Just started SLGS with CKD cat vet thinks is near death

Hi everyone


I'm hoping for some feedback/advice for my 9 1/2 year-old diabetic and CKD boy Leo.

I have details of Leo's history, bloodwork, etc, written up and can easily post it if anyone wants. But for now I'll try to just give the basics and details I think you'll need...

Leo was diagnosed as diabetic 8/17 (it actually took awhile to firmly determine that he needed insulin).

In 10/17 Leo had DKA and was hospitalized for a few days. This was when we were just starting insulin.

Leo has always been on Lantus. My vet said from the beginning that Leo was a very hard to regulate diabetic.

Leo was diagnosed with CKD 2/12/18.

Leo went to the vet on 2/10 after a couple days of not eating well. I also noticed he'd lost weight and had some dehydration. A Urinalysis showed a UTI and on 2/12 the bloodwork came back: BUN 91, CREA 3.1, SDMA 23. At the time his weight was 9.4 lbs. He is now 7.6 lbs but has been stable for 2 weeks.

Since 2/12 Leo has been receiving 150 ml subqs twice/day. My vet discussed hospitalization and IV fluids but felt Leo was getting good care at home.

On 2/24 my vet thought Leo had days to live. On 3/2 my vet said Leo had a week. Although his BUN and CREA had greatly improved with fluids (BUN 48, CREA 1.3) my vet said CREA looked good due to loss of muscle mass and felt both values would immediately go way up if Leo came off fluids (as of Leo's last vet visit on 3/2, my vet said Leo's dehydration has improved but he still needs the fluids).

After doing lots of research online over the past few weeks, I increasingly came to believe that Leo's CKD isn't as bad as my vet thinks it is. I think his poorly regulated BG has added to his dehydration and need for fluids. I do think he has CKD but I don't know how bad it really is. I think his BG needs to be in control for awhile before we can make that judgment. If you disagree with me here, please let me know!!

So that brings me here. I decided I was going to try and get Leo's BG under control myself.


After having consistently high #s and experiencing a series of erratic bounces since the CKD diagnosis, I got Leo into a good position to try the "Start Low, Go Slow" approach. I just started Wednesday but it seems to be working.


Remember, Leo's weight has dropped to 7.6 lbs and he still receives 150 ml subqs twice/day (with added Potassium). He gets Phos-bind in his food and is on Clavamox for a persistent UTI. He also is taking Mirtazapine every 3 days to help with his appetite.


I felt I was able to start SLGS Wednesday (3/7). That's also when I switched food from Hill's k/d to Fancy Feast Chicken (edit to add: 3/10 switched to low carb and low phos food).

[Edited post because I have now made a spreadsheet]


With changing diets, how long is or what exactly is meant by "until change is complete"?

Any advice/guidance on where I am so far would be greatly appreciated!

 

I only have time for a quick reply right now, but off the top of my head, I wonder if Leo actually has a kidney infection, rather than a "basic" UTI. A kidney infection can cause kidney values to jump as if it were CKD, but give that he's had a persistent UTI, I'd consider an actual kidney infection. A kidney infection (or any infection) can cause elevated BGs as well - and that could be why you're having a tough time getting Leo regulated.

If it is a kidney infection, he probably needs a different antibiotic. Zeniquin and Baytril are usually the go-tos for kidney infections, and the course of antibiotics is usually 4-6 weeks. I'm guessing that the clavamox is helping a bit, which is why you're seeing improved kidney values, but it's not fully doing the job. Usually ultrasounds are used to diagnose kidney infections, but given the presence a of a UTI, maybe you can just "assume" that's what's going on, given the kidney values as well.

You're probably going to have to balance getting his BGs under control and getting the infection under control at the same time. If this is a kidney infection, once it's taken care of, Leo's BGs might fall into place quickly.

We've had a couple members recently in this type of situation, with a kidney infection causing havoc. I'm tagging @Stacy & Asia , since her kitty Asia has just about gotten past her kidney infection now. I'm sure she'll stop by some time later to share her experience.

 

I can only offer hugs.. I see he is CKD but that's a lot of fluids in one day. I would be concerned of overloading his heart.

 

I'm going to second that that's a very large amount of fluids, especially for a smallish cat, which can cause its own serious problems plus fluids may not be indicated at Leo's creatinine levels. It may be helpful for dehydration if Leo is urinating huge amounts because of the high bg, but that amount is cause for concern. If you haven't seen Tanya's excellent site for CKD, here's a link to the page on fluids: https://www.felinecrf.org/subcutaneous_fluids.htm

Uncontrolled diabetes is certainly linked to kidney disease. The kidneys have to work harder to eliminate excess glucose in the urine. My Cyclone's kidney numbers improved significantly when his diabetes got under control.

 

Hi @colin72 Are you on Facebook? There's an amazing group on Facebook for cats with kidney disease & they have helped to save the lives of many cats when vets didn't think there was hope. I highly recommend you join that FB page. Here's the link: https://www.facebook.com/groups/felinecrf/ There's many on there dealing with Diabetes & CKD.

