Metabolic Acidosis help

Latte's kidney panel came back today. They (or should I say the ONE) are showing a pattern of deterioration in the last 6-8 months, which is a real bummer. One of my main concerns is the metabolic acidosis. Her bicarb was 12 and Anion Gap 29. This very well could explain her back leg weakness over the last few months. *sigh*

Her vet has said it is expected in cats with renal failure. He also knows that I would never accept an answer like that :lol: . Ive put a call into her specialist at the University, but he is in research not clinic rotation, so I am not sure if he will call back. What I need to do (with all my free time - YA RIGHT! :roll: ) is come up a guideline as to when and why we need to treat this. Also feedback from those with cats who have experienced this. He is very good at letting me be the driver, but I always need a plan and back it up with solid reasoning. The only other alternative is to go through testing at the university and see someone there. That, however would cost more money than I can pay since it would have to be with a different specialist.

I know this is very treatable. I have to at least TRY and treat the things I CAN.

Thanks for any help.

 

Carolyn,

I don't understand why your vet isn't helping and guiding you with a treatment plan.

Maybe you can share this info with your vet.

http://www.vin.com/VINDBPub/SearchPB/Pr ... R00122.htm



Best,
Pam & Layla

 

First, so terribly sorry about that Metacam thing.

"Bicarb" level of 12? Was that a TCO2? If so, I'd start treatment now, as soon as you check into it of course.

I have not dealt with metobolic acidosis personally, but a very few on my group have. My understanding is that it doesn't usually happen until later stages. However, since it's general a separate, request-only, expensive test, it is not done a lot, so it may be going undiagnosed a lot. I had it done on Sammy once and the results were pretty good so I decide not to do it again for a while.

But I can give you some links directly to some info on Tanya's site:
http://www.felinecrf.org/diagnosis.htm# ... c_acidosis
http://www.felinecrf.org/treatments.htm ... c_acidosis
Look around while you're there. This is like THE best CRF site, especially when the other ones get too technical.

Having blood results is always nice, but I realize this isn't a CRF site. If you haven't, I suggest joining one of the Yahoo groups, either mine (in sig) or one of the other groups. (Look for Melissa's daily post.)

As for sticking the famotadine directly into subq's, I'm not sure it works that way. I crushed it into Sammy's food and he ate it fine, but that was him.

 

Just a note, TCO2 is a marker of respiratory acidosis, HCO3 is a marker of metabolic acidosis. HCO3 is bicarb.

Carolyn how was this test taken? Blood gases don't "keep" well and so the test is usually run in-house or as a special test to the lab. I would hate to start messing with things without knowing that the bicarb is really so low. What was the blood pH? What is the potassium level? What is Latte's diet? Diet can help reduce acidosis, as can acid blockers such as Pepcid (it is not stomach acid that is causing the problem, but a reduction in the body's acid production can help)

 

Thank you SOOOOOOOO much for the responses.

Answers to some questions:

My vet is very new. He is very good, in the sense that if he does not know something, he will find the answer. If I disagree with him, he will follow my lead (usually I back it up with evidence). He is a total team player. I dont doubt in vet school he was told cats with renal disease are acidic and MA doesnt happen much or whatever. BUT, if I say I want to treat it and why he will cooperate if he knows its in Latte's best interest.

Jess-Thank you for chiming in yet again with one of Latte's posts. I know you are busy, so I really appreciate it.

Test was taken at regular vet clinic via blood. I do remember from a few years ago when I wondered if this was an issue that it might not be an accurate way to determine MA. I would have to go to the University hospital where they can do more specialized testing. I also remember discussions with her regular vet and specialist that its not something you try to treat unless you know for sure. So thank you for this reminder.

Blood pH is not on this test. Probably not relevant, but from the university in June it was 7.365

Potassium 5.2 (3.3-5.4) Over the phone it he said it was normal, which it is, but...its rising which was an issue for her in the ARF.

Latte's diet is wellness (turkey, chicken/beef, turkey/salmon, beef/salmon), FF (chicken/liver, beef/liver, chicken/beef), occassional EVO, and another grain free brand I cant remember off the top of my head. She also eats a fair amount of kibble. I know, bad. I try to encourage wet, but this is a cat that spent nearly a year syringe fed recently. She is not going to be around much longer. If she wants to eat, she can have it. (she is actually eating some wet food as I type!! ).

Latte takes .5ml pepcid injectible in fluids everyday.

