Vet disagrees w/ Potassium supplementation -- how do I proceed?

So I've posted recently about my old gal Cleo who had issues with patches of fur loss. Full senior panel done, hyperT ruled out.

Last weekend I went to the local Emerg Hospital to get a second opinion; this was prompted by my own Vet prescribing a deworming med for Cleo (Profender) and my other 4 indoor cats in the event that her fur loss was caused by mites. I sought the 2nd opinion mostly because I questioned the use of a dewormer for skin mites and I could find NO info online to indicate that Profender was ever used in the treatment of skin mites in cats (and I was not about to give this to all of my cats without good reason). The ER Vet I saw did a skin scraping and ruled out any kind of mite so good move not to give the Profender.

She was convinced that fur loss due to a food allergy. I did buy some Medi-Cal Hypoallergenic Dry and Canned and the canned was a total bust; not one of my 5 cats would even touch it. As I want them to eat a diet of mostly canned, it made no sense for them to eat the dry Hypo food but then still be eating other canned food.

She started Cleo on a 3 week course of Prednisone (to be tapered right off of the Pred by the end of the 3 weeks). This has helped tremendously. I no longer see Cleo obessively grooming. I've been able to remove her little infant sleeper......and I've come to the conclusion that her continued fur loss to front of chest and other shoulder area has actually been DUE TO wearing the sleeper!! Since she's stopped wearing it....5 days ago, no further spread to the areas. I have a feeling that the friction from wearing the sleeper was causing the increased fur loss......so my good efforts were making the situation worse!

ANYWAY..........here is my question.

I realize she's early CRF.

Her Feb 23/2011 bloodwork showered her Potassium level to be on the low end of the normal range.

Potassium: 4.1 (our lab's range: 3.9 to 5.3)
BUN 12.3 (lab's range: 5 - 12)
Creat 238 (lab's range: 71 - 203) (a year ago Creat was 200)
Everything else normal (liver enzymes, total protein, glucose, hct/hgb/RBC all good)

Urinalysis showed a pretty good specific gravity of 1.038, no protein in urine, evidence of a UTI (she had no symptoms!)...so was started on 10 days of Baytril which she's now finished.

I told my Vet I was a little concerned about her lowish potassium level......wondered if a bit of supplementation would be in order. From having had a CRF cat in the past and from all I learned them (from my research and from my Vet years ago who helped me deal with my CRF cat then), by the time the potassium level is actually low in the BLOOD, it's actually even LOWER at the cellular level (intracellular) ..... so even though the cat might be on the low end of the range and still 'normal', some supplementation is warranted. He is in total disagreement. Gave me the speech about how we have to be careful not to cause hyperkalemia. While i understand that high potassium level can be deadly....of course...low potassium level is not harmless, either......and it, too, can impact heart function and blood pressure...and can actually accelerate kidney failure.

Had he been more receptive to some supplementation with Tumil K, I would have been content to just give her small amounts and then recheck level in 3-4 weeks. Even if it just meant giving her a small dose than normal even 3x/week then rechecking after a few weeks. But he wasn't open at all.

Her appetite hasn't been great the past while but I've attributed that to the Baytril (he prescribed 25mg once daily; she weighs 9.5 lbs so a bit of a high dose I think?). I found that splitting the dose in half and giving half in morning and half 12 hours later helped some. Today was her first day without Baytril and though I had to coax her some, she did eat a full can of FF this morning (Yes, I know, crappy food but it is the ONLY canned food she will eat, trust me). She's seemed a little less energetic over the past nearly 2 weeks but from what I'd read, Baytril can cause a bit of lethargy in cats so I've attributed that to the Baytril.

Her coat is nice and sleek and silky. She pees as per usual, about twice a day. She's not drinking excessively at all, never has. I attribute that to a diet of primarily canned food (twice daily).

I do have Tumil K in my cupboard from a previous cat who has since passed on....it's not yet expired. I do not feel comfortable just supplementing her with Tumil K without my Vet's knowledge or approval.......but I'm frustrated by his refusal to consider supplementation. Do we want to wait until she's really low and symptomatic before we 'react' and then supplement her?