I agree with the others, 150ml of sub-q twice per day is way too much for such a small kitty and it can be dangerous. The dosage for sub-q fluids is 10ml per pound of body weight per day. For Leo I definitely wouldn't be giving him any more than 100ml per day.

Did the vet do another urinalysis & culture to double check that the UTI was gone? If not, I would definitely do that because he may need another course of antibiotics. Infections can make the BG go very high as well.

I do think that once you get Leo's BG a bit lower you will see better kidney values. The switch to low carb wet food will make a huge difference in his BG after a few days (and will also help his CKD) so it was wise to go to a bit lower of a dose. I would stick with the 1u for a week to let his body get used to that dose along with the change in diet. Keep monitoring his BG as you are, you're doing great with that

 

Hi there, all I can offer is hugs and lots of good wishes right now as I have no experience with UTI/kidney infections or giving sub q fluids on a regular basis. You have come to the right place for lots of good information and support.

 

Like others have pointed it, that is an extraordinary amount of fluids for such a small cat, overhydration is not without consequences. Read up on the Tanya’s site when you can. With a history of DKA and ketones, it is important to make sure Leo is getting enough insulin, eating enough food, hydrated, and doesn’t have infection. Sometimes vets don’t prescribe a long enough course of antibiotics to eradicate the UTI. Diabetics and CKD cats are particularly prone to these because of dilute urine and excess sugar in the bloodstream, it’s a perfect breeding ground for bacteria. Kidney infections are no joke, I believe Asia got hers from a UTI that wasn’t treated properly. Kidney infections require an even longer course of antibiotics and aren’t easy to diagnose.

I know you’re overwhelmed, but if you can figure out a way to set up your SS with the testing data you have collected, at least for the past couple of weeks, it would really help others to help you and make sure Leo is on track. We rely heavily on data and the visual of the colors in the SS makes it easier to spot trends.

 

There are several of us here who have balanced the needs of diabetes and chronic kidney disease. You might want to investigate a lower phosphorus food than Fancy Feast which is pretty high in phosphorus though low in carbs. Since you've just started the food transition, switching should be easier.

 

I discussed the possibility of a kidney infection with my vet. I asked that Leo be on Clavamox 4-6 weeks after reading some info on Tanya's site. From what I've read, and maybe I'm wrong, but specifically diagnosing a kidney infection is difficult. Basically, the info I read on Tanya's site said to treat the UTI as if it were a kidney infection... that's the reason for the extended course of Clavamox.

You said, "he probably needs a different antibiotic. Zeniquin and Baytril are usually the go-tos for kidney infections". I wasn't aware of this and didn't read it any where while researching kidney infections. Are there articles online that discuss this that you could point me to?

Thanks very much Amy!

 

I don't use Facebook (shocking I know!) but I might just to check out the group you mentioned.

Although I didn't realize it initially when my vet prescribed it, I've read that the amount of fluids is a lot. I also discussed it with my vet and my vet didn't think it was an issue, but then again, my vet keeps predicting Leo's demise so he might not be thinking about long term issues. However, I should add that the problem has been that Leo needs that amount of fluids. He 's having issues getting past the dehydration. It's gotten steadily better but my vet didn't thought he still needed that amount.

That's just one reason I'm frantically trying to get his BG under control. I hope that it will help solve the dehydration. Does that sound right to anyone? My mind is a bit hazy as I think about it now but I'm sure I read that consistent high BG would contribute to dehydration. I think there was even a term for it. Agh. My mind is fried.

I'm going to ask for another urinalysis this coming week.

Thanks Luanne

 

I don't know if there are any articles spelling out these two ABs for kidney infections; it's information I got from my own vet, and from folks around here.

Getting BGs under control will probably help with dehydration, but if there's a kidney issue at the same time, BG regulation alone might not completely solve the dehydration issue.

 

I know this is overwhelming. It will help us if you can transfer your BG numbers to a spreadsheet. We don't just look at numbers -- we look at trends. Most of us who always open a spreadsheet are used to looking at the color coding to get a better picture of what's going on.

My first thought was that Leo needs more insulin. If it were me, I'd consider increasing to 1.25u.

If you're using a phosphorus binder, the food doesn't matter. You have more flexibility to feed Leo whatever he'll eat.. I'm also amazed that your vet was having you feed one of the highest carb foods around. Yeesh!

 

I made the ss. I think I did it correctly. One thing will be clear from the ss, I am not sleeping... and it's been like this for weeks.

I've been careful increasing his dose because on 3/7 I switched from Hill's k/d that had 27 carbs to trying lower carb foods (3 or less). I noted above that SLGS says, “If changing diets... do not increase dose until change is complete and asked how long is or what exactly is meant by "until change is complete"? Maybe 4 days is enough time??

Thanks Sienne

 

Can you make your SS public? It is not yet viewable.

 

At 7.6 lbs your cat should not be getting more than 70 ml of fluids. You are giving double that. There are dangers to over hydrating. With the lower creatnine I would lower the frequency of the fluids as well.

