Aug. 28, 2020

Vet Vault Clinical: IMHA. With Dr Dave Collins

Vet Vault Clinical: IMHA. With Dr Dave Collins
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Season 1

Here’s another sneak preview of our upcoming clinical podcasts with this episode on the diagnosis of immune-mediated haemolytic anaemia. IMHA is one of those diseases where timely recognition and treatment can mean the difference between a patient that lives and one that does not, but it can be a challenge to diagnose. We’ve roped in Dr Dave Collins, a medicine specialist from North Side Vet Specialists in Sydney, to help you to create a solid plan for diagnosing and saving these patients. This episode is the first of a three-part series on IMHA. The other two will be available on the Vet Vault clinical medicine podcast soon. 

Head to https://thevetvault.com/podcasts/ to subscribe to our email list and we’ll send you the summarised notes for this episode and let you know when the clinical podcasts go live. 

We’ve also partnered again with our friends at Heska Australia. Heska is the best thing that’s happened to the in-house lab industry in Australia in a very long time. Check out they’re full range of diagnostic toys at heska.com.au, and make sure you look into their Reset Programme to see how you can get all of their top of the range in house lab equipment - for free! 

Click on this link: https://www.heska.com.au/vet-vault-podcast-imha/ to get access to the most recent consensus statement on the diagnosis of IMHA. This is a document that includes all the details of pretty much everything anyone knows about how to diagnose these cases. 

We love to hear from you. If you have a question for us or you’d like to give us some feedback please leave us a voice message by going to our episode page on the anchor app (https://anchor.fm) and hitting the record button, via email at thevetvaultpodcast@gmail.com, or just catch up with us on Instagram. (https://www.instagram.com/thevetvault/) If you like what you heard then please share the love by clicking on the share button wherever you’re listening to this and sending it to someone you know who will enjoy listening to this.

There's a few diseases ways to sort of get lulled into a false sense of security.You have a few cases that are really straightforward and you think you're all over them and I respond beautifully the treatment and go home, looking a million bucks.And then you get one that just crashes and burns throw every drug at them, or multiple transfusions every immunosuppressive, you can think of antithrombotic sand.
Then they crash and burn.Hi, I'm Hubert.This is Dorado.Hi, I'm Dave Collins small animal medicine specialist, who works In the north of Sydney, I've been enjoying doing some podcasts with you but in Gerardo I also like to ski and bike and surf as much as I can.
And once covid-19 is over, I'd love to get you all on my veterinary conferences as well.And you are listening to the vet V clinical podcast.Hello.
It V is and thank you for joining us again.We thought that would give you a sneak preview of our upcoming clinical podcasts with this episode on the diagnosis of immune mediated hemolytic anemia.I'm AJ is one of those diseases where timely recognition and treatment can mean the difference between a patient that lives and one that does not, but it can be challenging to diagnose.
So, we've partnered with dr.Dave Collins, who is a medicine specialist from Northside with specialists in Sydney to help you create a plan for Agonizing and saving these patients this episode is the first of a three-part series on.I Maj the other two will be available on the Red Rock clinical medicine podcasts as soon as we release it head to the red world.com And subscribe to our email list.
And we will send you the summarized notes for this episode and let you know when the broadcast go live.We've also partnered again, with our friends at hasker Australia has gotta is the best thing that's happened to the in-house laboratory industry in Australia in a very long time.
Check out all their cool diagnostic tools at hasker Dot com.au and make sure you look at their Reset program to see how you can get all of their top of the deranged in-house, lab equipment for free.
If you click on the link in the show description, that's their has scout.com that a UV V 1 and give them your details that will send you.The most up-to-date consensus statement.For the diagnosis of, I am Ajay this includes all the details of pretty much.
Everything anyone needs to know about how to diagnose these difficult cases.Now, back to Dave and how to diagnose imh a Dave.Thank you for joining us for this clinical episode and I am h a worries.
Thanks for having me great to be here.Now, this is a topic that I think it's important to talk about.In mediated, hemolytic anemia.It's one of those that sometimes I find quite straightforward and other times.It's a real bastard really can Blindside you.I remember, I spent a couple years working in the UK in a smallish practice in Wales and if we see like we saw a lot of it there.
