# Sticky  Lucky's Liver Treatment - Information from Walter



## maggieh

At a member's suggestion, here is information Walter (wkomorow) recently posted about his fluff's liver problems. This information was copied from a thread about another fluff with high ALT and BAT, so I've divided the responses.

Walter, thank you for such wonderful information!

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First, take a deep breath. Those numbers are very high. Lucky does have a liver issue but the highest his alt has been has been in the 170 range. Have you seen any odd behaviors in Lily? Certainly the demamarin or marin will help. Often the numbers will go up instead of down at first. What is the protein content of the food you are feeding her. Lowing the protein content and supplementing with a vegetable or dairy protein might not be a bad idea. You should work with your vet or a nutritionist for an optimum diet. If Lily is nonsymptomatic, maybe a lower protein diet with marin would help. ​The next step is a liver profile and a BAT test. If that comes back high, there is a Protein-C test that can help narrow down the issue. At that point you will want to go beyond your local vet to a referral board certified internal medicine vet. Cornell at Stamford has some excellent vets that are board certified and they have the staff of Cornell University for support. They certainly can help with liver issues, but if Lily is not showing any symptoms of liver issues other than the blood test, they will probably manage it with nutrition, diet, and medicine. Try not to worry, most Maltese have some type of liver issue, many go unexpressed and live a completely normal life. If Lily is not showing any symptoms, I would pursue things but not panic. ​========================================================
If it were me, biopsy should NOT be the next step. Ultrasound may be helpful depending on the skills of the radiologist and if it is doppler. The next step would be a protein C test which is an inexpensive blood test that is sent to Cornell to be read. For a BAT reading over 100, Protein C helps to distinguish between MVD and liver shutting. Lucky has a liver shunt, so I have been through this and recently meet with Dr. Center at Cornell to discuss his treatment. ​A lower protein food is really needed right now. If Lily is show no signs of liver distress but is being diagnosed my blood work, I would start her on a hepatic food soon and supplement that with plant and dairy proteins - peanut butter, cottage cheese, feta cheese, some pasta, a little ice cream. Several people here are managing their Maltese's liver issues medically and nutritionally.

I can also tell you any advise you get, anything you read, there will be an opposite opinion out there. Liver issues are very confusing and the information on them is contradictory.

Luck was diagnosed with a liver shunt almost a year ago and just last week he had a visit with Dr Center to evaluate his progress. He is being medically managed and is doing great, very active, healthy, etc. Under the right conditions and managed well medically, a liver shunt dog can live to their teens. But one needs to be vigilant. I am saying Lily has a shunt, I am just saying liver issues can be managed for many dogs.​In terms of biopsies, some dogs with liver shunts have lipoglanulomas and aspirations will not tell this well. Lipogranulomas make prognosis of surgery not so good. It correlates with additional shunting and with other problems. If we decide on surgery for Luck, I was told to get surgical biopsies of three lobes before proceeding.

Cornell University vet clinic is in Stamford CT and if it were me I would make an appointment with an Internal Medicine specialist there or travel to Cornell in Ithica as a next step. Luck was seen at Tufts and at Ithica, and our experience at Cornell was more helpful as least for us.​========================================================
Lucky is on RC hepatic 1/3 - 1/2 cup depending on how hungry he is. He get feta cheese - a couple of teaspoons and some peanut butter cereal - maybe 10 pieces - each morning. He has his hepatic kibble during the day and he gets some vegs and fruit for supper. Before bed he gets a teaspoon of vanilla ice cream.

I know a lot of people worry about the quality of Royal Canine, but you use what works. Hills also has a hepatic canned food, but Luck hated it. The advantage is that these formulae have the mineral and vitamin content balanced for liver support. It has been successful for him and he loves it, so for him I use what works.

Until you know what is behind this, I would stick to safe proteins, such as dairy, tofu, etc., certainly for a week or two it would be safe. You have to be careful that the protein is not one likely to build up ammonia in the system. Dogs with liver issues need protein to support the liver but it needs to be safe protein. Bile Acids over 100 can point (not always) to shunting. Low protein C makes shutting most likely.​Lots of things can raise ALTs, but those are super high. At this point, you know there is an issue and you can address it to give Lily a great life. A probiotic is probably a good idea along with the milk thistle. The good biotics will compete with the bad ones that can lead to ammonia accumulaion in the digestive tract.