I know you said you aren't in Facebook but the group Cats with Chronic Renal Failure would be really helpful.

Do you have copied of his most recent labs? Can you post them?

Dosage of fluids is 10 ml per pound.

I'm glad you switched foods.

Honestly id consider a second opinion from another vet.

 

On your spreadsheet, there's a button at the top that says, "Share." If you click that, you'll want to check off the option to share your spreadsheet with anyone who has the link. That will make your spreadsheet available to us.

Usually, when switching food, it takes a day or two to see a difference in numbers. If you're gradually transitioning food over several days, then it would be a day or two after the transition is complete.

 

To all- My ss should be viewable now. Please let me now if there are other issues. Thanks!


Hi Janet

I wrote a detailed history for Tanya's CKD Group. It includes bloodwork and urinalysis. I'll copy it below....


Leo's story...

From the beginning he has been a very hard to regulate diabetic. He has been on Glargine.

August 16 2017- Bloodwork and Urinalysis at his diabetes diagnosis [weight= 12 lbs]:

GLU 618 mg/dL
CREA 1.6
BUN 42
PHOS 6.1 mg/dL
CA 10.1 mg/dL
Na 144 mmol/L
K 3.7 mmol/L
Na/K 39

Urinalysis-

Glucose: large
bilirubin: neg
ketones: neg
Blood: mod
Specific Gravity: 1026
PH: C (7.35-7.45), F (7.25-7.40) 6.5
protein: ++
urobilinigen: neg
Nitrate: negative
Leukocytes: ++
WBC's: 10-15
RBC's: 40-50
Crystals: neg
Casts: neg
Epithelial cells: neg

October 2 2017- Bloodwork [weight= 11.06 lbs]:
GLU 480 mg/dL
CREA 1.7
BUN 36

October 19 2017- Urinalysis and Ultrasound:
Glucose: large
bilirubin: neg
ketones: trace
Blood: neg
Specific Gravity: 1022
PH: C (7.35-7.45), F (7.25-7.40) 6
protein: trace
urobilinigen: neg
Nitrate: neg
Leukocytes: +
WBC's: neg
RBC's: neg
Crystals: neg
Epithelial cells: Epithelial cells occ

Ultrasound single organ evaluation- Urinary bladder- normal bladder wall thickness, normal trigone

Two months into his diabetes diagnosis, Leo had ketoacidosis and was rushed to an ER vet where he stayed for a few days until he was OK.

Blood work from this time period in the ER:

October 22 2017- Bloodwork:
GLU 600 mg/dL
CREA 1.0
BUN 90
PHOS 10.4 mg/dL
CA 11.3 mg/dL
Na 142 mmol/L
K 2.6 mmol/L
Na/K 55

October 24 2017- Bloodwork [weight= 8.8 lbs]:
GLU 395 mg/dL
CREA 1.3
BUN 73
PHOS 7.6 mg/dL
CA 9.2 mg/dL
Na 158 mmol/L
K 2.2 mmol/L
Na/K 72

November 8, 2017- Urinalysis [ weight= 8.94 lbs]:
Glucose: ++
bilirubin: neg
ketones: neg
Blood: neg
Specific Gravity: 1020
PH: C (7.35-7.45), F (7.25-7.40) 6
protein: neg
urobilinigen: neg
Nitrate: neg
Leukocytes: neg

February 7-9, 2018 [weight= 9.4 lbs]:

Leo is not eating well and I have to syringe feed. I see some dehydration.

February 12, 2018:
After a trip to my vet, the blood test shows renal failure. The Urinalysis shows a UTI (which he has had in the past, common in diabetics)

Urinalysis
Glucose: trace
bilirubin: neg
ketones: neg
Blood: neg
Specific Gravity: 1010
PH: C (7.35-7.45), F (7.25-7.40) 8
protein: neg
urobilinigen: m
Nitrate: negativem
Leukocytes: +++

Bloodwork (CKD diagnosis):

ALP 92
ALT 77
AST 35
CREATINE KINASE 140
GGT 1
AMYLASE 2433
LIPASE 89
ALBUMIN 4.2
TOTAL PROTEIN 8.4
BILIRUBIN CONJUGATED 0.1
BUN 91
CREATININE 3.1
CHOLESTEROL 262
GLUCOSE 898
CALCIUM 12.4
PHOSPHORUS 10.8
TCO2 (BICARBONATE) 22
CHLORIDE 87
POTASSIUM 3.7
SODIUM 147
ALB/GLOB RATIO 29.4
BUN/CREATININE RATIO 29.4
BILIRUBIN UNCONJUGATED 0.0
NA/K RATIO 40
HEMOLYSIS INDEX 2+

ANION GAP 42
SDMA 23

T4 1.5

WBC 6.2
RBC 8.34
HGB 12.4
HCT 36.5
MCV 44
MCH 14.9
MCHC 34.0
% RETICULOCYTE 0.2
RETICULOCYTE 17
% NEUTROPHIL 50.3
% LYMPHOCYTE 45.1
% MONOCYTE 3.1
% EOSINOPHIL 1.5
% BASOPHIL 0.0
PLATELET 519
NEUTROPHIL 3119
LYMPHOCYTE 2796
MONOCYTE 192
EOSINOPHIL 93
BASOPHIL 0

Leo is given Orbax (10 days) for UTI.

Started wet k/d food (previously fed wet Wellness chicken)

Started Lactated Ringers. Initially vet said 150 ml ONCE/day (2/12). The next day we discussed the possibility of hospitalization and IV fluids. My vet thought Leo was better off at home and we decided to do 150 ml TWICE/day. Leo shows no signs of heart trouble so vet felt increasing fluids would be OK.

February 15, 2018:

We switch fluids to Sodium Chloride. I can't recall my vets reasons.

Leo is given Mirtazipine 3.75 mg once every 3 days.

February 19, 2018 [ weight= 8.5 lbs]:

Leo is doing better after a week of 150 ml twice/day. Vet decides to go down to 150 ml fluids ONCE/day. We switch back to Lactated Ringers.

Given Phos-bind to add to food. After mainly syringe feeding for the week, Leo starts to eat a bit on his own.

Because Urinalysis still showed moderate Leukocytes after 10 days of Orbax, Leo was given Clavamox 1/2 ml twice per day. I talked to my vet about keeping Leo on Clavamox for 4-8 weeks after reading about UTIs on Tanya's site

Urinalysis-

Glucose: +++++
bilirubin: neg
ketones: neg
Blood: neg
Specific Gravity: 1020
PH: C (7.35-7.45), F (7.25-7.40) 6
protein: neg
urobilinigen: neg
Nitrate: negativeneg
Leukocytes: moderate

Bloodwork (after the first week of fluids)-

CREA 1.6
BUN 48
BUN/CREA 30
PHOS 5.9 mg/dL

February 20, 2018- First day Leo received 150 ml of fluids ONCE (evening)

February 21, 2018- Leo seems dehydrated. After giving 150 ml on the 20th and none in the AM this day, I give 150 ml early evening. Leo has gotten worse the past two days. Today he is not well.

February 22, 2018- Spoke with vet, we go back to 150 ml fluids twice/day

February 24, 2018- [weight= 7.75 lbs]:

Vet says continuing weight loss is alarming. Says bloodwork looks much better than it is because of fluids and CREA is in normal range because of muscle mass depletion. He believes Leo has days to live. We again discuss option of hospitalization but vet believes the fluids we're giving are doing just as good as the IV would. Vet says he can hospitalize if I want but thinks Leo would be happier at home with me where he is getting great care.

Urinalysis-

Glucose: ++++
bilirubin: neg
ketones: neg
Blood: trace-non hem
Specific Gravity: 1020
PH: C (7.35-7.45), F (7.25-7.40) 6
protein: +
urobilinigen: normal
Nitrate: neg
Leukocytes: +-++

Bloodwork- (after second week of being on fluids)

CREA 1.4
BUN 54
BUN/CREA 39
PHOS 6.7 mg/dL

February 25, 2018- Leo is starting to eat on his own. He seems pretty good today.

February 26, 2018 [weight= 7.88 lbs]

After I read on Tanya's site about keeping Potassium levels above 4, vet adds 10 ml Potassium Chloide to Leo's Lactated Ringers.

Leo does well this week (2/26-3/2). At times he seems close to being himself. He is eating on his own and at times has been VERY hungry sometimes wanting food multiple times per day. For example, yesterday he ate 9 1/2 oz. A couple times he was ravenous. I suspected hypoglycemia and although his BG was low once when he was very hungry, the other time it wasn't. Very strange. I suspected hyperthyroidism but his T4 was average (1.5) in his bloodwork above on 2/12.

March 2, 2018 [weight= 7.6 lbs]:

Bloodwork-

CREA 1.4
BUN 48
BUN/CREA 34
PHOS 7.5 mg/dL

Na 157 mmol/L
K 3.4 mmol/L
Na/K 46

Vet says he believes Leo has a week to live. Again, he says the numbers look much better than they are because Leo continues to be on 150 ml fluids twice/day (fluids started 2/12). He says if we stopped fluids, the numbers would go way up.

So that's where we are as of today. I know Leo has CKD but I'm not sure it's as advanced as my vet believes.

Leo's Blood Glucose has been VERY hard to regulate throughout the last 4-5 weeks. The past couple weeks have been awful. I take anywhere from 4-9 readings/day trying to figure out what's going on. I believe he's gone through several cycles of Somogyi Rebounds. I think the weight loss and dehydration due to CKD are throwing his BG all over the place and making it even harder than usual to regulate. At the same time however, I think his erratic BG is contributed to his inappetance, weight loss, dehydration and subsequent dependence on fluids twice/day.

I'm hoping that although Leo does have CKD, it's not as advanced as my vet believes and he's not at the end.

 

The ckd is certainly not in end stages. If anything is early stages. Remind us what you are feeding and what you are changing to?

Thanks for making the ss viewable. That will be helpful.

What food are you transitioning to?

