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Cat Forum / Health and Behavior / April 2007CRF in Alex
Well, I just got the bad news from the vet. Alex, who is 16 years old, is just beginning CRF. The vet told me in addition to switching his food to NK, I should begin weekly subcu fluids. She stated that by so doing, since he is still in the very early stages of the disease process, it is actually possible to reverse the situation and return him to relatively normal kidney function. Has anyone ever heard of this before (that beginning subcu right at the beginning of CRF can reverse the process?). I did successfully cure him of diabetes with Lantus insulin, and I never would have thought that would be possible. Now that he'll be eating NK, we are going to have to keep a very close watch on his blood glucose to ensure the diabetes doesn't return. The doctor recommended that we repeat bloodwork to reassess kidney function in about three months. Does anyone have any thoughts on any of this? Best regards, ---Cindy S. > Well, I just got the bad news from the vet. Alex, who is 16 years old, is > just beginning CRF. The vet told me in addition to switching his food to NK, [quoted text clipped - 11 lines] > Best regards, > ---Cindy S. http://www.shirleys-wellness-cafe.com/felinekidney.htm http://www.catsofaustralia.com/urinestainremoval.htm http://www.felinecrf.org/related_diseases.htm Hi Cindy, I am so so sorry to hear your news about your baby. I have added a link to site that tells me that you can reverse it. I hope that it is of some use to you & gives you some of the information that you are looking for too. We had old Jasper who had CRF , but his condition had gone too far for treatment to reverse it. I think that there are others here who would be better qualified to advise you than me. Keep us up to date though, won't you? I am glad that you have nipped it in the bud, & will continue to think of you whilst you are going through this hard time Best Wishes, & devoted Purrs of a soothing nature from them all & us too of course!! S;o) > Hi Cindy, > I am so so sorry to hear your news about your baby. [quoted text clipped - 15 lines] > too of course!! > S;o) Sorry Cindy, I posted the wrong page to one of the links. It should have been http://www.catsofaustralia.com/cat-kidney-disease.htm http://www.felinecrf.org/related_diseases.htm http://www.petshealth.com/dr_library/felrenfail.html Aplogies, S;o) Sheelagh, I don't think I thanked you for these weblinks. Thank you! I'm reading them. Best regards, ---Cindy S. >> Hi Cindy, >> I am so so sorry to hear your news about your baby. [quoted text clipped - 27 lines] > Aplogies, > S;o) > Well, I just got the bad news from the vet. Alex, who is 16 years old, is > just beginning CRF. The vet told me in addition to switching his food to NK, [quoted text clipped - 3 lines] > function. Has anyone ever heard of this before (that beginning subcu right > at the beginning of CRF can reverse the process?). I'm sorry to hear about your cat- I'm going through the same thing with my 20 year-old. ARF (acute renal failure) is reversible in some cases but CRF is not. By the time CRF shows up in the bloodwork (high BUN/creatinine 60-75% of renal function has already been irreversibly lost. The reason why CRF doesn't show up in the bloodwork as its happening is because the feline kidneys' have a huge nephron reserve, and 'glomerular hyperfiltration'-- the indivudual intact nephrons increase their filtration rate to compensate for the lost and damaged nephrons. I did successfully cure > him of diabetes with Lantus insulin, and I never would have thought that > would be possible. Now that he'll be eating NK, we are going to have to keep [quoted text clipped - 4 lines] > Best regards, > ---Cindy S. Fluid therapy should be administered *only* to correct or prevent dehydration or short-term to augment GFR in a uremic crisis. Premature or unnecessary chronic fluid therapy can *promote* the progression of CRF because it makes the kidney work harder. What is your cat's BUN and creatinine concentrations and urine specific gravity? I think you should seek a second opinion from a veterinary nephrologist or a vet who is experienced in treating feline CRF. You might want to start thinking about giving your cat a potassium and omega-3 supplement. Both will delay the downward spiral of CRF. Best of luck, Phil >> Well, I just got the bad news from the vet. Alex, who is 16 years old, is >> just beginning CRF. The vet told me in addition to switching his food to [quoted text clipped - 45 lines] > You might want to start thinking about giving your cat a potassium and > omega-3 supplement. Both will delay the downward spiral of CRF. ------------------ Thank you. I don't remember what the vet said the BUN and creatinine were, but it would be easy enough to find out. She wants to put the cat on a prescription low protein kidney diet. On one of the websites for which Sheelagh provided a link, I read that this would actually be a bad idea because there is no evidence that low protein diets delay progression and in the meantime, the cat's body is not getting sufficient protein. Would you agree or disagee with that? BTW, I have a feeling my other approximately 15-year-old cat may be headed down the same path. His BUN and creatinine are high normal. Do you have any thoughts on anything I can be doing to prevent the development of CRF in him? (The other problem is that I have several younger, presumably healthy cats, and all my cats eat the same dry food. I also give them canned food, so I could continue to give the young healthy cats the high protein canned food, but one of my younger cats refuses the canned food and is only willing to eat the dry. She does not need to be on a low protein diet, which would be the net result if I switched over to the NK prescription food.) Thanks in advance. Best regards, ---Cindy S. >>> Well, I just got the bad news from the vet. Alex, who is 16 years old, >>> is [quoted text clipped - 71 lines] > Best regards, > ---Cindy S. Cindy, I'm not an expert on this but I've read that finding a food low in phosphorus is more important than a low protein diet. The bad part is that higher protein foods are frequently high in phosphorus. The biggest problem with the low protein, kidney diets is that they're not always that palatable. You may want to play around with different kidney foods. My CRF kitty was finally put on fluids last summer when she became dehydrated after several years of high normal BUN and creatinine. I'm currently giving her 100ml fluids every other day subQ. Molly's