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‘Port Wine’ Urine Points to Immune-Mediated Hemolytic Anemia

One of your dogs is acting really tired. It doesn’t want to take a walk, or, when it does, it has to stop to catch its breath. It’s not interested in fetching a ball or chasing that pesky squirrel in the backyard. Then you notice that when it urinates on a sidewalk the urine is amber-colored or looks like port wine.

A dog that doesn’t want to take a walk or has to stop to catch its breath while walking could have immune-mediated hemolytic anemia –or one of many other conditions. Photo © www.canstockphoto.com

Lots of conditions can make a dog less energetic than usual, but if you see a dramatic color change in the urine, your dog may have hemolytic anemia. Blood loss, inadequate production of new red blood cells or destruction of the cells result in anemia, with the latter being “hemolytic” anemia.

One of the conditions that cause destruction of red blood cells is more complicated. It’s immune-mediated hemolytic anemia. In years past, you may have heard it called “autoimmune hemolytic anemia.” Same thing. The fact that it has to do with the immune system is a clue to what’s happening. Your dog’s own immune cells are attacking its red blood cells, which are essential for carrying oxygen around the body. Made in the bone marrow, red blood cells live for about 100 days in the bloodstream, then die. As the immune cells destroy the red blood cells, the bone marrow can’t replace them quickly enough.

When you get the dog to your veterinarian, pale gums, jaundice, an elevated heart rate, a heart murmur or an enlarged spleen, and any combination of these clinical signs, will point the vet toward immune-mediated hemolytic anemia.

“Anemia with jaundice really makes us think that it may be immune-mediated,” says Audrey K. Cook, BVM&S,MRCVS, DACVIM, an associate professor of small animal internal medicine at Texas A&M University’s College of Veterinary Medicine and Biomedical Services. The other big indicator? Urine the color of port wine, she says.

Yellow nostrils – or gums, skin or genitals – often indicate jaundice, or increased bilirubin, one sign of IMHA. Photo © www.canstockphoto.com

“Some cases are very, very classic,” she explains, adding that the Texas A&M vet school sees a case about every couple of weeks, or about 25 a year. And she sees more cases in the summer for a reason not yet identified. While “it’s a very familiar disease for internists to see,” she says, “we see way more dogs with diseases like cancer or pancreatitis.”

Several diagnostics determine that the clinical signs do, indeed, indicate IMHA. “We look at the red blood cells under the microscope. Sometimes you can actually see where they have been ‘bitten’ by the cells of the immune system. Sometimes the red blood cells stick to each other.”

Veterinarians also can use special tests to identify antibodies on the surface of the cells and look for autoagglutination, or that clumping together of the cells. A positive result for either test strongly suggests IMHA.

The first step in diagnosis, Cook says, is to rule out other possible causes of anemia in general, and then investigate other types of hemolytic anemia. Some of the conditions that look like IMHA include certain infections and zinc toxicity. How would a dog get zinc into its system? Usually by swallowing a penny, Cook says, adding that a single penny can kill a Yorkshire Terrier.

If after testing, you learn that your dog has IMHA, you’ll naturally want to know the cause. It’s unlikely, though, that you ever will know what brought on the condition.

In the “vast majority of cases, we don’t find causes,” Cook says. Despite that, studies have shown that Miniature Schnauzers and Cocker Spaniels are the most susceptible.

Some dogs have what veterinarians call “secondary” IMHA where an underlying disease is identified as triggering the hemolytic anemia. This could be a tumor, a medication or an infectious disease, such as those transmitted by ticks.

Without a known cause, in what is known as “primary IMHA,” treatment includes a blood transfusion to address the anemia and “aggressive” drug therapy to suppress the immune system, such as prednisone, and perhaps cyclosporine or azathioprine.

“If they’re eating and drinking, they don’t need fluids,” Cook says, while other dogs may need anti-nausea medicine and supportive fluids.

Dogs with immune-mediated hemolytic anemia are often lethargic. Any dog with urine the color of port wine needs to see a veterinarian immediately. Photo © www.canstockphoto.com

A blood clot lodged in the lung, or pulmonary thromboembolism, is one risk of IMHA, according to the Merck Veterinary Manual. “Fluids are important to maintain renal perfusion [the passage of blood through the kidneys] and to protect the kidneys from the high concentrations of circulating bilirubin,” the yellowish pigment found in bile, made by the liver. If blood clots are suspected or the risk for forming them is high, heparin may be added to the treatment. Fresh frozen plasma may be administered if the time it takes for blood to clot is longer than normal or if the proteins that control blot clotting are too active, Merck says. Pointing to a poor prognosis are a rapid drop in packed red-cell volume, high bilirubin concentration, rupture of red blood cells within vessels, red blood cells sticking together and blood clot complications, according to Merck, which goes on to suggest that referral to a specialist or veterinary school clinic may increase the chance of survival.

Not all cases of IMHA are the same. “The disease is very variable in its severity,” Cook says. “Some dogs crash very fast” and “a fair number of acute cases don’t survive.”

“They get worse so quickly,” she says, however, if they can make to Day 7, it’s more likely they’ll recover.”

Overall, about half of dogs will survive the first “attack,” Cook says. That means the other half won’t, of course. Treating acute IHMA gets “very, very costly very quickly.” Sometimes owners simply admit, “I can’t keep watching my dog suffer like this,” she says. Merck Veterinary Manual puts the mortality rate between 20 to 75 percent, “depending on the severity of initial clinical signs.”

Cook says, “Some dogs will get through an attack, then relapse in a year. We look again for a cause, but in the ones that were primary [with no known cause for the first attack], we usually find no explanation the second time,” she says. At the time of a second attack, many owners will decide it’s time to let their dogs go.

Although people get IMHA as well, no big breakthroughs in diagnosis or treatment have been made in the last 10 years, Cook says.

