4/11 Jenks AMPS 73 +3 65 +5 56 +8 75 PMPS 86 +7 140 LABS POSTED

4/10

Great number to start out the day, but unfortunately, a not-so-great appetite to go along with it. He didn't want Mariner's Catch with or without FortiFlora. Same for the Mixed Grill. I offered him something he's never had before, Fancy Feast chicken, which he also turned his nose up at. I finally got him to eat a little by adding parmesan cheese to the Mixed Grill. I don't know how much food vs. cheese he managed to eat, but at least it was more than zero.

I'll try to source some slippery elm bark today, but I'm not sure what else we can be doing in the meantime. We may have to schedule a Friday afternoon appointment for another visit, although I'm not really sure what the vet's going to do that's an different from the visit 10 days ago.

 

I hope you can get Jenks to eat something consistently. Sending prayers.

 

Posted Jenks' blood test results in the LABS tab of his spreadsheet. I'd love to hear from those experienced in interpreting these things, while I manage to wade through the IDEXX manual in the meantime.

 

I’m not a lab interpreting wiz, you need @Marje and Gracie for that but we’ve had enough labs and Asia has had enough of these issues that certain bits I’m somewhat familiar with.

The SDMA is an early indication of kidney impairment, usually they look at creatinine in conjunction, but SDMA often catches kidney decline sooner and in earlier stages than creatinine would show it. The old school interpretation is once creatinine is outside of the normal range, they’ve lost a significant amount of kidney function already. I don’t know if that’s still the thinking, but either way, it shows up sooner for SDMA. Most cats end up with kidney disease if they make it to their senior years, it’s in the good to know category and what you can do about it right now, easily, is look for foods that are low in phosphorous (and carbs) and feed those instead. You can also add extra water to his food to make it a slurry or soupy.

The specfPL is really high. This is an indicator of pancreatitis, I think sometimes these lab values can be false and raised when other things are going on, so they use it along with symptoms presented and other diagnostics (like ultrasound, urine, X-ray, etc.) to decide what it means. Did they mention pancreastitis at all? It is very painful, it can cause nausea and vomiting and cause cats to be off their food. I would put a call in and ask about this one if they didn’t mention it. Usually they need to do an ultrasound to confirm an inflamed pancreas. I will dig up a link on here that talks about pancreatitis for you.

Monocytes and those other values that are out of whack above it, those indicate infection or inflammation, which could say pancreatitis or it could say something else is going on, like an infection, that is probably why they gave you the metronizadole, it’s kind of a catch all for anything untoward in the GI tract.

 

Here you go:

http://www.felinediabetes.com/FDMB/threads/a-primer-on-pancreatitis.79693/

 

Stacy, actually the SpecfPL is above normal but not really high. Max was up to 25-50 at times. Given the lack of appetite I think pancreatitis is a real possibility and I would ask for cerenia or ondansetron for nausea. If kidney disease, it’s super early. The creatinine is still under 2.0 and BUN is in the low normal range. High neural make me wonder about possible infection but much more likely due to stress of vet visit. Labs look good to me so my vet FWIW is pancreatitis. Does he appear to be in pain? If so some buprenorphine in addition to nausea medication might get him feeling good soon.

 

Asia’s specfPL was 31. I still think 14 is really high relative to 3.5 being the upper limit of normal and it’s 4 times that, Asia and Max I would put in the absurdly high category.

Pancreatitis is no fun, but Jenks would be in great company if he has it. Very many cats here do.

 

Keep in mind that the number does not equate to severity. Gracie’s specfPL was in the high 30s but she never had pancreatitis (she had many, many ultrasounds and the pancreas always looked great). So if the specfPL is ten times higher than the above normal number, it doesn’t mean the pancreatitis is worse.

Here is the huge red flag I’m seeing....his creatine kinase. You do not want to ignore that number. The last one I saw that was high was Karen’s Doodles and Jenks’ is much, much higher (almost four times higher). An elevated CK indicates some kind of muscle damage and, in Doodles’ case, it was hypertrophic cardiomyopathy. Any kind of body trauma can raise the CK level as can autoimmune diseases (inc Cushing’s disease), long term use of steroids, epilepsy, shots given into the muscle, toxoplasmosis, FIP, etc. Do you have any baseline data for that number? It’s definitely something I would not ignore. The other thing to check is the actual lab report and see if it says anything about hemolysis of the sample. Hemolysis will cause some elevation but not to that degree, IMHO.

It does appear he has Stage 1 CKD due to the elevated SDMA. But, at this point, I’d focus on finding out why the CK is so darn high. I doubt it’s due to pancreatitis because I look at a lot of labs of cats with active pancreatitis and I don’t see elevated CKs. In fact, the only one I’ve seen is Doodles’.

 

Following on from Marje's post, that CK does raise a red flag, along with the inappetance. Try counting Jenk's resting respiration rate. Count the number of complete in and out breaths per minute. You want it to be under 30 ideally. My concern is possibly the heart, or HCM as Doodles had or some other heart damage. Neko also had heart issues, the first sign was going off her food. HCM means enlarged heart, a too common enough occurrence in acrocats (plus others). Given that Jenks got to a higher dose, I'd keep an eye on his heart. If diagnosed, there are drugs that can help.