BUN and creatinine levels are actually slightly better than they were in August. I'm giving her omega-3 and potassium supplements. Molly has her good days and her bad days. I cherish the good days--they still outweigh by far the bad days. I wish you the best. Bonnie snip > Cindy, > > I'm not an expert on this but I've read that finding a food low in > phosphorus is more important than a low protein diet. Several websites that I've read have said the same. > The bad part is that higher protein foods are frequently high in > phosphorus. The biggest problem with the low protein, kidney diets is > that they're not always that palatable. You may want to play around with > different kidney foods. And right now, Alex is not eating an awful lot, and he has lost over a pound since last May. This is the pattern I went through with Molly during the last two years of her life. I've been feeding my cats Fancy Feast in the morning. What happens is that Alex eats a little and then Bullwinkle ends up polishing off the rest of Alex's portion (and Daisy's portion and Tux's portion as well) in addition to his own. Despite his voracious appetite, Bullwinkle has also lost weight. He was recently tested for thyroid problems and that came back negative. All of my cats have been on OM prescription food since Alex's diabetes diagnosis last spring. At any rate, Alex has not seemed overly enthusiastic about eating. He's not starving himself, but he's picking and eating small amounts. I'll give the kidney diet a try, but I can pretty much guarantee already that he is not going to go for it. For the last year of her life, Molly existed exclusively on human tuna. It was the only thing she would eat other than deli meats or my home cooking (beef or chicken). I supplemented her with feline vitamins. > My CRF kitty was finally put on fluids last summer when she became > dehydrated after several years of high normal BUN and creatinine. I'm > currently giving her 100ml fluids every other day subQ. Molly's BUN and > creatinine levels are actually slightly better than they were in August. So your kitty has actually shown improvement! That's great! My Molly never really went on subcu fluids. At the end, she did receive subcu fluids a few times at the vet. I was going to initiate them at home, but she was already close to the end of her life at that point and she was suffering, so I opted to euthanize. Now, I feel sort of confused. Phil (whose opinion I respect a great deal) is advising against the subcu fluids at this point because of additional stress on the cat's kidneys. A website I just read is saying the same thing as my vet (that the subcu fluids should be initiated early and will prolong the cat's life). Your cat has been on them for seven months and has shown improvement. And then, there's Bullwinkle whose lab values are still within normal limits but high. Is there any way to diagnose impending kidney disease before the BUN and creatinine are elevated (in an effort to prevent it)? I am so confused and so upset. I intend to speak to my vet tomorrow and follow Phil's advice to seek a second opinion from a specialist. There is no veterinary nephrologist in my area, but there is a veterinary specialist who completed a nephrology residency (currently specializing in some other organ system). > I'm giving her omega-3 and potassium supplements. Molly has her good days > and her bad days. I will absolutely give these supplements to Alex and Bullwinkle. I also gave Alex 5 mg of Pepcid today. He has thrown up some clear liquid several times (I know from experience this is due to nausea from kidney disease). His nausea may also explain why he is less interested in food. It seemed like he perked up a little bit after the Pepcid (I hope it wasn't wishful thinking on my part), but I'll give it to him again tomorrow before breakfast and see if his appetite improves. I will also begin offering him canned food multiple times during the day. >I cherish the good days--they still outweigh by far the bad days. > > I wish you the best. Thank you so much. Best regards, ---Cindy S. > snip >> [quoted text clipped - 70 lines] > Best regards, > ---Cindy S. According to my vet, cats will do better long term on the kidney diets but if they don't eat it, it won't help them! What I have been doing with Molly is mixing her diet food with a really stinky cat tuna food. It's the one thing she really likes. I wish she'd eat the kidney food alone but. . .I'm opting for calories. I'm not sure Molly has improved over all--her lab values are a little better but we've had some crises along the way. She was diagnosed with high blood pressure in February. As soon as we got that under control she had a raging urinary tract infection. She's now been off antibiotics for a couple of weeks and seems to be feeling pretty good. One endearing thing about her is her purr--it's the loudest purr I've heard on a cat. I can hear her in the next room when she's really going. She's been doing that a lot the past couple of weeks and she only does that when she's feeling pretty good. As far as the fluids my vet didn't put her on fluids initially; her kidney values were borderline for several years--it wasn't until she got dehydrated and was feeling punky that we started the fluids. As my vet explained it to me, a high BUN makes the cat feel nauseated. The additional fluids dilute the BUN and should help some with appetite. I know that once Molly was on fluids, she perked up quite a bit. I, too, really respect Phil's knowledge. He has a lot of good information regarding CRF. Getting a second opinion is a very good idea. There are a couple of crf support sites as well, a lot of information and people who are going through the same thing. Good luck with Alex and Bullwinkle, both. I love older cats but they bring their own issues! Bonnie She wants to put the cat on a > prescription low protein kidney diet. On one of the websites for which > Sheelagh provided a link, I read that this would actually be a bad idea > because there is no evidence that low protein diets delay progression and in > the meantime, the cat's body is not getting sufficient protein. Would you > agree or disagee with that? Protein shouldn't be restricted in cats until the BUN reaches 65-85 mg/dl, and only to ameliorate clinical signs of uremia. The theory of restricting protein to slow the progression of CRF was based on old studies in *rats*. Later studies showed that mechanisms that can alter the progression of CRF in the rat don't have the same effect in cats. In fact, protein restriction can have deleterious effects in