Guinea Pig with Nephrotic Syndrome, Advice on Treatment?

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ph08fhf

Post   » Wed Sep 02, 2015 5:26 pm


Hi All,

Summary: I have a 4 year old female rescue pig who was recently diagnosed with 'nephrotic syndrome'. My vet is very cavy savvy (I take her to Cornell Animal Hospital), but none of the whole exotics team have seen this in a guinea pig before now. They are treating based on (extrapolations from) the usual treatment for dogs, cats and humans, but the treatment is largely 'exploratory' in the sense that the whole thing is new to everyone. I'm posting on here to see if any of you have experience with pigs with nephrotic syndrome and/or whether you have advice as to what treatments are available.

Full Story: I adopted Barbara, an intact, female, american smooth - from a shelter (since shut down permanently) in NJ when she was approximately 2 years old. I have now had he for approximately 2 and a half years. She has been in good health, though quite small (typically 1 lb 11oz) since I got her, until this recent issue. We didn't know much about her background apart from the fact that she had several litters when she was quite young and all in quick succession.

About 1 month ago I noticed that Barbara was spending a lot of time sitting in a hunched position with her hair puffed out, sometimes he breathing also looked a little laboured or 'heavy' (but only a little). When disturbed or petted she reacted normally and showed no signs of pain when being picked up and examined by me. At that time she was peeing and pooping normally and she was eating and drinking normally. She would sit like this for periods of 20 mins to an hour or so. I made an appointment with the vet and she was seen a week or so later. Between the time of the initial symptoms and the vet visit Barbara's poos became smaller than usual - still well formed and bean shaped but smaller.

When the vet examined Barbara she was (of course) behaving completely normally. The vet did a routine examination and spent some time palpating her back end to check that there was no pain in that area. I had been worried about bloat (though I didn't see a distended stomach) but they said that was not an issue. They prescribed 0.2 ml of tramadol once daily because we were unsure if the posturing and 'puffing' indicated pain or defensiveness (Barbara lives in a large C and C cage with 9 other female guinea pigs - there was a possibility that the pecking order was shifting and she was feeling the pressure) and I moved her to a separate cage for around 5 days.

We monitored her for those 5 days to see if her symptoms improved. They did not so I returned her to the main cage and stopped the tramadol. I closely monitored her eating and drinking and her weight - none of which changed.

Around a week later Barbara had a short (1-2 day) period of soft stool. Not full diarreah, but ill-formed soft stool. She continued to eat and drink normally. I called the vet to schedule another appointment - they were booked up for several weeks.

Around a day later I noticed that her belly felt unusual - almost as though there was water or some fluid between her stomach and her skin. The area did not appear painful when I picked her up. I called the vet and they were able to move the appointment forward to the next week. Barbara was still eating, drinking, peeing and pooping normally.

When the vet saw her her symptoms were again diminished somewhat - the fluid on her belly was less pronounced and she wasn't puffing as much while at the vet. The Dr palpated her kidneys and did feel some abnormal shaping to them. She suggested an ultrasound, urinalysis and some bloodwork which we did. The ultrasound revealed several large cysts on both kidneys, some abnormalities in the kidneys themselves (the way the Dr explained it was that the ultrasound should show a bright spot in the middle of the kidneys, but that the middle of Barbara's kidneys were quite dark) and fluid on the abdomen. The bloodwork showed a marked decrease in protein (3.7 g/dL) with low albumen (1.6 g/dL), mild hypercalcemia and marked hypophosphatemia. The urinalysis (free catch) revealed specific gravity of 1.009, 300+ proteinuria and large positive (+++) for blood. At that point, the vet suspected nephrotic syndrome, but wanted to speak with the kidney specialists before prescribing anything (because none of the vets in the exotics department had ever seen this in a guinea pig - even the vet that has worked at Cornell for 20+ years).

The next day, the vet prescribed Enalapril 1mg/ml, 0.45 orally once a day and instructed that I get some non-fish based omega 3 for her. I have been giving the enalapril for 4 days now and am waiting for the omega 3 to arrive.

