Non-Regenerative Anemia: Ticking Time Bomb

[julia9ca]

Hello.  My 3 year old domestic shorthair Michelle (in my avatar photo) was losing weight and in general seemed more lethargic than her sister.    Michelle is eating extremely heartily (as usual), drinking OK, cleaning herself well, still making regular trips to litter tray, etc.  Everything seems normal.  Except for the weight loss, slight lethargy, occasional vomiting and weird behaviors (like licking bricks, concrete, litter).

So I took her in to the vet on Wednesday July 17th.  The vet did blood tests on Thursday (18th), then re-did them on Saturday (20th) as the first set clotted.  Tests included T4, Felv/Fiv.  From the blood tests, the vet concluded anemia and believes it to be the non-regenerative kind.

Today (24th) we've just returned from the bone marrow biopsy and I've been able to pick up the blood results from Saturday.  A summary of what the blood analysis shows (everything was in acronyms, I've looked up what I think might be the translations): 

Low Numbers:

RBC  (Red Blood Cells): 1.36x10^12/L

HCT (Hematocrit):  8.8%

HGB (Hemoglobin): 3.1 g/dL

NEU (Neutrophils): 0.43 x 10^9/L

High Numbers:

MCV (Mean Cell Volume): 64.8 fL

MCH (Mean Cell Hemoglobin): 22.5 pg

Normal Numbers:

RETIC (Reticulocytes): 33.0 K/uL

WBC (White Blood Cells): 6.21 x 10^9/L

RDW (Red Cell Distribution Width): 19.9%

MCHC (Mean Corpuscular Hemoglobin Concentration): 34.7 g/dL

LYM (Lymphocytes): 4.79 x 10^9/L

MONO (Monocytes): 0.81 x 10^9/L

EOS (Eosinophils): 0.14 x 10^9/L

BASO (Basophils): 0.04 x 10^9/L

PLT (Platelets): 182 K/uL

The UREA, CREA (Creatinine), GLOB (Globulin), ALT (Alanine Aminotransferase) and TBIL (Total Bilirubin) numbers are also high (and the ALB-Albumin-low), but the vet said these are probably being driven by and secondary to the above numbers.

 

It doesn’t specifically mention the results of the T4 (thyroxine, test of hyperthyroidism), FLV or FIV, but the vet didn’t mention any abnormalities to me on these points.   She’s sent in additional blood smears along with the bone marrow sample to the lab experts.  We’ve not yet been able to rule out bone marrow disease or leukemia.

 

Michelle is not on any drugs or treatment yet (except for the drugs to recover from the pain of the bone marrow biopsy), and we’re waiting 3-5 days for the bone marrow paperwork to come back.  I’ve switched her from her normal dry food to a high calorie food.  It’s food specifically designed for active, outdoor cats, even though she’s an indoor cat and only goes out with her sister into the garden when I’m at home to watch and during daylight hours.   And I’ve taken to feeding her wet food and cat treats more often to try to build back some weight.

 

I’ve also been giving her more petting and attention over the past few days, as I do not know how much longer we may have to be together.   At 3, she's still a young cat.  She is a very sweet, well-behaved cat, even the vet could not believe how angelic she was through the process (nor how energetic and friendly she is each time in the examination room).  I pray for her nightly, may she be granted with a treatable illness. 

 

I will update this thread as soon as any more information comes in from the lab results.    

 

[ldg]

I'm so sorry! It would be more helpful if you could post the "normal" ranges provided by the lab - they're all different.

But that 8.8% hematocrit is very low. DId anyone discuss a blood transfusion with you?

To give you an idea, normal hematocrit is 30% or more: 36%, 38% often the normal. Anything under 25% is considered technically anemic. High teens is survivable indefinitely; low double-digits is of serious concern, and single digits ... isn't good. I am sending many vibes that whatever is causing the problem, he's at least stable at this number while you wait for results. I'm really curious why a transfusion wasn't considered while you wait for results though....

FYI, we had a kitty with non-regenerative anemia that was determined to be an "autoimmune disease." His body attacked his red blood cells; it was not the result of a blood borne disease; no cause could be found.

We managed his anemia with the administration of the steroid depomedrol, which suppressed his immune system enough to stop his body attacking his red blood cells. Initially, he also needed shots of Epigen to help his bone marrow produce red blood cells. He also had a bone marrow aspirate, and it was determined he was capable of producing red blood cells, and the epigen did help. It was up and down, and we were at the vet weekly for quite some time. He did need a blood transfusion at one point.