cats- e.g., impaired immunological response and resistance to infection, reduced hemoglobin production and anemia, decreased plasma protein levels, and muscle wasting. I've been feeding my 20-yearl old x/d- its almost identical to k/d- its an alkaline diet with higher protein and a little more phosphorus. What you want to avoid are acidified diets. BTW, I have a feeling my other approximately > 15-year-old cat may be headed down the same path. His BUN and creatinine are > high normal. Do you have any thoughts on anything I can be doing to prevent > the development of CRF in him? Omega-3 fatty acids derived from menhadan fish- not flaxseed or any plant-derived omega-3. Plant-derived omega-3s contain too much omega-6- which are proinflammatory and contribute to the progression of CRF. Omega-3 fatty acids derived from fish down-regulate intrarenal inflammatory responses and are thus renoprotective. A potassium supplement would be beneficial also. You want to keep his K+ levels in the upper half of the normal range. > (The other problem is that I have several younger, presumably healthy cats, > and all my cats eat the same dry food. I also give them canned food, so I [quoted text clipped - 5 lines] > Best regards, > ---Cindy S. As I said, I don't think you should feed a restricted protein diet yet. Just don't let the normal cats eat x/d because it could predispose them to struvite. Best of luck, Phil > She wants to put the cat on a >> prescription low protein kidney diet. On one of the websites for which [quoted text clipped - 18 lines] > higher protein and a little more phosphorus. What you want to avoid are > acidified diets. Now, I'm confused. Isn't the idea to lower phosphorous while keeping protein the same? Won't an alkaline diet predispose him to crystal formation? Isn't K/D a low protein diet? How does K/D differ from this NF that my vet wants me to feed the cat? (I don't remember for sure what the lab values were, but I'm pretty sure the BUN was lower than 65 mg/dl). > BTW, I have a feeling my other approximately >> 15-year-old cat may be headed down the same path. His BUN and creatinine [quoted text clipped - 11 lines] > beneficial also. You want to keep his K+ levels in the upper half of the > normal range. Thank you. Omega-3 fatty acids from fish and potassium. I can make that happen tomorrow. >> (The other problem is that I have several younger, presumably healthy > cats, [quoted text clipped - 10 lines] > > As I said, I don't think you should feed a restricted protein diet yet. Okay. > Just > don't let the normal cats eat x/d because it could predispose them to > struvite. Are cats with CRF less inclined to get struvite or is it simply a question of the need for a more renoprotective alkaline diet needs to take priority (and we cross our fingers that the cat doesn't develop struvite)? Thank you again for all your advice. Best regards, ---Cindy S. > Now, I'm confused. Isn't the idea to lower phosphorous while keeping protein > the same? Its difficult to lower phosphorus while keeping protein the same because most of the phosphorus content in the diet in contained in the protein component of the diet. The difference in phosphorus content between k/d and x/d isn't that great-- .38% and .53%, respectively- which is only about 25 mg/100 kcal more and not a problem unless your cat is hyperphosphatemic. The higher protein content is more beneficial than the slightly higher phosphorus content is deleterious. > Won't an alkaline diet predispose him to crystal formation? k/d, nf and Euk Multistage Renal are all alkaline diets. You want to avoid acidified diets for cats with CRF-- especially acidified diets that are also magnesium restricted- which most diets are- because they can promote hypokalemia and metabolic acidosis. Acidosis will really make your cat feel sick and not want to eat anything. > Isn't K/D a low protein diet? Yes. How does K/D differ from this NF that my vet wants > me to feed the cat? Slightly different formulation- not enough to make a difference either way. (I don't remember for sure what the lab values were, but > I'm pretty sure the BUN was lower than 65 mg/dl). If your cat isn't dehydrated or severely uremic, I'd get a second opinion on fluid therapy at this stage. > Are cats with CRF less inclined to get struvite or is it simply a question > of the need for a more renoprotective alkaline diet needs to take priority > (and we cross our fingers that the cat doesn't develop struvite)? CRF cats already have a problem with renal acid excretion- so you don't want to add to it. Besides, older cats are more prone to develop calcium oxalate than struvite. > Thank you again for all your advice. > Best regards, > ---Cindy S. I hope it helps. Best of luck, Phil Hi Cindy, I am sorry about your cat. I hope he gets better soon. Take care. regards, David M >>> Well, I just got the bad news from the vet. Alex, who is 16 years old, >>> is [quoted text clipped - 71 lines] > Best regards, > ---Cindy S. > Hi Cindy, > > I am sorry about your cat. I hope he gets better soon. Take care. > > regards, > David M -------- Thanks, David. Best regards, ---Cindy S. > Fluid therapy should be administered *only* to correct or prevent > dehydration or short-term to augment GFR in a uremic crisis. Premature or [quoted text clipped - 8 lines] > You might want to start thinking about giving your cat a potassium and > omega-3 supplement. Both will delay the downward spiral of CRF. ----------- BUN 54.2 Creatinine 2.1 Urine specific gravity 1017 (Normal 10/23) Potassium is in the middle of the normal range. FTR, the BUN was around 24 or 25 in December, so it doubled in just a few months. I questioned the vet quite a bit about the subcu fluids. She said that while it is true that the diseased nephrons can never recover, the subcu will "open up tubules" and prevent more nephrons from being lost. She stated that she has almost never failed to see improvement in lab values once the subcu fluids are started. She said the low protein diet was less critical, and that it would be no big deal to keep Alex on his current diet. She said that her plan, anyway, is to repeat his bloodwork in three to six months, and then we can go from there. I know you think I should still get a second opinion regarding the subcu fluids. Do you know if it is possible for me to speak to someone at Cornell? I think the question at this stage is a simple yes/no, i.e., I would ask the second opinion vet whether he/she generally believes it's a good idea or a bad idea to start subcu fluids in a cat with early CRF. I don't think the cat would need to be reexamined. I