 

First things first, an excellent set of numbers today. He ate well at the post-AMPS feeding. He also ate well again just moments ago at PMPS. This was straight food without a FortiFlora enhancement. I got him to eat some more after a good dusting of the stuff.

Slippery Elm Bark question:
I was able to get some Slippery Elm Bark powder at an cute little herb & tea shop right down the road. How do I prepare the goopey slurry? Is there a recommended amount of powder to water ratio? And how much do I give him and how frequently? I don't want to waste it by putting it on food he may not eat, so is it OK to give the mixture to him with a syringe by mouth?

 

You can mix 1/8 tsp of the powder with enough water to make it a slurry. You want it thicker than water but not really thick. Yes, you can syringe it. Separate it by two hours from other meds or supplements. You can increase the SEB to 1/4 tsp if you think 1/8 doesn’t help.

Did you check his RR?

 

Hooray for eating well!

The photo I posted to your condo yesterday has instructions how to prepare it, you can make enough for 5 days. You make a gruel with the SEB and water. You can add it to food or syringe by mouth (but it’s a teaspoon’s worth, so it’s not a tiny amount either).

 

Thank you to @Stacy & Asia @tiffmaxee @Marje and Gracie @Wendy&Neko for stopping by with your wisdom. There's a lot to digest, so let me try to address what I can.

When the vet called with the results, he said everything looked great, but that Jenks had mildly elevated pancreatic enzymes consistent with diabetes. Had I not insisted on a copy of the report, I wouldn't have known about this other stuff. So right now I'm fighting some anger, and some fear because what I'm reading about the creatine kinase and heart involvement makes me very, very nervous.

Elevated Pancreatic Enzymes - The Spec fPL is 3.5x the max reference value. To me that doesn't seem "mild." But as @Marje and Gracie pointed out, a high Spec fPL does not necessarily equate to pancreatitis. While I understand that there's not one clear diagnosis for this, it's unclear if Jenks exhibits the usual symptoms.

Weighing in favor of a finding of pancreatitis: A recent bout of vomiting and diarrhea, followed by continuing inappetance. Lethargy.

Weighing against a finding of pancreatitis: He had two nights of acute vomiting and diarrhea 10 days ago, but nothing since and nothing similar in the last 5 years. He's not dehydrated. The doctor did not indicate that he felt anything abnormal in the abdomen during the physical exam. Jenks shows no signs of pain or discomfort. Temperature was normal. BG is not elevated, in fact, it's better than ever.

Vet recommendation: He said that even if it was pancreatitis, all he'd do is give fluids in the office and send him home, which seemed unnecessary because Jenks was drinking normally at home and didn't show any signs of dehydration.

Elevated White Cell Count - Innate immune cells up, adaptive immune cells down. According to IDEXX, the common causes for ______ are:

Decreased lymphocytes: Stress, acute systemic inflammation

Increased neutrophils: Inflammatory response (infection, immune related disease, tissue necrosis)

Increased monocytes: Inflammatory response (infection, immune related disease, tissue necrosis)

My thoughts: I'm not sure these are very indicative of anything by themselves, and may be a result of something else that's going on. The least concerning of the out-of-whack values, especially if the stress of the office can be a causative factor.

SDMA - A senior cat with perhaps some early stage kidney dysfunction? Not really a surprise I guess, but I'd like to learn more about what, if anything, we can do to ward it off to the best extent possible.

Creatine Kinase - 10x the max reference value and didn't even warrant a mention by the vet. But this is the one that concerns me the most. It was apparently worth a re-test by IDEXX, who noted "RESULT VERIFIED BY REPEAT ANALYSIS". I'm afraid there's no baseline number to compare to, so this is the only result we have to work with.

If it's heart involvement, what do we do and who do we see???? Is it clinically relevant that he's lost 3 pounds in the last year? What if some of that was from muscle?

According to IDEXX, "Significant elevations in CK are usually the result of skeletal muscle damage." Not sure how he would have that, but ok....

Common causes include (I have used a strike out on ones that can reasonably be ruled out as an issue):

Muscle trauma

• Restraint
• Difficult venipuncture
• Hit by car/other trauma
• Prolonged recumbency
• Surgical procedures
• Muscle biopsy
• Intramuscular injections

My notes: I shoot his insulin with an 8mm needle into a tented flap of skin along his belly just in front of his right rear leg. There shouldn't be any muscle there (right???), and this is the only injection he receives.

Muscle inflammation

• Ischemia (Post-infarct ischemia, Aortic thromboembolism, Disseminated intravascular coagulation [DIC])
• Necrosis (Snake/spider envenomation, Heatstroke)
• Infectious (Toxoplasma sp. Neospora sp. Pyogenic bacterial infections Endocarditis Systemic infections (septicemia) Parasitic)
• Inflammatory non-infectious myositis (Immune-mediated polymyositis, Eosinophilic myositis)

My notes: I'm not educated enough on these topics to exclude anything other than venomous bites.

