Need advice

Discussion in 'Feline Health - (Welcome & Main Forum)' started by C.W. Gortner, Aug 29, 2018.

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  1. C.W. Gortner

    C.W. Gortner Member

    Joined:
    Nov 13, 2016
    Hi all,

    I've posted here before and people have been so kind, I'm hoping for help. My beloved ex-feral Mommy went into crisis and was hospitalized in December of last year, which is when we discovered her diabetes. At the time, her vet said her outlook was very uncertain; she had severe pancreatitis, but we persisted and she pulled through. Her blood work at the time also indicated stage 1 CKD, with a high "normal" creatinine. With 1 unit of Lantus twice daily, we got her diabetes under near-perfect control. She went asymptomatic and has been fine for these past eight months.

    Last Monday, we woke up to find her drooling and lethargic, clearly in distress; I suspected a tooth infection and rushed her to emergency at the veterinary practice. It was indeed a tooth infection, but her blood work also showed her creatinine value had leaped to 7.6. My vet, who is part of this very expensive specialty practice, expressed panic at the renal values and wanted her hospitalized immediately for IV fluids, until I refused and offered to do sub-q fluids at home. With her insulin, Mommy needs to eat and she wouldn't when she was hospitalized before; we had to visit her twice a day and sing to her, getting her to eat a little, but never enough. Instead, we did sub-q at home, plus a week of Clavamox and Buprenex for pain. The antibiotics and pain med took their toll - she became quite nauseous and sedated by day 5 - but we gave her some Cerenia, which helped a bit. On Sunday, within 24 hours of ending pain med and antibiotics, she was eating again. On Monday, she ate her full three meals and seemed like her sweet self again.

    We had a follow-up today to re-check her kidney values and schedule her dental, which she needs. I'd thought her elevated renal numbers - they've just shot so high in eight months - was due to her untreated tooth infection, so I was certain the values would be lower, if not yet back to her Dec '17 level. Instead, her creatinine came in at 8.9 and her BUN was 140. Higher than Monday. Stage IV kidney disease, said the vet. She was gentle but grim; she told me it was likely "a matter of weeks" before we'd have to let Mommy go.

    Of course, I started to cry, as I know these numbers look dire. Paradoxically, Mommy's BG came in so low - it measured 32 at the vet - they told me to discontinue insulin for at least two weeks. She was eating until this vet visit today; we were at that practice for two solid hours, because they always run late, and the dental consult, which we had immediately after the follow-up, was interrupted by my vet with the in-house kidney panel they'd run. It was then, as the dentist slipped out, that my vet delivered the dire news.

    Once we got home, Mommy went under the bed and refused to come out. She's exhausted and very stressed out, so I let her rest. In the evening, we had to do sub-q fluids again - the vet now wants it daily - so I had to get her out. She showed immediate interest in food, but after nibbling a bite or so, she made a strange movement, as if she was either in pain or nauseous, lowering her head and staying very still as I soothed her. She tried again to eat a bit later, but took another bite and stopped. I couldn't tell if it was nausea or pain, but I gave her Cerenia and the sub-q fluids. She's now very lethargic. She went back under the bed and has remained there all night. She's not eating at the moment, which is a very abrupt switch from this morning, when she gobbled down her breakfast and asked for more. She was purring and resting in her usual spot. Two hours at the vet and she's a completely different cat.

    To complicate matters, I've been reading up as much as I can on chronic kidney disease (CKD) and she's not showing any of the classic symptoms of stage IV, except in her blood work. She did have significant nausea on Clavamox, but her appetite returned. Her BG hitting so low freaked me out, too, but the vet said this is common; as kidney function deteriorates, insulin requirements shift. I'll home-test her BG as best as I can during these next two weeks. She doesn't mind sub-q fluids or insulin shots, but BG home testing - mainly, pricking her ear - was never her cup of tea, and she'll evade / hide much more if I do it too often. Her entire temperament reverts to feral. She's very sweet and docile as a rule, but we simply haven't been able to get her fully comfortable or adjusted to daily BG home testing. Go, figure. That said, her BG has been relatively stable on spot checks, and she's had no diabetic symptoms once we figured out her Lantus dose.

    Today, my vet basically offered no alternatives except daily sub-q, Cerenia as needed, and to "watch and wait." She was very gentle, as I said, but convinced nothing more could be done, even though this dental issue could very well still be an issue. When she mentioned euthanasia, I kept repeating that Mommy's diabetes is under control. She was fine, happy. Eating. She had this awful tooth flare-up and suddenly, her kidney values skyrocket. I know CKD is incurable and progressive, but how can she go from stage 1 to stage IV in eight months? Something in my gut keeps telling me it's her dental issues, but maybe that's my denial. She is a senior; I'm not sure of her exact age, but no more than 13 at most, so this has all hit me like a falling brick wall.