am going to start Alex on the Omega-3 (from fish) as you have advised. I intend to give that to Bullwinkle as well (for prevention). My vet advised against starting the potassium until Alex's values slip out of normal range. Right now, they are in the mid-range of normal. Does all of this seem like a reasonable plan to you? Thanks in advance. Best regards, ---Cindy S. >> Fluid therapy should be administered *only* to correct or prevent >> dehydration or short-term to augment GFR in a uremic crisis. Premature [quoted text clipped - 43 lines] > Best regards, > ---Cindy S. Cindy, I don't know if you'd be interested in this or not--it's Cornell University's consulting service--looks like it's available for both vets and owners. Of course it's not free.. . but you might want to try it. http://www.vet.cornell.edu/fhc/camuti.htm Alex's numbers don't look that different from Molly's. His creatinine is slightly higher but that number isn't as important as the BUN. All I know is that she really started feeling better once we started her on fluids. Good luck, Cindy. HTH Bonnie > Cindy, > [quoted text clipped - 9 lines] > > Good luck, Cindy. ---------- Thank you so much. By description, the Cornell service seems to be made to order for what I had in mind. BTW, Alex had been looking under the weather for quite some time, sleeping all the time, very little appetite, not wanting to leave the kitchen much. He had also thrown up a few times, the clear liquid that is so typical for cats with CRF (due to nausea). On one of the websites (I think it was a website and not this forum), I read about giving the cat 5 mg of Pepcid daily. I just happened to have some (20 mg tablets that had been cut into four parts) left over from when my Molly was nauseated and dying and I tried giving it to her (I had forgotten all about that). To make a long story short, I gave Alex a single dose yesterday, not really expecting much, and today he was like a new cat! This is the liveliest and best we have seen him in weeks. Perky, happy, he came upstairs twice. Every time I went in the kitchen, he would follow me around asking for food. Great appetite. Overall, he was much more active than I've seen him in a very long time. It was a like a miracle. So, if you didn't know already, if ever your Molly seems under the weather, the Pepcid is something easy you can try. It's also inexpensive and relatively innocuous. Thank you again. Best regards, ---Cindy S. >> Cindy, >> [quoted text clipped - 36 lines] > Best regards, > ---Cindy S. So good to hear Alex is feeling better! And thanks for the great tip regarding Pepcid. My geriatric dog and I are both on pepcid so I already have some around--10 mg tablets--so I'll definitely keep that in mind! How big is Alex? Molly is pretty small--around 6 lbs give or take an ounce. I wonder if the dose would be the same. My dog is on 5 mg once daily and she is 45 to 50lbs. Let us know about the consultation service--I thought it was a neat idea and not that terribly expensive. Take care, I wish you and Alex the best. Bonnie >>> Cindy, >>> [quoted text clipped - 43 lines] > ounce. I wonder if the dose would be the same. My dog is on 5 mg once > daily and she is 45 to 50lbs. ----------- Alex weighs somewhere between 11 and 12 pounds. The dose mentioned on the website was 5 mg for a cat (without mention of the size of the cat). When I phoned my vet's office, I asked "would it be okay to give Alex a 5 mg dose of Pepcid?" and I was told yes. When I opened the Pepcid box, I saw that I had already quartered some of the 20 mg tablets the last time I used it. I am presuming that was for my Molly who weighed about 6 pounds at the time. So, I suspect that the vet must have told me 5 mg for her. But, I wouldn't swear to it, as I had also given Pepcid to Alvin (my dog) who weighed about 45 pounds. Somehow, I have it in my head that Alvin's dose may have been more than 5 mg. At any rate, I suspect the proper dose for your Molly will be 5 mg, but obviously ask your vet. > Let us know about the consultation service--I thought it was a neat idea > and not that terribly expensive. I agree. Not much more than the price of an office visit. I spent close to $200 at the vet last week, so $55 seems like a relative bargain. > Take care, I wish you and Alex the best. Thanks Bonnie. Same to you and Molly. Best regards, ---Cindy S. > Bonnie > ----------- > BUN 54.2 [quoted text clipped - 4 lines] > FTR, the BUN was around 24 or 25 in December, so it doubled in just a few > months. BUN is not as important as creatinine. What was his previous creatinine? > I questioned the vet quite a bit about the subcu fluids. She said that while > it is true that the diseased nephrons can never recover, the subcu will > "open up tubules" and prevent more nephrons from being lost. As her for a reference on that on.... She stated that > she has almost never failed to see improvement in lab values once the subcu > fluids are started. Its true that fluid therapy will impove renal parameters *acutely*, but it should not be used chronically as a form of dialysis. She said the low protein diet was less critical, and > that it would be no big deal to keep Alex on his current diet. She said that > her plan, anyway, is to repeat his bloodwork in three to six months, and > then we can go from there. > > I know you think I should still get a second opinion regarding the subcu > fluids. Do you know if it is possible for me to speak to someone at Cornell? You might want to give Dr. David J Polzin at U of Minn. a call @ 612-625-4254. You can also send him an email @ polzi001@umn.edu He's one of the leading experts on CRF in cats. I don't think he'll charge you for his opinion. > I think the question at this stage is a simple yes/no, i.e., I would ask the > second opinion vet whether he/she generally believes it's a good idea or a > bad idea to start subcu fluids in a cat with early CRF. I don't think the > cat would need to be reexamined. You're right. > I am going to start Alex on the Omega-3 (from fish) as you have advised. I > intend to give that to Bullwinkle as well (for prevention). My vet advised > against starting the potassium until Alex's values slip out of normal range. > Right now, they are in the mid-range of normal. I really think you should find another vet. The reason for supplementing potassium is so Alex's potassium *doesn't* "slip out of normal range" and to protect tissue from potassium depletion. Blood or serum potassium levels are not accurrate markers of the body's potassium stores because ~97% of the body's potassium is stored in *tissue* not in the