Exertional disorders

• Exertional rhabdomyolysis
• Seizures

Uncommon Causes include:

• Congenital/inherited degenerative myopathies (Muscular dystrophy, Myotonia, Hyperkalemic periodic paralysis)
• Nutritional myopathies (Hypokalemia, Taurine deficiency)

Toxic

• Ionophores (e.g. monensin)
• Castor bean (ricin)
• Gossypol (cotton seed meal)

My notes: He's definitely not poisoned.

Neoplastic

Artifact

• Hemolysis interferes with some CK assays

My notes: @Marje and Gracie asked me to check the report for any mention of this. There are no additional notations for this test.

Miscellaneous disorders

• Urinary obstruction
• Vomiting
• Shivering/trembling
• Malignant hyperthermia
• Hypothermia

My notes: Vomiting is what precipitated this visit, but I can't find any info about how this factor would affect the numbers.

 

Resting respiration was 28-30 for the one minute that I observed him. I'm not sure if that was influenced or not by him noticing that I was nearby watching him. I'll try again later.

 

RR can vary. I tried to do it when Neko was snoozing. The fact that he's eating well again is very promising. For heart conditions, you have to see what it is first. Neko had very mild HCM for a couple years that needed no meds, just monitoring. It wasn't until it got worse that it impacted her appy. She had a echocardiogram for diagnosis and went on a couple heart meds. Heart conditions can vary widely.

 

I have out of town company this week so forgive the short note.

With the CK being so high (which my vet said was nothing to worry about) X-ray showed nothing Doodles BW was all normal but his appy and behavior said something was wrong along with his his bg’s out of wack. His dose was low for him until it went wonky.

Long story short I got the echocardiogram done with the advice from Marje and Wendy and sure enough Doodles was in advanced HCM and CHF. He was also dx IAA at the same time. The meds gave us another yr together.

 

You can also get a blood test called BNP, it can tell you if there is an indication of something heart related so you can proceed to see a cardiologist or have further testing done.

 

This is all quite frankly terrifying, but I wanted to say how much I appreciate each and every one of you sharing your information. Not really sure what to do next, but we need to triage the appetite thing first to see if we can get him eating before moving on to something else. In the meantime, I'll try to get the vet on the phone to see what he has to say about the CK numbers. He's got some explaining to do.

 

Thank you for the great synopsis above. It’s late here so I’d like to remind spend tomorrow.

If you want to consider the potential for heart disease. I do agree that you could get an IDEXX cardioPet proBNP blood test which is a screening tool for cardiomyopathy. If it is positive, then you’ll need an echo. If $$ are tight, I’d just consider the echo.

Pancreatitis can cause the symptoms he has but so can many other things. As you said, getting him eating is the priority.

I’ll post again tomorrow.

 

I have no advice to add, but wanted to weigh in with vines and good thoughts, and a few s because this is so stressful - not knowing is just plain awful!

 

I'm sorry you are having to deal with a worrying test result, I had a similar experience with my vet telling me results were fine, but then when I looked at them and saw that some of the numbers were out of wack and posted them here we came to the conclusion that the results indicated early CKD, when I put this to my vet she agreed, but because George was at a point where he did not need medicating she felt she didn't want to worry me

• What I do for George at the moment, to help keep his kidneys steady, is feed a low Phosphorous diet (I keep it below 1%),
• he gets plenty of water with his food, he doesn't mind me adding water to his food so I make it quite soupy,
• he has a water fountain which helps his day to day drinking (he uses this more than if I just had a water bowl), keeping them well hydrated helps protect the kidneys.
• And even though he is OTJ he gets regular meals every 3-4 hours, (kitties with CKD can me prone to acid tummy, feeding regularly helps prevent this, though BFG has never been a puker)

You are probably doing most if not all of the above anyway.

 

I should've added some of these and extra scritches for Mr. Jenks.

My vet which was VCA and highly recognized in my area literally said "well his CK is high but it's not like he has heart disease I won't bore you with the details but lets just say after his echo, that vet and I did not leave on good terms. I did tell her very frankly that in the future it might be a good idea not to "blow off" CK results for future cats I'm certainly hope this is not the case with Jenks but it does still get my blood boiling. Once the heart meds were on board Doodles ate consistently until the day we let him go.

 

Since you are in AZ although up North I believe, Dr. Church is in the Phoenix and a wonderful, caring cardiologist. He's with http://www.dvmspecialists.com/specialty-services/cardiology and has locations in Scottsdale, Glendale and Gilbert. Marje has also used him with her kitties. Initially I had to schedule with the IM vet for the echo because Dr. Church typically has a long waiting list.

 

The Spec fPL can be elevated for other reasons, even kidney disease and diabetes so I’m glad you are checking this out with a cardiologist. I hope it turns out not to be heart disease but if it is the sooner you find out the better. I know this first hand.