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Diagnosed CKD - need diet advice

Discussion in 'Feline Health - (The Main Forum)' started by kimberbee, Nov 27, 2019.

  1. kimberbee

    kimberbee Member

    Joined:
    Jun 29, 2018
    Labwork results indicate CKD. Vet recommends 50ml subq fluids 2x/day and a low phosphorus diet. Blood glucose was in the 100-and-teens so I was told to focus on lowering phosphorus over worrying about carbs.

    I have the labs and can post exact numbers if needed.

    I can home with Science Diet k/d (pate with tuna) and Royal Canin Renal Support E. I also stopped and got a few cans of b.f.f., Wellness, and Weruva. I have a concern about not staying low carb, because Toasty has been eating Fancy Feast Pates for a year and has been OTJ for that whole time and longer.

    I also was given a powdered phosphorus binder to add to his food, 1/8t 2x/day.

    Any food advice anyone can provide would be helpful.
     
  2. Red & Rover (GA)

    Red & Rover (GA) Well-Known Member

    Joined:
    May 18, 2016
    The Renal Support E (canned) is 21% carbs and 90mg phos.
    I suspect the Science Diet k/d is also high in carbs.
    Most people balancing diabetes and kidney disease feed foods that are low carb and low phosphorus.
    A link to such food is here:
    Good for your vet for going with a powdered phosphorus binder (aluminum hydroxide?). The gel version contains sweetener.
    It must be given with food to be effective. The thing to watch for with a phosphorus binder is constipation.

    Tanya's site is the CKD bible. Like feline diabetes, it is a steep learning curve.

    If you can post your lab results, there are a few people here who are very good at interpreting them.
     
    kimberbee likes this.
  3. kimberbee

    kimberbee Member

    Joined:
    Jun 29, 2018
    Yes, I used that chart to determine what foods to get in addition to the prescription food from the vet. The foods on that list still have high phosphorus, as compared to the rx diets that have less than 100mg phosphorus.

    I am not sure how to balance out the need for low carb vs the need for low phos and how to meet in the middle. I do have a glucose meter so I suppose I can be monitoring that at home.
     

    Attached Files:

  4. kimberbee

    kimberbee Member

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    Jun 29, 2018
    I hope the first 2 pages of labwork, previous post, and these two pages are legible.
     

    Attached Files:

  5. Red & Rover (GA)

    Red & Rover (GA) Well-Known Member

    Joined:
    May 18, 2016
    I see that the glucose is in range. That's a good thing but still needs watching. Once a diabetic, always a diabetic. A higher carb diet is not going to help.

    Tagging
    @Marje and Gracie
    for help with the lab work.

    Handling diabetes and CKD is a question of balance. While the low carb foods on the list are higher in phosphorus, the phosphorus levels can be kept in check by the use of a phosphorus binder.
    Information on phosphorus from Tanya's site: http://felinecrf.org/phosphorus.htm
    If your cat will not eat a therapeutic kidney diet, or if his/her phosphorus levels are still too high (over6 mg/dl(US) or 1.9 mmol/L (international)), despite feeding such a diet for a month, products called phosphorus binders are used. These are simply added to the cat's food: they bind with some of the phosphorus in the food in the intestine, thus preventing it from being absorbed and thereby reducing levels of phosphorus in the cat's body.

    Phosphorus binder information can be found here: http://felinecrf.org/phosphorus_binders.htm

    There is also an excellent forum and facebook page (group Cats with Chronic Renal Failure).
    https://felinecrf.org/tanyas_support_group.htm
     
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  6. kimberbee

    kimberbee Member

    Joined:
    Jun 29, 2018
    Thank you for your input and tagging someone to look closer at the labs.

    I did give some of the Royal Canin food to Toasty just now - he scarfed down half a can, whichis the most he's eaten at once in a few weeks. It makes me very happy to see him eating.

    He even licked the phosphate binder off the bottom of the bowl. I will be more vigilant about testing his blood sugar going forward while I work on lowering his phos levels.

    I will check out that facebook page as soon as I can.
     