Of course, there are so many things that can cause anemia. But if this is ultimately determined to be an autoimmune problem, not a disease or FIP, many vets do not consider using Epigen to boost red blood cell production, and they often prescribe prednisone or prednisolone instead of depo. That worked for our Tuxedo for some time. When it stopped working, thank goodness, the depo did work. Tuxedo needed the shots every two weeks (the maximum dose) for some time; slowly but slowly, he needed them less and less frequently. The "active" fight was 2 years; there continued to be ups and downs for another 5, and then after the 6th year, he needed no more depo shots.

We'll never know what the problem was, but knock wood, it seems to be behind us.

I hope you have even better results with your kitty.

 

[julia9ca]

Ah, did not know normal was different for different labs!

HCT normal range on the lab blood results was defined as 30.0-45.0. 

As of yet, no one has discussed blood transfusions, nor any drugs/treatment. 

I think the vet is waiting for the bone marrow biopsy lab results before taking any action.  Perhaps the anemic condition is not acute (and so the vet does not consider it an emergency)?   I, meanwhile, have gone into crisis/emergency mode and am trying to learn everything I can about cat anemia before the marrow results come back! 

I'll do some research on Epigen, steroids, prednisone and depo ahead of my next conversation with the vet, see if we can speed things up.

Thanks for being there, LDG!

 

[white shadow]

Welcome to TCS, Julia9C!
 

I am very far from being able to offer any expertise on dealing with anemia.......I'm still learning.

Some years ago - when I knew absolutely nothing about it - I was faced with it when my cat showed late-stage symptoms of FeLV. I remember my feelings of utter helplessness - and, from other peoples' experiences I know how exasperating and difficult a journey it can be.

From the little I do know, there's something about what you're describing that doesn't make sense.

From what I do understand, there is only one way to distinguish between regenerative and non-regenerative anemia.......

The PCV [HCT] test shows if your cat is anaemic, but it does not show whether the anaemia is regenerative or non-regenerative.........

The only way to know for certain which type of anaemia you are dealing with is by testing for reticulocytes. Reticulocytes are immature red blood cells produced by the bone marrow. When seen in the blood stream, they are about 5-7 days old. Since anaemia means there is a lack of red blood cells, the body's usual response is to try to generate more red blood cells, so normally you would see reticulocytes if the anaemia is regenerative - this shows that the bone marrow is still making blood cells. However, in non-regenerative anaemia (as often seen in CKD), the lack of the hormone called erythropoietin means the bone marrow is not able to make blood cells, or not enough of them to replace old ones, so there will be few or no reticulocytes present.

http://www.felinecrf.org/anaemia.htm#retics

[ ] my addition

Michelle's reticulocytes are in the normal range........yet, your Vet is suggesting non-regenerative anemia?

The piece I quoted is taken from a larger comprehensive article on anemia in a very reliable website where the focus is kidney disease - despite that focus, you might find the larger piece helpful towards a fuller understanding of the subject. It's here: http://www.felinecrf.org/anaemia.htm

Because there's some reduced kidney function right now, perhaps you'd post exactly which pain meds she's on.

LDG was gently asking about blood transfusion - again, from the little I do know, intervention - long before HCT falls to 9% - is imperative.

 

[ldg]

Yeah, the blood values may be more standard than other stuff measured in blood work. :dk: Because for the HCT, that's the normal range provided on most recent bloodwork. Tuxie's problems were long enough ago I don't have that paperwork accessible any longer.

 

[dan32]

My Kinney has just had anemia where his HCT was down to 12% and he was like a limp dishrag (grantedly also severely anorexic).  A trip to the ER and a transfusion last weekend brought it up to 16% and he looks better.  I am getting an appreciation for the various factors that can cause anemia.  It took me over a month to get a diagnosis with four different vets.  It seems as if (in Kinney's case anyway) that they tried bacterial infections first, contagious diseases next, then bleeding somewhere after that.

With anemia, they will just get weaker and sleep more and more.

