C10020518 / invoice 10000

Reason: BP, PCV/TP, Darbo, Bloods, UPCR. Intern: Rylan McCrackenProblem List::1) Chronic non-regenerative anaemia (most recently macrocytic hypochromic) - likely secondary to CKD, chronic GI disease and liver disease > 12/05/2024: HCT 0.19 (L), MCV 76, MCHC 505 (H)> 09/07/2024: HCT 0.34 (L), MCV 76, MCHC 354> 22/01/2025: HCT 0.29 (L), MCV 76, MCHC 310 (L)> 07/02/2025: HCT 0.25 (L)> 07/08/2025: HCT 0.25 (L), MCV 76, MHCHC 325, > 17/10/2025: HCT 0.27 (L), MCV 77 (H), MCHC 322 (L)> 20/11/2025: Hct 0.24 (L), MCV 72, MCHC 342, retic 36> 22/12/2025: HCT 0.18, MCV 69, MCHC 344, retic 13. Given iron dextran IM + darbepoetin 5mcg SQ > 30/12/2025: PCV 22%. Repeated darbepoetin 5mcg SQ > 05/02/2026: HCT 0.26, MCV 66, retic 112) Protein losing nephropathy with hypercholesterolaemia (concern for nephrotic syndrome)> Stage II-III CKD with marked proteinuria and systemic hypertension. Bilateral chronic changes on AUS 20/11> Systemic hypertension currently managed with amlodipine (persistent proteinuria despite this)Trends:> 12/05/2023: creatinine 60, urea 8.6> 09/07/2024 creatinine 130, urea 13.0 (H)> 22/01/2025: SDMA 16 (H), creatinine 160 (H), urea 15 (H)> 07/02/2025: creatinine 164 (H), USG 1.015, UPCR 7.63 (H)> 07/08/2025: SDMA 25 (H), creatinine 220 (H), urea 16.4 (H), UPCR 6.6 (pooled sample)> 17/10/2025: SDMA 23 (H), creatinine 200 (H), urea 16.4 (H), USG 1.015 UPCR 6.8> 30/10/2025: USG 1.107, pH 6.5, pro +++, WBC <5, RBC <5> 30/10/2025: Urine C&S negative. > 20/11/2025: Urea 17.8 H, Creat 212, Phos 1.6, iCa  1.35. Commenced renal diet. > 22/12/2025: Urea 13.2, creatinine 162, phos 1.2. UPCR 3.0 (~3-4 weeks post renal diet, pooled sample)> 05/02/2026: urea 20.7, creatinine 269, phos 2.1, UPCR 3.7 (~2-3 weeks post 5mg telmisartan)3) Weight Loss with good appetite> 12/02/2025: TLI >50 (excludes EPI) > 22/01/2025: TT4 16 (excludes hypo and hyperthyroidism)> 30/10/2025: Cobalamin 246pmol/L -> 332ng/L. Commenced supplementation 3/11/2025. > 30/10/2025: Cortisol 67nmol/L (excludes hypoadrenocorticism) 4) Hepatopathy (ALP >> ALT, normal Tbili); mild hypercholesterolaemia with a mild hypertriglyceridaemia - unknown cause; consider hepatic neoplasia or chronic hepatitis> AUS 20/11 moderate hepatomegaly with 3-4 hyperechoic heterogeneous masses 20/11, cytology found only vacuolar hepatopathy but bactobilia (w/o inflammation) on bile cytology. C&S E.Coli, sensitive to enrofloxacin. Commenced 75mg enrofloxacin PO SID on 20/11/2025. Within lumen of the gallbladder is pedunculated hyperechoic nodule, measuring 3.7mm in diameter. The remaining biliary tract is normal.Trends: > 12/05/2023: ALT 52, ALP 2267 (H), chol 9.1 (H)> 09/07/2024 ALT 146 (H), ALP 4360 (H), chol 11.8 (H)> 22/01/2025: ALT 80, ALP 1981 (H), tbil 2> 07/02/2025: ALT 163 (H), ALP 1944 (H), trig 2.1 (H),> 07/08/2025: ALT 193 (H), ALP 4167 (H), tbil 3, chol 13.0 (H)> 17/10/2025: ALT 392 (H), ALP 4874 (H), chol 12.5 (H), trig 2.6 (H). Spec cPL 704 (H) > 20/11/2025: ALT 259(H), ALP 3750 (H), chol 11.1 (H), trig 5.53(H). > 22/12/2025: ALT 866, ALP 7001, chol 30.2, trig 5.08> 05/02/2026: ALT 188, ALP 5675, chol 12.2, trig 1.20, tbil 45) MMVD Stage B2> Echocardiogram 20/11:  La/Ao 1.81, LVIDd 40.9, FS 36%. MINE score 6 on 20/11> commenced pimobendan on 20/11/2025 6) Ocular disease - KCS diagnosed at rDVM>> Right mucopurulent ocular discharge, 20/01STT 14mm/min OU; Flourescin negative OU (query mild dull uptake OD, but suspect due to roughened cornea); IOP OD 6-8mmHg, OS 10mmHg7) Hyperlipidemia> 05/02/2026: chol 12.8, trig 1.20 8) Thickened nodular anal glands - concern for neoplasia vs impaction. 