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Dr. B.
Dr. B., Cat Veterinarian
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Experience:  I am a small animal veterinarian with a special interest in cats and am happy to discuss any questions you have.
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My 13 year old male cat has just been diagnosed with kidney

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My 13 year old male cat has just been diagnosed with kidney failure. My vet said it wasn't bad enough for medication, just a change in diet. The Hills wet food prescribed he would not eat, but he is eating Royal Canin Renal Feline Dry, albeit a small amount, and drinking water. He is still very quiet, sat in the same place all day, only going outside to toilet and back in again.
My vet said his results were good and could have been a lot worse. UPC level was 0.3. Creatinine was 182 and Urea 18.9 - Not sure what these mean, but we were advised he was not bad enough for any medication.
It has been two weeks now, only this week has he started to eat the Feline Dry food, but we haven't seen any improvement in his character.
The vet said to give it a month and then they would re-do his bloods and urine - Will this say whether there is an improvement, a decline, or still the same?
Is there anything else we can do / try? He used to enjoy being outside, catching mice, etc, and now he sits in the same position, usually the "meatloaf" position and occasionally curling into a ball. He looks sad too.
Also, not sure if it is relevant, but he had his thyroid removed 3 years ago, although since then he is on calcium tablets, rocaltrol and 40mg of Vidalta for ectopic thyroid - he manages to have his pills in some treats each morning, although eaten slowly and after one to three attempts.
Any advice welcome to try and improve our cats life.
Submitted: 3 years ago.
Category: Cat
Expert:  Dr. Deb replied 3 years ago.

Hello Kerry,
I'm Dr. Deb and I'll do my best to help you today.

I'm sorry that Turvy has been diagnosed with kidney problems.

We often stage or rate kidney disease based on the creatinine levels. As indicated by the International Renal Interest Society (IRIS) who created the protocol, a creatinine of 182 would be considered stage two (out of four) since the range is from 140-250...mild renal issues in other words. His UPC is normal.
But, having said that, cats don't always behave as we expect. I've seen cats with far higher numbers not act terribly ill at all while I've seen cats with number such as this who were.

I would have advised a renal diet if this were my case but emphasize that it's far more important to keep to a cat eating, rather than force the protein restricted diets on them.

I would also advise fish oil supplements such as Welactin which may be useful as an anti-inflammatory. This particular supplement comes in a liquid which can be drizzled on the food and is available on the internet.

Many of these cats experience an underlying nausea because their kidneys aren't functioning properly so I often suggest over the counter Pepcid AC at a dose of 1/4th of a 10 mg tablet twice a day.

And, fluids under the skin can definitely perk up a lot of them, even though they are drinking.

I would also advise that blood pressures be checked since many of these cats are hypertensive and need drugs for this.

Some owners will also start Azodyl (LINK) which appears to help some cats; I've used it in a number of cats with kidney issues but I can't honestly say if I think it helped or not.

In a case like this, we have to look at the cat's behavior and not necessarily focus too much on the fact that the numbers "say" he should be feeling more normal.

To answer your specific question about repeat bloodwork, we are looking for a trend. Have the numbers improved, stayed the same or worsened? If they've significantly improved, then perhaps there was a transient insult to the kidneys although this is rare for a cat this age. If they've stabilized, then the diet is working but if they've worsened, then the problem is progressing faster than expected.
It takes at least 75% of kidney cells to be damaged before changes are seen in the blood work. This condition is usually progressive in a cat this age but the rate at which it progresses is variable....there's no way to predict how quickly the kidneys will continue to fail, in other words.
I hate to even mention it, but there is always the possibility of cancer (usually lymphoma) which can involve the kidneys. You might want to consider an ultrasound as an additional diagnostic tool to evaluate them as well as other internal organs.

I hope this helps and that Turvy starts feeling better soon. Deb




Customer: replied 3 years ago.


Are you a vet in the UK?


As your recommendation of Welactin does not seem to be available in the UK?

Expert:  Dr. Deb replied 3 years ago.