It's a known fact that older cats are often low in potassium. when you add to that, aging kidneys, it adds to it. I don't want to just sit back and do nothing.

At the time she had her bloodwork done on Feb 23, she'd not been having diarrhea or vomiting or excessive urination or any common cause of losing too much potassium. I do know that the potassium level in the blood is constantly fluctuating so although it was 4.1 on Feb 23, it could be totally different now.......maybe I should wait a week and have it rechecked?

I joined a feline CRF Group to ask about "when" one starts potassium supplementation and I'm receiving pretty much no responses and I am frustrated and don't know where to turn.

I remember all too vividly, dealing with a cat with CRF whose potassium level was low.....and having to supplement twice daily with TUmil K....and her weakness, constipation, lack of energy....and I'd prefer to be PROACTIVE and not have to go down that road. I'd feel better if CLeo's level was a bit higher.

I don't know what to do.

Any suggestions?

Talking to my Vet about this again will be pointless because he claims he consulted with the Vet Lab who processed her bloodwork and they (I'm assuming there's a Vet at the lab who reviews the results) discouraged supplementation at this time citing the risk of hyperkalemia.........but again......I can't get out of my mind the fact that by the time the K level is low in the blood, it's even lower in the cells......

Thx

Hiya,

Because the Potassium level is well within normal range, I wouldn't mess with playing with Potassium supplements. I actually do have a cat with Hypercalcemia (which can turn to kidney disease (and vice-versa, and eventual failure very quickly if not treated with Sub-Q Fluids every couple of days, sometimes every day). Ohhhh yeah, I definitely wouldn't mess with a Potassium level that's within the levels.

The over-grooming could be Feline Hyperesthesia, often caused by stress or previous trama (I have a cat with this - she was brought to the kill shelter, newly born with no upper eyelids, had major surgery on both her eyes after I got a hold of her to create upper eyelids, has symblepheron and also seizures. She has some stress, medically! Loving as she always is.

Loss of fur could be a case of feline acquired symmetrical Alopecia (I have a cat with Alopecia as well, but a couple months have passed since we moved and her hair is growing back - alopecia (loss of fur) usually occurs on the hiney legs, stomach... well, that's where Graciela's did. So glad to see the fur growing back! Yay!

I'm kinda surprised your Vet never suggested these as possibilities . . .

Next time you go to the vet, you might want to ask about the possibility of Feline Hyperesthesia (for the over-grooming);

and Alopecia for the hair loss.

There are ways to make the environment much less stressful for cats. (We had recently moved; hence the alopecia with my one cat. My little cat was in the kill shelter overgrooming and hasn't stopped, except when she plays or sleeps which she plays a LOT!

Hope this gives you a couple extra ideas.

Warmly,

Julie O'

The thing is, the original spot of fur loss was over the left shoulder area. I came home from work, petted her, felt something crusty...had a look and saw a crusty nickel-sized area. Thought perhaps for some reason she'd overgroomed this area and her little tongue had excoriated the skin. Applied some Panolog, put on e-collar until I could get her into Vet the next day. He thought hot spot or lick granuloma. Gave a shot of Convenia in the event that there was an infection brewing beneath. Told me if no improvement after 2 weeks, to consider a shot of DepoMedrol.

The e-collar wasn't a big hit...so after about a week, I bought some infant sleepers and cut the bottoms off....and she proceeded to wear daily for 3 more weeks. I did begin to notice a new area of fur loss just to the side of the original area....but this was to an area COVERED by the sleeper. Then I noticed a nickel-sized patch on the right side...skin intact, no redness...again....to an area not-accessible (licking) because it was covered by the sleeper. Then a week later noticed thinning of fur to upper chest...again, to area covered by sleeper. A week ago I noticed some fur loss to her inner front leg (where the partial sleeve of the sleeper covered) I asked him if her wearing the sleeper could be doing this....he didn't think so.