9) Total hypercalcaemia > iCa WNL, 20/11/202510) Mild neutropaenia > 23/12/2025: neuts 2.3 (3.1-10.3)> 05/02/2026: neuts WBC 4.0 (5.3-14.9), neuts 1.9 (3.1-10.3), bands 0.0 Recent history: Appetite unchanged; no change in thirst/urination. One small vomit (unsure when or if blood specks) Faecal score 5-6/7. Energy levels are unchanged. Very lethargic in the mornings at times where he doesn't ask (eating same amount but later in the day). No LUT. No coughing or wheezing. Eyes seem okay; not too weeping; no noticed. Diet: Royal canin renal wet food (just over one can per day). Current medications: amlodipine 2.5mg PO SID , cobalamin 500mcg PO SID, pimobendan 3.12mg PO BID, clopidogrel 18.75mg PO SID (started 19/1), darbepoetin 5mcg (06/01), iron dextran 100mg (22/12)Physical examination: HR: xx	RR: xx       MM: xxx        CRT: <2	Temp:  xxxxOral: moderate dental disease, slab fracture of left maxillary carnassial, no pain on opening mouth, 2-3 small epuli on gingivaEars: no discharge, no erythemaEyes: Increased corneal opacity and pigmentation towards to the medial/central aspect of cornea OD; generalised increased speckled opacity OD. No blepharospasm, scleritis or pain on retropulsion. Fundic not possible due to lenticular opacity and corneal pigmentation > moderate mucoid/purulent discharge OD, predominately coating the eyelids. Nasal: no discharge, no pain on palpation of sinuses, no evidence of deformityCVS: Gd xxx/VI left and right apical systolic murmur, normal rhythm, strong synchronous pulses> systolic blood pressure xxxxmmHg (#3, RTL, doppler)Resp: eupnoic, normal bronchovesicular sounds all quadrantsAbdomen: no pain on deep palpation, no palpable fluid wave, no masses palpableGenitourinary: prostate not palpableRectal: Concern for bilateral anal gland nodules/tumours, or less likely asymmetrical thickening, no palpable irregularities to mucosaMSK: bilateral stifle thickening/medial buttress, full ROM not assessed today, no palpable joint effusions, ambulatory x4 limbs Neuro: appropriate mentation, normal gait and posture, discomfort on lumbar spinal palpation but not other locations. Brief CN exam WNLPeripheral LNs: submandibular, prescapular and popliteal nodes are symmetrical and smallBCS: xxx/9   ; MCS: xxx/3 Weight:xxxxLaboratory: PCV/TP CBC - CHEM - UA - UPCR - Problem List: 1) Marked mixed hepatopathy (predominately cholestatic), recent improvement> vacuolar hepatopathy on cytology; bactobilia (E.Coli) on bile C&S> marked nodular changes on ultrasound2) Protein losing nephropathy. Recent progression in azotemia post telmisartan> IRIS stage III (proteineuric, hypertensive)> Urine C&S negative > concern for nephrotic syndrome (hypoalbuminaemia, hypercholesterolaemia)3) Mild NNN anaemia > positive response to iron dextran + darbepoetin (first administered on 23/12/2025)5) Mild hyperlipidaemia (mild hypercholesterolaemia)6) Marked progressive weight loss > Cortisol 67, TLI >50, cobalamin 2467) Thickened nodular anal glands 8) Total hypercalcaemia > iCa WNL previously WNL 9) Stage B2 MMVD 10) Mild to moderate neutropaenia - mild progression 11) Ocular discharge, pigmentation, low IOP OSTreatment: Darbepoetin 5mcg SQAssessment: Raff's anaemia has responded positively to darbepoetin and iron. His PCV remains static at 28% with q2 weekly darbepoetin. He has ongoing ocular discharge with borderline STT and low IOP OS - this may reflect underlying KCS (as previously diagnosed) with potential for development of uveitis (consideration to lipaemic uveitis) The anaemia is likely multifactorial due to a combination of CKD, chronic liver disease with a potential role of internal blood loss (gastrointestinal ,hepatic) given the new hypoalbuminaemia and acute on chronic nature. Bone marrow disease may also be at play due to the development of a mild - moderate neutropaenia. Platelet count remains normal however. While this has been ongoing for 18 months, it recently worsened and is likely a contributing factor to Raff's lethargy. This has responded positively to iron dextran and darbepoetinThe protein losing nephropathy is likely idiopathic, with an immune-mediated cause being considered less likely (~30% of cases in Australia). However, given the chronic nature of this over the last 12 months it is possible that renal biopsies may be poorly diagnostic due to the development of glomerulosclerosis. When proteinuria was first documented Raff did not have azotaemia so it is possible the proteinuria has caused