Kerry:
No, unfortunately, I'm not a vet in the UK, but rather the States.
Welactin may not be available in the UK but I'm certainly that there will be other fish oil options which your vet could recommend that you could purchase locally.
It's also available on the internet (LINK); a prescription isn't necessary since it's a supplement.

If you'd prefer to discuss this issue with a UK vet, please let me know and I can opt out; however, I don't know when one might be available to chat with you.

 

Deb

Customer: replied 3 years ago.


Yes please, I would like a UK vet, as the products you recommend would take some time for delivery!

Expert:  Dr. Deb replied 3 years ago.
Kerry,

I actually found it on Amazon/UK as well but I understand that you might not want to wait for it to be delivered to you.

I'll opt out, then; please don't respond back to this message since it will prevent others from picking up the question.
I did check a list of veterinary experts who are currently online and none of them are based in the UK, so it might take some time before your concerns are addressed.

In any event, I wish you the best with Turvy:) Regards, Deb
Expert:  Dr. B. replied 3 years ago.

Good morning, Kerry.
I see you have asked for a bit of UK veterinary input and as I am UK based, I'd like to add to Dr. Deb's great answer for Turvy's kidney issues.

First, I do want to note that I fully agree with Dr. Deb's thoughts on Turvy's diet. Even if a special diet is amazing for managing a kitty health condition, if they won't eat it then its unlikely to be of benefit for them. Therefore, I would suggest that it may be worth trying the Royal Canin Renal wet diets (my own kitties love them so much that the healthy cat is always stealing my own kidney cats food). But if you do and he decides that he is stubborn and not going to have the special diet in any form, then we have to find a compromise with him.

In that case, we'd want to consider any diet he will happily eat but ideally aim to use one that is as close to those lower protein, lower phosphorus, and lower sodium levels that are in the kidney diet. (So it is worth a peek at the back of all the cat food labels to compare). Furthermore, if you find a diet he likes with as low values of those components, you may want to consider offering the wet food version if possible (since its 35% water and will get more hydration into him to support the kidneys --especially as they never drink as much as they should). Again, at the end of the day, eating is most important aspect for a comfortable kitty life and after that we then want to consider how we can make what they eat best for their respective conditions.

As well, I completely agree with Deb's mention of not letting the numbers blind you. We do use those kidney values to give us an idea of how severe their kidney disease is; but just like people some animals feel worse in early stage disease as opposed to others. The numbers are just a guide to let us know how fast kidney decline may or may not be happening. But in regards XXXXX XXXXX Turvy, the key aspect to focus on is how he is. Because if he isn't eating, is depressed, lethargic and not doing the things he loves, then the mildly elevated numbers are irrelevant and we have a kitty that we want to see if we can get feeling better.

So, if you get Turvy onto a dietary compromise and he still seems lethargic and down, then its worth a word with his vet. It may be that the diet change is a red herring and Turvy is just feeling poorly even with early stage disease. In that case its worth discussing using medical management (perhaps even just a single daily treatment with Fortekor) in place if intense diet modification or even just to trial and see if it helps Turvy's kidneys filter better and therefore make him feel better. If it doesn't, then he doesn't have to stay on it at that stage. If it does, then there is no harm in giving the kidneys some medical support sooner then we'd have perhaps thought about doing so.

A
s well, as Deb has noted, we do see nausea associated with kidney issues. Now Pepcid is a bit difficult to find OTC here, so instead you may want to consider trying or Zantac (LINK). Otherwise, you can speak to your vet about dispensing Pepcid/Famotidine (though may practices may have to order it in) or they may be able to provide liquid Zantac (which is a bit easier to dose and administer then OTC tablets) or Cimetidine. They should be amenable to do so since they have just seen him recently.