    I'm not sure if being CKD asymptomatic at her extreme renal values is even likely, either. The vet did admit the entire practice was in awe of Mommy; according to them, most cats at these high values will display unkempt coats, frequent and out-of-the-box urination, little to no appetite and significant ongoing nausea. Mommy has shown none of these, except nausea and no appetite, which coincided with her tooth infection, and both resolved after treatment. The vet now refuses to even consider a dental, saying putting her under anesthesia will kill her.

    I don't want to go to heroic measures, as I realize CKD will eventually win, but I do want to do as much as I can for Mommy. We love her so much. Any advice is welcome. I have so many questions. Could her values eventually decline on daily sub-q fluids? Was taking her values only a week after an infection too little time? Was a week of Clavamox enough for a tooth infection and/or might she need a different antibiotic for more time? The vet kept saying, no, that as her values have gone up, not down, that's it. She's on her way out. And we need to stop insulin. To the vet, it's hopeless.

    I tend to always look at things more holistically, but I'm near-despair. I'm hoping her current hibernation is stress-related and in the next day or so, she'll start eating again. I also have her labs, in case anyone wants a particular value. I know we're not vets here, but we know our cats. Often better than the vet.

    https://docs.google.com/spreadsheets/d/1sRDafKbj3GwqINulhVUrzIAuMkKzZjFvdfQUJZCOxy4/edit?usp=sharing
     
  2. JanetNJ

    JanetNJ Well-Known Member

    Joined:
    Jun 8, 2016
    So sorry your kitty is struggling. Do you have a copy of the lab reports that you can post?


    Also there's a great ckd group on Facebook called Cats with Chronic Renal Failure who can help.
     
  3. C.W. Gortner

    C.W. Gortner Member

    Joined:
    Nov 13, 2016
    I have her lab reports in PDF. I joined a CDK Feline group run by Helen that has an overwhelming website attached. I'll check out the Facebook group. Thanks!

    She did venture out this morning to eat (about half a plate or more than half of her usual breakfast, drink and pee). Then she went back under the bed, but in the mornings that's her preferred spot, so I'm a little less frantic.
     

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    Last edited: Aug 29, 2018
  4. JanetNJ

    JanetNJ Well-Known Member

    Joined:
    Jun 8, 2016
    Her phosphorus is very high. High phosphorus taxes the kidneys and makes them feel yucky. Ff is high in phosphorus... Maybe switch to something lower in phosphorus like Tiki cat. I would add a phosphorous binder such as aluminum hydroxide to the food as well.

    She's also boarderline anemic.... Add some b12 methylcobalamin which might help that.

    Continue daily sub q's. It could be the kidneys crashed or it could be an acute infection. The white blood cell count is VERY high. This means infection. He might need more antibiotics.
    Tagging marje who is good at reading labs

    @Marje and Gracie
     
  5. C.W. Gortner

    C.W. Gortner Member

    Joined:
    Nov 13, 2016
    She's on Fancy Feast Classic Pate because that was all she would eat with her diabetes. The first shorter course of labs are from our visit yesterday. The next more complete set is her blood work from her emergency visit, so she was in midst of the infection at the time and hadn't yet taken a week of Clavamox. They did not re-run a CBC yesterday so I don't know if any of those values changed. I have a full course of Orbax here; the vet initially thought she might have a secondary kidney infection and prescribed it while we were waiting on the urine culture. Since the culture came back negative 3 days later, the vet said she didn't need the Orbax.

    I mentioned the anemia and the vet said it was borderline, so she wasn't too concerned. As I said, there was really no attempt to address each individual value, but rather a general "your cat is dying and just keep her comfortable until her time comes." Yet Mommy came out and ate today; if she still has this infection, it should be treated. Also, I gave her some pain med late last night because she was acting like she had pain - it's in her eyes and posture - and the pain med seemed to provide significant relief. She slept soundly, we heard her snoring under our bed.
     
    Last edited: Aug 29, 2018
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  6. JanetNJ

    JanetNJ Well-Known Member

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    Jun 8, 2016
    I'm glad she's feeling better. If she won't eat anything but fancy feast then I would DEFINITELY start a phosphorous binder. You don't need a perscription. I would also take care of the anemia before it's a bigger problem. Anemia can cause a lack of energy and appetite. You don't need a perscription for b12 either. The antibiotic is probably still working since she just finished it. I would continue the sub q's and maybe in a week or two see if the vet will do another cbc.