 

[julia9ca]

White Shadow,

You are right!  RETIC is 33.0 K/uL out of a range of 3.0-50.0.  So it's very high within the normal range.   The body is releasing immature red blood cells too quickly into the blood, in order to compensate for lack of mature RBCs.  I now wonder why we're talking in the vet office about non-regenerative, bone marrow disease and leukemia??? 

Not sure what pain meds the vet gave her, I'll ask them as well as why no transfusion has been suggested/recommended.  The pain drugs were just a one-off for the bone marrow surgery, probably standard pain meds for post-surgery.  She doesn't appear to be in any pain today (day after bone marrow biopsy), so that's a relief.   Eating, drinking, going to litter tray as normal.  Even jumping up on chairs!

I am going to research the Internet until I get to the bottom of this!

 

[julia9ca]

Dan,

Wow, that's awful it took so long to get a diagnosis.  And 4 different vets!  I hope Kinney is on the permanent mend now. 

 

[ldg]

Like our Lazlo, Dan's cat has anemia due to a bleeding ulcer (or ulcers). Many things usually get explored prior to the ultrasound that finds something like that. It took a month to diagnose our Lazlo as well.

I'm so sorry, Julia, I wasn't paying attention. I didn't notice you'd organized the bloodwork in terms of low, normal and high. :anon:

There are two basic types of anemia: non-regenerative and regenerative. Regenerative means it's definitely not a problem with bone marrow - it's typically caused by internal bleeding or something. But it isn't the reticulocyte number alone (meaning in and of itself) that determines whether anemia is non-regenerative or not:

http://www.merckmanuals.com/vet/circulatory_system/anemia/overview_of_anemia.html

It's possible to have non-regenerative anemia with the bone marrow "working," just a different cause (at least that's my understanding). The CRF website is written from the perspective of chronic renal failure.

I suspect that because of the low neutrophils, the bone marrow aspirate was done to look for FeLV virus that was sequestered in the bone marrow. A cat can test negative for FeLV for years, but if they were exposed to it, one of the possible outcomes is just that. It recently happened to one of Momofmany's kitties.

 

[ldg]

This is why you're discussing FeLV: http://www.winnfelinehealth.org/pages/felv_web.pdf

 

[julia9ca]

Thanks LDG for the links. 

As per the Corrected Reticulocyte calculation provided on the Merck website: the observed %Retic on Michelle's blood test, 2.4%, equates to roughly 0.56% when corrected for anemia (2.4*(8.8/37.5)).    As this is below <1%, looks like it doesn't indicate regeneration.

I'm a bit confused.   I know that FeLV is feline leukemia, but the vet on Saturday specifically said "leukemia", never "feline leukemia" (Felv was tested in the blood, but I only knew this afterwards on Wednesday when I saw the detailed breakdown of the bill). She sounded very grave on the phone on Saturday when she mentioned leukemia as a possibility that might be identifiable in Wednesday's bone marrow.  And when I asked about outcome if it was "leukemia", she mentioned chemo, a potential cost of thousands, relieving pain and discomfort in the cat, but only adding a few months of life at tops.  Basically, no hope of recovery from the treatment 

    Do you know if she talking about leukemia or feline leukemia here?

I tried to contact her today to clarify this as well as find out about blood transfusions, see if any of Wednesday morning's results were back yet, etc, but the receptionist said the vet would be able to call me back Monday at the soonest.  

Another weekend of not knowing...

 

[white shadow]

Julia, just a quick word to you...

Waiting till Monday is completely unacceptable when this cat has a confirmed HCT of less than 9%......IMO,  of course.

I'd be calling back - if not going over there in person - and insisting on answers today.

This isn't the receptionist's fault - she likely knows nothing about the severity of Michelle's condition.

And, you really should get more than answers, some action has to be taken/treatment started......

I'd also suggest that you get a complete copy of her file.....in case you need to go to an ER, you'll have the goods. (You'll need to keep that up to date, too. I always ask for a photocopy of all new info entered after each visit.)

 

[ldg]

Are there other vets at the practice? Whenever our vet is out when it's a rather critical situation, another one can take a look at the file, and proffer answers. And if they can't, they can contact your vet on your behalf and get back to you. Or they should be able to. (We actually have the cell phone number of all of our vets, but we've been working with them all for years now and were very active in cat rescue).

FeLV can cause the cancer, leukemia, but there are also many types of leukemia that are cancer, not from the virus.