I have seen no change in Barbara yet, but the vet said that was to be expected. She still has the fluid on her abdomen, and she still sits in the hunched, puffed position for periods of time. I am concerned that she is in pain (she is still eating, drinking, peeing and pooping normally and not losing weight), but am reluctant to give pain meds to a pig who has damaged kidneys (the vet has said that we can give tramadol if i think that she really needs pain meds).

Does anyone have experience with this problem in a guinea pig? Any insight as to treatment options? My vet suggested that perhaps the condition itself isn't so uncommon, but that the symptoms are so subtle and hard to spot that they don't usually get to see the problem before the pig dies. Any words of wisdom would be greatly appreciated, i will do anything to keep this pig healthy and happy for as long as possible.

Do let me know if i have missed any important information. And sorry for the long post.

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bpatters
And got the T-shirt

Post   » Wed Sep 02, 2015 5:34 pm


You've been very thorough, and it sounds like you've got excellent vet care.

I really don't have anything to add or suggest. In humans, steroids are sometimes given to see if the symptoms improve, but they're certainly no cure.

I think, if she were mine, I'd give the pain medication if she seems to need it. It's a serious condition that will likely shorten her life, and I'd vote for it to be pain-free, even if somewhat shorter.

I'm sorry she's so ill. Do keep us posted on how she's doing.

User avatar
Lynx
RESIST

Post   » Wed Sep 02, 2015 8:44 pm


Was the possibility of doing an xray ever discussed? I mainly mention it because so many guinea pigs have bladder issues (stones, sludge) that could be involved in whatever's going on.

I don't think anyone has posted about nephrotic syndrome.

It does sound like you have good care. I hope the enalapril helps.

User avatar
ph08fhf

Post   » Wed Sep 02, 2015 10:34 pm


Thanks for the replies.

X-ray was never suggested. I do have some experience with bladder issues, and hadn't noticed anything in Barbara to make me think she has a bladder issue - no sludge in the urine or vocalising while peeing or pooping. Actually, in the past my vet has used ultrasound to identify sludge/stones in the bladder. Would it be expected that a bladder problem would show up on her ultra sound?

It is somewhat mysterious whether and why she would be feeling pain. The vet says that the kidney problem itself should not be causing pain. But I have difficulty attributing the posturing and puffing to anything else. Perhaps the fluid on the abdomen is what's causing discomfort...?

Talishan
You can quote me

Post   » Wed Sep 02, 2015 10:59 pm


I think ... and we have not had this happen at our house, so I'm not speaking from direct experience, but I think ... that kidney stones and/or stones in the ureter(s) (channels from kidneys to bladder) may not show up on ultrasound. It depends entirely on what the ultrasound is being used to look for, and the experience of the person doing the U/S (which from what you have posted, would be excellent).

Kidney stones or stones in the ureter will cause pain, and may cause additional pain secondary to urine slowly backing up into the kidney if it cannot flow freely to the bladder.

Stones in the kidneys and/or ureter(s) are nowhere near as common in guinea pigs as are bladder stones and sludge (and urethral calculi), but they definitely can occur. Use the Tramadol and see if she feels better (ditto bpatters), and I too would want an x-ray.

Look at this:

http://www.guinealynx.info/forums/viewtopic.php?p=2082059#2082059

http://www.guinealynx.info/forums/viewtopic.php?t=61285

Talishan
You can quote me

Post   » Wed Sep 02, 2015 11:06 pm



User avatar
ph08fhf

Post   » Thu Sep 03, 2015 12:04 pm


Thanks, Talishan. I'll contact me vet and ask about doing x-rays when they next see her (in approx 2 weeks). In the mean time I will have them start her on the tramadol.

Her condition is so odd at the moment, she is behaving very normally, enjoying food and meeping at the hay bag and running around. She seems so well for so much of the time, but I know that she has these severe physical problems and there are those periods where she just looks miserable. I wish she could tell me what she needs.