I accidently left her labwork at the U in May when she had an ER visit, so I dont have them right now to compare. I do know that BUN is up from 34 to 64, Phos is up from low 4's to 5.4, Creatinine has gone from 2.1(june), 2.3(oct), 2.4(jan) No bouncing between two numbers like she used to do (ie./2.3, 2.2, 2.1, 2.2). It appears as if that has a rising trend. Bicarb now is 12, Anion Gap 29. Albumin is 3.9 (end of range).
Others:
calcium 10.6 (8.7-11.7)
Sodium 154 ( 146-160)
Chloride 118 ( 110-123)
Potassium 5.2 (3.3-5.4)

University Test (ER) in June (in for severe onset vomiting/diahrea)
Na - 152
K - 3.7
Cl- 125
TCO2 20
TP- 7.0
PCV 33%
Bun 30
Glu 112
Hct 31%
pH 7.365
PCO2 32.9
HCO3 18.8
BEecf -7
AnGap 12
Hb* 10.5
*via hct

Sample type VEN

So Im guessing I probably need to get into the U where the only specialized equipment to test for this is available. This is one of those things I feel needs to be a priority because it is reasonable to treat, from what I remember. But, if left untreated it could be very bad. Is that correct? Looking back at all old labs the only time it was this bad was in the midst of the arf. I think bicarb was 8 or 9 and AG was in the 30's. It resolved itself as she returned to near normal kidney functioning.





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Yes, I do to. And I will forever be a fighter and advocate for its use ONLY in quality of life issues. Along with fighting for client information sheets to be given to owners for medications such as NSAIDS...but thats another topic in itself.

Helen's group and her site saved Latte's life, as I found it just a day before I was told I should pts and was mentally preparing to do so.... three years ago next month. Im a regular on her yahoo group, and often frequent the other.

It works, especially for a cat that really cant be pilled, or has absorption issues. ;-)

Thank you for the support. It really means a lot!

 

It took me a while to find something from a more "legit" place, but I finally did:

"TCO2, not to be confused with pCO2, is another measurement of [HCO3-] and is often used synonomously."

From vet.uga.edu. (WAY into the article.)

I don't know what pCO2 is versus just CO2, though this article does talk about both as though they are the same. CO2 can be decreased with MA and some vets do use that as a test. TCO2 isn't the same thing and is a better test. I'd never heard of HCO3 until I started trying to find it just now, but according to this is another measurement of bicarb. (Since I've only heard of the TCO2 and not HCO3, I only know it by total carbon dioxide and not as a measurement of bicarbonate itself.)

I do know the test we did was TCO2. That is also the one that is more difficult to get than CO2. I can't say anything really about HCO3 since I'd never heard of it, but I do know TCO2 is an appropriate test, and that CO2 appears (from this article) to be the one used for RA.

 

Yeah! Three years. Another testament that many seemingly untreatable things can be treated and add years. (And a testament to a non-renal diet.)

I'll have to trust you on that one. I've just never heard of anyone doing that.

The renal values are mostly good. I don't get too worried about BUN unless it gets really high. And it'd be nice for the phosphorus to come back down. Boy, Sammy would just go into carp mode and not eat if his got into anything with a 5 on it. Got unlucky on that one. Probably makes me paranoid about it.

I do see that in June a TCO2 was actually done and that it's very close to the HCO3. That may say something right there -- maybe like HCT and PVC aren't the same thing, but very close and can be used interchangably for our purposes. I agree with going to whatever university you speak of, if you trust their accuracy better. It is easy to screw up.

 

Re: Metabolic Acidosis help - Update

I spoke with latte's specialist today and he made it clear that if her lab results are 'true' than this is indeed serious. Most cats with a creatinine as low as hers should not be so acidic, but it is possible. He was curious of her BG at the time of the test. we did not have that measured. But her home test if I remember correctly was in the low 200's when we left and 79 when we returned. He was thinking ketones might be the cause, but was a bit perplexed if her BG was potentially under 100. He made it clear that if indeed she is this acidic, she will decline very quickly. It needs to be retested/confirmed and treated. He also said we need to differenciate between the kidneys or diabetes being the cause.

So, the first step is to get a ketone test. I was hoping to do a trade off of strips for some ketostix with someone local, but Im not sure if I should wait until I can reach them. Her numbers are running high today...well, lately they have actually. He would then like to have a full chemistry panel, fructosamine test, and the proper testing for MA. He is in research, not clinic right now but said he would meet us for a blood draw and quick visit, then follow up later in the month with a longer visit. He is more than willing to consult with her vet as well. I need to get an estimate on all these tests and hope it is realistic. This is one of those things I cannot afford to NOT diagnose or treat.

Im trying so hard to feel positive and grateful for everything we do have. But its hard.

 

Aargh, mea culpa, I just took a confusing subject and made everything more confusing, I'm sorry. I'll try to explain.