I don't know if it is the breeds, we saw, but we did it to see a lot.It was early in my career and my first few cases went really well.So I was under the impression, you know, either I'm really good at this or or it's not such a bad disease to treat.And then I specifically remember we had I remember the case really well.
Beautiful male Doberman and came in diagnosis of quickly.Vitamin what I thought was the right treatment and he just went to total crap, just fell apart within a day.He was critical, we weren't set up for for high level critical care and he was dead within almost 24 hours and that, that gave me a big fried that case and subsequently I've seen here.
I said the cases, I see I II left would find them really challenging these days instead of those nice easy ones.So I'd love to have your thoughts on one of the challenges with this.What?Why can they be so difficult?Yeah, some really good point.Yeah, I was just talking to someone the other day.You had a really bad case and there's a few diseases where you sort of get lulled into a false sense of security.
Pancreatitis is probably another one.You have a few cases that are really straightforward and you think you're all over them and they respond beautifully the treatment and go home, looking a million bucks and then you get one.It just crashes and burns throw every drug at them.I'm at show, for example, multiple transfusions every immunosuppressive.
You can think of antithrombotic sand then they crash and burn.They need transfusion after transfusion, they turn bright yellow and, and despite your best efforts.But it's really important to say is it's really common.It's probably the most common immune-mediated disease certainly that I see and I think establishing the diagnosis is really important as well and you know, recognizing anemia.
ER and significance of regenerative anemia but also the difficulty and the limitations of identifying anemia.Given it a little sometimes, take up to five days to develop some, some non regenerative I match Jays you'll never get a decent reticulocyte response because the immune systems knocking off the reticulocytes before they come into the bone marrow.
That's a fun one for you.Hey, yeah, absolutely.And you know, it's one of the things you need to jump on his regenerate.Shin is at Hemorrhage is a Moses and even some of these are called blades.The really difficult to rule out or some of the treatment as I get is because the diagnosis isn't quite right.
All the credit in the world isn't going to help her like a zinc toxicity.For example, he took my diagnosis being a challenge, right?But then also like diagnosis of the, the search for this underlying cause this trigger that kind of thing.I find that difficult to and yeah, well, I A question that's probably gonna throw you off track a little bit but do you DC like a seasonality die?
Mha.But really, there's been some Northern Hemisphere studies that have detected seasonality.And whether that sort of environmental or parasites or infections or whatever, it's hard to know as a study from Victoria about 10 years ago which also affect that found.
No effect of seasonality either.Yes, all of us are sort of in an emergency or a referral setting.So Galatians a bit skewed or biased, but I pretty much same to see them or you around.And, like, a lot of diseases.You don't see one for ages and then you see three all at once, but we haven't really identified a season.
It's just so many he's trying to identify, you know, cause Valatie and vaccines for example.And this temporal associations and statistical methods.I have no idea how to do to determined.We're all things in or out, but none, it's definitively establish.
Things is super difficult.Guilt.Okay.So that that leads us to causes are they because clients will always ask, well, what caused this, why?Why is it got it?And we got a list of common causes for it.We've got lists that have been reported in a lot of studies over the years and various things that we used to think cause and like a few drugs, skew cancers inflammatory disease, infectious disease.
And and yet the recent consensus statement from the American College of internal medicine said, you know, the evidence does really Pull any real disease to the high degree of evidence?He some infections such as the micro plasmas in, chats him your feelings, which frustrating there's not a huge thing in Australia.
Anyway, whereas other things like felv, if IV in cats, even if I pay have been Associated, but there's not a huge degree of evidence cancers.You've got to think there can be any inflammatory infectious or my plastic condition.
So, Gerardo back to your previous question.Certainly looking for an underlying cause is important and may well be a trigger.However, the evidence is not strong, but the other way I look of it look at it is also that you know if you've got a devastating cancer then this dogs not got along at look anyway, so you may not be worth spending hundreds or thousands of dollars as the case may be to try and treat the dog.
So traditionally my lower limb fro proliferative nearby.Which is like the came here and Lymphoma some soft tissue sarcomas, and carcinomas have been Associated.But again, the evidence from the consensus is not huge pancreatitis.
I've often thought can be Associated, I certainly don't know whether it's a cause or an effect, you know, if you put a pulley perfused or oxygenated pancreas is going to get pretty angry at time.So maybe it's an effect.Of course again is if you drugs antibiotics and things as well that have been established Associated over the years, even beestings snake bites, probably a different etiology, but all things you need to think about with unprecedented with him ulcers and you mentioned vaccines earlier is there is any evidence that links it?
No.Okay, simple.Simple answer.Okay, well there's been a lot of work done about causality and Temple associations.And while they're sort of talking about In secondary, I match a being true autoimmune versus secondary to another the disease and the consensus was sort of wanting to go away from that and go to associative and non-associative iron that changed.
So saying I'm a chose is so shared with vaccines associated with drugs associated with one Jimmer's but whilst a lot of people are suspicious of vaccines causing it.No doubt you want to get an immune response from your vaccine but it It is the evidence pointing to it being a definitive cause of iron which is quite poor.
It's difficult trying to convince anti-vaxxers upon the strength of evidence to, but but there's little evidence, little asides dream.I was interested the other day to see an article that there was red or first case of silicosis.
In Australia recently up in Northern wa, and it's in South Africa.We saw So that's of the Ella cases and then they were busy Oasis.And those guys definitely I don't know, is it certainly, is that what we were taught as is app?There's a trigger for and I'm AJ if every once in a while.
Absolutely.Yeah.Sort of ignored them some extent because we don't really say long, but yeah, but absolutely Olivia system.But basically there's actually strong evidence.Let's go back to picking this up to spotting them.So you're in your GP clinic and you have a sick dog coming in and do a basic Bloods and it's anemic, how are we going to To have what's going to make, you think?
I'm AJ versus not should be digging for another.Cause I guess, the basic work UPS going to be PC, vtp blood smear test for auto agglutination and based on that, you should be trying to identify regenerative.
Anemia blood smear examinations probably, really, really important for people to get used to.And a lot of people don't have the time, but if you can just get used to looking at a whole bunch of blood.You can get used to recognizing Normal and abnormal pretty quickly.
I was going to say, the new methylene blue stain is what you need to identify the DNA particular sites, which is not in most clinic so.So it can be tricky to pick up the reticulocytes.A CBC can be done in most clinics.
You probably need one of the new machine to identify reticulocytes some degree of accuracy.You can't really identify the most clinics on a blood smear, but if you can identify a regenerative response which may not be there for 25 days, I can be pre regenerative for that amount of time.
They can stay under eternity with reticulocytes the getting taken out.So they're kind of pitfalls.But I guess signs on a blood smear looking for us to parasites.They smaller rounder more, red erythrocytes, and the others, they lacking the central power there.
Can be common in other diseases to even stored blood.So it's important not to look at all try and get your samples before you blood transfusion, they talked about seeing at least three to five sfera sites per high-power field.
The more you see the more likely you're dealing with imh a and not some other cause polychromasia is another indication of generation in that you've got in a range of sizes or colors of Of the red blood cells and nucleated.
Red blood cells are also an important feature to to look for.I don't want to bore everyone with different terms of red blood cells and things but he might be able to pick up other sorts of red blood cells such as schistocytes, which little fragments are red blood cells, which might be left over.
If you've got something like d IC or heart worm or a Mangia Tacoma, and there's a lot of good atlases there that clinics might have by the microscope to kind of help.And if I weakened the cells and and this pretty readily available cameras, you can stick on the end of our Scopes, these days to take some happy snaps and send them to you and solid just friends to to identify or even the discussion groups, you know, on Facebook and stuff might help you out.
So the really important thing and I guess the pitfalls that we see, sometimes that people haven't identified, Sarah sites, and also haven't look for Ocho agglutination.Yeah.Hopefully you guys and a lot of Agency cleaning clinicians or first opinion that I used to kind of doing this test but drop of blood May well show.
What a good Nation, but you've also got as distinguished from rule 0, which is just the stacking of the red blood cells.So the way to kind of distinguish that is the sale inotropic nation.And the, the technique, that's well established.Now is four drops of saline, which will disperse the reuleaux, but Auto agglutination will stay there.
So, You need to give it a couple of minutes to settle, but if you've got a drop of blood for drops and sailing and still got clumping of the red cells and that's a positive Auto, glute Nation tests and your drop of blood straight from the dog, not a TT, I needed to Able.
Okay, it is.Yeah, so you are the name, parasites order agglutination ideally both.And, you know, I always get an auto gluten Ashen.It's only about 50%, maybe, hi.Fire of cases that you can demonstrate it.The other thing you will need to do otherwise is a Coombs test.
So that's you're looking for.Auntie erythrocyte antibodies which you can send off to the lab.There's more fancy techniques such as flow cytometry that can can be available.The sensitivity is about 80% in dogs so it's not always positive.
Anyway that the specificity is quite good with the exception of cases that have already been given steroids.So very important to send off samples ideally before treatment.Like a lot of diseases is if ideally if you can hold off steroids if at all possible to establish diagnosis, I don't think I've ever done a Cooper's death.
Never because it's like when we get them in emergency we get these pale dogs and it's probably now blood smear CBC in softball but blood smearing and slide, we have nation and then kind of that's it Riders.You kindly get it near done in manager.
But having said that you know like just because I really never had the opportunity to follow through the case or in everything done a groom school.I know it's there but I never really do it.Like how often would you would you do those?Yes.Good point if you've got or a great nation you don't need to do a coup it's the same thing.
Yeah I feel for you guys some time when you kind of heavily invested in Saving a patient's life and you get the diagnosis and then you've got no idea what happened to the caves.And as I said about 50% of them were positive autoboot Nations, there's no need It's it in the Combs test but the rest of the cases, particularly if this parasites are difficult to identify, then I think it comes can be very helpful.
We're going to take a quick detour to talk about the reliability of your in-house Diagnostics.Dave, talking about how important it is to accurately, identify regenerative changes on your blood samples when you working up cases of anemia.Now, one thing you don't want to have to worry about when you're struggling with an already complicated case, like an I'm AJ is whether your in-house machine is giving you reliable.
Results for missing subtle changes.So I thought this would be a great place to put in a plug for our podcast partner.His ghost raelia.So I got duct adjusted to on the line to sell them on my clever marketing idea.I told him that we could tell you all about how you don't have to worry about reliability.
If you're using hesketh, Flagship hematology analyzer, the element hd5 because of how its accuracy has been extensively, checked against all the other leading machines on the market and buy a bunch of very pedantic Pathologists and that we should tell you how the ht5 you Is not just one, but three separate Technologies to ensure that the results are accurate to quickest idea.
I won't bore you with the technical details, but it's actually pretty cool.If you're a bit of a tech geek, you should check out the videos about it.At Hayes goes website, it has frickin lasers, then I said that we should tell you that, all you have to do is check 15 micro mils of blood into the machine, because that's how much you need to get results with the HD 5, which is about the volume, over the tears of a b.
If B is ever cried and in under 60 seconds, You will have your reliable results but then Justin said, what I wait.You know, there's no point having the best hematology analyzer there.If you actually don't handle your samples correctly and let's face it, I've been guilty of this road.
When I graduated, no one detailed to me how to take a sample.I was the vet that it would actually take a sample and send a clotted sample to the Reference Lab.Let me alone running something in house and I would always just blame the lab for setting me a result that's not interpreted or caught it and it was actually my fault, right?
And until I started this role, I didn't really appreciate it, how important it is to get a good sample.As I say, right in technology garbage in garbage out, if you have a bad sample, you actually have possibly an accurate results, which will obviously send you down the rabbit hole when it comes to a diagnostic process.
So there's no point having the best machine in the world.If I'm not handling, my blood drive, absolutely.Every time I install an analyzer, I'm surprised by how little care that's taken into collecting a sample.Sample.The majority of problems actually comes down to sample handling rather than the quality and the accuracy of the analyzer.
Okay, now you've got me worried, give me the most common things that you think that I probably doing wrong in my sample and yeah.So number one, we tend to always try to use a smallest needle as possible, right?We recommend a 22 gauge or larger depending on how much the patient tolerates.
This is two.Mais hemolysis and also to prevent Michael clot formation.So, big a deal, better needle, absolutely.Yeah.What colors?22 black, black black would be here.Okay?Yeah, okay, that's one.So that's one.The second thing is not putting your sample directly into the tubes quickly enough right?
Again, want to minimize micro cutting and number three, one mistake that I see all the time is not removing the needle from the syringe.So number three, Three.Take the needle off.Yes.Yeah.Again, to minimize hemolysis, right?Actually?Reduce the risk of it.
Yeah.Number four would be not to fill the tube up at least halfway ideally took the top right?Because these anticoagulants EDTA, or lithium Heparin that we use most, commonly you need to mix it to the right ratios?
