When to start treatment ? Kidney and Cushings problems (10 y/o Shih Tzu)

[suztzu]

Hello, I am new to the forum and I have a 10yr old Shih Tzu named Leo my little bubba. He has been on the uphill climb towards Cushings for about a year now. Long story short I was going to bring Leo in for a routine dental and my vet wanted to do a routine blood panel to make sure everything was okay for the anesthesia, and his blood work came back with elevated ALT the usual story. So we proceeded to do more tests the urine cortisol test fasting bloodwork etc. All came back not too bad but not normal either the problem came with his ultrasound, the results were not good he has nodules on both adrenal glands and his kidney's were starting to deteriorate. So we have put off any treatment that would do any damage to his kidneys and at his 6mth blood recheck he is now starting to show some symptoms of Cushing's but his kidney function is showing as normal so far. I have not done the low dose dexamethasone test yet that is the next step. He is just now starting to show some symptoms like a little more water drinking a little agitation weakness in the hind end.
Has anyone else had this dual problem ? I am terrified to start him on medication that could potentially push him into kidney failure. Should I be looking at herbal remedies ? He is on a kidney diet now canned food etc. But I know the Cushing's is going to start doing a real number on his body. Any advice will be welcome I am going to set up the dexa test for this week just to confirm the diagnosis and determine whether its the nodules on the adrenals or if its pituitary. I don't have his blood work numbers now but I am going to get copies this week Thanks in advance Susan and Leo

[Harley PoMMom]

Hi Susan,

Welcome to you and Leo! I am sorry for the circumstances that brought you here but so glad you found us.

Cushing's is one of the most difficult diseases to get a confirmed diagnosis for because there isn't one test that is 100% accurate at diagnosing it and other non-adrenal illnesses share some of the same symptoms as Cushing's.

The tests generally used for helping to diagnose Cushing's are the low-dose dexamethasone suppression (LDDS), ACTH stimulation, urine cortisol:creatinine ratio (UC:CR) and/or ultrasound. With Leo already having been diagnosed with kidney issues I urge you to talk to your vet about having an ACTH stimulation test instead of a LDDS test because the LDDS test can have a false positive result when other non-adrenal illnesses are present.

When you get copies of all tests that were done on Leo could you post any abnormalities that are listed along with the reference ranges and units of measurement..e.g...ALT 150 U/L (5-50)...thanks!

It is sure a dilemma in deciding to treat the Cushing's when a dog has kidney disease. What stage of kidney disease has the vet diagnosed Leo at? Has Leo's blood pressure been checked recently? Cushing's seldom warrants really urgent treatment, so in your case I would be wanting to get some sort of handle on the kidney problem, particularly getting Leo's blood pressure checked out (Cushing's dogs often have high blood pressure and kidney disease can cause high BP and high BP can cause kidney problems too), and medication to help with the kidney function. You might want to ask the vet to repeat the kidney-related tests about 2-3 weeks after the changes in diet and medications were made.

Please know we will help in any way we can so do not hesitate to ask all the questions you want.

Hugs, Lori

[labblab]

Hello and welcome from me, too. Lori has already given you some great information and asked some helpful questions. Like her, I am wondering as to the exact nature of the kidney issues. You mention that the ultrasound revealed some "deterioration," but all the tests of kidney function remain normal up to this point. I'm assuming this means that the BUN and creatinine are normal on the blood panel, and that there have not been significant amounts of protein found in the urine? Do you know whether the ultrasound deterioration represents anything other than just age-related changes?

The reason why I ask is because it really does make a difference as to whether there are genuinely pathological changes going on. If not, delaying effective Cushing's treatment may actually hasten the risk of kidney damage rather than prevent it. Primary kidney disease can indeed be an issue in terms of medication choices. But if the kidney changes that are being seen are instead secondary to Cushing's and actual renal function has not yet been compromised, then I think you will want to move more quickly with lowering the cortisol level if Cushing's is indeed diagnosed. For this, prescription medication is required as opposed to herbs or supplements.