Can you add info to your signature? It will help so we don't ask the same questions repeatedly.

Click on your name at the top right corner and choose signature. Add info such as your pets name, age, date diagnosed, insulin type and protocol you're following, and other health concerns and medications, and food you're feeding.

 

You're spreadsheet (SS) is now visible. Thanks! I don't' know if you noticed, but there's a tab for entering lab values. At least for here, it makes all of the information available in one place and you can then compare values from each date that they're run. The only headache is if the reference range is different (usually if the labs are done at the vet's office or sent out).

Leo's numbers are not horrible by any means. He is bouncing around -- his numbers drop into a lower range and his liver and pancreas "panic" dumping a stored form of glucose along with counterregulatory hormones into his system which cause BG numbers to spike. It can take roughly 3 days for the bounce to clear. It's an annoying phenomenon but it's very common among cats that are not yet regulated. Their body isn't used to being in normal numbers so there''s an overreaction.

A couple of observations...
If you are up all night testing, you're not taking care of yourself. Understand, I was a testaholic and known to comment that sleep was vastly overrated. If you look at Gabby's SS, especially at the beginning, you'll see that I understand. The bottom line, though, is if you're totally sleep deprived, you're not going to be able to care for Leo. You don't have to be quite as compulsive but you may need to get to a level where you're more confident in how Leo is responding.

Take a look at the two approaches we use for dosing -- the Tight Regulation Protocol and the Start Low Go Slow method. They differ with regard to when you reduce the dose and how long you wait before increasing. As long as Leo has been off of any dry food, you can use TR. You certainly test enough. TR is more aggressive in that you change doses after 3 days if numbers are not in normal range and a dose reduction hasn't been earned. That's the simple version -- it's a little more complicated but you will get the hang of it fairly quickly. I went back and looked at your first post and it sounds like you were leaning toward SLGS. If you've transitioned Leo to low carb, canned food, I'd encourage you to consider TR. It will get his numbers under renal threshold more quickly.

I'd also suggest putting a note in the comments section regarding where you started a low carb diet (3/7 ??).

 

Sienne asked me to pop in and look at the lab results. She is correct that adding them to the lab tab on the SS is best when you have a chance to do it. It makes comparing them much easier.

One thing I will say is that I have heard vets indicate to caregivers that the CKD is hopeless and at end stage when the cat is only at Stage 2 or 3. I’ve also had a cat with a creatinine of over 8 and phosphorus over 15 who was still eating and playing. He had polycystic kidney disease which presents as CKD and is treated the same although longevity is always shorter once the cysts really start growing and response to normal treatment is almost nil.

It is a challenge to know what the creatinine might actually be because muscle wasting can cause a drop in creatinine. However, with the exception of the phosphorus.....which has greatly improved so kudos to you....the numbers don’t look bad at all. And when his numbers were the worst, he was still just at 3.1 which is early Stage 3 and not that big of deal. I have had CKD kitties at 3.5 - 3.7 for years.

How did your vet diagnose a UTI? Did he do a sterile collection sample (cystocentesis) and do a culture and sensitivity? Because Leo’s creatinine did jump so suddenly, I also would suspect a kidney infection and I agree that, while uncomplicated cases might do fine with clavamox, typically you would want to use a bigger gun, as Amy mentioned, like Zeniquin or Baytril (they are from the same family of drugs) for 6-8 weeks. In my experience with CKD and kidney infections, clavamox usually can’t do the job. You have to be sure the dosing with a Baytril or Zeniquin is correct since that class of drugs (Enrofloxacins) can result in neurologic side effects if not dosed properly. And, actually, if you read Tanya’s closely, she does state that the Enrofloxacins are typically required for more complicated cases. But.....it’s important that the culture and sensitivity is considered in determining the appropriate antibiotic.

What makes you think Leo is so dehydrated because it’s not showing in his BUN. BUN would not be as affected by muscle wasting as the creatinine would be. I also agree that the amount of fluid you are giving him is excessive. Has your vet done an echocardiogram? Just observing that the cat is not showing any signs of heart problems is a way to get into trouble fast. You can quickly get to a tipping point on hearts and overwhelm them. Cats are really great at compensating for a long time with a bad heart and then it’s too much (and I’m referring to cats that just might have hypertrophic cardiomyopathy and not have CKD).

As an example, I had a 21 year old cat diagnosed with Stage 2 CKD and we did an echo. Heart was in great shape especially for her age. When her creatinine hit 3.5, we started fluids...100 mls/day. It didn’t take long to push her into congestive heart failure. Yes...an aging heart is much more at risk with fluids but even a healthy heart can be overwhelmed by over hydrating.

The maximum amount of fluids I’ve ever given in a day (and I’ve given fluids to many, many of my cats) for CKD is 200 mls divided up into 100 mls in the morning and 100 mls at night and that was to a 12 lb cat with polycystic kidney disease. Normally, that would be a lot of fluid for a 12 lb cat.

Because you have so many things going on here with him, it’s hard to unequivocally say that lightening up on the fluids caused him to feel bad. With some of his high BGs, it could have been that. Just tossing out some ideas.

