? (See quote below and you can click on the arrow by her name to get to the entire post.) She mentions "moderately high" ... your Malt's results were 70, which would fall in this range.



MaryH said:


> At whatever age, if a puppy has extremely high bile acid values (greater than 100) I personally would do a Protein C test next. If a puppy has moderately high bile acid values (50-99) I would think about doing a Protein C test after taking into consideration other factors ... weight, activity level, occurrences of diahrrea and/or vomiting, behavior after meals, neurological symptoms, etc.


----------



## MTC

Thanks Sher for the quick reply! I did see Mary's post and trust me the "moderately high" comment is what I am hanging all of my sanity on right now. 

I do plan on contacting UPenn for an appointment since I believe it may be difficult to convince my current vet of the intricacies of the Maltese breed. I feel like even if I continue to see him he is going to make all of his decisions (some more expensive than others) based on his belief that she definitely has a shunt.


----------



## Humbug

Anyone have an opinion on whether it would be beneficial to periodically re-test BA? I have always had the impression that if MVD is diagnosed, then the BAT will always come back in the abnormal ranges (my baby's numbers have always been quite abnormal). My vet however wants to continue rechecking every 6 months to a year. I would prefer to continue running a CBC and monitoring her ALT values which came back well within the normal range the one and only time we have done this.


----------



## MaryH

Repeat bile acid tests are going to tell you one thing and one thing only .... that your dog does not have a perfectly functioning liver. Running an annual CBC is far more beneficial. ALT/AST levels will tell you if the less than perfectly functioning liver is causing problems (which a bile acid test won't).


----------



## Humbug

MaryH said:


> Repeat bile acid tests are going to tell you one thing and one thing only .... that your dog does not have a perfectly functioning liver. Running an annual CBC is far more beneficial. ALT/AST levels will tell you if the less than perfectly functioning liver is causing problems (which a bile acid test won't).


 Thanks! That's what I thought too.


----------



## SammieMom

moving to another


----------



## cometgrrl

Indy's bile acid test results were 60 pre and 4 post. The test was done at 17 weeks by Stacy's vet. 

Indy is healthy, happy, active, and has NO symptoms. However, I am pretty sure my vet is going to recommend a follow-up BA test, but after reading up, I don't think that is needed. My question is what *should* my vet be doing to follow-up? Should we do ALT/AST testing, protein C test? We are going in for Rabies vaccination @ 5 months and to schedule neutering, so I want to be prepared and not bullied by the vets into any testing that we don't need. I do want to make sure though, that we are doing everything necessary to make sure he continues to be healthy and happy!

Thanks so much in advance! There is a lot of great information here on SM, and I am happy to be here and able to ask you all for advice.


----------



## jmm

There is no reason to repeat the test unless it was done incorrectly. I highly doubt it since I've spoken with Stacy about the test protocol. Your dog is probably absolutely fine. If you are extra paranoid, you can always have the Protein C done. Routine labwork prior to the neuter should be standard (that should include an ALT and ALKP).


----------



## cometgrrl

JMM - thanks, that's exactly what I was looking for. I wasn't sure what tests are included in the pre-neuter blood work, so I just wanted to check and be sure.

Just want to make sure we are doing everything we can to ensure Indy has a long, healthy, happy life.

I lost my first maltese last year... in the end, he had acute renal failure caused by medications (diuretics) for his congestive heart failure. The only silver lining was that we caught the heart failure early, and with proper treatment, he lived a whole YEAR longer than all the vets (even our cardio specialist) thought possible. I am so happy that we had that extra time with him, so I am keeping my eye on Indy already (hopefully without being too paranoid!!).


----------



## myfairlacy

cometgrrl said:


> Indy's bile acid test results were 60 pre and 4 post. The test was done at 17 weeks by Stacy's vet.


It was higher PRE and normal POST? 

My London had a bile acid test at 17 weeks too...pre 2.1 and post 12.1


----------



## cometgrrl

Yes, I read somewhere (I think here on SM or a link from here) that about 15-20% of dogs have inverted results, which is why the test is done in pairs (pre and post).


----------



## myfairlacy

cometgrrl said:


> Yes, I read somewhere (I think here on SM or a link from here) that about 15-20% of dogs have inverted results, which is why the test is done in pairs (pre and post).


that's really interesting. Is it possible it was just a fluke and that the gallbladder contracted and released bile? I think I've heard that that is possible and that sometimes just the smell of food can trigger it. I think I'd almost want to retest one more time just to see. I'd be curious if anyone has any additional info on Pre-meal results only being high


----------



## jmm

Michele, 
The reason you do paired testing is because a certain percent are reversed. There is no reason to retest because you get reversed number (pre higher than post). Dr. Center presented this information when she spoke at our Nationals a few years ago.


----------



## shelly whitley

*My Baby Nicco*

I am new on here and was told by someone that I could possibly receive some advice and help on here. I have a 2 year old maltese baby that has been diagnosed with PSS or portal systemic shunt. I have been to my vet and a specialist and so far have spent over $1800 on treatments and visits. My poor Nicco has to have surgery to save his life but the surgery will be $2500 to $3900 and they want half before surgery and the rest following the procedure. I would be able to pay it out but not all at once like they want. I Just don't have that type of money right now. My daughter and her baby moved in with us and my son is still in college. Any help on a vet that you know that would let me make payments would literally be a lifesaver. We love him so much and it is killing us to watch him. He will eventually die without this surgery.