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ph08fhf

Post   » Thu Sep 03, 2015 2:36 pm


The vet got back to me within 2 hours via email (outstanding), she is confident that they would have seen any stones on the ultrasound (it was very comprehensive, she talked me through the stills from the ultrasound and they had looked across a large area), and mentioned that the kidney changes in Barbara were different than the changes they usually see with stones.

The prescription for the tramadol will be in tomorrow and I will pick it up. The fluid on her belly does seem to be increasing and she is up to 2lb today which is as high as she has ever been, but with poor muscle condition comparative to her weight and size.

The omega 3 arrived today. We had to order a specialised blend for horses so that it wasn't fish-based. It's quite comical - the smallest size was 5 lb, more than twice the size of her!

Thanks again for your insights.

Talishan
You can quote me

Post   » Sun Sep 06, 2015 4:46 am


Please keep us posted. My very best to her and to you.

User avatar
jacqueline

Post   » Sun Sep 06, 2015 7:31 am


I know in humans nephrotic disease can cause fatigue. Maybe those times she sits puffed up, she's just so fatigued she can't move?

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ph08fhf

Post   » Sun Sep 27, 2015 10:03 am


Barbara died on the 15th of september.

I am sorry to have been so slow in posting about this, but I just didn't have the strength to share with you until now. It was a huge shock for everyone, she was in at the vets to have a routine blood draw and some urine cultures. While the blood was being drawn she just stopped breathing. They performed CPR on her for some time, but Barbara did not respond.

In between my last post and her appointment at the vets, the fluid on her abdomen had increased. I have been giving her 0.2 of tramadol twice daily for pain and that seemed to have some limited effect on her periods in serious discomfort; she was still posturing and 'puffing' but just seemed slightly less uncomfortable. She was energetic, playful and loving until the last. She loved her enalapril and would tolerate the omega 3. She would greet me every morning at the side of the cage.

After a discussion with the vet we think that her pain and fluid retention was worse than we had anticipated and that the pressure on the lungs was just too much along with the stress of a blood draw. During her visit and examination, she had been behaving normally and seemed very relaxed so I think her last day was not too horrible. I am glad she is no longer in pain. I was lucky enough to have a quiet cuddle with her in the waiting room before her blood draw, which in itself told me that not all is well (she was a very wriggly pig towards the end).

Barbara's remains were donated to the school of veterinary medicine so that they can further investigate this rare illness and perhaps help some pigs in the future. Her ashes were returned to us on friday and are next to me as I type. My vet promised to share their findings with us and when she does I will post them on here if that would be helpful.

I think I will never stop crying.

bpatters
And got the T-shirt

Post   » Sun Sep 27, 2015 10:34 am


I'm so sorry you lost her. But how great of you to donate her body so someone could learn more about the syndrome. Will they share the results of the necropsy with you?

User avatar
ph08fhf

Post   » Sun Sep 27, 2015 10:46 am


Yes, they have promised to share the results with me, and also with the wider vet community. They will still submit the blood and urine tests for the samples they took on her last day, to see if there is any change from the treatment. Everything I hear from them I will be happy to share on here. Would it be best to post findings on this thread or start a new one?

A big source of turmoil for me is that I wish I has pushed for imaging earlier on - the first time I took her in for the posturing/puffing. Having said that, I am also very lucky to have some experience with pigs, know their weights, and have a very cavy savvy vet - so i wonder how many pigs actually have this syndrome and are not diagnosed at all. So i would like it if my experience could help some other cavy owners to identify the problem earlier on and push for imaging. She really didn't have any of the big markers of illness - she was eating well, she was energetic most of the time, she was peeing and pooping well and she wasn't losing weight. The only marker at first was the posturing and puffing.

bpatters
And got the T-shirt

Post   » Sun Sep 27, 2015 11:31 am


You can post them here, and/or you can write up a summary for the records forum. If you decide to do that, one of the mods/admins can post it for you.