So just as Lori has said, I think the bottom line is that you need to get a speedy assessment of any actual kidney issues so that you will know how to safely proceed with other treatment.

Marianne

[suztzu]

Hello again my vet wants to do the low dose dexa test to determine whether its pituitary or adrenal and we are going to go from there but that's not until next Tuesday. As for the kidney issues she's not sure why the deterioration is occurring but since there has been no change in function as of yet we are just watching and waiting. So thanks for the info and we shall see. She really wants to do the low dose test instead of the ACTH test at this point so I guess we might as well have it done it can't hurt. I will let you all know what will be happening next I will have many questions by next week I'm sure so it's all to be continued... Thanks again

[Harley PoMMom]

She really wants to do the low dose test instead of the ACTH test at this point so I guess we might as well have it done it can't hurt. I will let you all know what will be happening next I will have many questions by next week I'm sure so it's all to be continued... Thanks again

I feel I should reiterate what I mentioned in an earlier post, when a dog has a non-adrenal illness the LDDS is more likely to return a false positive result. I am providing an excerpt from a renown canine Cushing's expert, Dr Peterson, he is also a contributor to Dechra's continuing education site:
The specificity of the LDDST can be low (40% to 50%), especially when measured in a population of sick dogs (4). Because of the low specificity of this test, diagnosis of Cushing's syndrome should never be based on results of an LDDST alone, especially in a dog with nonadrenal disease. It is best to delay testing for hyperadrenocorticism until the dog has recovered from the concurrent illness

Full article can be found here: Helpful Tips to Improve the Accuracy of the Low Dose Dexamethasone Suppression Test (http://endocrinevet.blogspot.com/2012/05/helpful-tips-to-improve-accuracy-of-low.html)

I would be reluctant to have the LDDS test performed because there is a greater chance that it may produce a false positive result, if this were me, I would instead put that money towards an ACTH stimulation test...just my opinion ;)

Hugs, Lori

[lulusmom]

Hi Susan and welcome to you and Leo.

I've read your initial post and while I now there is little information to go on to form an opinion, cushing's is not jumping out of the screen at me. For instance, you mentioned that ALT was elevated. Dogs with cushing's have mild elevations in this liver enzyme but have moderate to severe elevations in the ALKP liver enzyme. Can you reconfirm that it was the ALT that was elevated? Can you also post the abnormal values on the blood chemistry and cbc. We need only see the high and lows and please include the normal reference ranges. Was a urinalysis also done? If so can you please post those results as well? I would be most interested in the urine specific gravity (USG) and results of any culture.

You mentioned that you did a urine cortisol fasting test and that all came back not too bad but not normal either. I assume you are talking about the urine cortisol creatinine ratio (UCCR)? If so, can you please post the results of that test here? If not, can you please explain what the actual test was and post the actual results here?

Dogs with cushing's pee huge amounts due to their inability to concentrate their urine. They drink huge amounts of water to keep up with all the peeing. You mentioned that Leo is doing a little more water drinking. This does not sound as though Leo's kidneys are not concentrating. The results of the urine test, specifically the USG will help us understand if he truly has polyuria/polydipsia as a result of cushing's.

What do you mean by agitation? Are you seeing an aggressive behavioral change? What are you seeing that makes you think Leo has hind end weakness? Do you notice any loss of muscle mass in his hind quarters? Any skin or coat changes, panting, increase in appetite?

I apologize for all of the questions but the goal of cushing's treatment is to remedy problematic symptoms and based on the little information you have provided, I'm just not seeing any problematic symptoms at this point. I am hoping that by your providing additional information, we can better understand why your vet is pursuing a cushing's diagnosis.

I sure am sorry for the reasons that brought you here but I'm glad that you found us.