1- TCO2 (I did a search today) can be run on samples sent into the lab if specific handling requirements are met. I actually didn't think that was possible, but I found it listed as an option for some labs today. Generally, blood gases can't hold for more than 1/2-1 hr max. More on that in a second.

2- TCO2 is an approximate measure of bicarb (which is HCO3) because it measures the CO2 contained in blood as bicarb plus the CO2 as blood gas. (This is if it is handled properly.) So it is not the same as measuring HCO3 but can give a decent measurement of a bicarb excess or deficiency. Blood gas analyzers read HCO3, or both HCO3 and TCO2, and in the latter case the TCO2 is disregarded in favor of the HCO3. TCO2 is only useful because of #1--unlike most other blood gases, it can be measured even after some time delay.

3- Yes, sorry for being confusing, your CO2/paCO2/pCO2 goes up for respiratory acidosis, TCO2 goes down with metabolic acidosis. Blood gas reading in general is complex because compensatory mechanisms make them change whether the underlying derangement is metabolic or respiratory, and then the similarity in names doesn't help. I also inexplicably ignored the T in Erimess's statement and helped fuel confusion. [In my defense, in my world (critical care vet med), no one cares about the TCO2 since we know what the HCO3 is so I hardly read or write the letter T anyway! ;-) I was actually surprised when I looked at this thread tonight and saw that I had even written TCO2--all day I was thinking of how to explain PCO2 since that's what I thought we were talking about. Sigh.]

Anyhoo, about the blood test, Carolyn -- if your vet doesn't have an in-house blood gas analyzer (a handheld iStat machine is most common), the bicarb result is suspect. If the vet said bicarb but meant TCO2, you should ask (and this may annoy him) if the blood sample was handled completely anaerobically and marked as such when it went to the lab. I doubt it, as it's not common practice, but if they were specifically looking for a TCO2 result, maybe. The bottom line is, unless the vet is absolutely sure the sample was handled properly both at his place and that instructions were sent to the lab, I'd re-do it before initiating treatment. In cats not at risk for hyperkalemia (high potassium), one of the easiest means of treating acidosis in renal patients is giving potassium citrate (not gluconate) supplementation. You can actually use baking soda, too, but cats tend not to like it and some clinicians feel it doesn't work as well. You need to keep an eye on the potassium if you use the K-citrate, and I wouldn't start without confirmation of the blood test and dosing recommendations.

Clear as mud now ? ;-)

 

Re: Metabolic Acidosis help- Jess?

Im really confused if I should be scraping together all the last pennies to bring her to the University for the specialized blood/gas test. Along with that the specialist wants a u/a and complete blood chemistry and/or EC8(?). What is an EC8?

Dr. P made it sound urgent *if* the values were true. Ive only ever seen these wacky values when she was in ARF. So, I like to think the samples are handled well.

Sorry. Im just really confused now, LOL I did just wake up from a nap, though.

 

Re: Metabolic Acidosis help- Jess?

EC8
I know what it is know!

She had it done in the ER over at the U back in June
Incl: Na, K, Cl, TCO2, Bun, Glu, HCT, pH, PCO2
HCO3, BEecf, AnGap, HB

Now to decide if I want to spend 78 for full chem or 28 for ec8

Any thoughts? I have until Monday to decide

 

Confusing subject? Nah, never.

Yup, that's why it's hard to get. I believe mine was sent to a university about an hour away. From what I understand, if it's not handled correctly, it can measure a bit too low, so I've seen it suggested to not do anything about if it only looks a little too low. (And re-test if you can afford it.)

That's actually the part I didn't know. Had never heard of HCO3. I think I misinterpreted that quote that the site was trying to say they were the same thing, but my understanding was that TCO2 wasn't the bicarb itself (apparently it's not ONLY bicarb), but was supposed to be a good indicator that the bicarb was "probably" low. I guess what the site was really saying is that people have a habit of using them interchangeably even when they're not. I figured out they weren't the same thing when both were listed in Latte's blood panel, slightly different.

I have to say it's a bit upsetting that I've never heard of the HCO3 when it's apparently even easier to get. (Unless that's fairly new or something.)

I'll let you in on a little secret. I wrote TCO3 and had to go correct it before anyone noticed the blunder. LOL. It's rather confusing on the fingers to say the least.

Yeah, that concerned me a bit since her potassium seems to be going up. Although... hate to open my mouth when I have no idea what I'm talking about, but I have this vague thought in the back of my head about something causing false high potassium readings. It's been about two years since I'd looked at that, so can't for the life of me remember what it was. If someone perhaps could remember... (I mean something not terribly uncommon for CRF cats.)