Thank you so much for any help and advice on this. I am truly scared. I live in Texas between Galveston and Houston.

Again thank you and God bless!
Shelly Whitley


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## Cosy

You might try organizing a benefit or something that will help to raise funds for LS and your little dog. Even the Yorkie aid for shunts is unable to handle all the incoming liver shunt yorkies who need help these days.
Also, ask your vet if they have any ideas how to raise money. Check the rescue groups near you for ideas. A car wash! A bake off! If you have kids check with their schools on helping to raise funds. It would be a great human interest story for kids.


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## jmm

Does the vet doing surgery accept CareCredit? That is an option. The cheapest place to get shunt surgery in the U.S. is probably still the University of TN vet school in Knoxville, TN. 
Cornell is managing a lot of Maltese with diet and medication. If this is an option for your dog it would be worthwhile looking into.


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## hallalfie

*Liver Shunts and Cholestrol*

When my 3 yr old seemed quite sickly over a year ago, we had tests and scans done. I was so upset, thinking it was shunts, knowing that the op is very dangerous. However, we were relieved to be told that although he may have a small liver shunt, it wasn't the problem and the liver hadn't begun to shrink. The specialist told us that although his Cholestrol levels were very high, this was normal for Maltese dogs and he gave me a download of information on a study carried out re this.
Our little boy's problem turned out to be an underactive Thyroid. He is now on medication for the rest of his life, but he is so much better. He has tests every 3 months to ensure he is on the right levels of meds and we have cut out a lot of foods that contain fat. He has lean skinless chicken or turkey and dry kibble mixed together, plus low fat chicken treats. 
He will never be the most agile or energetic dog, but we love him in spite of this. He is now 4 years old and absolutely adores going out to the park or the fields and being let off the lead to mooch around, sniffing and peeing everywhere! He gets 'selective hearing' issues, and is not so obedient as when he is at home.


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## MaryH

Any living being health problems can either be genetic, acquired, or a combination of the two. In the case of liver problems in our dogs usually the cause is genetic.


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## Alex

I'm very confused here, I'm new to SM. I also want to get a maltese, I was wondering what tests I should ask the breeder to run before purchasing the dog? And what tests should I run after I get the dog?


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## edelweiss

That is between you and your breeder.
I would ask her/him if he is aware any genetic issues w/liver, neurological, etc., in his line---a history? "Is this the first pairing of these 2 dogs" is an important question to ask. Ask the breeder if they keep a data base of issues from their breeding. 
Most Bile Acid Tests (BAT) are given at 16 weeks or there about so will you want to take possession of the dog before then? If so, then you would have to specifically order the test from your own vet. I would prefer my own vet to do the testing---personal preference only. Also, just so you know this test is not part of the regular blood draw. 
I would also get names from your breeder of people who have bought from her and call them to ask about particular issues. Ask other people who have experience w/your breeder. 
A good breeder will admit where the issues are---some don't, and you become a detective of sorts. If a breeder doesn't appreciate your curiosity, then keep looking, but do be sensitive in how you formulate your questions!


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## Oscar

OMG! Your pups are so cute! The tiny one caught my eyes b/c my Maltese is around 12 lbs (but ALL Love). Is yours consider a "toy"? Thanks!

P.S: My oscar is having a **** of a time with re-occurence Urinary Tract Infections. This is his 4th?? And has been in so many antibiotics. I am searching for a holistic way to treat it from now on. His little liver can't take all these drugs. I read that "Cuban Oregano" also known as Mexican Mint has properties that Fight Bacteria in the U.Track. Confrimed by researches and I holistic vet had mentioned it to me over the radio a while back but when she said Oragano Herb, I said what? I regret not taking her advice!


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## Oscar

Hello: I have some personal experience with the Adrenal Glands (not sure if it is the same thing) but the Neurosurgeon has explained to me that Adrenal Glands, if out of balance is (or will be) the cause of Liver Cushing Decease and others. I download a report from the Universary of TN. We just had Oscar tested yesterday. The blood work will be sent to the U. of TN and tell us which hormone is out of wack. If you need some information on the Adrenal Panel, feel free to contact me. Clinical signs that hormones out of balance: Humping (although fixed), excessive water intake, especially at night, reoccurance Urinary track infections, weak back legs, panting for no apperant reason and the urine is very clear or clinical term: "has no gravity". Sure enough, we had his adrenal gland ultrasound and the left one is larger than his right one. too large for this breed! Now we are just waiting to determine which monthly treatment he'll receive. The Neurosurgeon has explained to us that the Adrenal Panel is responsible for liver issues, like tumors and kidney failure. If you want the 2 page report from the U of TN. Please email me and I will send it to you. I am not sure I can post such a long report?? Thanks! Please: Get Pet Ins. Most small breeds are having problems due to cross breeding *unless you got yours from a Very Reputable Breeder!!!!


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## Oscar

This is our personal story and experiences with the Adrenal Glands, which regulate many parts of your Dog's chemistry and health. It is a Bit long and when you get to the U. of TN Report, there is a lot of medical terminology. I hope this helps. 