  7. katiesmom

    katiesmom Member

    Joined:
    Mar 1, 2013
    I just wanted to mention something I noticed on the labs. The glucose was good at 107, but urine showed a trace of glucose. Meaning at some point since the last time he urinated his BG was high, high enough to spill into his urine. Just wanted to point that out, so you keep an eye. Maybe it was just stress spiked it (but then you would think it would of been high on the bloodwork too). Just thought I would mention it.
    I know you have your hands full with the CKD.
    Having been through both, FD and CKD with my kitties, I empathize with you.
    I saw your other post you having trouble with Toasty accepting the fluid treatment. Fluids are tougher than insulin shots, IMO. Insulin shots only take a few seconds, fluids require them to sit still for minutes. You can try offering treats while the fluids are in, see if that helps him be more accepting. Wishing you and Toasty the best.
     
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  8. kimberbee

    kimberbee Member

    Joined:
    Jun 29, 2018
    Thank you.

    Yes, he was very stubborn about fluids last night. I have been doing half kidney rx food and half low phos commercial food in an effort to 1. Keep phos low, 2. Keep BG low, and 3. Get him to eat something... he is still not eating as much as he should be.

    My confidence from yesterday at the vet has been shattered. I'm trying not to worry, but I couldn't sleep last night. I really wish today wasn't a holiday so I could bring Toasty in for fluids and stay home to encourage him to eat.
     
  9. kimberbee

    kimberbee Member

    Joined:
    Jun 29, 2018
    Alright... fluids are being given, though not quite as much as we should be. It's still quite difficult everyone involved - Toasty gets growly, I get anxious and start to shake, and my husband get nervous that he's going to end up bitten. We're working on it.

    Next is the food. While he's eating more than he had been, he's still not eating enough. The renal diet is only ok, he doesn't eat it happily.

    Weruva FAILED - he licked some of the juices and left all of the meat...
    B.F.F is hit or miss. He'll eat a bit when I first put it down, but won't go back to it later.

    Does anyone else have experience with the lower carb/lower phos foods on the list? I hate to order from Chewy since it all seems to come in cases, and my options locally are very limited. Petsmart and Petco are 45 minutes away, so I can't be making that trip multiple times a week.
     
  10. Marje and Gracie

    Marje and Gracie Senior Member Moderator

    Joined:
    May 30, 2010
    Sorry to just get to this today but we’ve had holiday company.

    First, before I forget, perhaps the video we did on how to give subq fluids at home will help. Personally, after having had several CKD cats, with his creatinine where it is, I’m surprised your vet is only advising 50 ml a day. If Toasty does not have any heart issues, he should be getting 100 ml a day so I’d discuss that with my vet.

    Here is what I see besides the creatinine and SDMA being elevated; the things I’ve listed below are absolute priorities and will directly influence his longevity:

    • phosphorus is way too high; you need to be using a phosphorus binder in addition to feeding low P foods. The lowest P foods are the renal diets but they aren’t the best for FD. You want to try and find foods that are less than 1.00%P on a DMB or less than 200 mgP/100kcal on an as-fed basis. Below are three resources for you all from Tanya’s Comprehensive Guide to CKD:
      • All about Phosphorus
      • Phosphorus Binders including dosing instructions (I don’t know what you are using but I highly recommend Aluminum hydroxide powder which you can get from ThrivingPets.com); also, for where his P level is, the dose is too low. Double check tanya’s but I would think he needs closer to 1/4t and you don’t dose it just twice a day. You need to sprinkle some in every single bit of food he gets. For my cats, I just got out a 1/4 tsp measure and sprinkled a little on every daytime meal and then did it again for the evening meals. (as an example for recommended dosing, for P levels between 6 and 7 for a 10 lb cat, it would be 60 mg/pound. That’s 600 mg per day and 600mg of aluminum hydroxide powder is 1/2 tsp as the daily amount.
      • Read about giving niacinamide which is discussed at the bottom of the P binder page and also on the Vit B page.
    • HCT is trending towards anemia so I would start on B vitamins to help with this. You will want to give methylcobalamin and a multi-B vitamin; he needs both so don’t skimp and just give one.
    • He has protein in his urine and it’s quite high. Your vet needs to do a urine Protein:creatinine ratio as proteinuria is very common in CKD cats; if he is proteinuric, there are remedies for it.
    • Has your vet checked his blood pressure.....that is really, really important so be sure it’s done. It is very common for CKD cats to have high blood pressure and it’s easily treated.
    • While Ca is normal, Ca x P is really high and that’s because his P is so high. Anything over 70 when you multiply Ca x P puts them at risk for calcification of tissues. While Calcitriol has been very helpful for some cats to help them feel better, until his P is down, you don’t want to give anything that can raise his Ca.
    I hope that helps to get you started on treatments.
     