    What have the folks in the ckd forums said?
     
  7. Olive & Paula

    Olive & Paula Well-Known Member

    Joined:
    Sep 6, 2015
    Any chance there is a dental specialist you can consult with?
     
  8. C.W. Gortner

    C.W. Gortner Member

    Joined:
    Nov 13, 2016
    The folks at Tanya's site are all over the potassium levels, which the vet never mentioned.

    We were consulting with a dental specialist at the practice, which my vet interrupted. I feel as if they've given up, so I need to look around the area for another dental specialist.
     
  9. JanetNJ

    JanetNJ Well-Known Member

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    Jun 8, 2016
    I have no experience with low potassium so I'm glad they are able to give advice in that department. I know it can make them weak. I think you can just give potassium supplements that can be added to food.
     
  10. C.W. Gortner

    C.W. Gortner Member

    Joined:
    Nov 13, 2016
    My vet called today to check up on Mommy. Actually, my emergency vet called; she's the one who saved my cat in December during her diabetic crisis and has been monitoring Mommy's case throughout this latest ordeal. She told me my regular vet at the same practice is . . . well, he's very respected, but not warm and fuzzy, and my emotionally charged oversight of Mommy, coupled with the fact that I do my own research and am well informed (after all, I was the one who ended up finding Mommy's ideal Lantus dose) tend to intimidate him. Apparently, like most doctors, he'd rather not be challenged.

    The emergency vet also assured me there are still some options we can try: a new antibiotic in case the tooth infection is still simmering. A potassium supplement to address her low value. Continue to hydrate with sub-q and, most importantly, the emergency vet is personally referring me to another internal specialist at the practice. She said to me, "You need a vet who will appreciate your take-charge attitude and handle your questions." She was very understanding of my frustration and reiterated that while Mommy's health is precarious and CKD is ultimately fatal, at this time, given that her tooth infection coincided with the sudden rise in renal values, I may be right: this is a stubborn infection, that is affecting Mommy's entire system adversely.

    I'm cautious because I've come to believe many vets simply don't do due diligence with a senior animal who has more than one illness, despite the thousands of dollars they charge. But I have a good rapport with the emergency vet; unfortunately, she's not an internal specialist so she can't take full charge of Mommy's care. That said, maybe this new specialist can actually work with me to see Mommy is as well cared for as possible, rather than deliver dire pronouncements and zero options.
     
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  11. Chris & China (GA)

    Chris & China (GA) Well-Known Member

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    May 10, 2013
    I think you need to get her potassium up (low K can be fatal, the heart needs potassium to work properly) and I'm also wondering how much insulin you're giving

    The fact that her glucose was only 36 in the last bloodwork is worrying....that's definitely too low.

    Yes, it does look like she's got some degree of CKD, but the potassium and low BG would be first on my list of things to get working on

    Do you have any more blood glucose tests? Your spreadsheet stops at 8/18
     
    Last edited: Aug 29, 2018
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  12. C.W. Gortner

    C.W. Gortner Member

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    Nov 13, 2016
    I have a potassium supplement on order. The vet charges five times what chewy.com does, but the scrip needs to be faxed in, etc. We stopped her insulin yesterday. She was getting 1u 2x daily, her standard Lantus dose. Right now, she's OTJ. I'm watching her closely and will home-test her BG later.

    My last home-test on Alphatrak was on 8/18. She ran at 440 right before her shot, so I thought she still needed her usual dosages. She was tested at the vet yesterday morning, where she came in at 32, which, yes, is very low. I can't home-test her too often - she reverts to hiding / evading a lot more due to the ear prick, no matter what I do to ease the process, and I need her as trusting and calm as possible for sub-q - but I will test her tonight, maybe while I do her sub-q. She's eating and drinking again today. Last night, she was so lethargic I thought she was crashing. But she rallied this morning and is back to her usual routine. I need to go easy on her; the vet visits obviously traumatize her, and so stressing her out is something I'm trying to reduce as much as I can.
     
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  13. Marje and Gracie

    Marje and Gracie Senior Member Moderator

    Joined:
    May 30, 2010
    I’ve had a chance to look at her labs and there are many, many concerns. While it’s possible that the tooth infection is affecting the creatinine, I doubt that you will see a large improvement once the tooth infection is resolved.