He suspected it was some kind of endocrine-related alopecia. Well actually before that he suspected it was stress (which I disagreed with; absolutely no changes in my home). I'd initially asked him about the possibility of food allergies (as I had switched to a different type of dry food about 2 months prior. He told me originally that food allergies manifest with 'symmetrical' fur loss (and originally it was just that one spot).

he was very anxious to give a shot of steroid which I told him I was greatly opposed to; too great of a risk of her developing diabetes; had a cat with that for 6 years, no thanks.

She did seem to be grooming the areas not covered by the sleeper a lot.....but I wondered if maybe I was just paying more attention? Usually it was just done after eating (when cats usually groom). I think not being able to groom herself properly (areas beneath the sleeper) bugged her. The areas she could access, no fur loss at all to those.

I don't see her grooming much at all now....mind you, on Thursday I took off her sleeper just to see how she'd do and there were no problems. So does she not seem to be overgrooming now because of the Prednisone she's on or is it because I took the sleeper off?

It seems evident to me, looking at the areas of new fur loss (since the original spot) are likely where the sleeper would have been rubbing against her fur when walking......friction. The area where the fur protruded over the neck of the sleeper is nice and thick but the fur all under it is thinner..........so I think the sleeper was causing the NEW fur loss.

Still don't know the cause of the initial spot though. Maybe a hot spot? Maybe a lick granuloma?

She'll be weaned right off the Pred on about Mar 20th so then we'll see what's what.

I've done occasional spot checks on her blood sugar, just to see if the Pred is impacting it at all and it's not. It's consistently nice at about 90 mg/dl (or 5 mmol/L. I felt okay trying Pred not no long acting steroids for my cats, no way, unless a total last resort.

I don't feel like he was willing to walk through the various possibilities and rule one out at a time. He was gung-ho from the start to consider a Depo shot (well, once the Convenia had worn off because you can't give DepoMedrol if Convenia is in the system). After 3 weeks of me reading everything I could get my hands on with respect to fur loss, I finally asked him about the possiblity of skin mites (which made no sense because my cats are strictly indoors). It was then he prescribed the Profender....which I didn't give because I could find no info about it being used for mites (though he claimed it was used for this, but 'off-label'.....but still i could find nothing that supported this....and I even called up 2 local vet hospitals and had them ask the Vets there if they'd ever heard of it being used for skin mites and both said they had not).

It was me who requested she have the Free T4 to check for HyperT.

It was me who had another Vet give a 2nd opinion and do a skin scraping.

One thing noted on her bloodwork....that he didn't even mention......was her Eosinophils were quite high....and lymphocytes were low. The former is common with allergies. When I asked him about this, he told me that eosinophil count wasn't very accurate in cats. Hmmmm.

The 2nd Vet I saw, for a 2nd opinion, didn't dismiss this result so quickly...she wondered about it being some kind of eosinophilic complex (but admitted she hadn't had a cat with that....other than an indolent ulcer to the lip area).

I've spent over $1200 and it feels like I've done all of the work. But anyway.....

My plan is to take her in next saturday and have her K level checked again.

I wonder how long it takes for a cat's appetite to really return after having been on Baytril? She will eat very well (canned) when I sit there and coax her......but she wasn't this way prior to the Baytril (last dose was over 24 hrs ago).

I think I screwed things up a bit. I've been using Pill Pockets to give her the Baytril and Pred...a Godsend! She gobbles them up like nothing....but prior to that I was pilling her the hard way.......and she's very very feisty when it comes to pilling, cranks her head to the side so strongly that it's a real feat to get the pill into the mouth. I was foolishly doing the pilling on the soft shaggy mat in my kitchen (sitting on the floor with her between my legs). Even though I stopped giving the pills this way, I think she associates the 'kitchen' with nasty pillling and now she doesn't want to come into the kitchen...which is where I have always fed them all. TIP TO OTHERS: don't ever pill a cat or do anything stressful in an area they eat in.......I learned the hard way. She used to be one of the first ones in the kitchen when I was opening the cans....now she's not there and i have to bring her into the kitchen...she'll nibble a bit of canned then get the heck out of there. I then have to wander all over the house with her and a plate and coax her to eat.