Glynda

P.S. I noted that your vet has put Leo on a kidney diet. That concerns me because protein restriction is not recommended unless the dog has lost the majority of kidney function. If your vet put Leo on a kidney diet, I would think he has formally confirmed a diagnosis of renal failure, in which case BUN, creatinine would definitely be elevated as well as phosphorus. Once you post the results of the blood chemistry, we'll be in a better position to understand that diagnosis and the reduction of protein in the diet.

[suztzu]

His symptoms are so mild its hard to tell whats going on, he's not aggressive in any way he's just a little more hyper than normal sometimes. He's not peeing copious amounts he barely pees at all just like 3 or 4 times a day. He's a little more hungry than usual and he can hold his urine for a super long time ( I don't require him to he just hates to go outside sometimes) even when I carry him outside to pee he just looks at me like really lol. I try to make him potty as much as possible. He is not on a normal kidney diet i.e. low protein I will not feed him kd canned. He gets Fromm chicken and Wellness Senior canned its has appropriate phosphorus levels for a dog with beginning kidney disease. I also will probably start home cooking for him soon I have a recipe from a canine nutritionist ive consulted with. He's has had no increase in his bun or creatinine levels in his urine indicating kidney disease just what was seen on his ultrasound.
His last ALT was 648 his bile acid test was normal his urine cortisol creatinine showed low levels of cortisol. That's all I can remember off the top of my head. I don't have a copy of his current blood work so I cant give you all the results. I am going to pick up a copy on Thursday. I am concerned that he will have a false positive test when doing the LDDS I am going to push for the ACTH test or find a new vet. I am not really convinced he has cushing's disease. Whatever is happening with him has been so slow moving is that normal for Cushing dogs or does it usually come on suddenly ?

[labblab]

It would be great if you could also get a copy of the interpretation of the ultrasound report so that we'll have a better understanding re: the adrenal nodules and also the kidney deterioration.

Thanks!
Marianne

[suztzu]

ok I will see if I can get all his test results thanks for all the help Im wondering if I should get a 2nd opinion Thanks again

[molly muffin]

Hello and welcome from me too. If you aren't seeing an internal medicine specialist then I would probably make an appt to go see one. Get referred if you need to. Any time things are getting complicated they are usually your best option. Maybe just to work with your vet but a second specialized opinion is always good.

Sharlene and Molly muffin

[suztzu]

ok gang here are Leo's last test results I really don't know what indicates Cushings but here are some things

ALP 1539 normal 5-160
ALT 87 normal 18 -121
glucose 87 normal range
BUN 14 normal 9-31
Creatinine 0.8 normal 0.5 to 1.5
Bun/Creatinine ratio 17.5
WBC 9.0 normal 4.9 to 17.6
RBC 7.51 normal 5.39 to 8.70
urine cortisol 36.5
urine creatinine 124.8
urine cortisol/creat ratio 91

so anything above 34 for urine cortisol could indicate hyperadreanalcorticism but it is highly unlikely. ( so the report says? So this is why my vet wanted to do the LDDST test to rule out pituitary or adrenal cushings.

His ultrasound report conclusions are as follows-

Smallish liver This could be a normal variation for this patient an unseen portosystemic shunt or hepatic cirrhosis is possible. Bilateral adrenal nodules these could represent adenomas ( likely functional given the clinical history provided neoplasia cannot be ruled out. Bilateral renal degeneration with poor corticomedullary definition.

So we did have the LDDST done today I just felt it was necessary I don't know if it was the right thing to do but Ive had this vet for 20 years and I trust her judgment Does any of these test results look familiar or does anyone have any insight as to what my next steps should be ? How long can he go with ALP liver values so high ? I still am not sure what non-adrenal illness would be for the test result to be a false positive. I already know he has some adrenal malfunction due to the nodules on his adrenal glands so I think that a false positive would not be likely. So I guess the question would still be is it Cushings or just tumors on the adrenals and when to start treatment. I know my vet will be hoping its pituitary otherwise she said she will refer me to a surgeon. Thanks all for letting me post this it helps me. I am so confused by all this, and so worried.

[molly muffin]

What did the LDDS show, do you have those results yet?