From FabCats: http://www.fabcats.org/owners/felv/info.html

Cancer develops in around 15% of cats infected with FeLV. The most common is lymphoma, a cancer of lymphocytes (a type of white blood cell) resulting in solid tumours or leukaemia (tumour cells in the blood stream).

From Max's House: http://maxshouse.com/Oncology/feline_lymphoma_and_leukemias.htm

Obviously your vet suspects the cancer leukemia, if chemotherapy was mentioned.

and many continued vibes

 

[julia9ca]

I've gone to the vet and clarified.  She's only received half the test results back from the lab.  She's still waiting for the other half, and advises we shouldn't sit down to discuss and intepret until she's gotten all the results back from the lab.

She's hoping (fingers crossed) the other half of the results return from the lab on Monday.

 

[ldg]

:nod: Right, that's how the thread started, waiting for results from the bone marrow aspirate.

Did she clarify on the FeLV vs leukemia-as-cancer, or just left both out there as possibilities?


Perhaps there's a history here, we're not familiar with? :dk: Was she on antibiotics to which her HCT and white blood cells didn't respond?

Or did the vet explain why a blood transfusion isn't in order now? Or why she would want to wait 5 (or so).days? Just the HCT can be run, usually in-office, and with a number that low, with no blood transfusion, I'm surprised the vet doesn't want to at least monitor the rate of change, or ensure it is stable. :heart2: :cross:

 

[ldg]

How's Michelle? :cross:

I hope the lab results are back today! Waiting is the worst.

 

[julia9ca]

LDG, yes, the results came back yesterday.  But vet didn't call until today, as she needed to double-triple-check the diagnosis with the experts. 

It's Myelofibrosis and we've just started our first 5mg dose of Prednisolone (snuck into a piece of chicken breast), a steroid to slow the immune response from turning more bone marrow into fibrotic mass.

The vet did explain why no transfusion:  Michelle is still very bright and active (jumping, running up stairs, romping around the garden) and not in a 'flat' clinical state.  They only want to risk considering it for Michelle if she goes into a 'flat' state.  I'm watching Michelle very carefully, and if I see a sudden, severe downturn, I'll take her into hospital for a transfusion ASAP. 

Until then, Pred twice per day.  And then the vet wants to see her after a week on the Pred.  The prognosis will depend how the treatment goes.

Meanwhile, I'm researching all I can about Myelofibrosis not just in pets, but also in humans.  It's terrible to get a diagnosis like this, but because we were able to get a diagnosis, I'm finally able to narrow my research to the correct disease.

 

[ldg]

I'd never heard of the disease before, I had to go look it up. I'm so sorry for the diagnosis, it seems this will be a tough one. :heart2:

I'm SO glad she's bright and active, and that explanation about the transfusion makes sense.

I was wondering about stem cell treatment when I saw the cause, but apparently it's stem cell transplant, not treatment, and it's risky and not worth it. You saw there was a human drug approved in 2011? I wonder if it can be tried on a kitty. http://investor.incyte.com/phoenix.zhtml?c=69764&p=irol-newsArticle&ID=1631201&highlight=

My thoughts go with you and Michelle. She's clearly in very good hands. :grphug2: Many vibes as you travel this journey together.

I do hope you'll keep us updated! And any time you need a hug, we're here for that too. :heart2: :grphug2:

 

[julia9ca]

Thanks,  LDG, I've seen stem cell and Jakafi (Ruxolitinib) mentioned in the research.   Pity about the stem cells, there might have been potential there to reverse the disease.

The Jakafi looks promising:

Ruxolitinib Boosts Survival In Patients With Myelofibrosis: http://www.medicalnewstoday.com/articles/262671.php

Ruxolitinib for Myelofibrosis: From ‘Palliation’ to Prolongation of Survival: http://www.cancernetwork.com/hematologic-malignancies/content/article/10165/2150165

Ruxolitinib in Myelofibrosis: 'Unprecedented' for Some Patients: http://www.medscape.com/viewarticle/759466

Still searching to see if they've ever tried it on cats/dogs...

 

[ldg]

Given that it was only approved in November 2011 for people, I doubt very much you'll find anything already published about its use in cats or dogs.

Your vet would probably be able to calculate the proper dose, or I'm sure your vet could contact a specialist, be that someone at Cornell or Texas A&M, etc. In fact, your kitty could be the first write-up on its use in cats. :nod: