Chronic Active Hepatitis #1

by Mervi Ihantola DVM

Introduction

Chronic active hepatitis (CAH) is a yet relatively unknown liver disease with dramatical consequences for the Dobermann. The disease was first discovered by us in Finland at the end of the 70s. Articles in medical journals began appearing in the beginning of the 80s in the USA. As there is too much copper in the liver, the condition has been also called copper toxicosis. Other names used for CAH are chronic hepatitis and Dobermann hepatitis. The symptoms are so typical of CAH patients that they caught the eyes of the Finnish Dobermann breeders in the 80s. This led to the beginning of an eradication program. This disease is recognized worldwide as data has been published at least in USA, Finland, Holland, Sweden, Germany, England, Australia.

Signs

The disease is most likely to affect a female aged four to six years. Males seldom develop CAH. The initial symptom, though often neglected, is polydipsia (heavy drinking). The dog may eat a lot of snow during the winter and tends to seek some other sources of water, besides its own cup. Heavy drinking may only be temporary or intermittent. When the condition progresses further, a poor appetite vomiting and weight loss soon follow. As the disease advances, the mucous membranes start to turn yellowish. This is most apparent in the eyeballs (sclera), the gums and on the skin in areas where hair is scarce such as the ears and the inguinal region. This stage is called icterus and is typical of any liver condition because bilirubins (bile pigments) accumulate in the blood stream and tissues due to the liver dysfunction. Weight loss becomes accelerated and the dog develops free fluids in the abdomen, often so much that it looks like a puppy that has just eaten a huge dinner. The only differences in the appearance are the pronounced ribs and spine. The dog is tired and lethargic, although not entirely incapable of running and playing if required, as Dobermanns always like to do.

History

The Finnish Kennel Club supported the start of a wide based collection of blood samples from healthy Dobermann females in 1987. We anticipated to find changes in liver enzymes like ALT (s-ALT) from normal dogs before the onset of clinical signs. The suspicions proved to be valid. The serum ALT values were clearly elevated for a long time before the individual itself showed any signs of the disease. As a matter of fact, as the project has continued we have noticed that some dogs with elevated liver enzyme values may develop the clinical signs quite late. Only the elevated liver enzymes indicate the presence of problems in the function of the liver. The right nutrition among other yet unknown reasons is believed to play an important role in keeping the individual from developing symptoms. This is not surprising considering the responsibility the liver takes in metabolism; it becomes over loaded with the wrong nutrition.

Eradication program

In Finland, we want to discover the sick animals long before the problems show up. During the years we have collected blood samples from dogs that do not present any signs of the disease. A majority of the test are normal of course continuously. The ideal procedure is to start investigations at the age of two to three years and continue yearly or every two years up to the age of about seven years. Nowadays CAH testings are official and obligatory for Dobermanns which are used for breeding. To get puppies registered, both parents must have results no more than ten months old at the time of the mating.

Every now and then we discover individuals with abnormal values. Many of them are just innocent, once in a life time jumps, but few of those elevated values remain high. These are the dogs that should be to followed by blood tests. The definitive diagnosis of CAH is made only by biopsies taken from the liver. That is recommended for individuals with high ALT values for two to three consecutive tests or several high peaks during one year. We are able to detect any deterioration at their health condition by following the test values. Those Dobermanns with ALT values over the normal laboratory range (VETLAB, Tampere; the normal range is 24 – 136 U/I ) more than once, are also controlled for SAP, bilirubin, bile acids, and if needed, other blood parameters to get more information about the situation and to know more about the prognosis. Different laboratories have different normal ranges for ALT. In order to obtain reliable and comparable results, qualified lab is needed. In Finland, we approve only one lab for official tests by Finnish Dobermann Club / Finnish Kennel Club.

Treatment

What if the dog gets the clinical signs? Then the situation is worse. Blood tests may show s-ALT to be five to ten times over the normal. Other blood parameters are often not good either. At the moment we do not know the cause of the disease and it is very difficult to try to cure CAH with specific treatment. We have to try the medicines which relieve the symptoms. Initially, drugs which chelated the copper (D-penicillamine) were used. This didn’t seem very encouraging. It would seem that copper is not the reason for the liver damage, as is the case in Bedlington hepatitis. Copper appears only secondary and not in the excessive amounts of Bedlington. The most valuable medicine is still corticosteroids. On the other hand, steroids and the Dobermann is not a good combination and the use of this medicine can result in some problems. It seems that the breed is sensitive to its use. Corticosteroids often results in side effects which we would prefer to avoid. The treatment of clinically ill dogs demands a lot of precision and caution. With the proper treatment, it is possible to ease the progress of CAH and prolong the inevitable a little further. The difference between the beginning of the symptoms and the start of the treatment makes a great difference in survival time. According to our statistics, the survival time can be from some weeks to several years. New medicines to treat patients with CAH are continuously being researched, but until this day we do not have many promising alternatives. We prefer a strict diet based on home-made food low in copper and abandoning all commercial preparations. The food regiment is the same for dogs with no clinical symptoms.

Discussion

Just by controlling all breeding stock, the number of CAH cases seems to be decreasing. We had great difficulties in the 80s just before our quarantine system for dogs was abandoned. Most individuals were related to some heavy used carriers of CAH. In 1988 and onwards we were able to import many new Dobermann lines. It seemed to help a lot. Or perhaps the problem is just hidden by some of the owners and breeders? Anyway it is almost impossible to breed with individuals with high ALT results nowadays in Finland. Not because it is not allowed (because it is, only test has to be made), but mostly because the results are public. Public opinion is important in selling the puppies. We are not free from CAH. Our first recognized cases to Finland came with the
imported animals from Germany. We have still found many individuals with CAH to have direct ancestors of imports or are imported themselves. So it is not possible to stand against CAH alone. It is sad that we are dependent on European breeding stock, which is totally out of control with CAH. That is of course mainly because breeders and veterinarians are not aware of the problem called CAH. The problem can come more common again in Finland, but also elsewhere due to two reasons. We sometime use some males heavily all over Europe not knowing their health state and population number can drop quickly in the near future because of the ear and tail cropping legislations, leading to serious genetic problems .
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