 

Re: Metabolic Acidosis help- Jess?

That's 13 things, not 8. They should re-name that.

OK, this is just my opinion, but since the EC8 includes the difficult tests that you're really needing at this point, and also includes potassium (which I think would be a good idea to check again), and since you recently got bloodwork done, I think that would be sufficient for your current purposes. If you start treatment, you'll have to re-do blood work soon anyway.

 

hahaha! Actually 15 because they scribbled pcv and TP on there, too! :mrgreen:
It actually says EC8+. That might be the difference. Still torn as to whether or not I should do everything he is asking/wanting, or cut it back. What is going to help give him the best picture of what is going on? Its hard because he is a scientist and wants everything he can get to piece it together. Cant blame him. Guess I need to figure out what would be missing on an ec8 vs a full chem. I could always ask at the lab or call them later today.

I do worry, because her potassium is on the higher end. However, I really trust the knowledge of this specialist and him figuring out what will be best *if* she does have MA.

Its strange because she is eating and gaining weight (probly from the steroid, and those wonderful BG drops she takes). She sleeps a lot, but she is an old cat with many ailments. She still gets up and walks around, bats at her toys, obviously wants attention, etc. She has been vomiting white foam more often lately and her tummy gurgles. Her back legs gave out on her back in sept, right around the FD diagnosis. She really couldnt walk for 2 days. Then it improved quickly, but she is still very wobbly. Its hard to say if its coming from the FD, arthritis, or maybe this was the problem all along?

 

Well, that's OK then.

Does this guy know you had blood work done recently? And can't he get a copy of that? Or hung up that he do it himself? I'm a bit like that myself and I can understand it, but I think you need to decide whether you feel it's really worth it. Checking what this doesn't include is a good idea - see if it's anything you think would need re-checked. Otherwise, get him a copy of the latest - he'll at least have it to look at. (Unless he's wanting stuff you don't have of course.)

The back leg stuff can be diabetic neuropathy -- Sammy's got solved when we started insulin so it didn't take much. (Did you ever try the Methyl-B12?) It can be low potassium, high phosphorus, anemia, the MA, other stuff. When you know, for instance, there's low potassium, it needs treated anyway so easy to find out if that takes care of it. It's always difficult when several things can cause a symptom.

 

i'm not dipping my toe into the TCO2, HCO3 etc etc or any of that. I just about went cross eyed.

carolyn- latte has renal issues? are all the foods you listed low phosphorus? i limit cosmo's food to low phosphorus (lowest phos wellness foods are chicken and turkey). Seems as if almost anything with fish has high phos. Janet and Binky's charts have phos levels in a column. I was advised to look for something under 250, closer to or under 200 is best for his CRF.

 

Yes, he knows about the bw...I gave him the rundown on the phone and thats what alerted him to the potential seriousness of this. I think, since I usually bring labs in from our regular clinic, he may once and for all just want everything run on theirs - where it is consistent. I may have to bite the bullet on this one, as much as it may hurt. She only had a renal panel done, so the complete chem is going to include a lot more.

Also remember, he is a scientist...a researcher. One of the top in the nation, if not the world. He wants his data. I am very fortunate not only to have him 20 min away, but be able to get my cat in to see him a handful of times. I have complete trust in his ability to offer the appropriate treatment no matter what the complications....unless he requires more and more testing. Then we are limited.

I am going to call tomorrow and see if they will take the time to let me know everything on the complete chem. I believe they run their own tests (dont send them out), so I cant go off other labs.

 

:lol: Im right there with you! Tough stuff!

Cyn - Latte has so many complications. Just to get her eating period, is amazing! I have rarely spent much time fussing over phos. or giving binder. She has also generally stayed under the dreaded 6. I do worry about the day when I have to be more concerned with it...and that may be right around the corner. For example, her vet recommended trying her on the renal diet after these latest labs. Problem is, it has grains (will flare ibd or whatever gi disease she has), AND its super high in carbs (obviously affecting the diabetes). Plus she wont eat it. So is it worth giving it to her, in my eyes? No. It seems it will only make everything else worse. Its a fine balance and difficult choices we have to make.

She does eat wellness turkey. I used to syringe feed the chicken. I think most fancy feast are lower in phos than the average commercial brand. The kibble, however...probably not helping. She is not a big fish fan, unless its her whisker licken's treats. She likes the salmon.

 

Re: Metabolic Acidosis help- Jess?

Hi Carolyn. If you have had a recent chemistry panel done, I would just do the EC8+ (that is with the iStat machine, which your vet must have in his clinic for this to be run, it can't be sent out) since you want the most accurate info on her acidosis.