Yeah.Okay.So number five, it's the order and, you know, we don't think about it, right?We just sort of put whatever order That's in our hand or what the nurses hand over to us.Hmm.But there is a correct order and we can actually drill down on why specifically if we need to.
But typically the correct order is number one.If you're doing a blood culture that goes first, mmm, followed by sodium citrate tube for clotting, followed by a plane tube or a clot active, attitude, for serum, followed by a lithium Heparin tube for running on your in-house biochemistry, analyzer.
Number five, then you put in your Ed th you for hematology.And lastly, if you're doing glucose testing, especially delayed, you put in your sodium chloride or potassium oxalate tube.So why is it is the a number five?
You think that the delay is going to cause a little clutch?It.Surely.You want to get your CBC into the EDTA quickly?Yeah, good point really.It's because ETA is a key later so he lights calcium as She know, we're not particularly careful, especially if we were rushing that.
We may do some cross contamination.So not only if you did your EDTA first and then put it in your lithium Heparin, you get a low calcium level and, and we also get an increase potassium level because you know, these tubes actually potassium EDTA.So, that's if you don't your need a lawyer of your syringe.
Yeah, you get any idiot contamination of you?That's right.That's right.I mean, yeah, if you're careful to ensure, it probably doesn't matter so much.But, you know, we're not Careful at the end of the day.Yeah.Okay.Cool.And then the last thing would be that we don't mix the sample, adequately, obviously we do it once we put the sample into the choose, but then we don't mix it again.
Carefully for hematology sample, right?And so, rather than get a full count, we get the, you know, partial count.So I guess another point I'd like to bring up is that we would always recommend doing a few blood smears.Hmm.Straight out of the patient, right?
Whatever.Left in that syringe.After you've aspirated into your tubes, just do a couple of blood smears right now.You may not actually need to stain it or look under the microscope.But certainly the if you do set it off or if you know, do look at it later, the cells will look, the best Straight Out of the patient.
Okay?So if you say straight out of the patient, not even out of the EDTA straight away, just before you even go to you today, just put a drop on a smear on a slide.Smear it out.That's right, that's right?Yeah, yeah.All right.You're right.Those are there's several of those that I am not all that particular about and I can guarantee you from working in several practices that I've seen exactly that happened where they're not handled correctly, so that that could make a big difference just to thank you so much.
That was really helpful and really valuable my pleasure anytime.So there you go.Remember that.He's got some machines will cost you a grand total of zero dollars.That's Australian dollars, u.s. dollars Canadian dollars and even some open dollars to buy and install.
You just pay for your consumables.I know it sounds too good to be true but you can call Justin and ask him yourself.Go to his cannot come today.To find out more.Now, let's get back to Dave and I am.Aha and the main reason is because there are other causes of hemolysis the snakes, such as red-bellied black sober, the side of the country.
I don't know what you've gotten wiu, but Hamas is really common in black specks over here.You know, even these things can, cause at the low phosphates a good whining cat.If you too aggressive with the ensuring that and the low phosphate come drive phimosis in microangiopathic and she's just 50 sites.
We've talked about congenital things and bagels like pyruvate kinase and pasta cooked, egg, car's efficiency, Bagels, Marley's and abyssinians are the breeds.You think of usually younger than the other one that can be real tricky is zinc.Sometime.So radiographs cannot know if you guys have seen it as Inky Moses but through a Socratic, graphs are great for looking for underlying disease.
But if you can kind of sneak a bit of abdomen in there and see metallic foreign body and hemolyzed patient and maybe you've got think toxicity rather than I'm a child, we had a severe mha I think the two of them, one was an owner trying to manage a large wound at home with human creams.
Yeah, and it was high levels of zinc in it and actually developed High Mage am.Okay.Hang on, is that I am?Aha.Or is that a without the immune component?Let me know.I've never been more.Sorry, but - if you're not into so him 99 immune-mediated diseases.
Yes, yes.That can be the pitfall in some of these cases and yeah the classic one I can remember, is the dog that had this weird what ended up being a earring?Look like a pirate and it was a Orders hearing that the dog had eight and then it was it was full of zinc and their vocals.
Hey, my eyes are not crazy.So yeah, so the diagnosis of that, probably the most common, most difficult cases I get really all call him or Hemorrhage.So GI and particular so there's some really important Clues to look out for to recognize that image as well.