*STEROID PROFILES IN THE DIAGNOSIS OF CANINE ADRENAL DISORDERS*​*Jack W. Oliver, DVM, Ph.D*​*Knoxville, TN*​​*Hello: My name is Teresa and the reason for this information is to help educate Maltese & All pet owners about the Adrenal Panel-Testing. It is very important to know that if your pet is not showing ANY Clinical signs of Adrenal issues, then this information is not for you. I am NO Doctor or pretend to know it all! To the contrary, I was Lost when my Maltese, our only “child” got sick. *
* I have simply spent 100’s of hours doing research. Since I have already done the work, why not share it? If I can help one pet and their owner, my hours spent up at night will be well Worth it!*
* We were forced to learn quick after we made over 50 visits to 3 different animal hospital in search for answers (met with 8 Doctors) and 9 months of pure ****; I’ve decided to share with you some of my research. My 6 year old Maltese Was Healthy, until……*
*What are Adrenal Clinical Signs**? The following are clinical signs from our pet: I’m sure there are many other symptoms that I am not aware of! Only a good vet or specialist can decide your specific case: *

* 1. **Re-occurrence bladder infections (UTI). Which our baby had four of them *
*2. **I noticed his water intake would increase, especially late at Night! Of course, he’d urinate on his pads about 2-3x over night. *
*3. **His urine would be “diluted” or what the professionals call “low gravity urine”. His pee-pee pads looked like it was just plain water. *
*4. **4. He humps his stuff animal everyday after having his dinner and would “get it on, if you know what I mean”. (Yes! He was Neutered at 7-8 months old).*
*5. **Once in a while, he would pant for no apparent reason. *
*6. **Anal Glands getting full/packed up within weeks of extracting them by the vets. And/or infected—greenish color. *

*I am going to warn you right now: If you want to save your dog from this ailment, you better have 1 of 3 things: a cushy savings account, a credit card with a good line of credit OR GOOD Pet Insurance! After years of my husband bugging me for pet insurance and a $10,000 Plus in bills, I finally got it (too late now). That’s another thing too. When you purchase Pet Insurance, READ THE FINE PRINTS! VIP as of few months ago, has a limit of $1,500 (might as well don’t have any ins). AND they treat a condition ONLY for the calendar year! Why? The following year, when your policy “renews” that condition now becomes a “Pre-Existent”. Guess what? They do not cover Pre-Existence Conditions: How Clever! I would have Never known about this, if I didn’t take the time to read their fine prints. I chose PetPlan. They are rated #1 in customer service. Look them up. Good reviews for a pet insurance company. I do NOT work for them or make any commissions (although I wish to help us with our vet bills). We are simply impressed with their policies/coverage. We haven’t put any claims yet and pray we will never have to, but many people have and got their checks. I chose the gold plan which covers up to $20,000 per calendar year. My monthly payments are $33. Ok! Back to the subject (Sorry).*

 ******After meeting with one of the Best Animal Neurosurgeon in the Country, we have learned the above conditions are “clinical signs” of the Adrenal Glands! The glands regulate hormones. Too much or too little of one or more hormones can cause health problems, such as reoccurrence urinary track infection and/or anal glands getting full within weeks of being drained. They can also get infected.*

*until one day I noticed a drop of blood on his pee-pee pads. He ended up having a stone in his bladder. Had surgery to remove it but 6 weeks post op, he couldn’t hold his urine. This incompetent vet, which I am convinced he Learned a big lesson with our horrible experience and therefore, have decided not to name (I promised to the specialist)Maltese having 3 surgeries (one was to correct a botched one by an incompetent vet)*

*INTRODUCTION*
 Diagnosis of adrenal disease in domestic animals usually is dependent on the manipulation of the hypothalamo-pituitary-adrenal axis (HPA) and the measurement of cortisol (i.e., ACTH stim test; low dose dexamethasone suppression (LDDS) test; urine cortisol/creatinine ratio test; or the combined dexamethasone suppression/ACTH stimulation test). More recently, other steroid measurements have been utilized to evaluate the HPA, including steroid hormone profiles1,2, and 17-hydroxyprogesterone,3-5 which have revealed that suspected adrenal disease conditions may be caused by steroids other than cortisol (or in addition to cortisol).3 Determination of pituitary-dependent hyperadrenocorticism (PDH), or adrenal-dependent hyperadrenocorticism (ADH), is now usually made by evaluation of the 4-hour timepoint of the LDDS test6, by endogenous ACTH measurement,7 or by ultrasound visualization of the adrenal glands.7,8 *Hyperadrenocorticism (HAC) is defined as an overproduction of steroid hormones by the adrenal cortex.4 Cushing’s syndrome refers to all causes of hyperadrenocorticism with excess production of cortisol,6 while atypical Cushing’s disease refers to hyperadrenocorticism caused by increased levels of intermediate adrenal steroids that frequently are referred to as “sex steroids”.9*