Also, I do want to just note that kidney kitties can be prone to urinary tract infections. This is because their kidneys just cannot make urine as concentrate as it once was, therefore the diluted pH is less of a defense against bacteria. To make these situations even more of a challenge, it can be quite easy to miss urinary infections in these wee ones since their kidney condition tends to cause them to have voluminous urination (therefore we don't see the increased frequency of small volumes). Therefore, if he is a bit down with a non-specific lethargy, you might want to just have a urine sample checked.
Urine samples can often be collected by leaving the cat in a non-carpeted room with an empty litterbox overnight. Otherwise, if time is of the essence and he has a full bladder on examination, then vet can take a sample directly from the bladder for testing (+/- culture). Often the treatment approach in these cases is just the same for any cat with a bladder infection, its just that we have to be more vigilant in picking up when they may have one.

I
n regards XXXXX XXXXX product that Deb mentioned, I see it on our Amazon but it doesn't appear to be in stock. I can see the benefit of the product for Turvy's situation but must note that it isn't something we really have over here or regularly use. Instead, we still tend to use the Omega 3 fish oils for their anti-inflammatory properties and support the old fashioned way (with a trip to Hollands & Barrett). Typically we will give kitties a daily dosage of
the Omega-3's DHA/EPA at a rate between 300-500 mg combined each day.

Finally, I did just want to give you a few links to help you get an idea of the treatment approach we take with kidney disease in our kitties. First, the FAB (now known as International Cat Care) has a good link on treatment overview
(here). As well, since Deb mentioned giving subcutaneous fluids (something to speak to your vet about), I wanted to give you a wee overview of that as well (which you can find HERE).

I hope this information is helpful.

If you need any additional information, do not hesitate to ask!

Dr. B.

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Customer: replied 3 years ago.

I also have the Royal Cainin Wet packets, but he didn't like them.


I have also tried Whiskas and Felix Senior pouches on their own, he may eat a small teaspoon amount and like the gravy. I have also mixed in a binder, but he won't eat it at all then.


 


If he eats "normal food" as well as renal dry food, I would assume it is not really doing any good for him?


 


We discussed with the vet putting him a drip, but she said it is only a temporary thing and he would need to go back regularly or we would be taught how to do it at home. We don't want to go down this route, as he has been in and out of hospital for the last 3 years and we said we wouldn't want to put him through that, especially as it is a temporary ongoing fix.


 


Do CRD cats at his stage seem "happy" or do they all sleep all day. He sits in a "roast chicken" pose for a lot of the time, and curls up into a comfy ball occasionally, and goes out into the garden for the toilet a few times a day. He rarely purrs, usually he will purr once he comes into the house after being outside and seems to ask for food, but his intake is a small amount in one sitting. Then we offer him more food every hour or so, when he will eat a further small amount.


 


I was of the impression that once they started to wee in the house, and their breathe smelt, this was a sign it was getting to the end - Is this true?

Expert:  Dr. B. replied 3 years ago.

Hi again,

If Turvy didn't like the wet renal diet, then that is fair enough. In regards XXXXX XXXXX him normal food alongside the renal diet, the benefit would obviously be reduced since he'd be getting more sodium, phosphorus, and protein then on the kidney diet alone. That said, if he ate them together, one could argue he'd be getting a wee bit less of these. But the significance of that on that taking some of the strain off his kidneys would be questionable (only the bloods/numbers would give us an idea if it were of any help at all). That all said, if he is not amenable to any diet compromise then that alone may be an indication that he should be be on a kidney support medication at this stage and the diet left unchanged. That way, you'd be supporting the kidneys but keeping Turvy eating properly as he should.

In regards XXXXX XXXXX they are a temporary measure. As I am sure you can appreciate, the kidney works by filtering metabolites/toxins from the blood (like urea -- which is a protein metabolite, hence why we feed lower protein) and excreting them into the urine. If a kidney is getting older and not working as well as it used to, then we see those metabolites not being removed from the blood as well as they used to. This leads to an elevation of these within the blood that then give us the reading the vet saw in the blood sample and can make the cat feel unwell.

