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Cat Forum / Health and Behavior / February 2005FurFace - On His Way Out
Furface is pushing 15 yo and was diagnosed with CRF in Aug '03. He was doing ok with just subcutaneous fluids, but started to lose weight. In Aug '04 they added Pepcid AC, Sucralf, something for high blood pressure ( I don't remember the name) and Bupren, as needed for pain. I picked him up from the vet on Saturday. I was out of town on a business trip and I have always boarded him there. He hasn't eaten or had a bowel movement since I brought him home and it appeared that he had blood in his urine (hard to tell in the kitty litter). When I took him to the vet yesterday, we were able to confirm the blood in his urine (he urinated in his carrier on the way there) and his weight is down to 6 pounds from a high of about 10, down 2 pounds in the past 2 months, 0.5 pounds since Saturday. Right now he is laying on the bed under a blanket. His temperature was subclinical and my girlfriend insists that I keep him under a blanket so he will not get cold. I am giving him the Bupren twice a day and trying not to move him too much since that seems to cause him pain. The vet suggested I think about putting him to sleep, but I just can't do it yet. As long as he seems to be comfortable, I am just going to let nature take its course. Thanks for letting me unload. Tom > Furface is pushing 15 yo and was diagnosed with CRF in Aug '03. He > was doing ok with just subcutaneous fluids, but started to lose > weight. In Aug '04 they added Pepcid AC, Sucralf, something for high > blood pressure ( I don't remember the name) Norvasc, maybe? and Bupren, as needed for > pain. > [quoted text clipped - 19 lines] > > Tom I'm sorry about FurFace & his CRF. BTDT, twice now. In '91, basically just sub-Q's were advocated for my first cat who had CRF at age 17, but 10 years later, the treatment had become much more sophisticated for my second cat w/ CRF, as you're alluding to here. You could try Lactulose for his constipation, to help him be a little more comfortable for his last weeks or days. Cats with CRF can go into convulsions at the end, so although I agree that as long as he seems to be relatively comfortable & can enjoy the simple pleasures of life (laying in the sunshine, that sort of thing), I'd also advise against waiting too long, not letting nature tasking its *complete* course. Do you know of this site? It's excellent, IMO - very, very useful. http://www.felinecrf.org/ Cathy > Cats with CRF can go into convulsions at the end, so although I agree that > as long as he seems to be relatively comfortable & can enjoy the simple > pleasures of life (laying in the sunshine, that sort of thing), I'd also > advise against waiting too long, not letting nature tasking its *complete* > course. Cats can also be extremely stoic and not clue us in to the full extent of their pain. I waited too long with my first cat, and I regret it to this day. I'll keep you in my thoughts, Tom and FurFace. Priscilla >> Furface is pushing 15 yo and was diagnosed with CRF in Aug '03. He >> was doing ok with just subcutaneous fluids, but started to lose >> weight. In Aug '04 they added Pepcid AC, Sucralf, something for high >> blood pressure ( I don't remember the name) > >Norvasc, maybe? Amlodipine. I just looked at the bottle. > and Bupren, as needed for <snip> >I'm sorry about FurFace & his CRF. BTDT, twice now. In '91, basically just >sub-Q's were advocated for my first cat who had CRF at age 17, but 10 years [quoted text clipped - 14 lines] > >Cathy Thanks for the link. It is a very helpful site. Furface is staying about the same. I have gotten him to take some water from a syringe, but he will not eat anything, even if I try to put in in his mouth with my finger. It seems to be painful for him to walk or move much, so I am keeping him on the Bupren. Mostly I am giving him all the TLC I can. Thanks to everyone who answered. I really appreciate your words. God Bless, Tom Tom - I'm so sorry that Furface has taken a turn for the worse. My thoughts & prayers are with you all. You will know when the time comes that you need to let him go - just went through that this week. I'm very sorry...Carol > Furface is pushing 15 yo and was diagnosed with CRF in Aug '03. He > was doing ok with just subcutaneous fluids, but started to lose [quoted text clipped - 23 lines] > > Tom > Furface is pushing 15 yo and was diagnosed with CRF in Aug '03. He > was doing ok with just subcutaneous fluids, but started to lose [quoted text clipped - 5 lines] > business trip and I have always boarded him there. He