*WHY? This explains why this test is being done: STEROID HORMONE PROFILES/GENERAL*
 ****Steroid hormone profiling in veterinary medicine was begun at The University of Tennessee Clinical Endocrinology Service, with the premise being that multiple steroid hormone analyses would increase the diagnostic accuracy of adrenal function tests.1 Measurement of multiple steroids in Pomeranians2 led to the recognition of a syndrome called “Alopecia-X”11 by dermatologists. Others have reported on adrenal syndromes in dogs called “atypical Cushing’s disease”,3,9 or “adrenal hyperplasia-like syndrome”,9,10-13 that used steroid profiling. Cortisol is known to have negative control effect on the HPA axis, but it’s now also understood that other steroids can have this effect as well.9,14,15 *Steroid profiling in dogs and cats has led to the realization that HAC can be due to primary adrenal tumors that secrete other steroids besides cortisol.16-21 Steroid profiling in ferrets led to the realization that HAC in this species is primarily due to increased levels in blood of estradiol, 17-hydroxyprogesterone and/or androstenedione,9,22 and measurement of these steroids has helped define medical control of ferret adrenal disease.23-27 Steroid profiles have also helped to better understand the condition of SARDS in dogs, where steroids other than cortisol frequently are involved.28 Steroid profiling is also helping to understand drug effects on adrenal secretory activity (mitotane, trilostane, melatonin).29-31 *

*STEROID HORMONE PROFILES/SPECIFIC*
 Steroid hormone profiles are indicated when other routine tests of adrenal function are negative (ACTH stim; LDDS; combined dexamethasone suppresson/ACTH stim) and the dog still exhibits signs of Cushing’s syndrome, indicating the likelihood of atypical Cushing’s disease being present.3,9 The issue of non-adrenal illness has been raised as a possible consideration in atypical Cushing’s disease cases.21 Results of studies in dogs with chronic illness, but without clinical evidence of HAC, have shown that 17-hydroxyprogesterone (17OHP) concentration may be increased.21 However, results of other studies of adrenal function testing in dogs with non-adrenal illness have demonstrated only minor effects on test results.32,33 Also, in studies that have measured only 17OHP as a means of detecting HAC, the sensitivity and specificity of using post-ACTH 17OHP concentration as a diagnostic test for HAC were low, and post-ACTH 17OHP analysis was not recommended as a screening test for HAC.4 These studies provide evidence that measurement of a singular adrenal intermediate steroid (such as 17OHP) may give equivocal results, but when profiles of steroid intermediates are used, the sensitivity and specificity of the test procedure is much improved.29 *It has been emphasized that adrenal function testing should be performed in dogs with clinical and/or biochemical evidence of HAC, and not in dogs with non-adrenal related disease.6 *
Steroids that may be involved with atypical Cushing’s disease are androstenedione, estradiol, 17-hydroxyprogesterone, progesterone and aldosterone.9 Other steroids that aren’t commonly measured may be involved as well, such as corticosterone21 and deoxycortisone.16 Estradiol is unique because treatment of excess estradiol can be difficult, the hormone can be secreted by tissues other than the gonads or adrenals35-38 and because secretion is independent of ACTH stimulation or dexamethasone suppression testing, as currently done. For dogs with atypical Cushing’s disease (PDH etiology), expect hepatomegaly, hepatopathy and bilateral adrenomegaly to be present along with increased endogenous ACTH level and the usual clinical signs, bloodwork and often haircoat problems. *Steroid profiling in dogs and cats has led to the realization that HAC can be due to primary adrenal tumors that secrete other steroids besides cortisol.16-21 Steroid profiling in ferrets led to the realization that HAC in this species is primarily due to increased levels in blood of estradiol, 17-hydroxyprogesterone and/or androstenedione,9,22 and measurement of these steroids has helped define medical control of ferret adrenal disease.23-27 Steroid profiles have also helped to better understand the condition of SARDS in dogs, where steroids other than cortisol frequently are involved.28 Steroid profiling is also helping to understand drug effects on adrenal secretory activity (mitotane, trilostane, melatonin).29-31 *
*Treatment Implications*
 Primary adrenal tumors. Adrenal steroid profiles reveal that adrenal tumors in dogs, cats and ferrets have a variety of secretory patterns, with serum cortisol levels often being normal.l9,17,18-22,29,39 Similar findings have been reported in humans with adrenoadenomas.42 In ferrets, mice, rats, guinea pigs and hamsters, sex steroid-producing adrenocortical tumors occur following gonadectomy, in association with the significant increase in serum gonadotropin levels that develop.43-47 The elevated luteinizing hormone (LH) level that occurs following gonadectomy leads to neoplastic transformation and expression of LH hormone receptors on sex steroid-producing adrenocortical cells in ferrets46,47 and rodents.48 Also, in humans, there is evidence of stimulatory effects of LH on adrenocortical cell growth and function,49 and LH receptor protein has been identified in the zona reticularis layer of the adrenal gland by immunohistochemical staining.50 In spayed female dogs, plasma gonadotropin levels post-gonadectomy rise to levels ten times what they were pre-gonadectomy, providing evidence of the strong and continuous LH stimulus that possibly plays a role in adrenocortical tumor development.51,52 Evidence is accumulating in human studies that some cortisol and other steroid-producing adrenal tumors or hyperplasias are under the control of ectopic or aberrant hormone receptors (e.g., gastrointestinal peptide, beta-adrenergic, vasopressin, serotonin and angiotensin II), and that these receptors may provide alternative mechanisms for pharmacologic control of adrenal tumors.53,54 Control of the secretory activity of adrenal tumors with beta-adrenergic and LH receptors has now been demonstrated by use of beta-receptor antagonists (propranolol)53 and gonadotropin antagonists such as leuprolide and deslorelin.23,24 Surgical removal of adrenal tumors is usually indicated, but age and health considerations impact this decision. If surgery is not an option, then mitotane is usually the next consideration. Adrenal profiles are indicated to determine the functionality of adrenal tumors in light of the multiple hormone secretion patterns that are seen.
 *Mitotane. Adrenal hormone profiles reveal that most intermediate hormones are decreased by mitotane the same as for cortisol, but that estradiol may remain unaffected. In cases that continue to have elevated estradiol levels, varying clinical signs of Cushing’s disease will be present.29 *
 Trilostane. Enzyme inhibition by trilostane occurs for 3-beta hydroxysteroid dehydrogenase, but also for 11-beta hydroxylase.30 Thus, 11-deoxycortisol levels build-up in dogs treated with trilostane. It is also apparent that other intermediate steroid levels increase (androstenedione, 17-hydroxyprogesterone, estradiol and progesterone) in dogs treated with trilostane,29 which could be due to the 11-beta hydroxylase inhibition, and possibly 21-hydroxylase enzyme inhibition.29 The reason why only 11-deoxycortisol levels were increased in the above study30 may be due to the length of trilostane exposure (3-7 weeks), compared to dogs that are exposed to trilostane for extended periods. *Steroid profiling in dogs and cats has led to the realization that HAC can be due to primary adrenal tumors that secrete other steroids besides cortisol.16-21 Steroid profiling in ferrets led to the realization that HAC in this species is primarily due to increased levels in blood of estradiol, 17-hydroxyprogesterone and/or androstenedione,9,22 and measurement of these steroids has helped define medical control of ferret adrenal disease.23-27 Steroid profiles have also helped to better understand the condition of SARDS in dogs, where steroids other than cortisol frequently are involved.28 Steroid profiling is also helping to understand drug effects on adrenal secretory activity (mitotane, trilostane, melatonin).29-31 *
*For dogs with atypical Cushing’s disease* (ADH etiology), expect hepatomegaly, hepatopathy and unilateral adrenomegaly to be present (and maybe atrophy of contra-lateral gland) along with decreased endogenous ACTH level and *the usual clinical signs, bloodwork and often haircoat problems*. *For primary hyperaldosteronism conditions, due to primary adrenal tumor or bilateral adrenal hyperplasia, expect hypertension in association with hypernatremia and muscular weakness (cervical ventroflexion, hindlimb weakness) due to hypokalemia.39 Retinal hemorrhage and blindness40 and renal disease41 can occur in cats. For hyperadrenocorticoid cases that also have low aldosterone levels, this pattern can be indicative of a primary adrenal tumor, and ultrasound is indicated to confirm a tumor’s presence or absence.29*