When they get high or a cat is feeling poorly due to the elevation in these metabolites, this is where the fluids are helpful. IV fluids, which require hospitalization, aim to flush as much of this build up out of the blood in a short period of time. This aids the kidney in its work and get the levels back down to what is tolerable for the cat. Subcutaneous fluids, the ones people give regularly at home, achieves the same but at a smaller, more regular interval. The aim of these is to give the kidney little pulse therapies of fluids to just aim them in flushing out those metabolites and keeping their levels stable. That all said, it isn't something every cat tolerates or every owner wishes to do. And if you are not keen to go down either route, that is absolutely fine to choose since it is not a cure but only a management method.

In regards XXXXX XXXXX behaviors of CRF kitties, this does vary by cat. Most kidney cats are old dears and therefore sleep or lounge more; but they should still be happy and themselves. Therefore, we need to differentiate that OAP slowing down from feeling unwell. We'd not want him depressed, curled up, withdrawn and not interacting with the world. And I must say that the behavior you have described sound divergent from how he used to be (even in recent history), and that does concern me that he is feeling at least nauseous with this. And if his breath smells (which can be due to high urea levels --uremia and can be associated with painful oral uremic ulcers) and appetite even for normal food is poor, then I'd be further concerned that despite the 'lower numbers' that for Turvy this is still taking too much of a toll on him.

So, I'd not say that urinating in the house and bad breath are a sign of the end, but if he is depressed with this then I do think it is worth a further discussion about at least trialing kidney support medication at this stage to see if we can get him feeling better and more like himself. As well, if he has uremic breath and isn't keen to eat even his own favorites, then I'd say that that is a sign that it'd be worth ringing his vet and updating them on the situation. They can tell you if they had seen any uremic ulcers in his mouth, and if so they may prescribe some pain relief (ie oral bupenorphine) to see if that is behind his appetite decline. Or if there was no signs of these, then you may want them to dispense an anti-nausea/sickness medication to see to rule out nausea.

In any case, since he is so adverse to the renal diet, I would discuss potentially using a kidney function support medication at this stage. Because at the end of the day, we want him feeling as well and comfortable as possible with the time he has left with us. And it'd be daft to let him feel poorly and persevere with a diet he doesn't like for the month, when we could try some alternative steps to see if we can get him feeling more like himself at this stage.

All the best to your wee lad,

Dr. B.

-----------------------------------------------------------------------------------------------------------------

Remember that if you have any lingering questions or concerns, please reply so that we may continue our conversation. I will be happy to work with your further and do everything I can to provide you with the service you seek. Please remember to rate my answer when you are satisfied (with4-5 stars or a happy face) so that I may receive credit for my assistance. Thank you & have a great day. : )





Customer: replied 3 years ago.

I mentioned to my vet about his lack of eating, even his favourite treats, and asked if he may have a gum or tooth problem, but she said she would not want to give him any antibiotics at the moment.


 


Also I asked about any medication for his kidneys, she said they don't like giving the medication in the early stages as it can cause more harm than good?

Expert:  Dr. B. replied 3 years ago.
Hi again,

I have to admit I am surprised that she didn't seemed concerned about his appetite decline since this is quite important for normal kitty life. I appreciate that one would be reluctant to perform a dental under general anesthetic in a kitty with kidney troubles unless absolutely necessary; but if there was a tooth problem or a uremic ulcer then we'd need to address these. I suppose perhaps she had hoped that Turvy would like the new diet and that its lower stress on the kidneys would help with any renal induced nausea.

Still since that isn't the current state of affairs, then Plan B needs to be formulated. And in this instance, if he has CRD then a kidney support medication could be useful. I am not sure which medication she is referring to that would be harmful early on but useful at later stages (it seems that surely would be a bit counterproductive for a drug). Of course, whichever medication one was using, they'd want to use a low dose for kidney support if the cat is in an early stage of the disease. Unless she perhaps isn't sure that his signs are indicative of renal disease and she needs to test him further (ie kidney ultrasound to make sure he doesn't have kidney based lymphoma, via rechecking the bloods to see if he responds to current diet treatment, or if she feels that the urea being significantly elevated alone is suggestive of something else like a stomach ulcer, etc). In any case, we can only speculate on her thoughts and a clear channel of conversation would be prudent to get things back on track in the wake of Turvy turning down the diet.