Because there does seem to be some breed predisposition, Cook recommends that dogs whose family members have had IMHA not be used for breeding. While no proven connection with vaccination exists, Cook also suggests that owners give careful consideration to vaccine protocols with the consultation of their dog’s veterinarian.

Fortunately 25 cases a year at Texas A&M, multiplied by all the vet schools in the country, plus those treated by veterinary internists, makes this a somewhat rare disease. However, knowing the signs can help you get your dog into treatment sooner than later.

“This is not a wait-until-Monday-morning thing,” Cook says. “If a dog looks yellow [in the nostrils, gums, genitals or skin] or its urine looks amber-y or like port wine,” it’s an emergency.


Written by

Susan Chaney has been on the editorial side of publishing since 1990, starting her career as a newspaper features writer and editor. A lifelong lover of dogs, Susan has lived with German Shepherds, Labs, Yorkies, an Irish Setter, a Great Dane-Bloodhound mix, a Sheltie and currently a Chihuahua mix of unknown pedigree. She was the editor of Dog Fancy magazine, content editor of DogChannel.com and group editor of Dog World, Dogs USA, Puppies USA, Natural Dog, Cat Fancy, Cats USA and Kittens USA from March 2005 to December 2009 when she left her position to work at home, part-time. Susan lives in Long Beach, Calif., with her artist husband, Tim, that Chi mix and two big cats. As an editor and writer for Best In Show Daily, she is reveling in the amalgam of three loves: writing, editing and dogs.
  • Linda G. October 18, 2012 at 9:25 AM

    I’ve seen 2 cases of what was diagnosed initially as IMHA but ended up being something else. The first case some 25 years ago was as described the port wine urine, yellow gums. The pathology report said IMHA. But after an x-ray was taken it clearly showed the bolt of of a dog crate. At that time they were made of zinc not plastic as they are today. After it was removed the dog recovered quickly.

    The other case was a 10 year old dog (not old for my breed) that aged dramatically within a couple of months. The dog was diagnosed with IMHA and died. After several months the family got a young dog from us from a totally different line. By 7 months of age, this pup was biting as it’s feet. A common early symptom of Hemolytic Anemia as the red blood cells that are breaking down “clog” up in the capillaries of the extremities. The dog was diagnosed with IMHA. I thought it was odd that these 2 very different aged dogs and breeding lines came down with this disease. Turns out the family was having a Pest Control company spray frequently for “pests”, When we finally got the name of the chemical used, one of the side effects from “exposure” was Hemolytic Anemia. The neighbors that were also having the chemical sprayed had a couple of cats die during this time and squirrels had been dying. The spraying was stopped. The young dog recovered and lived a long life.

    Because of these experiences we never spray anything in our dog yards and firmly request the same from people that buy our dogs.

  • Kathy S. October 18, 2012 at 3:39 PM

    We lost our 9 1/2 year old Newfoundland to IMHA. From diagnosis to his loss was a total of 7 days. We were devasted and never could locate any possible cause.

  • Christi McDonald
    Christi October 21, 2012 at 9:49 AM

    I also lost one of my Toy Poodles to IMHA, at age 11, in less than four days from diagnosis to her death. After diagnosis she stayed under my vet’s care (with frequent visits from me, of course) on IV fluids, and had a major blood transfusion and other treatments in that time, but nothing helped.
    I first noticed that she was listless, then when she refused food and didn’t want to go outside I took her to the vet. I never saw any dark colored urine, but that’s difficult to monitor when they exercise in a large grassy yard.
    Her condition worsened so rapidly. It took a few hours for my vet to diagnose her, but I don’t believe that contributed to her death. I think it is just a devastating condition that is impossible, in some cases, to explain, and also in some cases difficult to identify in time to save them. Her own immune system simply went completely haywire and destroyed all of her blood cells.
    The only advice I can offer is to err on the side of caution if your dog doesn’t seem “right.” My Marcie was 11, but I felt that she should have had a much longer life.

  • Tracy October 28, 2012 at 3:51 PM

    My dobe was diagnosed with IMHA at 5 yo and lived to 10 years without another problem. It was a very costly process and took her quite a while to fully recover but she was able to return to her regular routines, including agility. Trust your instincts, if you think something is wrong get your dog to the vet. Be prepared though, my vet did not have anybody on staff capable of looking after Jada during the night so I had to pick her up each night when my vet closed, take her to the emergency clinic, about an hour’s drive away and then pick her up in the morning when they closed and get her back to my vet for monitoring. Even though I loved my dog dearly if I knew how much it was going to cost I don’t know if I would do it again. BTW, when I told the breeder about the diagnosis the first words out of her mouth were not, is she ok or anything supportive it was ‘It’s not genetic’ and the next sentence out of her mouth was “You can still breed her”. I was floored, as a long time breeder I would never breed an unhealthy dog. To me, this may be part of why dobermans are as unhealthy as they are – irresponsible breeding by ‘big name’ breeders who should know better. Sorry, had to vent – breeding unhealthy dogs isn’t specific to dobe breeders; unfortunately, it’s endemic throughout the dog world.

  • Elisha November 10, 2014 at 9:39 PM

    I lost my shih tzu to imha just over two weeks ago. I am still devastated. He was only 4 years old. It happened so quickly. Late Saturday night he seemed more sleepy than usual. Sunday he was very lethargic and at 11:30 that night his I noticed his urine was bright red. We took him to the vet and because it’s a small town we had to go an hour away for an over night stay to get a transfusion of packed red blood cells. Even after the transfusion and the immunosuppressants his rbc count remained extremely low. He quit eating, drinking, walking and by day 5 had seizures. I had to put him down and it breaks my heart. This is the most devastating disease. RIP Fritzy.

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