User avatar
Lynx
RESIST

Post   » Sun Sep 27, 2015 11:50 pm


I am so very sorry you lost her, ph08fhf.

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LS in AK
Upside-down & Backwards

Post   » Mon Sep 28, 2015 1:15 am


That is so sad, to lose her so quickly like that. I am so sorry for your loss.

Any knowledge gained from the necropsy is sure to be incredibly valuable, though.

GrannyJu1
Armcavy

Post   » Mon Sep 28, 2015 1:15 pm


So, so sorry you lost Barbara. She was lucky to have you to care for her. We all know you did everything you could, so don't even think about beating yourself up. Everyone has what they think is perfect hindsight, but it isn't always true. Take comfort in knowing she's no longer in pain.

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ph08fhf

Post   » Tue Oct 20, 2015 6:31 pm


The following is a copy of the necropsy report for Barbara. Please feel free to repost this elsewhere on the site if it would be helpful. You can use information from this report elsewhere also if it would be helpful.

The only comforting thought is that this may help to save a life. Thank you all for your kind words.

PRESENTING COMPLAINT:
Recheck protein losing nephropathy

HISTORY:
Barbara, a 4 1/2 year old female intact guinea pig, was initially presented to the Cornell University Hospital for Animals Exotics Service on 5/4/15 for a fluffed and hunched posture, which continued and was further evaluated on 8/27/15. At this recheck in August, Barbara was diagnosed with Protein Losing Nephropathy (Severe) and Ovarian Cysts (Left Ovary, Small) along with ventrally dependant pitting edema. At that time abdominal ultrasound and blood work confirmed these diagnoses. Barbara was prescribed Enalapril, Tramadol and Omega 3 supplements. Since the last visit, Barbara has had a good appetite, energy level and attitude. She has had occasional soft stools which cake onto her back end. She is weighed daily and her family has noted that as the ventral edema has decreased, so has her body weight. The family is still concerned about her hunched up, fluffed posture (seen in her up to 5 times per day) and are concerned that they have not seen her lay down, likely due to discomfort, in the last week. Barbara is currently housed with 9 other guinea pigs and is fed an assortment of timothy hay based pellets, blue grass hay, and vegetables.

VISIT SUMMARY:
On presentation, Barbara was bright, alert and responsive. Her heart rate was within normal limits and sounded strong and clear, with no murmurs or arrythmias noted. There was mildly increased respiratory sounds on auscultation and a slight abdominal component to her breathing. She was underconditioned, with a Body Condition Score of 2/9 (5/9 ideal), with abdominal distention (fluid filled) and ventral edema (fluid in her subcutaneous tissues) extending from her pubis to her neck.

After discussing Barbara's apparent continued good quality of life, and that the goal of treatment is to maintain this in the face of a poor long-term prognosis for severe protein losing nephropathy, it was decided to proceed with an ultrasound-guided cystoscentesis (using a needle to retrieve a sterile urine sample from her bladder) for culture (to rule out kidney infection) and urine protein creatinine ratio (UPC - to assess degree of protein loss), and recheck chemistry panel to assess kidney values while on enalapril.

Barbara's bladder was too small for safe cystocentesis therefore a catheter was passed into her urethra to obtain a sample of urine. This procedure was able to be done quickly and without complication. The first two attempts to retrieve peripheral blood (from lateral saphenous and cephalic) yeilded clotted samples that could not be read in house. A third attempt was made successfully, with Barbara in dorsal recumbency and accessing the cranial vena cava. On recovering Barbara from dorsal recumbency, she collapsed and became non responsive. Cardiopulmonary resuscitation was started immediately, including placement of a catheter into the trachea for ventilation and administration of epinephrine. No response to therapy was seen and resuscitation attempts were stopped after consultation with Ms. Fairbairn. A post mortem evaluation was requested to learn more about Barbara's cause of death and her protein losing nephropathy.

We are so sorry for your sudden loss. Barbara was a sweet girl and it was an honor to be part of her medical team. We know she will be greatly missed.