So, it sounds like you do really need to touch base and chat with her about the current situation, lack of diet acceptance, lack of appetite and activity he is showing. From her blood results but also her examination of him, she should be in a position to determine whether the next step will be a kidney medication (like Fortekor -More information) or if she needs to move up her blood sample (or do further tests) to definitively diagnose this condition. Otherwise, it might be a case of taking steps to settle and rule out the associated issues like nausea or oral pain with the trial treatments I have noted above. But in any case, it sounds like Turvy has turned down her first management plan and its a case of letting her know and see what Plan B will be for getting him back on track.


Take care,

Dr. B.

-----------------------------------------------------------------------------------------------------------------

Remember that if you have any lingering questions or concerns, please reply so that we may continue our conversation. I will be happy to work with your further and do everything I can to provide you with the service you seek. Please remember to rate my answer when you are satisfied (with4-5 stars or a happy face) so that I may receive credit for my assistance. Thank you & have a great day. : )





Customer: replied 3 years ago.

We had to rush our boy to the vets this morning, he was shacking his head and wobbly on his back legs. We assumed it was a calcium deficiency. The vet has done tests and his calcium levels were fine. They can only think it may be a leak from his kidneys and they will flush him through this evening.


Can you explain this to me please. Is it a temporary fix and for how long?


 


Also, he was only at the vet yesterday as I took him to see about an appetite enhancer pill. The vet took his temperature twice and it was 35, she thought her thermometer was wrong as she said that read couldn't be right....but could it and would it mean something?

Expert:  Dr. B. replied 3 years ago.

Good evening,

I am very sorry to hear that Turvy has had this sudden turn for the worse. If his blood calcium levels are normal and the vet suspects his kidneys are to blame, I would be suspicious that they have seen a sudden spike elevation in his kidney blood parameters (the urea, creatnine +/- phosphorus).

Now this wouldn't be due to a kidney 'leaking' (since kidney design would not make physical 'leaking' a straightforward process like it would be if a bladder or other hollow organ would); rather it'd be a case of a severe decline in its ability to filter toxins/metabolites. This would lead to those body wastes/metabolites to 'leak' back into the bloodstream. (these are the same ones we check for on the blood sample). And these toxins/body wastes can then cause the signs we have discussed before (ie nausea, uremic ulcers, poor appetites, increased thirst, appetite decline) and in severe cases we can see dizziness, wobbliness, weakness, trembling, tremors, and even seizures.

In regards XXXXX XXXXX I am glad to see that he has been hospitalized and is receiving IV fluids. This will support the kidneys and as your vet have said, flush these toxins from his blood stream. Hopefully, the level of those 'toxins' are such that they can be significantly lowered with this intense IV fluid therapy. And if they can be lowered, then hopefully we will see Turvy start to pick up for us and stabilize.

Now in regards XXXXX XXXXX long term prognosis, as I am sure you can apppreciate, this is a wee bit guarded and does depend on him as an individual and the remaining ability of his kidneys to function (ie renal shut down vs. just struggling). We do find some cats respond well to IV fluids and can continue on for months normally. But if those kidney levels are too high (or high enough that it makes him feel unwell), then it is possible that the IV fluids won't be enough. In cases like this, I tend to put my patients on the intense IV fluid therapy for 48 hours and then recheck bloods at that stage. If we find improvement, then I may continue therapy until we can get them feeling more like themselves. But if the cat is feeling poorly and we don't see any change over that period, then often those wee ones have poorer prognoses and we have to consider letting them go.

Finally, you noted quite a low body temperature for wee Turvy. It is difficult to assume the significance of this for him, but it is an indication that his body is struggling to thermoregulate itself. This could be due to the body being overwhelmed or his circulation being very poor but it would be a case of his vet's also closely supporting him with external warmth during treatment. And hopefully as the blood if flushed by IV fluids, he will regain his strength and the body will resume managing his proper body temperature.

Please take care,
Dr. B.


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