*****Trilostane reportedly offers effective control of Cushing’s syndrome,30 but the long-term effects of the elevated intermediate steroids remain ill-defined. Some dogs do have return of clinical signs of Cushing’s syndrome while on trilostane.29 Because trilostane seems to pre-dispose dogs to increased adrenal toxicity with mitotane, an acute switch from trilostane to mitotane treatment should not be done.29*
 Aromatase enzyme inhibitors (anastrozole, exemestane, melatonin). The aromatase enzyme occurs in gonadal and adrenal tissues (and other tissues such as fat and skin cells), and converts androstenedione to testosterone or estrone, both of which are then converted to estradiol. Neither estrone nor testosterone have been observed to be increased in dogs with adrenal disease, but estradiol frequently is increased, and causes many of the clinical signs associated with Cushing’s disease.29 Aromatase enzyme-inhibiting drugs will decrease estradiol levels, but currently are infrequently used (except melatonin) in animals due to cost considerations. 
 Anti-gonadotropin drugs (melatonin, leuprolide acetate, deslorelin acetate, androgens). Adrenal tissues in different species (e.g., ferrets, rodents, humans) are known to have luteinizing hormone (LH) receptors present.44-50 In ferret studies, anti-gonadotropin drugs are effective in lowering sex steroid levels.23-24,27 Sex steroid levels are also decreased in dogs with adrenal disease that are treated with melatonin,31 but it is not known if LH receptors are present in canine adrenal tissues. Androgenic drugs have anti-gonadotropin effects via negative feedback effects on the hypothalamo-pituitary tissues.
 Melatonin. Results of _in vitro _cell culture (human H295R adrenocortical carcinoma cells) studies in our lab55 revealed that both 21-hydroxylase and aromatase enzymes were inhibited by melatonin. Also, in dogs with adrenal disease that are treated with melatonin, and repeat adrenal steroid panels are done, cortisol levels are consistently reduced, and estradiol levels are variably reduced.29 Inhibition of the 21-hydroxylase enzyme would lower cortisol levels, and inhibition of the aromatase enzyme would lower estradiol levels. Estradiol levels were decreased in a prior study of dogs treated with melatonin.31 Results of _in vitro_ studies with human MCF-7 breast cancer cells also revealed that melatonin inhibited aromatase enzyme, which resulted in reduced estradiol levels.56 Melatonin treatment for cases of mild adrenal disease in dogs may be effective, and particularly in cases where sex steroids are increased.
 Melatonin plus phytoestrogens. Melatonin has the above listed effects, and phytoestrogens (isoflavones, lignans, genistein) are known to inhibit 3-beta hydroxysteroid dehydrogenase.57,58 Lignans and genistein are also known to decrease the activity of aromatase enzyme in MCF-7 cells _in vitro._58 So, combinations of melatonin and phytoestrogens may have efficacy in treating hyperestrinism conditions.