blood or serum. By the time potassium "slips out of normal range" potassium depletion has already begun in the tissues. IOW, cats with normal serum potassium levels can still have deficient potassium levels in the tissue. "Interestingly, muscle potassium content has been shown to be decreased in normokalemic cats with spontaneous CRF, indicating that a total body deficit of potassium may develop well before the onset of hypokalemia." (David J Polzin, DVM, Dipl. ACVIM) > Does all of this seem like a reasonable plan to you? Dump your vet *now* before its too late. Btw, Pepcid was a good idea. Uremia can cause uremic gastritis. > Thanks in advance. > Best regards, > ---Cindy S. Best of luck, Phil >> ----------- >> BUN 54.2 [quoted text clipped - 6 lines] > > BUN is not as important as creatinine. What was his previous creatinine? I don't remember the exact number, but I do remember that there was not a significant change. >> I questioned the vet quite a bit about the subcu fluids. She said that > while [quoted text clipped - 26 lines] > charge > you for his opinion. Thank you, thank you! >> I think the question at this stage is a simple yes/no, i.e., I would ask > the [quoted text clipped - 24 lines] > still > have deficient potassium levels in the tissue. And being in the medical field myself, I should have known/remembered that. > "Interestingly, muscle potassium content has been shown to be decreased in > normokalemic cats with spontaneous CRF, indicating that a total body [quoted text clipped - 5 lines] > > Dump your vet *now* before its too late. We've been going to this office for years. We were previously seeing a different vet in the same office who left for a different practice (a much further drive and very limited hours). It's also going to be hard because the vet has become somewhat of a personal friend, the office is near our house, it's staffed 24/7, it has overnight boarding, and a hospital, etc. Most of the other vet hospitals around here don't offer all of this. In spite of all of that, I am willing to change to another vet, but how will I know that the new vet will be better than the old one? One way, was I was thinking of phoning a particular Cats Only practice and asking them how they would treat my cat's CRF and see what they say. Or I could say "I was thinking of doing this (naming what my vet had suggested), do you think that's a good idea?" Again, Phil, thank you so much. Best regards, ---Cindy S. > Btw, Pepcid was a good idea. Uremia can cause uremic gastritis. > [quoted text clipped - 5 lines] > > Phil >> Dump your vet *now* before its too late. > [quoted text clipped - 10 lines] >thinking of doing this (naming what my vet had suggested), do you think >that's a good idea?" Is your vet open to exchange of ideas and other opinions? Perhaps Phil's advice may sound logical to your vet and he will modify his recommendation. >>> Dump your vet *now* before its too late. >> [quoted text clipped - 16 lines] > Phil's advice may sound logical to your vet and he will modify his > recommendation. ------- Well, she'll go along with what I think is best for Alex, i.e., she's not going to give me an argument about what I want to do, but that's not the same as modifying her recommendation. When I told her that I didn't think I wanted to change the food to NF, she said fine. When I asked about the omega-3 and potassium, she said fine to omega-3 but advised against the potassium for the reasons, stated etc. And if I speak to Dr. Prozin (I have e-mailed and also left him a phone message), and he agrees with Phil, and I tell her I don't want to initiate subcu fluids, she will say okay to that too. But I don't think that's the issue. I think the real issue here is that I have five cats, all of whom are her patients. After this, will I still have confidence in her abilities, as a whole? What happens when my next cat gets sick with something else? Am I always going to be second guessing this doctor? That's really the issue at hand. I have already made an appointment to get a second opinion at another veterinary practice. Once I hear the other doctor's opinion and Dr. Prozin's opinion, I will decide what I want to do. I lost another cat (Molly) to CRF last October. The vet whom we were seeing during most of that time (the one who moved to a more distant practice) never once suggested putting Molly on subcu fluids until she was in acute renal failure at the end (as Phil said). OTOH, she also never suggested omega-3, potassium supplementation at any point. She did suggest the K/D food at some point in the middle but Molly wouldn't eat it, so that was a moot point. My husband feels that overall she was a better vet than this one. But was she really? Who knows? The reality is that at some point down the road, Alex will die from CRF. No matter when that happens, I will never know for sure if the interventions (any of them) actually prolonged his life or shortened it. How can I know for sure if he would have lived for six months more or six months less if only I had done this or hadn't done that? Best regards, ---Cindy S. snip >And if I speak to Dr. Prozin (I have e-mailed and also left him a phone >message), ---- Dr. Polzin, not Prozin. I did get it right on the phone message and e-mail however. Best regards, ---Cindy S. > We've been going to this office for years. We were previously seeing a > different vet in the same office who left for a different practice (a much > further drive and very limited hours). It's also going to be hard because > the vet has become somewhat of a personal friend, I realize switching vets or even getting a second opinion can make you feel uncomfortable- especially if you have a close relationship with your vet. However, I think your first loyalty should be to your cat, not to your vet. You have to ask yourself "is this vet doing the best thing for my cat?". From what you said she said, I'd have to say no. Just because she says she has treated cats with CRF before doesn't mean she's good at it. Sounds like she's mediocre at best. the office is near our > house, it's staffed 24/7, it has overnight boarding, and a hospital, etc. > Most of the other vet hospitals around here don't offer all of this. In > spite of all of that, I am willing to change to another vet, but how will I > know that the new vet will be better than the old one? I know what you mean. You could go from bad to worse. If you have a vet college near you, you might want to give them a call for a referral or you could do a search for a ACVIM diplomate or ABVP feline specialist in your area. They have much more training