The best fluid to give a cat with CKD is LRS unless the kitty has high potassium values. If it does, then you would want to give the sodium chloride so I’m glad you are back to LRS. It already has potassium in it. One thing that your vet might not have mentioned but for you to be aware of is that insulin causes the potassium to be taken up into the cells. So even with a non CKD diabetic cat, you might see the serum potassium lower than 4. Since you are giving potassium and also LRS, please be sure to keep an eye on that potassium value so you don’t shoot his potassium way up.

Also, while fluids at home can keep them stable with CKD, it can’t drop the creatinine like IV fluids. So I do disagree with your vet on that point. I also disagree with your vet that Leo is in end stage renal failure. His numbers don’t show it but the real question that you should always ask is how is Leo doing? I’ve seen horrible renal values and the cat is doing great. It’s important to know how kitty is feeling. We always say treat the cat, not the numbers just meaning that you shouldn’t elect to let a kitty go just because of the numbers. If he’s doing well and has a good QOL, why not let him/her fight? Amy’s Trixie had Stage 4 numbers for a few years and was really stable.

I’m surprised your vet is doing such abbreviated panels or perhaps you didn’t list everything because one thing that is a huge flag, other than the phosphorus is his calcium level on 2/12. That is definitely hypercalcemia and your vet should have done an ionized calcium test to get a true picture. Also, because you don’t have reference ranges, I don’t know if his Anion Gap and TCO2 are normal for your lab or not. Oft we can see the numbers do what Leo’s have done due to metabolic acidosis (which is very different than DKA) which can be common in CKD cats.

Has your vet ever checked his blood pressure? That’s very, very important. Also, it’s interesting that he’s not even close to anemia. Most CKD cats with a creatinine of 3.1 will show a hematocrit that is at 30% or below. Leo’s is pretty decent as of 2/12.

Addressing the diabetes, to be quite honest, his curves look totally normal and what we see here on a daily basis. IMHO, the CKD is not affecting his BG. The infection might be but really, his numbers don’t look any different than many, many that we see. Sienne explained it above but one thing I will add is that Somogyi has not been documented to occur in cats (or really even humans). Vets always look at a SS like this and assume Somogyi but they are incorrect.

One other thing is that there is a syndrome called “euthyroid sick syndrome”. It’s where we see the tT4 levels artificially low due to other health issues the cat is having. So while you might be assuming his thyroid levels are normal, they might not be. Is he drinking a lot of water? Is he peeing a lot? While you don’t have enough info here to tell whether he could be euthyroid sick, if he’s drinking and peeing a lot or you have to give him fluids to keep him hydrated and he’s losing a lot of weight, I’d also be looking at the thyroid closer. My vet and I use Dr. Jean Dodd’s lab for thyroid testing. It’s her specialty and she has a feline panel that includes the fT4, tT4, fT3, and tT3. With medical records available to her, she is also excellent at determining if you are seeing euthyroid sick syndrome. Her cost to do the tests is actually less than the labs that would do it. Your vet draws the blood as specified on her website and you can mail the blood to her. Your vet will likely charge you for the blood draw (mine does) but it’s still cheaper than having one of the labs run those tests.

It would be really helpful, for me, if your vet actually ran superchem and cbcs so I can look at all the values which you could perhaps put on the lab tab. If he’s just running abbreviated tests, he’s missing the boat. If the Ca is still high, you need to take action. Keep putting that PhosBind on his food because his P needs to come way down (as close to 4.5 as you can get it). But...you can’t just dose it arbitrarily or you risk causing some toxicity issues. That’s why I disagree that you can feed the Fancy Feast and just add binder. If he were my cat, I’d be getting as low a P food as I could that he will eat and add binder.

Please let me know if you have questions. I’ll check back later.

 

So glad Marje has been on this thread--I was abruptly told my 12 year old shot cat had little and I LOOK for symptoms and she had none--I did routine BW because she was depressed a little.

Anyway--we were doing 100 sq a day as the ER vet instructed and her BUN was about 180-creat around 8 and phos I think 11

She gets a everything pill with cerenia ondansetron tiny bit of potassium (she was low) b complex- b12-moxxor-azodyl - I recently switched to mirtz for app stim and phos binder in the cap.

I started giving 100sq 2x a day as she is small as well.....
I recently started a MSM product and I am beside myself with what seems to be a great improvement.

the mirtz is helping more than ciproheptadine.

https://www.theholistichorse.com/shop/animal-products/cats/su-per-msm-ultra-pure-powder-2/

They also have lots of knowledge ....I just started my boys on it too for aging-I think it greatly reduces the inflammation in the body and helps blood flow-all I know is she is doing great and tonight she did not need her 2nd dose of sq
andddd she is eating!!

 

I'm working on responding to your great posts and getting my labs together to get into Leo's SS but I have a couple quick questions...

As you'll see on his SS, last night Leo's BG was 257. I shot 1 U. At +3 his BG was 143 and at +6 it's down to 97 . That seems great I'm just worried that it will drop further into dangerous levels and I won't know it (I need to leave the house for a few hours). Should I be concerned about the 97 at +6 or do you think that's the nadir?