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  11. kimberbee

    kimberbee Member

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    Jun 29, 2018
    Toasty has been getting about 50ml a day - that's about all we can get into him before he really starts throwing a fit. I have been adding water to all food (though he hasn't been eating much) and gave him a water fountain. I have a second fountain and I will put it up if I can find a suitable place (we have a dog that will drink it dry if he can get to it).

    I have been using the phos binder (aluminium hydroxide powder) with all food I have been giving. Some of it is low phos, some is low carb, some is a bit of both. He is not eating much so I'm trying everything. But I am always adding the powder.

    Vit B12 was added to his Normosol bag. Note on the bag says 5000mcg, and we give him 50ml. I'm awful at math and even though that should he simple math, I'm not going to pretend I know what that amounts to. Is a multi B something I should get and give without consulting my vet? I can call to speak with them Monday morning.

    With blood pressure and protein in the urine - I had brought that up to the dr. though he seemed more interested in getting Toasty fluids and eating. I had called earlier today because it's been very hard to give fluids, and he's still not eating much.

    Rec #1 was 5-7 days in hospital with IV at a rough estimate of $2k.
    Rec #2 is to bring him in 2x/wk for fluids at a cost of $35 per visit.

    We were able to pick up Mirtazapine for appetite just before they closed today. Toasty got a small dose and then 2 hours later vomited twice, started drooling a bit, and is now hiding somewhere.

    I'm a bit concerned for the last part... he is normally not a hider...

    One more thing - I did join Tanya's support group and am trying to gather all info I can from the webpages. Sorry if I have repeated myself.
     
  12. kimberbee

    kimberbee Member

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    Jun 29, 2018
    I found Toasty under the bed. Sat down on the floor near the bed and he came out and climbed up right into my lap. He's shaking a bit. I am hoping this is just a side effect of the medicine.

    I have a Walmart and a Meijer near me, oth open 24 hours. If there is a B-supplement I can get for him there I will be happy to. I totally forgot until just now the dr also recommended fish oil. Again, if that's something I can grab tonight I will.

    Petsmart and Petco are much farther and I may not be able to make the trip tonight.
     
  13. Marje and Gracie

    Marje and Gracie Senior Member Moderator

    Joined:
    May 30, 2010
    It is very likely that what you are adding to his bag (I prefer lactated ringers over Normosol and the reason why he might not let you do more than 50 ml is that Normosol stings), is cyanocobalamin, not methylcobalamin. Cyanocobalamin is great for intestinal issues and just to help the cat feel better but it does not address anemia. You do not have to consult with your vet. While there are some places where you can get methylcobalamin in a liquid to inject, typically, it is a capsule. Again, without the multi-B, the methyl B12 will not help his HCT. Please read the link I gave you on B Vitamins.

    It really concerns me that your vet does not have a good handle on treating CKD. That’s not unusual. You absolutely must be addressing the BP and the proteinuria. Giving fluids is actually secondary to getting P under control, addressing any potential high BP, addressing developing anemia, and also proteinuria. Those are the things that are tied to longevity more than an elevated creatinine.