and experience. Very few general practioners are really knowledgable about treating CRF. Renal diets and fluid therapy are about the extent of their experience. One way, was I was > thinking of phoning a particular Cats Only practice and asking them how they > would treat my cat's CRF and see what they say. Or I could say "I was > thinking of doing this (naming what my vet had suggested), do you think > that's a good idea?" I don't think a vet will give you a specific recommendations for a treatment plan without seeing your cat. If your email is working I can send you a very good file about CRF and the importance of potassium. Best of luck, Phil >> We've been going to this office for years. We were previously seeing a >> different vet in the same office who left for a different practice (a [quoted text clipped - 5 lines] > feel > uncomfortable- especially if you have a close relationship with your vet. Hi, Phil! I'm bringing Alex to a different veterinary practice for a second opinion on Monday. > However, I think your first loyalty should be to your cat, not to your > vet. [quoted text clipped - 4 lines] > like > she's mediocre at best. Thank you so much for the phone number and e-mail for Dr. Polzin. I have been in touch with him. Basically, what he said was that it would be unethical for him to provide a treatment plan for my cat. I wasn't really asking him to do that, but since I did provide him with the lab values and Alex's medical history, I can see why he would have interpreted it that way. He said that he thinks some of my vet's suggestions are "optional," but he disagreed that I needed to switch to a different veterinarian. He said he would be willing to act as a consultant and communicate with the current veterinarian directly if she were open to that (and I initiated that). I thought that was incredibly kind. > the office is near our >> house, it's staffed 24/7, it has overnight boarding, and a hospital, etc. [quoted text clipped - 9 lines] > practioners are really knowledgable about treating CRF. Renal diets and > fluid therapy are about the extent of their experience. We have a *veterinary specialist* group. It is by referral from the primary vet only. There are five specialists, none of whom is specifically for renal. Two are for ophthalmology, one is for orthopedics, one may be cardiology, one is surgery. But one of them (I can't remember which one) did complete a renal residency, so I would try to see him. I have made an appointment to get a second opinion from a different (general) vet on Monday. Depending on how things go, I could ask her for a referral to the specialist. Actually, what I would prefer to do is to make a photocopy of the article you e-mailed me and present it to my current vet. Can you reference for me any articles specifically about the subcu fluids? (Unless the subject is addressed in the article you already e-mailed me- I just turned on my computer five minutes ago and haven't read the potassium article yet). > One way, was I was >> thinking of phoning a particular Cats Only practice and asking them how [quoted text clipped - 6 lines] > treatment > plan without seeing your cat. I have an appointment on Monday. > If your email is working I can send you a very good file about CRF and the > importance of potassium. I got it. Thank you! I will ensure that Alex starts on potassium. Do you have an article about subcu fluid treatment in early CRF? Thank you again for all of your help. Yesterday, I was wreck, but after communicating with you and Dr. Polzin, I am starting to feel better. I think my next step is to e-mail back to Dr. Polzin and asked him what he thinks about subcu fluid treatment in early CRF *in general* and thereby he won't feel that I am asking him to write a treatment plan for my cat (which I really wasn't). Again, thank you again for all of your help and for e-mailing me that article. I will keep you updated as I go along. Best regards, ---Cindy S. > Hi, Phil! I'm bringing Alex to a different veterinary practice for a second > opinion on Monday. Hi Cindi, I'm glad to hear it. You made a wise decision. > Thank you so much for the phone number and e-mail for Dr. Polzin. You're welcome. I have > been in touch with him. Basically, what he said was that it would be > unethical for him to provide a treatment plan for my cat. I wasn't really [quoted text clipped - 3 lines] > He said that he thinks some of my vet's suggestions are "optional," but he > disagreed that I needed to switch to a different veterinarian. I think that was just a professional courtesy. He's a very nice person. It was bad enough that your vet didn't recommend a K+ supplement to protect Alex's body's K+ stores, she should have definitely recommended a K+ supplement when she recommended fluid therapy. Cats with CRF produce more urine and urinate more frequently because they lose their ability to concentrate urine. Producing urine rapidly and frequently promotes potassium loss-- fluid therapy induces diuresis which increases rapid urine formation and thus even greater K+ losses. That's why most vets and human doctors prescribe a K+ supplement whenever they prescribe a diuretic. I think she erred at a very basic level- which is inexcusable as far as I'm concerned. I couldn't trust a vet who made such a basic error with my cats' lives. I see it as an early waning sign to find another vet with more experience in treating CRF. Alex can't afford to have a vet that learns by trial and error on him. He said he > would be willing to act as a consultant and communicate with the current > veterinarian directly if she were open to that (and I initiated that). I > thought that was incredibly kind. That's why I suggested you contact him. He's a very kind person and he really cares about the animals' well-being. > We have a *veterinary specialist* group. It is by referral from the primary > vet only. There are five specialists, none of whom is specifically for [quoted text clipped - 4 lines] > Monday. Depending on how things go, I could ask her for a referral to the > specialist. It would be great if you could find a general vet who has a special interest in nephrology- or at least CRF- and is up to date on current treatments. Actually, what I would prefer to do is to make a photocopy of > the article you e-mailed me and present it to my current vet. Here's another quote about potassium by Gary Norsworthy (excerpted from Feline Practice): "Recently, two important discoveries have been made concerning potassium and older cats. A mild form of hypokalemia (low blood potassium) has been identified in the older cat; it