*Hyperestrinism in Dogs*
 Hyperestrinism in dogs may be a new and emerging disease entity. In sample submissions to the Clinical Endorinology Service (2005) at The University of Tennessee, 40% of adrenal panels had elevated estradiol levels present (>70 pg/ml).29 *In hyperestrinism cases, estradiol is the estrogen that is increased, ACTH stim and LDDS tests are usually normal for cortisol, thyroid function is normal or controlled, liver problems are frequent and typical (very elevated alkaline phosphatase, hepatomegaly, steroid hepatopathy, hyperechoic liver by ultrasound), PU/PD is frequent, panting may be present, haircoat problems often are present, skin biopsy results suggest an endocrinopathy, there is no change in estradiol level in response to ACTH stim or LDDS tests as currently conducted, resistance to mitotane may occur and increase often occurs in response to trilostane. Effective treatment options for hyperestrinism in dogs is limited at the present time, and drugs that could be expected to be efficacious (aromatase inhibitors – excluding melatonin) often are limiting due to cost. Melatonin and phytoestrogen treatment may be effective for the above listed reasons.* Mitotane will likely be effective if the source of estradiol is the adrenal tissues. Trilostane treatment frequently results in increased estradiol levels,29 and this may be a reason why less than effective treatment with the drug sometimes occurs.


*CONCLUSIONS*
 Steroid hormone profiles in dogs are indicated when hyperadrenocorticism is suspected due to typical clinical and/or biochemical signs of disease, but the usual tests of adrenal function have been normal. The profiles are effective in ruling out presence of atypical Cushing’s disease, cases of hyperestrinism and for delineating the secretory profile of adrenal tumors (functionality), which often are associated with elevated levels of steroids other than cortisol.

*KEY WORDS*
 Hormone, Tumor, Endocrine, Atypical, Hyperadrenocorticism

*REFERENCES*

 1Lothrop CD, et al. *AJVR* 1984; 45:2304.2Schmeitzel LP, et al. *JAVMA* 1990; 197:1333.3Ristic JME, et al. *J Vet Intern Med* 2002; 16:433.4Chapman PS, et al. *Vet Rec* 2003; 153:771.5Benitah N, et al. *JAVMA* 2005; 227:1095.6Feldman EC et al., In Feldman E, Nelson R eds. *Canine and Feline Endocrinology and Reproduction, 3rd Ed*. St. Louis: WB Saunders, 2004; 252.7Gould SM, et al. *J Sm Anim Pract* 2001; 42:113.8Saunders MH, *Proc of the 24th ACVIM Forum*, 2006; 523.9Oliver JW, *Proc of the 20th ACVIM Forum*, 2002; 541.10Schmeitzel LP, et al. *Kirk’s Current Therapy XII, Small Animal Practice*, J Bonagura and R Kirk, eds. Philadelphia: WB Saundsrs, 1995; 600.11Schmeitzel LP, *Proc of the 15th AAVD/ACVD*, 1999; 131.12Kintzer P, *Proc of the 17th ACVIM Forum*, 1999; 435.13Rosychuk R, *Proc of the AVMA Annual Meeting*, 1999.14Selman PJ, et al. *Eur J Endocrinol* 1994; 131:422.15Selman PJ, et al. *Steroids* 1996; 61:133.16Reine N, *J Vet Intern Med* 1999; 13:386.17Syme HM, et al. *JAVMA* 2001; 219:1725.18Hill KE, et al. *JAVMA* 2005; 226:556.19Boord M, et al. *JAVMA* 1999; 214:666.20Rossmeisl JH, et al. *JAAHA* 2000; 36:512.21Behrend EN, et al. *JAVMA* 2005; 227:1762. 22Rosenthal KL, et al. *JAVMA* 1996; 209:1097.23Wagner RA, et al. *JAVMA* 2001; 218:1272.24Wagner RA, et al. *AJVR* 2005; 66:910.25Ramer JC, et al. *JAVMA* 2006; 229:1743.26Johnson-Delaney CA, *Exot Mammal Med Surg* 2005; 3:7.27Murray J, *Exot Mammal Med Surg* 2005; 3:1.28Carter R, et al. *Proc of the Am Coll of Vet Ophthal*, 2003.29Oliver JW, *Clin Endo Serv Univ TN*; unpublished data.30Seiber-Ruckstuhl NS, et al. *Dom Anim Endocrinol* 2006; 31:63.31Ashley PF, et al. *JAVMA* 1999; 215:1111.32Kaplan AJ, et al. *JAVMA* 1995; 207:445.33Gieger TL, et al. *J Vet Intern Med* 2003; 17:154.34Behrand EN, et al. *JAVMA* 2005; 226:1662.35Bulun SE, et al. *Semin Reprod Med* 1999; 17:349.36Bulun SE, et al.* J Ster Biochem Molec Biol* 2003; 86:219. 37Simpson E, et al. *Endocrine-Related Cancer* 1999; 6:131.38Ackerman GE, et al. *J Clin Endocrinol Metab* 1981; 53:412.39DeClue AE, et al.* J Vet Intern Med* 2005; 19:355.40Ash RA, et al. *J Feline Med Surg* 2005; 7:173.41Javadi S, et al. *Dom Anim Endocrinol* 2005; 28:85.42Glaz E, et al. *J Ster Biochem Mol Biol* 1993; 45:57.43Russfield AB, *Meth Achiev Exp Pathol* 1975; 7:132. 44Bielinska M, et al. *Endocrinology* 2003; 144:4123.45Bielinska M, et al. *Endocrinology* 2005; 146:3975.46Bielinska M, et al. *Vet Pathol* 2006; 43:97.47Shoemaker NJ, et al. *Molec Cellular Endocrinol* 2002; 197:117.48Apaja PM, et al. *Endocrinology* 2005; 146:3224.49Breuschlein F, et al. *Horm Metab Res* 2004; 36:392.50Pabon JE, et al. *J Clin Endocrinol Metab* 1996; 81:2397.51Olson PN, et al. *AJVR* 1992; 53:762.52Reichler IM, et al. *Theriogenology* 2005; 63:2164.53Lacroix A, et al. *Endocrine Reviews* 2001; 22:75.54Lacroix A, et al. *Trends Endocrinol Metab* 2004; 15:375.55Fecteau KA, et al. *Clin Endo Serv Univ TN*; unpublished data.56Cos S, et al. *J Pineal Res* 2005; 38:136.57Wong Z, et al. *J Ster Biochem Molec Biol* 1999; 71:191.58Brooks JD, et al. *J Ster Biochem Molec Biol* 2005; 94:461.  Proc. 25th ACVIM, 471-473, Seattle, WA 2007