    His creatinine is not high enough for this. That is usually done with cats whose creatinine is almost double where Toasty is.
    I read in another condo that you watched the video I linked and it was the same as what they taught you. I’d be extremely surprised if it’s the same as what they taught you because I’ve not only seen at numerous vets how they teach how to give fluids, I’ve had my vet ask me to go out to other clients’ homes and teach them how to do it so the cat will be ok with it. In the description of the video, I also give a link for getting a little vest that helps because the needle can be inserted and the cat not sequestered after that. Again, I would ask for Lactated Ringers Soln and see if that helps. My video description also tells you how to get less expensive LRS than the vet (if they even carry LRS) and also where to get 21g needles instead of the harpoons they use at the vet’s office. If you are using 18g needles, that might also be something he doesn’t like.

    The problem with mirtazapine is two-fold. One is that you can only give it every three days (although some vets seem to be using a daily option for it). The bigger issue is that high P levels make a cat nauseous. Therefore, you need something for nausea before you give an appetite stimulant. This is another thing I just can’t understand why vets don’t “get”. Why stimulate the appetite of a cat who is nauseous without first addressing the nausea? You need cerenia and ondansetron to help with those. In case your vet isn’t up on the ability to use cerenia long-term, you can. It’s dosed once a day. Ondansetron is a human drug which, IMHO, works best for nausea but the two together are great because they address nausea from different modalities. Ondansetron can be given 2-3 times a day based on the strength and the need.

    Slippery elm bark syrup is also good to help with acid tummy caused by CKD and high P. You just want to be sure it’s given separated by two hours from meds.

    I doubt that the pet stores have the B Vitamins you need. I got mine through VitaCost but a health food store might have them. Again, please read the link on Tanya’s as she goes through those. You don’t have to rush out and get it tonight. Although he is considered to be anemic, the big guns for anemia are not brought out until the HCT is below 20%. Your goal is to keep it from doing that.
     
  14. kimberbee

    kimberbee Member

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    Jun 29, 2018
    Again, I really appreciate your responses and you taking the time to help.

    I am honestly at a complete loss for what to do at this point.

    My vet is closed until Monday morning, so I have what I have and can either get something else from Walmart, or go to the ER vet for $99 plus whatever they recommend. I can try to see a different vet, but that would mean going to a different office entirely, and would have to wait until Monday morning to call and see who is available to see us.

    We are trying with what we have... My husband and I have both watched videos on giving subq's, I've messages two vet techs who are friends of friends. I can buy other supplies, but it will take time for it to arrive... I've spent $40 on canned foods and now Toasty is not even licking the water off of what I've given him. I can talk to the vet about a different medicine, but I can't source it from anywhere until Monday morning at the earliest.

    I feel like Toasty should probably be hospitalized and watched. I do not feel that I have the funds to do so.

    I am debating the $99 fee at the ER vet for at least a second opinion, but again, I'm not sure I have the funds to hospitalize him or pay for a full round of diagnostics again.
     
  15. kimberbee

    kimberbee Member

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    Jun 29, 2018
    Well, a little update, though I feel I'm going disappoint a lot of you here...

    We did bring Toasty to the ER vet Sunday and bloodwork was done again. Many of his values were slightly "worse", unfortunately.

    Our current plan is to bring him in for acupuncture and subq fluids for a few weeks, and we have a few medications and supplements to give at home. Reevaluate at the 3 week mark or if his demeanor changes. Other than not eating much, his energy level and attitude is normal.

    Unfortunately, pills are getting harder to give, and paying for every vet visit is becoming a strain. I understand that many people are able to go further with additonal diagnosing and testing, but we just don't have that ability. I am very sad and would love for him to be around longer.

    Just wanted to let you all know we're still here and doing the best we can. Not sure if there are other resources for us at this time.
     
  16. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

    Joined:
    Aug 5, 2016
    I'm really sorry to hear how much you and Toasty have been struggling, just as FD, CKD can be overwhelming at first but it can be handled is just a lot to learn in the beginning, and once past the initial diagnose the test that you will need are usually blood tests every 2-3 months in the beginning and around every 6 months once everything gets more stable.