is associated with lethargy and inactivity, a poor appetite and haircoat, and the development of a mild anemia. Formerly, we have considered these to be part of the aging process. Now we know that this process can be reversed with supplementation of potassium. Unfortunately, we do not have a test to conclusively identify these cats because the blood test for potassium is a poor reflection of the body's total store of potassium. Blood potassium may be normal in cats who are actually depleted of potassium within their body's cells. For these cats, a 30 to 45 day trial of potassium is necessary. If response occurs and potassium supplementation is continued, the cat will continue to feel, act, and eat better and will live longer. The second discovery about low blood potassium is related to the effect of potassium on the kidneys. The kidneys are the organs that usually wear out first in the older cat. As the kidneys become less efficient in removing waste products from the blood, the cat drinks more and more water in an attempt to flush toxins from the body (via the kidneys). An undesired consequence of increased urination is the loss of potassium from the body in the urine. As urine production increases, more and more potassium is lost, eventually leading to hypokalemia. The potassium loss associated with increased urine production has a negative effect on the kidneys. Research has demonstrated that low potassium will depress kidney function. This results in a vicious cycle: declining kidney function results in increased loss of potassium, and the loss of potassium then speeds up the deterioration of the kidneys." Do you see why its very dangerous to wait until Alex's K+ values "slip out of the normal range"? Can you > reference for me any articles specifically about the subcu fluids? (Unless > the subject is addressed in the article you already e-mailed me- I just > turned on my computer five minutes ago and haven't read the potassium > article yet). Sure. Here's a quote by Dr. Kathy James- the Urology/Nephrology Consultant for VIN: "There are certainly some theoretical reasons why prolonged diuresis could promote progression. The elevated glomerular filtration rate could be associated with hypertension in the kidney itself. Also diuresis will result in more Na+ filtered that has to be reabsorbed and more energy consumed by the kidney. More energy consumed means more O2 burned and more O2 metabolites the kidney has to process. Just some theoretical reasons why we need to start SQ fluids when crf cats are at risk for dehydration but not before." Here's a link to a chart on my site that shows you how to calculate the amount of fluid to administer at different levels of dehydration: http://maxshouse.com/Calculation_of_24-Hour_Fluid_Requirement_at_Different_Level s_of_Dehydration.htm > I got it. Thank you! I will ensure that Alex starts on potassium. Do you > have an article about subcu fluid treatment in early CRF? [quoted text clipped - 6 lines] > Again, thank you again for all of your help and for e-mailing me that > article. I'll send you Drs. Polzin & Osborne chapter on CRF from the lastest edition (6th) of Ettinger's TBVIM. You won't find a better paper on CRF anywhere. >I will keep you updated as I go along. Please cc a copy of your updates to my email (topcatATmaxshouseDOTcom). With kitten season beginning I have even less time to follow the group. > Best regards, > ---Cindy S. Best of luck, Phil >> Hi, Phil! I'm bringing Alex to a different veterinary practice for a > second [quoted text clipped - 140 lines] > > Phil Hi Phil, Is there a risk of a CRF cat getting too much potassium? I have a very early stage CRF cat (16 years old) he does not appear to drink or pee excessively, though. His first test results were: Bun 42 mg/dl (Lab normal 16 - 36) Creat 2.9 mg/dl (Lab normal 0.8 - 2.4) I will be taking him back in for follow up blood work. He appears to be doing well on NF food, though. Thanks for all your wonderful info, I will be discussing this with my vet. Patty snip > Hi Phil, > > Is there a risk of a CRF cat getting too much potassium? Knowing what I know now, yes. If he's not urinating enough. >I have a very > early stage CRF cat (16 years old) he does not appear to drink or pee [quoted text clipped - 5 lines] > I will be taking him back in for follow up blood work. He appears to be > doing well on NF food, though. The NF food contains additional potassium. > Thanks for all your wonderful info, I will be discussing this with my vet. Phil provided me with tons of information and really made a huge effort to help me. I'm really glad he is participating on this group, and I can't thank him enough. Best regards, ---Cindy S. > snip >> [quoted text clipped - 23 lines] > Best regards, > ---Cindy S. Thanks, Cindy. I read your other post. Rusty is doing very well, I'm surprised since he was diganosed very early CRF a year or two ago and I began feeding him Hills k/d at the time. When my other cat, Grady, got so sick with liver failure, poor Rusty sort of got put on hold while all the attention went to Grady. I wasn't even feeding him renal food, but just senior food. When Grady passed away, I had Rusty re-tested and his numbers were still pretty low for a CRF kitty. So, he held his own through everything. I'm waiting now to see how well his tests come out now that I have him on renal food again. The thing with Rusty is, though, he never has stuck with one food. He needs variety, so I'm thinking of going back to the vet to see if I can get another renal food to help give him more variety, however, he won't touch the k/d food anymore. Rusty is an outdoor cat. He always was a hunter. He never ate catfood exclusively since he always ate what he caught. Perhaps that's the issue with him now, he'll never be happy with just a cat food, because he's always had variety in his food from birds to mice. Patty Hi, Phil (and everyone else) ! I went to see a different veterinarian for a second opinion. Here is what she said: 1. She thought that in Alex's case the subcu fluids would be a good idea since he is a little dehydrated. She said that it might be problematic to do them every day but once a week should be okay (would not stress his kidneys). She said she would not supplement with too much fluid however because he does havecardiomyopathy. 2. She thought that the Pepcid 5 mg was a great idea. She said 2.5 to 5.0 mg was okay, but not to go higher. 