We also want to thank you for allowing us to perform a necropsy on Barbara. We hope that through Barbara we can learn more about this kidney disease in order to help other piggies in the future. We will be sure to keep you informed of our findings.

Please do not hesitate to contact us at any time with questions or concerns. Again, please know that we are thinking of you.

DIAGNOSTIC TESTING RESULTS:

Recheck Chemistry Panel:
Test Name: 8/27/15 Result>>>>>9/15/15 Result

Sodium (mEq/L) 145>>>139
Potassium (mEq/L) 7.3>>>8.9
Chloride (mEq/L) 108>>>94
Bicarbonate (mEq/L) 31>>>31
Anion Gap (mEq/L) 13>>>23
Na/K Ratio 20>>>16
Urea Nitrogen (mg/dL) 29>>>54
Creatinine (mg/dL) 1.1>>>2.1
Calcium (mg/dL) 12.0>>>12.5
Phosphate (mg/dL) 1.2>>>2.0
Total Protein (g/dL) 3.7>>>3.2
Albumin (g/dL) 1.6>>>1.4
Globulin (g/dL) 2.1>>>1.8
A/G Ratio 0.8>>>0.8
Glucose (mg/dL) 124>>>270
ALT (U/L) 27>>>27
AST (U/L) 71>>>100
Alkaline Phosphatase (U/L) 41>>>27
GGT (U/L) 3>>>5
Total Bilirubin (mg/dL) 0.0>>>0.0
Direct Bilirubin (mg/dL) 0.0>>>0.0
Indirect Bilirubin (mg/dL) 0.0>>>0.0
Amylase (U/L) 5101>>>5142
Cholesterol (mg/dL) 37>>>39
Creatine Kinase (U/L) 1135>>>2800
Iron (ug/dL) 174>>>144
TIBC (ug/dL) 187>>>176
FE saturation (%) 93>>>82
Lipemia 10>>>5
Hemolysis 59>>>18
Icterus 0>>>0

Total Protein-Creatinine Panel:
Protein Quantitative (mg/dL) 226.0
Creatinine (mg/dL) 7.5
T.Protein Creatinine Ratio 30.1

Urine Culture (Catheterized Sample):
No growth

Final Necropsy Report (at the request of Ms. Fairbairn):
Final Pathology Diagnosis:
Chronic progressive nephropathy

Histologic Morphologic Diagnosis:
Kidney: Severe, diffuse, chronic glomerulonephropathy with glomerular loss and synechia, periglomerular fibrosis, tubular degeneration and regeneration, marked tubular ectasia, tubuloproteinosis, tubular casts, hyaline droplets, and chronic interstitial nephritis

Lung: Mild, diffuse, chronic, eosinophilic and lymphoplasmacytic bronchiolitis and pneumonia with emphysematous change, osseous metaplasia and pulmonary edema.
Liver: Mild, multifocal, subacute, lymphocytic cholangitis

Heart:
1; Myxomatous degeneration of the left atrioventricular valve (low grade)
2; Mild, diffuse, chronic, epicarditis with fibrous connective tissue and rare Anitschkow cells.

Gastrointestinal tract: Mild to moderate, diffuse, chronic, histiocytic and lymphoplasmacytic enterocolitis and mucoid enteropathy

Gall bladder: Mild, diffuse, chronic, lymphocytic cholecystitis

Adrenal: Mild multifocal, subacute, adrenalitis with rare individual necrotic cells, lipofuscin and extramedullary hematopoiesis

Final Comment:
The histological findings are consistent with the chronic progressive nephropathy, similar to the well described entity in the aging rat.

Histologic Description:
LIVER (Slide 1; 3 sections): Multifocally in portal tracts, surrounding the bile ducts and rarely migrating into bile duct walls is a moderate infiltrate of lymphocytes admixed with rare heterophils. Partially occluding the lumen of blood vessels in portal tracts are occasional fibrin thrombi. Diffusely in the hepatocytes the cytoplasm contains cytoplasmic vacuoles which are the size of the nucleus or larger and the vacuoles displace the nucleus to the periphery of the cell (macrovesicular lipidosis).