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## TuckersMama

Sorry I'm new to all this. My little guy Tucker is 13 weeks old. I have only had him for a week and he started vomiting a few days after I got him, refused to eat or drink and ended up at the vet with dehydration and hypoglycemia and almost didn't make it through the night. I had bloodwork done and they found elevated liver enzymes. My breeder told me that none of her dogs have had liver problems and she doesn't think this is what he has. The vet said that because he is so tiny (about 2 lbs) it isn't safe to do the bile testing because he has to fast for 12 hrs and that if it was a liver shunt he would probable be too tiny to do well with the surgery. She said the prognosis for him isn't good. I am to feed him every two hours (which he refuses) and keep him well hydrated. He eats well first thing in the am but after that refuses. I've been trying to use a syringe to feed him his wet food watered down slightly but he resists that too. I feel like I am being mean! He is on a pill for his liver, lactulose, neoease and Amoxicillan. I am wondering what I can do to ensure him the best outcome possible. I am so worried. It's such a tough call because I've only had him a week and I love him so much. I am a single mom so money is a concern as well. The breeder seems completely unconcerned and feels he is just adjusting to his new home and will straighten out with time. I go back to the vet on Friday to see if the bloodwork has improved at all. Any information or ideas would be greatly appreciated! Thanks


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## CloudClan

TuckersMama said:


> Sorry I'm new to all this. My little guy Tucker is 13 weeks old. I have only had him for a week and he started vomiting a few days after I got him, refused to eat or drink and ended up at the vet with dehydration and hypoglycemia and almost didn't make it through the night. I had bloodwork done and they found elevated liver enzymes. My breeder told me that none of her dogs have had liver problems and she doesn't think this is what he has. The vet said that because he is so tiny (about 2 lbs) it isn't safe to do the bile testing because he has to fast for 12 hrs and that if it was a liver shunt he would probable be too tiny to do well with the surgery. She said the prognosis for him isn't good. I am to feed him every two hours (which he refuses) and keep him well hydrated. He eats well first thing in the am but after that refuses. I've been trying to use a syringe to feed him his wet food watered down slightly but he resists that too. I feel like I am being mean! He is on a pill for his liver, lactulose, neoease and Amoxicillan. I am wondering what I can do to ensure him the best outcome possible. I am so worried. It's such a tough call because I've only had him a week and I love him so much. I am a single mom so money is a concern as well. The breeder seems completely unconcerned and feels he is just adjusting to his new home and will straighten out with time. I go back to the vet on Friday to see if the bloodwork has improved at all. Any information or ideas would be greatly appreciated! Thanks


The 12 hour fasting rule is outdated. These dogs do not need to be fasted that long. Your vet may not be up on the latest information about the test but you can bring this handout with you to help them understand the newer protocol: http://www.ytca.org/health_biletestproced.doc-1.pdf This was written by Dr. Sharon Center, the leading expert on Liver Shunt and Bile Acid testing in dogs. 

I am sorry your breeder is not more concerned. I hope that you are able to find the best course of treatment for your little one and I kinda hope the breeder is right that he just has had issues adjusting. It would not be unusual for a puppy just separated from his litter-mates and mom to struggle with the stress.


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## edelweiss

Nicole, the Amoxicillan also can cause tummy issues so a probiotic should be added & 1/4-1/2 tablet of pepcid AC. The most important things are keeping his blood sugar up and him well hydrated, even if you need to syringe liquid into him. 
I agree w/Carina that 12 hrs. is no longer mandated. She always is right on the button w/info & advice. 
Please let us know how he is doing. If your vet doesn't like the info. from Dr. Center I would look around for a vet who specializes in small breed dogs. I had a small dog w/liver shunt who was operated & lived a long (if sometimes difficult w/seizures) life. He was diagnosed w/in the lst 6 months.