hasn't eaten or > had a bowel movement since I brought him home Tom, I suggest you get a second opinion about that drug protocol as soon as possible. Sucralfate is well known for causing constipation and amlodipine is known to cause azotemia, lethargy and weight loss in cats, and buprenorphine should not be used in cats with renal insuffiency or debilitated or geriatric cats. You might want to speak to a vet about benazepril - an angiotensin converting enzyme (ACE) inhibitor for his hypertension. Benazepril also improves renal function and slows the progression of CRF in cats. We've had nothing short of miraculous results with benazepril in some of our CRF cats. As long as your cat is urinating, you might want to mention a potassium supplement, also. Before giving up, I think you should seriously consider a second opinion as soon as possible. Best of luck. Phil. Best of luck. Phil and it appeared that he > had blood in his urine (hard to tell in the kitty litter). When I > took him to the vet yesterday, we were able to confirm the blood in [quoted text clipped - 14 lines] > > Tom > Tom, I suggest you get a second opinion about that drug protocol as soon as > possible. Sucralfate is well known for causing constipation and amlodipine > is known to cause azotemia, lethargy and weight loss in cats, and > buprenorphine should not be used in cats with renal insuffiency or > debilitated or geriatric cats. Amlodipine is the drug of choice for hypertension in cats. Benazepril is far more likely to cause azotaemia than amlodipine. > You might want to speak to a vet about benazepril - an angiotensin > converting enzyme (ACE) inhibitor for his hypertension. Benazepril also > improves renal function and slows the progression of CRF in cats. We've had > nothing short of miraculous results with benazepril in some of our CRF cats. > As long as your cat is urinating, you might want to mention a potassium > supplement, also. And I've seen cats die from benazepril. If benazepril "improves renal function" so definitively, why is it not used all the time for every CRF cat? It's a controversial treatment for a reason. Some cats do well on it, some do very badly. Problem is, you don't know which category a particular cat will fall into. The Evidence Panel of ACVIM gave the use of ACE Inhibitors in CRF a Grade 3, the lowest grade available. Novartis have still not published the full results of their trial into the use of benazepril for CRF cats. I wonder why not? Tom, I would not risk giving benazepril to a cat with high creatinine. It may increase the creatinine and push the cat over the edge. http://www.felinecrf.org/treatments.htm#ACEI http://www.felinecrf.org/treatments.htm#control_of_blood_pressure > As long as your cat is urinating, you might want to mention a potassium supplement, also. Phil is a great fan of potassium supplements too, but if FurFace really is end stage, than chances are his potassium levels are already pretty high even if he's still peeing, in which case a potassium supplement could be very dangerous. Please never give a potassium supplement without checking potassium levels first. Tom, I suggest you join the CRF Support list: http://groups.yahoo.com/group/Feline-CRF-Support/ Did the vet not do any tests, BTW, regarding the blood in the urine? HTH Helen > > Tom, I suggest you get a second opinion about that drug protocol as soon > as [quoted text clipped - 24 lines] > not published the full results of their trial into the use of benazepril for > CRF cats. I wonder why not? You haven't looked hard enough. The results have been out for four years: Am J Vet Res 2001 Mar;62(3):375-83 Effects of the angiotensin converting enzyme inhibitor benazepril in cats with induced renal insufficiency. Brown SA, Brown CA, Jacobs G, Stiles J, Hendi RS, Wilson S. Department of Physiology and Pharmacology, College of Veterinary Medicine, University of Georgia, Athens 30602, USA. OBJECTIVE: To determine effects of the angiotensin converting enzyme inhibitor benazepril in cats with induced renal insufficiency. ANIMALS: 32 cats. PROCEDURE: Renal mass was surgically reduced, and cats were assigned to 1 of 4 eight-cat groups. Group 1 received placebo, whereas groups 2, 3, and 4 received benazepril hydrochloride orally once daily for approximately 6.5 months at the following doses: group 2, 0.25 to 0.50 mg/kg of body weight; group 3, 0.50 to 1.00 mg/kg; and group 4, 1.00 to 2.00 mg/kg. Arterial blood pressures, glomerular filtration rate (GFR), and renal plasma flow were determined before treatment and during the treatment period. Other determinants of renal hemodynamics