Jonathan's re-diagnosis

[JMM]

Jonathan does NOT have hepatic microvascular dysplasia. He has another disease that is often mistaken for it. There is not even a paper published on it yet (in the works), but it is definately distinct from MVD. Luckily for Jonathan, his treatment will be a tofu diet and monitoring blood work. It is a good thing that is liver enzymes (like ALT) are not elevated and mean he does not need additional drugs that are used as treatment. So the other question is: Is it genetic? The answer seems to be yes, particularly in Maltese. The fact that I have potentially two dogs with it is very interesting in and of itself. We'll be talking with this specialist more and see if any future monitoring will be helpful to her and if perhaps we can get more dogs' to be properly diagnosed.

[Traci]

Can you tell us the term your vet used?

Tofu? Is this anecdotal or?

[JMM]

I assume you mean the name for the disease. I am under the impression it does not have a name yet, but when I get a hard copy of the report I am more than happy to share.

Tofu based diets have been used for a few different liver conditions. Obviously there are other ingredients added to balance it. Again, as soon as I get copies of these things I am happy to share if you are interested.

Since I may have another dog with the same disease, I am interested in pursuing possibly long-term following of my two if the specialist is interested.

[Traci]

Yes, the disease condition...I would love to hear what your vet has to say.....I do think it's odd about nothing published/surmiseable info on this. I wonder if your vet has considered yet the possibility of a conversation with the specialists on VIN?

As for the tofu, I must admit, I have never heard of this as a diet for liver conditions, I might look for some info on that

[JMM]

Perhaps I should have specified that my regular vet did not make the diagnosis, just got the biopsy and is the middle man with the specialist. The tissue was originally sent to Antech and diagnosed as MVD. I was referred to a liver specialist at Cornell for the case by Dr. Tobias who is well known for her liver shunt work in my breed. The specialist is Dr. Sharon Center. She is very knowledgable in MVD. This has been a wild ride!

Would I be correct to assume that my vet can find an article published in Australia on Maltese having high bile acids/liver enzymes (I'm not sure which) or is there another resource for an Australian article? The article I'm thinking of is one many Maltese people use as a justification for not pursuing elevated liver "stuff" as being normal for Maltese which I am finding out is not normal and this article is criticized for lack of real evidence in stating that (something like 3 actual liver biopsies done). This condition may be related.

[Traci]

Would I be correct to assume that my vet can find an article published in Australia on Maltese having high bile acids/liver enzymes (I'm not sure which) or is there another resource for an Australian article? The article I'm thinking of is one many Maltese people use as a justification for not pursuing elevated liver "stuff" as being normal for Maltese which I am finding out is not normal and this article is criticized for lack of real evidence in stating that (something like 3 actual liver biopsies done). This condition may be related.

I'm sure he could, he could start with a PubMed (Medline) search, if he knows what to look for. He can also utilize various veterinary journals through other sources to obtain abstracts and research studies, it depends on his access to them, if he subscribes, etc. This is why I suggested he get in contact with someone at VIN as a start. The Australian Veterinary Journal might also contain the report, but your vet would probably need at least the author/university/date/or 'team' information that concluded the study. Remember when reading abstracts or studies, consider the source, peer-reviewed status, evidence, or conclusive evidence and/or incomplete findings.

I am confused about one thing...you said that Jonathan does not have portosystemic liver shunting, but indeed an intrahepatic shunt was a suspicion. Some small breed dogs do have a predilection for shunting, usually extrahepatic (surgical correction possible), including maltese, yorkies, miniature schnauzers, poodles, dachshunds, etc. I'm also confused when you say that Jonathan does not have elevated liver enzymes (has he ever?). With shunting or other biliary problems, liver enzymes are not always necessarily elevated. Bile acids are a general tool for diagnosing shunts, biliary obstructions, stasis, bile duct overload or blockage, gall badder disorders etc. When in doubt, ultrasonography or ultrasound-guided needle biopsy is usually the option to rule out other causes of liver disease or when testing and ultrasound is nonconfirmative.

[Guest]

I am confused about one thing...you said that Jonathan does not have portosystemic liver shunting, but indeed an intrahepatic shunt was a suspicion. Some small breed dogs do have a predilection for shunting, usually extrahepatic (surgical correction possible), including maltese, yorkies, miniature schnauzers, poodles, dachshunds, etc. I'm also confused when you say that Jonathan does not have elevated liver enzymes (has he ever?). With shunting or other biliary problems, liver enzymes are not always necessarily elevated. Bile acids are a general tool for diagnosing shunts, biliary obstructions, stasis, bile duct overload or blockage, gall badder disorders etc. When in doubt, ultrasonography or ultrasound-guided needle biopsy is usually the option to rule out other causes of liver disease or when testing and ultrasound is nonconfirmative.

Jonathan does not have PSS and the biopsy of his liver does not support an intrahepatic shunt. Ultrasound is very useful when looking for PSS if you have somebody who knows what they are doing. I am lucky that I do.

Jonathan had his bile acids done because his chem screen and cbc were normal and he had a seizure. He has also been lethargic, but it was a hot summer and his chem screen was normal. None of his liver enzymes on the chem screen have ever been elevated since I got him. The bile acids were very mildly elevated. Due to the recommendation of a neurologist, they were repeated. He was ultrasounded to help rule out PSS. FNA or ultrasound-guided biopsy of the liver would not have been adequate in this case. It was suspected to be MVD and to diagnose that you need to get a surgical biopsy. His biopsy sent to Antech came back as MVD. I then found a vet who had actually done research on MVD and she requested that she be able to review his pathology slides as she has seen a distinctly different liver disease misdiagnosed as MVD. Upon her review, she determined he did not have MVD and in fact had this other disease. I don't have anything written about his path review in front of me (I just got the news Sat from my vet), but hopefully will next week.

I have Jonathan's paternal nephew, Mikey. Mikey has had chronic GI problems attributed to IBD. After getting Jonathan's initial results, we did Mikey's bile acids (Mikey's chem screen has always been normal). They are even more elevated than Jonathan's are. Mikey was also ultrasounded to check for PSS. We are planning to biopsy his liver in Oct or Nov. Due to his other problems, we will also do full-thickness biopsies of his stomach and intestines to be absolutely sure if he has IBD or not.