3. Omega-3 she also thought was a great idea. 4. She stated that she generally gives supplemental potassium only when the blood levels drop. She stated that this is also the policy of the internist at the veterinary specialty clinic.She stated the reason is as follows: *If* the cat is being fed NF or K/D or X/D or some other special kidney diet, the special food contains extra potassium. She said if I wanted to give my cat additional potassium (since he is not eating a special kidney diet), that would be okay provided that he is urinating a lot. If he is only urinating a little, potassium supplements could be dangerous for his heart. Dr. Polzin (in his paper) also recommends potassium supplementation *only when the blood levels drop*. He states that the justification for prophylactic (preventative) potassium supplementation in cats who have normal blood potassium levels has not been well established. He then goes on to state that potassium supplementation is not harmful as long as the cat continues to urinate copiously. Phil, you cited some other authorities who endorsed potassium supplementation in normokalemic cats, but this is not Dr. Polzin's view. 5. The second vet also mentioned that kitties with CRF can high phosphorous levels, so I might want to ensure that I am not feeding Alex high phosphorous food and that down the road, he may need a phosphorous-binding agent to get rid of the phosphorous. Again, I can't thank you enough for providing me with advice and Dr. Polzin's research paper (extremely lengthy and detailed) and also Dr. Polzin's phone number and e-mail address. I hope to know a lot about CRF by the time I'm finished. My mind is at much greater ease than it was a week ago. Best regards, ---Cindy S. > Hi, Phil (and everyone else) ! I went to see a different veterinarian for a > second opinion. Hi Cindi, That's great. Here is what she said: > 1. She thought that in Alex's case the subcu fluids would be a good idea > since he is a little dehydrated. If he's dehydrated-- absolutely. But just enough to replace the deficit and keep up with urinary losses. She said that it might be problematic to do > them every day but once a week should be okay (would not stress his > kidneys). She said she would not supplement with too much fluid however > because he does havecardiomyopathy. That's good to hear. Fluid overload can be fatal for cats with HCM/CHF. Sounds like you've found a good vet. > 2. She thought that the Pepcid 5 mg was a great idea. She said 2.5 to 5.0 > mg was okay, but not to go higher. Great. > 3. Omega-3 she also thought was a great idea. Great. > 4. She stated that she generally gives supplemental potassium only when the > blood levels drop. She stated that this is also the policy of the internist > at the veterinary specialty clinic.She stated the reason is as follows: > *If* the cat is being fed NF or K/D or X/D or some other special kidney > diet, the special food contains extra potassium. That's a pretty big "if". I have the same argument for the protein content of renal diets. All of the nutrient levels are based on the ASSumption the cat will eat his entire portion-- which most cats on renal diets don't. She said if I wanted to > give my cat additional potassium (since he is not eating a special kidney > diet), that would be okay provided that he is urinating a lot. If he is only > urinating a little, potassium supplements could be dangerous for his heart. Absolutely. > Dr. Polzin (in his paper) also recommends potassium supplementation *only > when the blood levels drop*. He states that the justification for [quoted text clipped - 4 lines] > endorsed potassium supplementation in normokalemic cats, but this is not Dr. > Polzin's view. I don't know he said that when everything else he says about potassium depletion suggests supplementing potassium even if serum K+ is in the normal range. "Interestingly, muscle potassium content decreased in normokalemic cats with spontaneous CKD, indicating that a total-body deficit of potassium may develop well before the onset of hypokalemia." "Total body potassium depletion is likely to be even more common than hypokalemia" "Thus although the value of providing supplemental potassium to cats with chronic kidney disease having normal serum potassium concentrations has not been established, it is clear that muscle potassium, and probably total body potassium stores, are likely to be reduced in cats with chronic kidney disease, increasing the risk for developing hypokalemia." Dr. Kathy James- the Urology/Nephrology Consultant for VIN says: "I try to maintain serum potassium concentration in the upper half of the laboratory normal range because serum potassium concentration may be preserved when total-body potassium is low. " I'm a firm believer in supplementing K+ to keep it in the upper half of the normal range as long as as the cat is polyuric. > 5. The second vet also mentioned that kitties with CRF can high phosphorous > levels, so I might want to ensure that I am not feeding Alex high > phosphorous food and that down the road, he may need a phosphorous-binding > agent to get rid of the phosphorous. Most of the Science Diet line is low in phosphorus- but after the recall, I don't trust Hill's as much as I used to. Some oFancy Feast diets are lower in phosphorus but their protein content is very high. > Again, I can't thank you enough for providing me with advice and Dr. > Polzin's research paper (extremely lengthy and detailed) and also Dr. [quoted text clipped - 3 lines] > Best regards, > ---Cindy S. I'm glad it helped. Best of luck, Phil > > Hi, Phil (and everyone else) ! I went to see a different veterinarian for > a [quoted text clipped - 109 lines] > > Phil Thanks for keeping us updated Cindy. It is very kind of you to find the time to share it all with us. I am delighted to hear that your mind is at ease now that you have seen her too. Continued Best wishes & mega purrs on their way over to you and yours S;o) > Hi, Phil (and everyone else) ! I went to see a different veterinarian for a > second opinion. Here is what she said: [quoted text clipped - 39 lines] > Best regards, > ---Cindy S. Hi Cindy, I was just wondering how Alex is doing presently, & more to the point, how are are you coping too? Hugs, S;o) Hi Cindy, Just wondering how Alex is doing. Did he see the second vet today? I hope all is well. Bonnie >>> We've been going to this office for years. We were previously seeing a >>> different vet in the same office who left for a different practice (a [quoted text clipped - 93 lines] > Best regards, > ---Cindy S. Same here. I haven't been posting, but I have been following this one Cindy. I really hope that all goes well with the second vet too. S;o) |
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