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Post Systemic Shunt

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I had a first time client come in today with her 4 yr old M/N Min. Schnauzer, Max for an acupuncture consult. I am feeling like this case may need more help than I can give her on my own so I am hoping that I can consult with you to get this guy some help ASAP.
Here is a brief history: Christmas Eve she noticed hematuria and took him to her vet. They found kidney stones and removed them surgically. Stone analysis showed Ammonium Urate stones. The lab work pre-op showed AST 236 (15-66), ALT 550 (12-118), AP 307 (5-131), TP 3.4 (5-7.4), Alb 1.2 ( 2.7-4.4), BUN and Chol barely below normal, Ca 6.9 (8.9- 11.4), WBC 25.3 (4-15.5), HGB 11.1 (12.1-20.3). Then Max was transferred to a referral center where a scan showed singular extrahepatic PSS of 90%blood flow away from liver. He was told that he was not a surgical candidate due to the low albumin and ascites. He was started on Denamarin 90 mg PO q 24 hr, Spironalactone 2.5 mg 3/4 tab PO BID, Famotadine 10 mg PO q 24 hr, Amoxicillin 250 mg 3/4 tab Po BID, Neomycin 200 mg PO BID and a probiotic powder supplement PO q 24 hr. The nutritionist she consulted with has him eating 1 egg white or 1 oz baked talapia , 21/2 - 3 cups of rice, potato, or spaghetti, 2 tsp canned pumpkin 1/2 tsp olive oil and 1 cup steamed veggies per day divided into 3 meals.
He is hardly eating anything, although he is not vomiting, he has soft brown stools and has lost 4 lbs in the past 3 weeks. Upon presentation he was quiet, mildly jaundiced, extremely atrophied in the rear end and trunk, hepatomegally, a lavender tongue, thin - wiry pulses, severe dental disease although no signs of gingivitis currently (antibiotics?), dry hair coat. He has a preference for warm places, gets up at 1:30 am to urinate and otherwise sleeps undisturbed, has to be coaxed to get out of bed in the morning, is drinking less and urinating less frequently, his voice has changed to a quieter but higher pitched sound, he has become exercise intolerant after 1-2 blocks where he used to walk 2 miles a day, he has started licking his owner's hands and his feet frequently, I couldn't find any "active" points, but he had a general warmth about his ventral thoracic area and a coldness about his dorsal thoracolumbar area. I would love to get him to where he has put on some weight, and his albumin is high enough that he could be a surgical candidate. Any diet recommendations (it seems a very protein depleted diet), herbs and acupuncture point selections you can recommend would be appreciated. I feel as if we are running out of time with this guy. He screams deficiency to me, but this case feels really over my head. She is desperate for help and willing to do anything.
Thank you so much for your very valuable time. If there are any clarifications or further info that you need, just let me know!

by naturevet

February 23, 2009

You've got quite a challenging case there, but with luck, you can probably help him. He has several different diagnoses:
hematuria and urolithiasis is a Damp Heat sign
ascites and low grade jaundice count as Damp signs
the PSS coupled with the low BUN, chol, alb, and mild to moderate liver enzyme changes suggest Blood deficiency. I'm guessing it's microvascular, given the delay in onset. Microvascular shunts, in turn, are caused by chronic liver inflammation
in terms of a self propagating dynamic, Liver Blood deficiency is leading to Qi stagnation and Spleen deficiency, which leads to more Damp and less Blood
treatment goals are thus to nourish Liver Blood, move the Qi, tonify the Spleen and drain Damp
we'd also like an anti-inflammatory and anti-oxidant effect on the liver, at the same time as we encourage blood flow
points that achieve these objectives include BL 18, BL 17, BL 20 (tonify at least the first two points, and see if the pulse improves. BL 20 might require either tonification or sedation to improve the pulse; LV 13 would be a great point, most likely you'll be sedating it
needle daily until he starts to rally, if the owner will let you
Herbs are probably a good idea. Given the entirety of the case, I'd probably go with a formula called Dang Gui Shao Yao San (Angelica and Peony Combination). You should be able to get this easily from Dr. Mona Boudreaux, via atthherbs@aol.com. They'll ship it very quickly if you ask them. Go for about 1/4 to 1/2 tsp twice daily of the powder. You can learn more about it at www.nphc.ca

As for diet, it's important to have a low carb, higher protein minimally processed diet. See if the owner will make the food for a while, and try to use the paleolithic diet outlined in the appendix in Manual of Natural Veterinary Medicine. The dog will be able to handle a decent protein level as long as the food isn't very processed. Better yet, for the next little while, let the dog eat what it wants. If that means giving it some roast chicken or something from the store, then so be it. We can try to get more picky later once it gains some strength.

Good luck with the case. If it works out for you, it'll make a good one to write up.

All the best,

Steve Marsden

by

February 23, 2009

Thank you, thank you, thank you. Those are the points that I used today, along with KID 3, LIV 3 and PC6. I will see how he is doing tomorrow and start the diet reccs when he's put on some weight and the herbs when they arrive. Would you change any of the other medications that he is on? Would you try to wean him off of them? Will they be safe in combination with the herbs?
Thanks again so very much!

by naturevet

February 24, 2009

Any drugs which the owner feels the dog tolerates poorly should be stopped ASAP. I presume the Denamarin is some proprietary extract of milk thistle, which should be okay, but will not radically change things. I would guess antibiotics are not helpful and maybe poorly tolerated, for example by suppressing appetite. Famotidine and spironolactone are probably okay, but of peripheral benefit if at all. So again, anything that isn't clearly helping can probably be discontinued too.

Have a talk with the owner and ID which drugs seem like they could be creating problems. Stop those. Find out which ones really seem to help. Keep those up. If the owner is not sure, but the dog is generally better, continue everything. If the owner is not sure, but the dog is declining since all drugs were stopped, definitely stop everything.

That's how I would feel my way through it, anyway. Given the drugs involved, weaning of any of them does not seem necessary or advantageous.

Good luck!

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