LUNG (Slide 1; 2 sections): In the parenchyma are two small foci of osteoid production (osseous metaplasia). Multifocally, there is rare mild emphysema characterized by confluent alveolar spaces with shortened alveolar septa with blunt, clubbed ends. Multifocally, within alveolar spaces there is a mild infiltrate of heterophils. Within mildly thickened alveolar septa is a diffuse mild infiltrate of heterophils admixed with fewer plasma cells and lymphocytes. The adventitia of the blood vessels are diffusely widened up to three times the normal thickness, pale and loosely arranged (edema).

SPLEEN (Slide 1; 1 section): WNL

GALL BLADDER (Slide 2, 1 section): In the lamina propria is a mild diffuse infiltrate of lymphocytes.

SMALL INTESTINE (slide 2; 1 section): The submucosa is expanded by a mild diffuse infiltrate of macrophages admixed with fewer lymphocytes and heterophils. In the crypts are large number of goblet cells.

LARGE INTESTINE (Slide 2; 1 section): Same as small intestine

ADRENAL (Slide 2; 1 section): Within Normal Limits (WNL)

CEREBELLUM (Slide 3, 1 section): WNL

CEREBRUM (Slide 3, 1 section): WNL

KIDNEY (Slide 4; 3 sections): All levels of the nephron are diffusely affected. There is a mild reduction in the number of glomeruli. Multifocally, arterial walls are thickened and glomeruli have one or more of the following changes: variable thickening of Bowman’s capsule, periglomerular fibrosis, multifocal adhesions of the glomerular tuft to Bowman’s capsule (synechia), and dilated urineferous spaces. Occasionally, glomeruli contain variable amounts of eosinophilic proteinaceous material in urineferous space. Diffusely within the cortex and medulla, tubule epithelial cells have one or more of the following changes: marked thinning of the epithelial cells with dilated lumen, microvacuolated hypereosinophilic cytoplasm (degeneration), and frequent hyaline droplets; markedly ectatic with attenuation and loss of epithelium; or abundant basophilic cytoplasm with large nuclei, and occasionally pile up and form irregular tubules (regeneration) with thickened basement membranes. Multifocally, ectatic tubules contain variable amounts of pale to brightly eosinophilic proteinaceous casts, basophilic granular material (mineralized debris), sloughed epithelial cells, cellular and karyorrhectic debris, degenerate neutrophils, and rare erythrocytes. Multifocally, varibly sized cystic expansions of both tubules and glomeruli range less than 1 mm to 7 mm in diameter, lined by a single layer of cuboidal cells and are filled with homogeneous fluffy transparent fluid (mucus). Diffusely, the interstitium is moderately expanded by fibrosis, edema, and low numbers of lymphocytes and plasma cells. Multifocally, the capsular surface is irregular.

UTERUS (Slide 4; 3 sections): WNL

HEART (slide 5; 2 sections): On one section there is a locally extensive area of hemorrhage. On the other section is a focal area of loss of myocytes, replaced by fibrous connective tissue and fibroblasts admixed with few plasma cells and red blood cells. Rare Anitschow cells are noted around the area, interpreted as an attempt at myocardial regeneration. The left atrioventricular valve is widened by the accumulation of myxomatous ground substance and proliferation of sppindle cells arranged in a loosely organized nodules. The fibrous layer of the valve leaflets is not apparent, interpreted as collagen degeneration and loss. A focal area of osseous metaplasia in present in the fibrous ring at the base of the left atrioventricular valve.

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Lynx
RESIST

Post   » Tue Oct 20, 2015 7:55 pm


Thanks for taking the time to post the necropsy. I will read it later.

Talishan
You can quote me

Post   » Thu Oct 22, 2015 2:05 pm


Thank you for posting this.

If Barbara's information can help save others, that's not a poor legacy to leave behind.

Blessings to her spirit. She will be remembered and always loved.

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