were measured by use of micropuncture techniques. Renal biopsy specimens were examined microscopically. RESULTS: Compared with cats that received placebo, mean systolic arterial blood pressure was significantly less and GFR significantly greater in cats that received benazepril. Glomerular capillary pressure and the ratio of efferent to afferent arteriolar vascular resistance were also significantly less in treated cats. However, histologic differences in renal specimens were not detected. CONCLUSIONS AND CLINICAL RELEVANCE: Treatment with benazepril sustained single nephron GFR in remnant nephrons of cats with induced renal insufficiency. Administration of benazepril was also associated with a small but significant reduction in degree of systemic hypertension and an increase in whole kidney GFR. Benazepril may be an effective treatment to slow the rate of progression of renal failure in cats with renal disease. hth, Phil > You haven't looked hard enough. The results have been out for four years: Oh, I've looked, in fact I link to that study. A study, incidentally, on cats with *induced* renal failure. There are other studies out there on cats with naturally occurring renal failure. > CONCLUSIONS AND CLINICAL > [quoted text clipped - 12 lines] > > disease. Note the use of the word "may". Not "will", as your original post implies. I think we've had this conversation before, Phil. Studies support hypotheses. Unfortunately, they are not guarantees. I only wish they were, then treating illness would be a no-brainer. I've reviewed all the information I've found to date on using benazepril in renal failure and I have reached a different conclusion to you, I think the evidence in support of using benazepril in CRF cats is poor. We don't have to agree, I'm glad you've had good results, but I personally think benazepril is overhyped, particularly in the UK where it is often the only treatment provided, occasionally in addition to prescription diet. Incidentally, from correspondence I have received (and yes, this is anecdotal), cats with diabetes in addition to CRF seem to do particularly badly on benazepril. HTH Helen > > You haven't looked hard enough. The results have been out for four years: > > Oh, I've looked, in fact I link to that study. A study, incidentally, on > cats with *induced* renal failure. There are other studies out there on cats > with naturally occurring renal failure. That's the major problem I've had with most feline CRF studies. Aside from being infuriated by subjecting healthy cats to the surgical removal of 3/4 or more of their kidneys while thousands of cats are suffering from naturally occuring CRF can be studied, surgical removal does not, and cannot duplicate the morphologic changes a kidney undergoes during the natural development of the disease. btw, here's the Novartis study you've been looking for: Effect of Benazepril in Chronic Renal Insufficiency in Cats: Interim Results from the Benric Clinical Trial *J.N.King, A. Font, for the BENRIC Study Group, Novartis Animal Health Inc OBJECTIVES Inhibitors of the angiotensin-converting enzyme (ACE) have been proven to have beneficial effects in chronic renal insufficiency (CRI) in man. Benazepril has been shown to prolong survival time and reduce proteinuria in a large clinical trial in humans (Maschio et al., 1996) and to have beneficial haemodynamic effects (normalization of glomerular hypertension with maintained or increased glomerular filtration rate) in a model of CRI in cats (Brown et al., 2001). The objective of the current study was to evaluate the efficacy and tolerability of benazepril in clinical cases of CRI in cats. MATERIALS The study was a double-blinded, randomized, prospective, parallel-group design, placebo-controlled clinical trial. Inclusion criteria were CRI of renal origin with plasma creatinine greater than or equal to 177 micromole/L and a urine specific gravity less than or equal to 1.025. The cats were randomized to receive benazepril (0.5-1 mg/kg) or a matched placebo once per day for up to 3 years. The cats were re-examined after 7 days and then every 1-3 months. Current results are from an interim assessment made at the mid-point of the trial. RESULTS Benazepril produced a significant (p<0.05) reduction in urine protein (UPC). The magnitude of the benefit of benazepril was proportional to the initial UPC, but significant effects were observed in all sub-groups, including cats with low UPC (<0.2). There was no significant difference in survival time for all cats between the two groups, mean (SE) times were 501 (34) for benazepril and 391 (22) for placebo. In