renal injury with time and resulted in CKD (currently sitting at early IRIS stage III). There may also be pre-renal disease contributing to the degree of proteinuria given the detection of hyperlipidaemia, hypertension, liver masses and possible bacterial cholecystitis. The development of hypoalbuminaemia and hypercholesterolaemia raises concern for emerging nephrotic syndrome (but could also reflect underlying GI and liver disease). Raff has had a good deal of improvement in his protein losing nephropathy with diet change to a therapeutic renal diet alone. His azotemia has progressed after commencement of telmisartan (and could be falsely decreased by the degree of muscle wastage). His UPCR initially had dropped by >50% with diet alone (from 6.8 -> 3.09), and remained static with the addition of telmisartan despite the worsening azotaemia. Raff's hepatopathy remains marked and predominately cholestic, but has had recent improvement. While this could indicate an improvement in liver disease, loss of functional tissue leading to lower levels is a real consideration (however there has not been a decline in functional values). The hepatic masses on cytology were not different to the more normal regions of the liver. This could be consistent with a diagnosis of nodular hyperplasia secondary to underlying chronic liver disease or chronic illness. There is concern than an underlying neoplastic process has been missed on cytology (correlation between cytology and histopathology is ~30-50% in dogs). An underlying chronic active hepatitis is an alternative consideration, which may now be progressing to the point of cirrhosis. Thromboembolic disease is also an important differential given the likely loss of anti-thrombin with Raff's PLN. Ultimately histopathology will be required for definitive diagnosis and to look for underlying copper storage disease. It is possible that liver biopsies are poorly diagnostic due to the degree of fibrosis/cirrhosis that may have developed if this is a chronic hepatitis, however may be crucial for the diagnosis of neoplasia. Leptospirosis is deemed extremely unlikely given the previous lack of response to doxycycline, enrofloxacin, long standing nature of the disease and that Raff is clinically well. Given the lack of improvement with enrofloxacin for the E.Coli bactobilia, this was likely an incidental finding and not inciting cause. Raff's anal glands now palpate as nodules/tumours and are not expressible. This may be due to chronic impaction (given expressed material was previously very firm) or more concerning anal gland neoplasia. While the total hypercalcaemia is increased, this is likely due to the hyperlipidaemia given the iCa was normal 8 weeks ago. Raff's stage B2 MMVD remains stable. Plan: A previous discussion was had regarding 1) performing surgical biopsies (liver, kidneys), 2) trialling immunomodulatory medication, 3) implementing supportive care in an aim to maintain QOL, with the understanding that the renal/hepatic diseases processes are progressive. Option 3 has been elected. In regards to the anaemia: Continue 5mcg darbepoetin SQ q2-3 weekly to maintain PCV ~30%In regards to the PLN: Continue Royal Canin renal. Stop telmisartan due to progression of azotemia. Continue clopidogrel 18.75mg PO SID as thromboprophylaxis due to risk of thromboembolic disease related to PLN.  In regards to the systemic hypertension: continue amlodipine 2.5mg PO SID. In regards to the B2 MMVD: continue pimobendan 3.1mg PO BID. In regards to the suspect chronic enteropathy: continue cobalamin 500mcg PO SID. In regards to the ocular changes: xxxLong term, if not pursing further diagnostics, then recommend managing conditions such as anaemia and ocular disease to maintain QOL. Ultimately, there will be progression to the point that humane euthanasia is recommended. Treatment: Amlodipine 2.5mg PO SIDClopidogrel 18.75mg PO SID- 1/4 of 75mg tablet Pimobendan 3.1mg PO BID Cobalamin 500mcg PO SID  Darbepoetin 5mcg SQ 05/02/2025Iron Dextran 100mg IM 22/12/2025    Vital Signs