One is the protein level should be lower.Whereas I match a the tend to be pretty normal or even increased globulins if they're up that can actually push the protein up as can dehydration.
So the protein levels are really important.Look at either your teepee and remember things like fat in the blood can distort your TP.So now begin in globulin, reading on your bike and machine can be really helpful.The other really important thing people neglect to look at is is Red Cell indices?
As soon as I say that most people's eyes glaze over, but they can, I can give you some really good clothes.So you know, MCV and MCH particular volume and hemoglobin is if they're down hips approaching down and you've got a pretty poor regenerative response.
You may actually be dealing with a blood loss, chronic blood loss, maybe even an iron deficiency and GI bleeds for the classic for that.I guess General, if you've got a car Regular, apathy, or thrombocytopenia if you've got any epistaxis hemoptysis and America Asia, or in the whole lot of words, start with hame in any sort of blood loss, then you obviously need to have for a source of bleeding or a coagulopathy and you know and you guys I'm sure you guys employ a fast and T fastest looking for bits of fluid.
It's important to look at the urine and stool a rare tool looking for my liner as well.To give you any clues that you actually need to do a hunt for an occult bleeding.Believe me, they can be an absolute nightmare to diagnose sometimes.And some of these cases have already been smacked with steroids before they get to referral.
So which which is marked, which is pretty reasonable sometimes because I think it's pretty common.I'm at Chase.Oh, so good.Quick question from a clinical perspective to get us in the right direction in my head.Almost always going to associate an IM h a with a stronger flavored response, which normally presents with that with a pyrexia.
Is it is then to get like, if I ever turn on verdict anemic, dog, I'm going to be thinking lace or let's say not just pyrexia, but other indicators of information, so white, blood cell count and, and this could be a completely side topic, but we've started using CRP in dogs.
Quite a bit, isn't an index of of inflammation to go.All these no inflammatory responses to me.It's a hell of a lot less likely to be to be.I am aha.I want to know is that how is that?How does the logic stack up with that?And then the other thing is just when you spend those blood samples, just the serum color.
So red serum you're listening to him.If it's him a little kiss, him oolitic, if it's not in political that bleeding somewhere.Is that does that make sense in principle?It does here.Look at it's not going to catch all and you're going to get some slipping through the Nets there.
Not all of them, have her ex you can.I think only about 50%, okay?A lot of them will actually have an inflammatory local G or some kind of leucocytosis but not all knowingly.A lot of patients with inflammatory disease.
Don't have fevers or inflammatory dag, but but, you know, I agree with you.A lot of these cases and crazy, inflammatories, they think some of the massive neutrophil ears are actually due to Paddock necrosis from.The hypoxemia of the liver and the crowd was incredible inflammatory.
And neutrophilic response.Oh, okay.And that also will often be the reason that I'll tease up as well just through hypoxemia liver damage since the little little sucker deliveries and it's a demanding for ya.That is the brain.
Gosh.Yeah.And CRP.Yeah, that's interesting.Yeah.Look at if you've got no No CRP elevation.Then it's pretty hard to imagine that you've got.What is usually markedly inflammatory disease.
Like I'm at Che going on if it's positive you know I think it can still be a million things.Yeah.The cause inflammation clone ha tireless and I think CRP comes into its own.When you see really measuring it, it's regard to.
I guess also heard about him into lactate.You guys are but your life a lot of Is how I left her.It's indicate poor of the fusion and poor prognosis.Yeah, and the color of the, the serum.Yeah, absolutely.
Nearly all of those have got high bilirubin with the higher, the bilirubin, and often associated with poorer prognosis.It usually means the extravascular because the red cells have been processed by the money, nuclear practice siddik system and Blaine whereas hemoglobin, Amy You will cause a red serum and sometimes he would live in your area as well.
So certainly very important close to the, to the identification of hemolysis as you saying.So let's, let's flip it around.I know specialist never like to say, always, I'm learning that really, but if you have, if you don't have yellow or big serum, can you can you say very?
I like it to be remediated than enough said.Oh, as my whole career but it makes it a hell of a lot less likely.You've got intravascular only 30 percent of the cases.Most of them are extravascular.