[edit to add] BG dropped to 79 at +8 so I fed 1 oz.
[edit to add] Preshot # was 99 .... it looks like I'm skipping the shot


Thanks so much to everyone! You've been a tremendous help!

 

It looks like he’s clearing a bounce so he could potentially continue to drop by AMPS.

Just post your preshot number with a comment in the subject line like “need help shooting” that will get attention.

Someone will guide you through it. However, as a general reference, if you are doing SLGS, you would skip a shot if the AMPS is below 150. Also, because he dropped below 90 last night, you’ll want to take the dose back down to 0.75u and hold it for a week or unless he drops below 90 again (but I wouldn’t do back to back reductions due to the depot).

 

Those sound like great healing safe numbers.

 

Leo's feeding and shot times have been pushed back further and further over the last month because sometimes he took longer to eat, sometimes I had to syringe feed, etc. And of course with Daylight Saving Time, everything is pushed back another hour. My question is would this be a good point where I could move his PMPS forward a bit since he didn't get an AMPS shot? If so, could I move it 30 minutes? More?

 

Since he didn’t get an am shot, you can make his shot time whatever you want it to be tonight and just keep it 12 hours apart from there (depending on his number, of course, and if he’s high enough to shoot).

 

Any thoughts on Leo's recent numbers? AMPS was 99 and PMPS was 188 so I skipped two shots. That has me worried. I seriously doubt nearly 7 months into his diagnosis that he'll go into remission. I'm worried I'll make a bad decision on the next dose, give to much, and it will lead to erratic highs and lows. I might be looking for your your help when I get Tuesday's AMPS!


Still haven't had time to reply to previous posts. So much good info from you all and it is greatly appreciated. Also, I have an appointment with a different vet on Wednesday and I'll need some advice on what tests, etc I should ask about.

 

It's harder for a cat to go into remission after a year but we've seen cat's go into remission after 3 yrs. (And that kitty has now been in remission for 6 yrs.)

 

What Sienne says is true...my Trixie went into remission after 3 years and stayed there until she crossed 3 years later. You never know!

 

Please check out Tanay's Renal Cats you can review all of the info on the web site and also make a request there to join the support group. You might need to learn how to give sub q fluids at home. I never in my life thought I'd be able to do that but you get over being scared and you learn and just do....

 

My ER vet said to enjoy my shop cat while I had the time because it would be soon and she would be gone--well guess who is doing awesome! (dx CKD stage 4)
Rico cardio said 2 weeks and that was over 2 years ago....

 

Update:

Leo is doing great. As you can see from his SS, his BG is looking good. It's better than it has been for months. Using SLSG has been great for him. He is now getting 150 ml subqs once/day (instead of twice) and that may decrease after tomorrow.

I couldn't get in with my usual vet so I have an appointment tomorrow (3/16) with a different vet. She asked for all of Leo's records to review.

For now I've switched to Whole Earth Farms Chicken Pate (Prot%:39 Fat%:51 Carb%:10 mgPhos/100kcal:182 Cal/5oz:143). He is no longer taking Mirtazapine and is eating very well.

I think getting away from a high carb food and getting his BG under control helped his dehydration and turned him around. Now we'll be able to get a truer look at his kidney values.

I had trouble entering his Labs in the Google speadsheet. I've scanned everything and put it on Google Drive:
https://drive.google.com/drive/folders/1KSDcdIt-TtxABnGMALeExUpfY1aS1rH9?usp=sharing

Any feedback would be appreciated. As I said, Leo goes to the vet tomorrow (3/16). Let me know if anyone has ideas on things I should bring up.

Thanks so much for all of your time, support and advice. It has meant more to me than I could say.




Marje and Gracie...

My vet has done 2 or 3 urinalysis. I've taken urine samples to the vet but I know at least one was done using cystocentesis. I don't know enough about how a urinalysis works/the process. I assumed there was just one way to do it. I do know that there was never any mention of a culture. I will definitely ask the vet about that and Zeniquin and Baytril.

Leo is now on 150 ml once/day and hopefully less after my next vet visit.

About an echocardiogram- No, I know Leo hasn't had one. I don't know anything about them.

Wow. That's great news! Is that a "fact"? Do you have any sources on this? I would love to ask my vet about this.

I didn't list everything. I've scanned everything now and put it on Google Drive:
https://drive.google.com/drive/folders/1KSDcdIt-TtxABnGMALeExUpfY1aS1rH9?usp=sharing

Yes, my vet did check his blood pressure. I think it was sometime after 2/24.

I've probably read it but what would a high Ca indicate?

I've switched food but my Phos-bind dosing is arbitrary. I was told to give one scoop, which would be 100 mg. I've been giving 200 mg until I can get back to the vet to get his Phosphorus levels checked.

Thank you SO MUCH for taking the time to help. If you have any other advice and can look over his labs, I would be very grateful.

 

I’ve got to get my cats taken care of and then cook/eat dinner but I will respond this evening later.