    Here are the critical issues with her labs besides the high creatinine and BUN:
    • the phosphorus is way, way, too high and needs to be down around 4.5 but absolutely below 6; it’s very hard to play catch up to P when it’s this high. P has been linked to longevity in CKD cats because it can make them feel really bad and develop ulcers in the mouth and tummy. You absolutely need to get her on a binder, like aluminum hydroxide, right away. Tanya’s discusses Binders and dosing.
    • her calcium x phosphorus is way too high; it should be below 70 and it’s over 90; this puts her at risk of tissue calcification so it’s another enormous reason to get the P down. Even though you say all she will eat is FF, I’d really try and get some lower P foods in her although it is true that the best food for a sick cat is the one it will eat.
    • her potassium is way too low as you’ve already noted and so I’m glad one of the vets is going to get a potassium supplement started immediately; this will need to be monitored closely as too high of a potassium level is as dangerous as too low.
    • it is very doubtful that you will be able to decrease the creatinine and BUN with subq fluids; in order to get a big drop in those numbers, you typically need to have them hospitalized on IV fluids (I speak from experience on this) and that is not always a given that it will work. Subq fluids can make her feel a little better but I don’t think you will see a significant drop in creatinine. I highly suggest you ask for lactated ringers as it has electrolytes like potassium which will help her.
    • I would start her on 250 mcg methylB12 twice a day and 1/10 capsule of Jarrow’s BRight divided into two doses; they have added sugar to the latter but you can always adjust her insulin dose if it impacts her BG. I believe it is such a minute amount that it won’t matter. Her HCT is right at 30% so it is the ideal time to address anemia with B vitamins (don’t just use methylB12....you need them both). We don’t pull out the big guns for anemia until the HCT is below 20%.
    When you give subq fluids, try to give it later in the cycle as, in some cats, subqs can drop the BG. ECID.

    I’m going to let others address the insulin dose once you get the SS updated. I’ve got my hands full helping a few others but I did want to give you some input on the CKD.
     
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  14. C.W. Gortner

    C.W. Gortner Member

    Joined:
    Nov 13, 2016
    Thank you all so much for your advice, support, and expertise. Of course, it's disheartening and sobering to hear. Her kidney decline came on so fast; she was acting fine only a month ago, eating, purring, and happy. Last Monday, she woke up drooling and miserable from a tooth infection and suddenly, we're plunged into this nightmare. But I suspect CKD can indeed progress from gradual decline to sudden drop off the cliff, and I must face the reality of the situation. I've been a fighter all my life and I fight for my pets, always, but I also always make a solemn vow: No heroic measures. Animals don't understand scary vet visits and constant poking and prodding; Mommy, in particular, perhaps because of her former feral nature, acts traumatized after every vet visit. Last night, she shut down completely and it was terrible to see. My husband and I were heartbroken for her. Like I said, she rallied again this morning, but I can see that the stress is taking its toll on her.

    I will do the potassium supplement, I'm picking it up tomorrow at the overpriced vet, as chewy.com apparently views it as a supplement, despite the fact that it's labeled Rx, and is taking their sweet-ass time faxing the order to the vet for approval. I'll try the vitamins, too, and continue with her daily sub-q. I'll look into the binder, as well. She's eating okay for now, only not as much as she used to or probably should; today, she ate little less than half a can of FF, her favorite flavor, and though I enticed her with caresses and belly rubs tonight, all of which she loves, she wasn't interested in her dinner. She is losing weight, I can feel it when I stroke her. I have an appetite stimulant in addition to Cerenia, but she might decide to eat later on, she's always been a nibbler / graze-eater. She's often done most of her eating late at night, after we go to bed and the house is quiet and dark. I'm checking her for nausea and pain, too; at the moment, she has no obvious signs like I saw last night. The question is: will she detect any additions, like the binder, in her food and decide not eat at all? I read that it's tasteless and odorless, so guess I won't know until I try.

    She's off her insulin for now, with her BG having dropped so low. We're now giving her the sub-q at around 9:00 in the evening, which was her standard PM dose time for Lantus. If she goes back on the juice, I'll adjust the fluids for late in the cycle. I'll try to BG-test her tomorrow.