Long term I would work with a nutritionist, but right now it is most important to do no harm. You need to stabilize her numbers to give you time to determine the course of action.​======================================================


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## edelweiss

Thanks Maggie! :ThankYou::you rock::you rock:


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## Maglily

Awesome, thank you. this is very useful.


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## sherry

maggieh said:


> At a member's suggestion, here is information Walter (wkomorow) recently posted about his fluff's liver problems. This information was copied from a thread about another fluff with high ALT and BAT, so I've divided the responses.
> 
> Walter, thank you for such wonderful information!
> 
> =======================================================
> 
> First, take a deep breath. Those numbers are very high. Lucky does have a liver issue but the highest his alt has been has been in the 170 range. Have you seen any odd behaviors in Lily? Certainly the demamarin or marin will help. Often the numbers will go up instead of down at first. What is the protein content of the food you are feeding her. Lowing the protein content and supplementing with a vegetable or dairy protein might not be a bad idea. You should work with your vet or a nutritionist for an optimum diet. If Lily is nonsymptomatic, maybe a lower protein diet with marin would help. ​The next step is a liver profile and a BAT test. If that comes back high, there is a Protein-C test that can help narrow down the issue. At that point you will want to go beyond your local vet to a referral board certified internal medicine vet. Cornell at Stamford has some excellent vets that are board certified and they have the staff of Cornell University for support. They certainly can help with liver issues, but if Lily is not showing any symptoms of liver issues other than the blood test, they will probably manage it with nutrition, diet, and medicine. Try not to worry, most Maltese have some type of liver issue, many go unexpressed and live a completely normal life. If Lily is not showing any symptoms, I would pursue things but not panic. ​========================================================
> If it were me, biopsy should NOT be the next step. Ultrasound may be helpful depending on the skills of the radiologist and if it is doppler. The next step would be a protein C test which is an inexpensive blood test that is sent to Cornell to be read. For a BAT reading over 100, Protein C helps to distinguish between MVD and liver shutting. Lucky has a liver shunt, so I have been through this and recently meet with Dr. Center at Cornell to discuss his treatment. ​A lower protein food is really needed right now. If Lily is show no signs of liver distress but is being diagnosed my blood work, I would start her on a hepatic food soon and supplement that with plant and dairy proteins - peanut butter, cottage cheese, feta cheese, some pasta, a little ice cream. Several people here are managing their Maltese's liver issues medically and nutritionally.
> 
> I can also tell you any advise you get, anything you read, there will be an opposite opinion out there. Liver issues are very confusing and the information on them is contradictory.
> 
> Luck was diagnosed with a liver shunt almost a year ago and just last week he had a visit with Dr Center to evaluate his progress. He is being medically managed and is doing great, very active, healthy, etc. Under the right conditions and managed well medically, a liver shunt dog can live to their teens. But one needs to be vigilant. I am saying Lily has a shunt, I am just saying liver issues can be managed for many dogs.​In terms of biopsies, some dogs with liver shunts have lipoglanulomas and aspirations will not tell this well. Lipogranulomas make prognosis of surgery not so good. It correlates with additional shunting and with other problems. If we decide on surgery for Luck, I was told to get surgical biopsies of three lobes before proceeding.
> 
> Cornell University vet clinic is in Stamford CT and if it were me I would make an appointment with an Internal Medicine specialist there or travel to Cornell in Ithica as a next step. Luck was seen at Tufts and at Ithica, and our experience at Cornell was more helpful as least for us.​========================================================
> Lucky is on RC hepatic 1/3 - 1/2 cup depending on how hungry he is. He get feta cheese - a couple of teaspoons and some peanut butter cereal - maybe 10 pieces - each morning. He has his hepatic kibble during the day and he gets some vegs and fruit for supper. Before bed he gets a teaspoon of vanilla ice cream.
> 
> I know a lot of people worry about the quality of Royal Canine, but you use what works. Hills also has a hepatic canned food, but Luck hated it. The advantage is that these formulae have the mineral and vitamin content balanced for liver support. It has been successful for him and he loves it, so for him I use what works.
> 
> Until you know what is behind this, I would stick to safe proteins, such as dairy, tofu, etc., certainly for a week or two it would be safe. You have to be careful that the protein is not one likely to build up ammonia in the system. Dogs with liver issues need protein to support the liver but it needs to be safe protein. Bile Acids over 100 can point (not always) to shunting. Low protein C makes shutting most likely.​Lots of things can raise ALTs, but those are super high. At this point, you know there is an issue and you can address it to give Lily a great life. A probiotic is probably a good idea along with the milk thistle. The good biotics will compete with the bad ones that can lead to ammonia accumulaion in the digestive tract.
> 
> Long term I would work with a nutritionist, but right now it is most important to do no harm. You need to stabilize her numbers to give you time to determine the course of action.​======================================================