the sub-group of cats with UPC>1, benazepril treated cats had longer survival times (401 versus 126 days) and significantly higher survival rate at the end of the trial, quality life and appetite scores. > > CONCLUSIONS AND CLINICAL > > [quoted text clipped - 15 lines] > > Note the use of the word "may". Not "will", as your original post implies. Based on our experiences, I'd have to say will because it did. > I think we've had this conversation before, Phil. Studies support > hypotheses. Unfortunately, they are not guarantees. I only wish they were, [quoted text clipped - 5 lines] > particularly in the UK where it is often the only treatment provided, > occasionally in addition to prescription diet. Based on the initial literature I read, I was also very skeptical, but the very favorable results soon changed my mind. Also, as long as the cat is urinating, potassium supplementation also improved renal function and the quality of life in many of our CRF cats. You can't access body potassium stores by serum potassium levels because potassium depletion can occur well before the onset of hypokalemia. > Incidentally, from correspondence I have received (and yes, this is > anecdotal), cats with diabetes in addition to CRF seem to do particularly > badly on benazepril. Have you read the Leiter &Lewanczuk HOPE (human) study? In short the study showed blocking the renin-angiotensin system (RAS) may reduce the risk of developing type 2 diabetes mellitus. This is a brand new study (2005) - I'm looking forward to reading the results of studies in cats. Phil > btw, here's the Novartis study you've been looking for: > Effect of Benazepril in Chronic Renal Insufficiency in Cats: Interim Results > from the Benric Clinical Trial *J.N.King, A. Font, for the BENRIC Study > Group, Novartis Animal Health Inc That's the interim study results. They still haven't published the final results, and told me they have no date in mind for doing so. I think they probably never will. > Based on the initial literature I read, I was also very skeptical, but the > very favorable results soon changed my mind. There have been mixed results on the CRF list, and certainly a few deaths probably attributable to the benazepril. I would not use it in a cat with creatinine over 3, and I would only consider using it in a cat with proteinuria - that's the one group everybody seems to accept may benefit from benazepril. Also, as long as the cat is > urinating, potassium supplementation also improved renal function and the > quality of life in many of our CRF cats. You can't access body potassium > stores by serum potassium levels because potassium depletion can occur well > before the onset of hypokalemia. I know the serum levels don't necessarily reflect what's going on at cellular level, but I still wouldn't supplement unless potassium levels were below 4. Ideally, the serum level should be firmly in the middle of the normal range, which is safe and should indicate sufficient potassium at cellular level; but too high and there can be risks too. > Have you read the Leiter &Lewanczuk HOPE (human) study? In short the > study showed blocking the renin-angiotensin system (RAS) may reduce the risk > of developing type 2 diabetes mellitus. This is a brand new study (2005) - > I'm looking forward to reading the results of studies in cats. Thanks, I'll check it out, sounds interesting. Helen > Also, as long as the cat is > > urinating, potassium supplementation also improved renal function and the [quoted text clipped - 6 lines] > cellular level, but I still wouldn't supplement unless potassium levels were > below 4. Below 4 would already be too late. Serum potassium should be kept in the upper half of the normal range to maintain serum potassium levels if body potassium stores drop - i.e., ECF to ICF. Also, potassium depletion can induce metabolic acidosis -- which further increases potassium losses -- which further increases metabolic acidosis -- which even further increases potassium losses -- which leads to a self-perpetuating cycle. Also, most CRF cats are on fluid therapy fluid -- which causes rapid urine formation. Rapid urine formation increases potassium excretion. Renal cats drink more and urinate more (those in polyuric CRF). PD/PU can have the same effects on potassium excretion. I know you've been opposed to potassium supplementation for years. However, as long as the cat is urinating and the serum potassium levels are monitored, there is very, very little risk of hyperkalemia and the benefits certainly outweigh the very low risks. Phil
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