If you've got a you can get quite low grade.Lumber rumbling cases, switch him.I'll hemolyzed but don't overwhelm the liver and conjugating capacity of the Liberty hard to imagine.No, bilirubin elevation with the ribbons elevated enough. 90% of cases but you you may not get enough to become each trick.
You noted that patients are metric to abilities and those 30 or 40.Hmm.So you can get even early in the disease or if they're just a low-grade, you may not get Beatrice identify all.So this is this is recap a little bit.
So likes me, throw sites and ordered with nation went been positive.Okay, straight back together than that, to go further than that, so that you might direct your Diagnostics towards identifying potential primary causes or something like that on a primary secondary causes, right?
The, the otherwise is if you still think that I'm AJ and use your organization's - and stuff, then, the next step would be Grooms.Yes.Yeah.And the other thing that I've learned here are value is just because He realizing anemia, doesn't mean it's immune-mediated.
So don't be sad if you don't have that organization and the suicides don't whack it at steroids straightaway consider that it could be zinc or one of the other things you listed.Yeah.Look I think you've it's yeah it's critical and you need to treat them and get steroids.
And if you've made a really good effort to rule out other causes phimosis, I don't think it's unreasonable to do so, you better think about the gut health and things like that.But it you've just got to keep in your mind and it's and that's what I encourage conditions to do is, you don't, it's not wrong to go down One path way, but you need to, at least have considered it is an alternative Awesome.
So Dave, you mentioned earlier when we talked about big theorem, which is yellow serum we mentioned, yes.Hey, it's intravascular versus extravascular hemolysis.It's something that I've always struggled with a little bit, the relevance of it.In the end, the percentages.Would you do?It will do a run us through that.
Yeah.So it's not as common intravascular, it's more intravascular losses and more compliment mediated lysis membrane attack complex.It's lysosome.Ethology those coming back.
So only about 30% of cases that are intravascular.You should have hemoglobin, name Arrowhead with glow, but when urea and important thing with you and is to distinguish from hematuria rather than hemoglobin, let me say need to spin it down.Traditionally all the studies, used to put the fear of God into us about intravascular hemolysis, that are really serious.
You're treated really aggressively and personally I've struggled to let go of that.And to agree that you need to not muck around with these guys or like, and jump in with more than one immunosuppressive, which we'll talk about another day, but the traditional prognosis was worth with intravascular but and now that more and more Studies have been done.
It's not bearing out as truthfully.So they tend to do almost as well as extravascular, it's a little bit T-cell and b-cell Lymphoma scenario.They used to think one was a hell of a lot worse than the other, but I'll intravascular School is very important to identify it.
Also marks the diagnosis of iron at change important.It probably does need to be treated more seriously, but the survival times are turning out to be relatively similar, okay?It was there.Anything else you wanted to add to?Did you start saying something about pitfalls day?
I guess the pitfalls of protein levels include that I was referring to the particular, given the massive inflammatory response of I'm at shave off and got a really high globulin account.So that's going to push up it TPP, and I guess, also, if you've got a tumor like a multiple myeloma, you lost again, ridiculous protein level, which isn't going to help identify him molasses or Hemorrhage.
So, this is just a few little things that you need to put into consideration.They were straightforward.Is it nothing to track for?Just going back to the extravascular aspect.Is there anything else that we can add there?In general, extra vascular's will be Victor Eric from the outset and of high, bilirubin levels.
I mean, intravascular is may not pick trick yet.Just have hemoglobin anemia.But given enough time for everything to go through the liver to process, everything they will also become ectric so you probably can't draw any any helpful guidelines.
I don't think install directly order a good night and so forth.Yeah.So still you've got to go Acts parasites or an autoclave Mission Coombs to establish the diagnosis vehicle.All right, thank you so much for that day.Will catch up next time about treatment.
How do we manage this?I successfully.We'll talk about prognosis, is another thing.I think that's a really great, a great start to I'm AJ.Thanks again here.Okay, let's go.Thank you so much for listening.We hope you found value in that and that you will join us.For part two, which will be all about what's new and what works in the treatment of.
I major, remember to go to the vet volts.com to register for our email list.So we could send you the summarized notes for this episode.And so we can let you know when the clinical episodes drop, and don't forget to click on the link to the his capacious in the episode-description, wherever you are listening to this, to get access to the consensus statement on diagnosing, imh, a, which has all the details on everything, You need to know about mha have a great week and we'll see you next time.

Dr Dave Collins