scott@vtx-cpd.com

Thanks for sending.

I would definitely not pin too much significance on this result, especially when everything else is very normal.

Is the dog on any liver ‘support’?

I hope you get away tomorrow. The session will be recorded and available like the other sessions.

It is so typical of veterinary practice… whenever you have plans… you never get away on time!!!

Scott 🙂

Hello.

Really sorry about the delay with this one. Thank you so much for the question. Basically, the evidence is varied regarding which exact dose to use:

I would normally start with 2mg/kg/day as this would be appropriate for immune mediated disease. Having said that, I have chickened out and started with 1mg/kg/day.

Depending on response (clinical and bloods), I would normally reduce the dose by 25% every 4 weeks.

Hope that helps.

Scott 🙂

Really great question! It is not something we have on our liver profiles. Could you post a copy of the full results? How is the patient doing and is it mon any medication?

It is definitely something that is used more in large animal medicine.

Increases in GLDH activity are used primarily to reflect leakage from damaged or necrotic hepatocytes. Since it is quite a large mitochondrial enzyme, injury needs to be sufficiently severe to damage mitochondria. GLDH is a useful enzyme for hepatocellular injury in large animals and exotic species (birds, amphibians, reptiles). GLDH is found in many tissues in the body, including hepatocytes, kidney, intestine, muscle, and salivary gland. However, most of serum GLDH originates from hepatocytes (in health and disease states). GLDH is located more in the centrilobular areas of the liver, whereas AST is more homogenously distributed and ALT is more periportal in rats. Due to its preferential location in centrilobular areas, liver injury involving these areas (e.g. hypoxia) may result in higher activity of GLDH than ALT. GLDH is a sensitive and specific marker of liver disease in all animals, including non-mammalian species. In rats, increases in GLDH were greater in magnitude, persisted longer or occurred without concurrent increases in ALT in drug-induced hepatic injury. In calves, horses and sheep, changes in GLDH paralleled changes in SDH after acute injury induced by chloroform. GLDH activity is not increased in horses or exotic animals with severe muscle injury (extremely high CK activity), supporting its specificity for liver injury. Like SDH, GLDH is not specific as to the cause of liver injury.

Overall, I would question the significance here. Would be great to see the other results and a bit more about the case.

Scott 🙂

Hello.

This is an excellent question about the gastroprotectants. It is one of my favourite topics. We definitely massively overuse these drugs. If there is no obvious signs of gastroduodenal ulceration, there is really very little indication. I might pick this up in the liver Q&A tomorrow is that is OK, I can expand a bit more there. We also have a full webinar on the topic (shameless plug):

Gastroprotectants: Taking the acid out of the suppression

There is also a brilliant consensus from ACVIM, which is open access:

https://onlinelibrary.wiley.com/doi/full/10.1111/jvim.15337

The antibiotic question is also a great one! I am definitely more likely to start antibiotics in cats, as there seems to be more of a role of bacteria in their liver disease. I probably am ore inclined to start antibiotics in sicker patients. So yes, I would consider antibiotics if there was a neutrophilia and pyrexia. The degree of neutrophilia is not that helpful in decision making. If ultrasound was performed and there was evidence of gallbladder inflammation, I would also be more inclined to start antibiotics.

I hope that helps.

Scott 🙂

Hey Mike.

Hope you are safe and well. These are really great questions. As with everything in medicine, there is never a black and white, but I will do my best.

Regarding the ‘everything else’… I think the following table summarises well the other main causes of increases in liver enzymes:

These would be the main things that I would want to rule out if you were at the stage of just having initial blood work.

If things had progressed to a stage where you had taken biopsies… the following is the most useful regarding decision making:

Based on this I would do the following:

1. If there was significant inflammatory change, copper came back as a non significant quantification and culture was negative then I would treat as immune mediated.

2. If copped was in a significant range… I would treat copper first.

3. If there was a positive culture… I would treat that first.

4. If the inflammation was not that significant… I would be looking again for the possible causes in the table above.

Hope that helps. Thanks again. This is a really great question.

Really appreciated your interaction and support.

Scott 🙂