    I want her to feel comfortable and safe at home; she's such a sweet, loving cat and she's brought us so much joy. Her son Boy is here with us, and her; this is their refuge. If she decides to stick around for more time than the vet predicted, I'll continue to fight for her and do whatever possible, within her limitations. Given her temperament, I honestly don't see a carousel of treatments and frequent vet visits in her future as adding to her quality of life. I have to respect what she can and cannot tolerate, much as I'm willing to do everything in my power to prolong her life with us. In the end, she deserves her dignity, she's earned it, and I won't let her suffer. If prolonging her life means stressing her out with monthly vet visits, endless tests and treatments, it's probably not worth it. Some may disagree with me, but she's at least 12 or 13 by now, certainly not ancient as far as cats go, but elderly, and she had a very rough life in the park before we rescued her. She might surprise us and react well to the additional treatments. If not, I'm prepared to do what must be done when her time comes.

    I'm devastated. I thought diabetes would kill her when she was first diagnosed and she pulled through the crisis, ending up well-controlled for eight months, with some minor bumps here and there. But CKD is a different monster. After we lost our beloved Corgi, Paris, seven years ago to a sudden onset of mega-esophagus, another monstrous ailment, my grief was so profound, I thought I'd never recover. Mommy and Boy were already here and loved me through the full year of mourning. This is the promise we made when we took Mommy and Boy in to live with us, just as we did when we adopted Paris as a puppy: to love and protect them, always, and see them through to the very end.

    I just hope I can be brave and strong for my Mommy Cat.
     
  15. JanetNJ

    JanetNJ Well-Known Member

    Joined:
    Jun 8, 2016
    Give some of the suggestions given a try. If in a few weeks you see no improvement, then consider setting her free... But I would at least give the supplements a go first unless you see the fight leave her. She will let you know when she's ready.

    You can get aluminum hydroxide on amazon or through thrivingpets.com
     
  16. C.W. Gortner

    C.W. Gortner Member

    Joined:
    Nov 13, 2016
    I spot BG tested her this morning; I'm getting better at it, one prick and enough blood to get a reading. She came in at 540, which is high. She's been off insulin for three days. The vet wanted her off insulin until our follow-up next week, because during our visit she hit 32 and they said she was running too low. I think I should re-start insulin. I have a call in to the vet but my inclination is to treat her preemptively.

    Never mind, I dosed her anyway. Then the vet called back 20 minutes later to say, yes, give her insulin.
     
    Last edited: Aug 31, 2018
  17. Chris & China (GA)

    Chris & China (GA) Well-Known Member

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    May 10, 2013
    Good call!!!

    Hope Mommy Cat can fight through this and give you many more purrs and head-bumps
     
  18. C.W. Gortner

    C.W. Gortner Member

    Joined:
    Nov 13, 2016
    We made the decision to give Mommy freedom today. She told us, it was time. Her assisted passage was swift and peaceful. I wrote this tribute to her:

    https://medium.com/@christopherwgortner/always-in-my-heart-10d22512d7e7

    Her son Boy is still with us. I must be strong for him now as we grieve her loss.

    Thank you for all your advice, guidance, and support in the past year, and during what has been one of the most devastating times in my life. She was my feline warrior-queen, and she's very deeply missed.

    I wish you much love and good health on your journeys with your cats. It never gets any easier to say goodbye, but the joys they give us are worth every tear at the end.
     
    Last edited: Sep 4, 2018
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  19. JanetNJ

    JanetNJ Well-Known Member

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    Jun 8, 2016
    So sorry it was her time to go. Sorry for your loss.
     
  20. Chris & China (GA)

    Chris & China (GA) Well-Known Member

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    May 10, 2013
    So sorry to hear it was Mommy's time to leave you :bighug::bighug::bighug::bighug::bighug:

    Fly free sweet Mommy and land softly...there are lots of friends at the Bridge to welcome you and keep you company until the one you love most comes to be with you forever cat_wings>o
     
  21. Kris & Teasel

    Kris & Teasel Well-Known Member

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    Aug 17, 2016
    I'm sorry you had to let your kitty go. :bighug::rb_icon:cat_wings>o
     
  22. Idjit's mom

    Idjit's mom Well-Known Member

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    Apr 3, 2018
    Very sad news, I am so sorry for your loss. Peace and comfort to you and your family. :bighug::bighug::bighug:
     
  23. Harley Baby & Michele

    Harley Baby & Michele Member

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    Jun 3, 2018
    I am so sorry to hear about the passing of Mommy. What a Beautiful story you wrote in her memory. What an amazing journey and perseverance you had to make Mommy and Baby a part of your family. Tears and hugs for you. :bighug::rb_icon:
     
  24. Tracey&Jones (GA)

    Tracey&Jones (GA) Well-Known Member

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    Dec 12, 2016
    I am so sorry you had to see Mommy go to her next adventure. Peace vines for your heart.
     
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