 

Been searching the literature here and there... this 2009 paper seems relevant to the puzzle. I normally only post the link w/ a paraphrase or two, but to save you a bit of time, here are some excerpts (I left out the hypokalemia parts). Since Latte's potassium is on the high-normal side but slowly rising, there may be a synergy of effects on her metabolism, between the FD and CRF... and minerals, electrolytes and blood gases may point the way.

I agree w/ others re: handling of the sample can skew the results for delicate blood gases. Dr P may want to do all of it in his lab so he can measure and evaluate all of the parameters from the same sample, with confidence. I'd opt for a full chem panel if you can swing it. There's just so much going on inside that little girl! The short list of 8 (or 13 or 15??) didn't have PTH or fPLi or some of the liver enzymes. Her calcium is w/in range (wasn't it high in the past?), but w/mineralization in her kidney and phos on the rise, I'd want to check her parathyroid. And with suspect pancreatitis, might as well throw it in along with the rest! nailbite_smile

Does she get LRS for her fluids? Could ask vet about switching to saline.
Sending you guys big hugs -
Deb, angel Evie, and the boys cat_pet_icon
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Potassium and Acid-Base Balance: Myths and Facts (EXCERPTS)
http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2009&Category=8064&PID=53679&O=Generic

Internal distribution of potassium is affected by acid-base equilibrium. These changes, however, are only clinically relevant during acute mineral acidosis (e.g., infusion of HCl). [ED NOTE: WITH LATTE, *EVERYTHING* IS CLINICALLY RELEVANT, DOWN TO THE LAST TINY DROP! ] Extrapolation of information obtained in experimental animals to the clinical setting has led to misconceptions regarding the effects of acid-base changes in potassium balance (Table 1).

Table 1. Myths and facts about potassium and acid-base disorders.
Myth 4 : Hyperkalemia in renal failure or ketoacidosis is due to metabolic acidosis
Fact 4 : It is due to poor renal function (renal failure) or lack of insulin (ketoacidosis)
Myth 5 : Hypokalemia causes metabolic alkalosis
Fact 5 : True in rats. Not true in cats, dogs and human beings.

Hyperkalemia
Chronic hyperkalemia almost always is associated with impairment in urinary potassium excretion.

Increased intake of potassium only causes sustained hyperkalemia if renal excretion of potassium is abnormal.

Translocation of potassium from ICF to ECF can occur in diabetic patients. Insulin deficiency and hyperosmolality contribute to the development of hyperkalemia in diabetic patients.

Decreased urinary excretion of potassium is the most important cause of hyperkalemia in feline practice. It usually results from anuric or oliguric renal failure. Oliguria or anuria with hyperkalemia are more likely to occur in acute renal failure, but they may be observed terminally in chronic renal failure.

Patients with chronic renal disease have reduced ability to tolerate an acute potassium load and may require 1-3 days to reestablish external potassium balance when intake of potassium is abruptly increased (e.g., fluid therapy). Fluid therapy with potassium-free solutions ameliorates mild hyperkalemia by improving renal perfusion, enhancing urinary excretion of potassium, and by diluting the potassium in ECF.

Mild hyperkalemia: Administration of glucose or NaHCO3 can be attempted in patients with mild hyperkalemia that did not respond to potassium discontinuation and fluid therapy. Administration of glucose (1-2 ml/kg of the 50% solution) will cause release of insulin and move potassium into the cells. The effects begin within an hour and last a few hours. Concurrent administration of insulin may improve the response but it increases the risk of hypoglycemia. Sodium bicarbonate (1-2 mEq/Kg, repeated if necessary) also will move potassium inside cells within an hour. All potassium driven inside the cells will come back out after a few hours. Therefore, drugs that translocate potassium have a short duration of action. ...
...
###

 

Just a couple of comments:

It's better under 4, but they're also just numbers. Pay more attention to how she feels. Higher phosphorus can contribute to inappetance problems, so that might be something to pay attention to. The tasteless power stuff can just be sprinkled on food, so it's not like fighting with pilling or anything.

Not to mention that it's low quality, and that many of us don't even really go for that low protein thing anyway, and I don't like taking chances with the low protein. IMO, being low phosphorus is its only good point. And binders can work very well in many cats, so I don't see the point of a crappy food and all the problems that come with it. Especially when it's tough feeding her right now. Just get food in her and don't worry about it so much. Canned and good quality would be better of course, but it doesn't do much good feeding the "right" thing if they're not going to eat it and just shrivel up. (If you must syringe feed, then by all means, pick high quality.) Hopefully you can get her feeling better and then eating more on her own.