They think that there are bilateral functional tumors? one on each adrenal gland? If this is functional Adrenal cushings, then the LDDS should show it.

I am not sure what the procedure would be with a tumor on both adrenal glands, since you can't remove them both. I think that if that is the case and the LDDS is supportive of that, then you want to go over your options with your vet and possible see a specialist, who would work with your vet.

It isn't as worrying having a high ALKP, as it would be if the AST, GGT etc, all started to rise to triple their normal value. Then you'd be concerned with liver disease, but it was mentioned that the liver is actually on the small side. Normally with high cortisol levels the liver intends to enlarge.

Some of the others will be by who might have some other thoughts.

Sharlene and molly muffin

[suztzu]

Thanks for the response we did get the LDDS back and it confirms Cushing's syndrome but it did not indicate which form pituitary or adrenal. My vet is leaning towards pituitary because that is most likely but the tumors could be growing on his adrenals, really all I can do is try to control his symptoms. We talked about starting Trilostane (Vetoryl) but at this point I'm not sure its necessary his symptoms are pretty mild and I am worried about shocking his kidneys into failure. What experience does anyone have with Trilostane ? Side effects ? Advice anyone treat a dog with mild symptoms or just let it go until it gets worse ?

[molly muffin]

We were just actually talking about it on another thread, that if there is No symptoms, then usually you don't treat until there are. There has been some back and forth discussion as to whether to start treatment early so as to actually help prevent organ problems. As kidney, liver, can all be affected by continued high cortisol.

If you start at a low dose, you should have no problems with trilostane, it is when the dose is too high that probems usually occur. With mild symptoms I'd start even lower than the 1mg/1lb recommendation that one normally starts at. It doesn't hurt to start low and go up. Giving them time to adjust to the medication and see how they react on it.

Did you get the actual test results so you can post the LDDS test and any abnormal results?

Sharlene and molly muffin

[suztzu]

Hello everyone after much testing I am going to start Trilostane for my little guy Leo a 10 yr old shih Tzu. Is there anything I need to look out for and specific side effects ? We are starting at the lowest dose and going to see how it goes. Any advice would be welcome thanks.

[Squirt's Mom]

MODERATOR NOTE: I have merged your post about Trilo questions into Leo’s original thread. We normally like to keep all posts about each pup in a single thread as it makes it easier for members to refer back to the pup's history when needed. If it has been a while since you posted, you may have to scroll back a few pages to find your original thread. If you need help locating it, just ask and we can help. Thanks!

[molly muffin]

So a low dose would be no more than 1mg/llb or 1mg/lkg.
You do not want to see any vomiting, diarrhea, lethargy, not eating.
Trilostane should be given with a meal, usually in the morning and you will get an ACTH test in about 12 days to see where cortisol is at. The test should be administered, non-fasting, 4 - 6 hours after the medication is given in the morning.

Sharlene and molly muffin

[molly muffin]

Hello, checking in to see how you and Leo are doing? How has he been on treatment?

Sharlene and molly muffin

[suztzu]

Well started Vetoryl today then a ACTH test in 2 weeks any advice on side effects and what to look for ? We are using the lowest dose 1 capsule a day in the AM

[molly muffin]

Watch for lethargy, not able to stand, vomiting, diarrhea, not eating. Those are the typical signs of cortisol going too low.

What is the dose you started at? You said you are on the lowest.

Sharlene and molly muffin

[suztzu]

Well we are on day 2 so no side effects yet the dosage is 30mg capsules and we will go back in 2 weeks for a check on cortisol levels. I have seen no change yet he is still acting the same ( pretty normal) a little more begging for food a little more water but other than that its been more of a physical change for him. Losing a little muscle tone legs getting a little wobbly coat thinning skin getting a little thin. So time will tell at least I know what to look out for thanks for the info I will keep you updated. Good to have support and know what to look for.

[Squirt's Mom]

How much does he weigh?

[suztzu]

Leo weighs 18 lbs