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## TuckersMama

Thanks for the input. I also was wondering about diet. The vet gave me some Medi Cal Recovery canned dog food. Tucker doesn't really like it, I have to water it down and feed him with a syringe. I had asked the vet if I should be making his food. She kind of brushed me off and said not now because he needs to get bigger and gain weight. I would assume that feeding him something that will help his liver work the best it can would be benificial and then he will want to eat and gain weight.....am I wrong in thinking this? He never pooped at all yesterday when he was eating the medi cal so this am I gave him some food I made with chicken and brown rice and boiled egg and veggies and he ate about a tsp witih very little encouragement. It seems promising. He also had a soft bm about 2 hours after. (sorry if this is TMI) I just want to make sure I am doing what is best for him. Thanks


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## edelweiss

Nicole, there are some already prepared canned foods for liver issues (for example Hill's LD, Royal Canine Hepatic (which I have used)) and others that I have used in the US. RC also has an hepatic kibble. There are also lots that can be home cooked, but for now I would stick w/one that you know is balanced. There are a few members here that make their own liver diets. My Kitzel also used Sam-E when his enzymes went up due to too many meds w/his surgery or the anesthesia. With the hepatic food and the Sam-E for a month his came back down in the normal range. 
You can also add pumpkin (not pumpkin pie mix) but the veggie, to his food for a while to firm up the bms.


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## elly

My Ellie had liver disease and she LOVED hills ld and kd.


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## MaryH

Nicole, can you share the blood results with us? I'd be curious to know what the ALT/AST levels are. And I'd also be curious why the vet has prescribed lactulose ... which will cause your puppy to have a very soft stool. Lactulose is something that generally is not prescribed except in the case of a definitely diagnosed liver shunt.


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## SammieMom

When I had Sammie tested as a puppy, he was a (59 post food) which is elevated, but he is still totally healthy. MaryH helped me so much several years ago. I found many Vets just aren't up to date with BAT or shunts. But I have a new Vet that is.


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## TuckersMama

MaryH said:


> Nicole, can you share the blood results with us? I'd be curious to know what the ALT/AST levels are. And I'd also be curious why the vet has prescribed lactulose ... which will cause your puppy to have a very soft stool. Lactulose is something that generally is not prescribed except in the case of a definitely diagnosed liver shunt.


 
Hi Mary, the vet actually did not tell me the levels. She just said that because he was so sick she was going to try these meds out and I go see her again on Friday. He definitely is feeling better today! Playful and eating more frequently. He is even getting easier to give the meds to. I will ask her for a copy of the lab report so I can get a clearer picture of what is going on. He is getting repeat labs on Friday as well I think. Are there any other questions I should be asking her? I also had something weird happen today. My cat started throwing up. Tucker hasn't thrown up since before we went to the vet on Friday but I am wondering if it isn't related somehow. I questioned another vet on the phone and she wasn't wanting to speculate but didn't think they were related. She said where we live, viruses like Lepto aren't common and it would more likely be something the cat got into. But still makes me wonder...


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## Charllote24

Hi everyone!. I am a new member joining this forum, and the reason because I am here is that my 16 weeks old Maltese has a liver shunt. I am totally scare I do not know much about this disease. My baby is still very small I do not know how to treat this disease or genetic issue. I need some advice she can't get her surgery done until I save some money. Thank you I will keep you up date!


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## Charllote24

Hello guys, I am just new in this forum, and I was wondering if anyone knows about liver shunts or MVD in Maltese puppies. Charlotte got her bile test high 75. She is three months already and I am pretty scared about it, she had a seizure once two weeks ago, and was not eating well, she refused everything except chicken. The vet suggested a very low protein diet, she is now eating pretty well, I am not feeding her with chicken anymore. I got dry food Eukanuba and I gave to her small amounts, she likes it, but seems like she is still hungry after I feed her. She was weighing 1.45 kg. two weeks ago. I do not know how much food should I give to her since a I am not sure if she has a liver shunt or MVD. Thank you, if you have any questions please let me know I will appreciate any advice or comments. I will keep you update it. I promise to tell you Charlotte's story since the beginning is not easy to face this issue, but we love her so much, and we want to do our best to keep her happy and healthy


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## Charllote24

:


Charllote24 said:


> Hello guys, I am just new in this forum, and I was wondering if anyone knows about liver shunts or MVD in Maltese puppies. Charlotte got her bile test high 75. She is three months already and I am pretty scared about it, she had a seizure once two weeks ago, and was not eating well, she refused everything except chicken. The vet suggested a very low protein diet, she is now eating pretty well, I am not feeding her with chicken anymore. I got dry food Eukanuba and I gave to her small amounts, she likes it, but seems like she is still hungry after I feed her. She was weighing 1.45 kg. two weeks ago. I do not know how much food should I give to her since a I am not sure if she has a liver shunt or MVD. Thank you, if you have any questions please let me know I will appreciate any advice or comments. I will keep you update it. I promise to tell you Charlotte's story since the beginning is not easy to face this issue, but we love her so much, and we want to do our best to keep her happy and healthy:thumbsup:


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## edelweiss

Welcome to SM Charllote---please hit the Search button above & read up on Liver Shunt as much as you can and come back w/your questions. There are lots of people on the forum who have experience w/dogs w/high bile acids. I, myself, have had a dog w/liver shunt so, again, there will be some who can help you.


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