 

Good job on finding a lower calorie and relatively low P food. The renal diets are about 40 mg P/100 kcal but with my CKD cats, using binder and a food that was under 200 mg P/kcal really helped me keep their P around 4.5. Of course, every cat is different and while the ideal thing would be for him to eat one of the renal diets until his P is down, they aren’t always palatable to cats and he must eat. You can’t and shouldn’t do arbitrary phosphorus binder dosing. While you don’t have to get the absolute exact amount (e.g. if you are giving 1/4 tsp daily, it doesn’t have to be exact as the powder is so fine), you should strive for consistency.

Thank you for making his complete labs available. That really helps see the whole picture. It will be interesting to see what his creatinine and BUN are on the next labs especially if he puts some weight on. Losing muscle can be attributed to metabolic acidosis but Leo’s TCO2 and Anion Gap are high, not low, as you would expect to see with metabolic acidosis.

There are roughly three ways to catch urine:

• free catch which you can do at home where you just slip a large spoon under his bottom and then titrate it into a tube you get ahead of time from the vet
• vet can express a full bladder at the clinic and catch it
• cystocentesis

The first two are good for running most of the tests but not for checking for infection or bacteria. The cystocentesis results in a sterile sample of urine as it is being withdrawn directly from the bladder via a needle. So if the vet is looking for a UTI, that’s how you want the urine drawn. If the vet is checking urine specific gravity, pH, or most of the other parameters, the first two methods are fine.

Personally, I still think that is a little high so I’m glad you are going to discuss it with the vet. Leo really shouldn’t need more than 100 ml/day and actually, most information these days indicates subq fluids for CKD don’t need to be started until the creatinine is 3.5 or higher. One reason is because you want the kitty to get as much fluid as possible on their own through drinking water or by the caregiver adding water to their canned food. At about 3.5 for the creatinine, they can no longer keep up with hydration and that’s when the subq fluids are started. However, every cat is different. The other reason you don’t want to start too soon is if the kitty is stable for a long time (mine was for four years) and they are getting fluids every day, you risk building up scar tissue even using small ( e.g. 21g) needles and moving the insertion site around.

An echocardiogram is basically an ultrasound of the heart. The wall thicknesses of the chambers are measured to ensure they are normal. Cats are very easily able to hide when they have heart issues until it gets severe. Giving fluids daily to a cat with heart issues can push them over the edge quickly into congestive heart failure. You can discuss it with your vet but I really like to be cautious because I know what can happen if you give a cat with an unknown heart condition too much fluid.

The bold is mine. You can also read more about hydration for the CKD kitty here.

It would be good for you to get his readings. If he were mine, I’d have them check his BP every visit. This usually consists of taking the average of several readings. It is very common for CKD cats to have high BP and, if they do, not treating it can put further stress on the kidneys as well as put them at risk for stroke.

It’s not uncommon for CKD cats to have high calcium levels. When you multiply the Ca x P, you want the number to be under 70 or the kitty is at risk of tissue calcification. Leo’s is well above 70. Hypercalcemia by itself can cause severe effects. You can read more about calcium and phosphorus imbalances here.

Keeping the P under control is critical to longevity. Some vets aggressively dose binders when the P is as high as his is. You should discuss this with your vet but a “middle of the road” dose is 40 mg/lb/day. If he weighs 7.6 lbs still, that is 300 mg a day, if you are using aluminum hydroxide binder. That means you aren’t giving him enough and your vet might even recommend higher until his numbers come down below 7 but please be sure and consult the vet before giving more than 300 mg/day. Double check the dose for the binder you are using as they do vary. Some, a scoop is about 1/2 tsp which can vary between 500-600 mg P. You want to sprinkle some of the binder in each meal over the course of the day so it’s all gone by his last meal. Mix it in well with the food and let it sit just a minute so it can bind the phosphorus.

You can read more about dosing the binders here.

I hope he’s eating well and feeling better. His BG does look better. Please let me know if you have additional questions. You have done a good job asking questions and addressing his issues. CKD takes constant attention, that’s for sure!

 

Long time ago I had such information from a very kind and good vet. I dud everything possible as a nurse for my "doomed" kitty , who made a full recovery. When I checked back with my vet, he did a thorough check of my kitty, and pronounced her cured.
after that announcement there was a long thoughtful silence. Finally he said, "You know, I think many more of my patients could have been saved, if their owners had been as good nurses as you are."

 

Hi Marje

You and others in this thread helped me tremendously. I have an update and some questions. If any of you have some time, the thread is here:
http://www.felinediabetes.com/FDMB/threads/leo-update-triaditis-possible-metabolic-acidosis.195957/

THANKS!!!!

 

Sorry, I hadn't read all the IMs.
At any rate, whatever the correct dose, I always think that 2 sessions of fluid/daily is more effective and safer than once a day.
Dsregard200mls of fluids once a day is more than most cats can handle. Usually a number that large is divided up into 2 administrations: 100 mls in the morning, and 12 hours later, 100 mls in the evening/night.)