    First thing is you want to address both issues, diabetes and CKD, because an uncontrolled diabetes will complicate things more and cause his kidneys to struggle extra which as they've mentioned means you will probably not be able to use the kidney prescription diets because they are not low carbs ( on the good side of this is comercial diets are cheaper), mixing the high carb-low phosphorus with the low carb- high phosphorus is really not a good idea since you will not achieve either one of your goals, so I do recommend that you try and get a low carb food with the lowest phosphorus level that you can find and compensate with a phosphorus binder which you mentioned that you are already giving, it takes a few days ( between two to 3 weeks ) for you to see results on his phosphorus levels once you start giving them.

    Just as with the blood testing pilling them is a matter of you both getting used to it and after a while ( given the proper treats) it gets easier, some cats eventually even ask for them knowing that it means treat time, and for some of the supplements you have to give there are options and you can mix them with the food instead of giving a pill (B12 for example you can open the pill and mix it with the food) What meds and supplements did the vet gave you?

    If he's appetite is low he may be having some stomach acid or nausea, both are common with CKD which you can address with SEB or Cernia you could talk to your vet about giving something for this

    Hang in there:bighug::bighug::bighug::bighug:
     
  17. kimberbee

    kimberbee Member

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    Jun 29, 2018
    Ouch. That is going to be very difficult...

    We have cerenia, famotidine, and mirtazapine. For supplements, we were given a Chinese herbal that is supposed to work together with the acupuncture to help his appetite and kidneys. B12 is added to his fluids and I've been given the ok to try slippery elm bark and cbd oil.
     
  18. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

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    Aug 5, 2016
    Cernia and farmotidine all are usually given for nausea and vomit, as well as SEB even though SEB has some other properties and may help with constipation and diarrhea too and usually is recommended to try one at a time to see which one works better for him (on rare occasions a cat uses more than one but is usually after one alone does not work) so probably you need to check with the vet which one would you be using first, if he's not vomiting maybe start with SEB that is a bit more gentler and see if it works

    Here's a link with a lot of information on nausea and vomiting from Tanya's web page
    http://www.felinecrf.org/appetite_loss_nausea_vomiting.htm#maropitant

    Sometimes B12 in the subq's can sting a bit (not always there are cats that don't have a problem with this) so maybe you could talk to your vet about giving it orally which would allow you to give the methylcobalamin form which is better for CKD cats

    Also you could talk to the vet about giving him B complex not only B12 given the anemia that Marge mentioned.

    Something else that helps a lot is giving him omega 3 fatty acids
     
  19. kimberbee

    kimberbee Member

    Joined:
    Jun 29, 2018
    Well here's an interesting and possibly related or possibly not development...

    Toasty vomited this afternoon and there was a WORM in it! I happened to just be getting home when I heard the tell-tale howl he makes just before a hairball. I managed to catch the spew in a cat blanket and then it started MOVING!!

    I put the worm in a dish and rushed it over to the vet - their initial thought was that it's just a run of the mill intestinal worm. I'm going to bring a stool sample back tonight so they can be sure. I do wonder if that contributes to his feeling unwell, and if treated would help him feel a bit better, eat a bit more, and get his anemia and kidney values to a manageable state.

    No idea where he got worms from, as he's an indoor only kitty. He does eat the flies that get into the house. We do have a dog, but he is a very lazy, mostly indoor dog. If Toasty was infected before we even adopted him a year ago... I have to imagine he's got a pretty bad worm population having a party in his gut!
     
  20. Veronica & Babu-chiri

    Veronica & Babu-chiri Well-Known Member

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    Aug 5, 2016
    OMG!! That's nasty and gross and adding to his discomfort and I'm guessing it does not help to his overall condition but probably is something that is easy to deal with demorming him
     
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  21. kimberbee

    kimberbee Member

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    Jun 29, 2018
    It was sooooo gross!! Such good timing though! I had literally just walked in the door and was about to bring my son upstairs for a nap. Had timing been different, I could have still been out, or upstairs and wouldn't have seen the worm as he puked it out!
     
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