I have reread this and feel like I am doing everything right with Riley's diet. However, I just had a new BAT test ran on him after his being diagnosed 9 months ago with MVD. His pre was almost 300 and his post was almost 200. 9 months ago his pre was 71 and post was 267. His protein C was normal. I'm open to any suggestions.


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## wkomorow

sherry said:


> I have reread this and feel like I am doing everything right with Riley's diet. However, I just had a new BAT test ran on him after his being diagnosed 9 months ago with MVD. His pre was almost 300 and his post was almost 200. 9 months ago his pre was 71 and post was 267. His protein C was normal. I'm open to any suggestions.


Sherry,

Bile Acids are ejected from the gall badder. When the gall bladder contracts bile acids goes up. The first reading could have been just after a contraction. Bile acids are good to indicate the presence of liver issues, but their values are not good to indicate the progression of liver issues. 


A little technical:

http://www.idexx.de/pdf/de_de/smallanimal/snap/bileacids/diagnosing-liver-disease.pdf

"We’ve done repeatability
studies on unconjugated bile acids,
and they are all highly variable when
they are abnormally high.The concentrations
are all abnormal, but the range
from day to day or even hour to hour
is huge. Post-feeding changes are also
enormous.Total bile acids can also
vary markedly, and it is not uncommon
for fasting serum bile acids to be
greater than the postprandial levels,
probably reflecting contraction of the
gallbladder in the fasting state."

What Center told me is that once diagnosed they look at how the dog is behaving more than anything else to indicate whether the disease is getting worse or better.

High bile acids can lead to other conditions including acid reflux and even gall stones. They do repeat bile acid test after surgery to see if the levels return to normal. But a variation from one high reading to another is not an indication that things are getting better or worse. The more important question is how is Riley, is he active, are you noticing behavioral changes etc.

Hugs.


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## sherry

Thanks Walter. Except for Riley's behavior problems he seems healthy. I have finally found a behavior trainer who will travel 90 miles to my home for evaluation. Hopefully when the weather clears up we can set up an appointment. I picked up a copy of his bloodwork and his pre was 247 and post 190. His ALT was 534, ALP was 194, and AST at 89. His BUN was low at 7. I really feel like he's OK except for his behavior, and we'reworking on that.


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## wkomorow

It sounds like things are going well. Numbers are just a snapshot in time and there is so many things that can affect them. If Riley on denamarin. That can really help with liver support

We are headed back to Cornell over Spring Break next month to see how Lucky is doing. During the last exam at Cornell, the prognosis was very positive: I quote you what they said: He had previously had a bile acid test and they did not think there was a need to repeat it.

"Lucky presented today in very good physical condition, stable physiologcal parameters and with good medical management. Prognosis with medically managed shunts is often good for cases that respond and many dogs can live normal lives. However, these dogs are at greater risk for developing infections then the general population and Lucky has the potential to develop ammonium biurate urinary stones. Due to these issues, in is imperative that you monitor his demeanor and let us know if anything
changes."

We are hoping for the same prognosis this time.


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## sherry

Yes Walter, Riley is on Denamarin. At this point I am going to stop worrying and continue with what I am doing. You have calmed my nerves.


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