First, that's a great tip about not pilling in the kitchen or where they eat. (I do "Pill-Pocket" one of my girls in the kitchen because she comes to me an meows for the "Godsend". Another I pill doesn't like the pill pocket at all.

When you mentioned ". . . a crusty nickel-sized area." Had the Vet ever mentioned Ringworm?? Ringworm is crusty and generally round and spreads like wildfire, like if there was petting and part of a finger touched the ringworm and then another area was immediately pet - it would transfer. (I can't remember if you ruled this out in your first post). There are a couple good pictures of ringworm (which is not caused by or infected with any type of actual worm) to see if any of it looks familiar. There are many more sites with pictures of cat ringworm:

http://www.catsofaustralia.com/ringworm-in-cats.htm

If I haven't gotten the answers I needed after a couple visits, I have them refer me to a real expensive place with super pro DVM surgeons, oncologists, neurologists, etc. that is about a 2.5 hour drive for me. You pay, but you definitely get what you pay for because you will finally know exactly what's up. You can check out the website for the place I go to in Ventura, California called VMSG (Veterinary Medical and Surgical Group). You can't just walk in, you have to be referred:

http://www.vmsg.com/

I had a C.T. scan done there on my cat who saved my life and ALL of the doctors came in - they also have a bereavement counselor who is the wife of the oncologist. They all came in to explain what was happening to my Pagode (welling up here). When they were finished, they let me stay in there as long as I needed, a nurse came in with 8-10 different kinds of foods in little dishes, a smorgesboard for Pagode, she was loving everybody there - ACK, sorry, turned this to be about my cat.

I highly recommend these specialized places if you want, once and for all, to know what exactly is going on with your cat and get the correct medicine for the problem! They are so professional. (And all the money you spent at the vet (like I've done) could have gone for one trip to one of the specialty hospitals nad all would be known and meds given and your cat on the road to recovery. (Just a suggestion if you have a place around your area like this).

The sleeper, while your cat was moving around in it, may have easily spread the ringworm IF it is ringworm. (which again is generally round and crusty)

I believe you're totally right on about the reasoning of her grooming any area she could and that the sleeper was bugging her. That sounds right on.

First, did they give you Prednisone? Or Prednisolone? I only ask because the Prednisolone is a bit safer as it absorbs much more quickly to take care of the problem, while Prednisone as to fester for awhile to become Prednisolone itself. I'm guessing she stopped overgrooming because of the Prednisone for sure.

I also agree totally with your feelings about no long-term Prednisone or Prednisolone usage 100%.

Here is some very interesting information about Profender for your perusal purposes:

http://www.vetinfo.com/profender-for-cats.html

It's like you have to push the Vet to do bloodwork, x-rays, anything.

What result came out of the skin scraping??

Sheesh, about the Eosinophil count - is that all he said to you? That this type of count being high wasn't an accurate test? (If I'm understanding correctly).
Did he say why it's not accurate, and what would be an accurate test?

About the Baytril, I've never used it on my cats (except after Fuzz' dentals) and it took him a few days to really get back into the swing of eating normal.

I don't mean to laugh (I'm laughing) and know it's hard work, but I'm picturing you (with no picture, lol) wandering all over the house with a plate of food to coax your girl to eat. I'm only laughing because I have to do that with a few of the meds I do. Especially the fluids for Autumn. She knows it's fluid day when I just pull out the big, green "warming bowl" where I warm her fluids. She hides in places I never knew existed. Truly sorry you have to go through that, I truly know what that's like.

There's always force-feeding with wet food mixed into a soupy consistency and using an oral syringe (just make sure the head is not pointed upwords so your girl doesn't aspirate any soupy food into her lungs. It's one way to go until she starts eating and to keep her well enough hydrated until she's ready to eat.

Hope this is all resolved soon for you!! What a lot of money and not enough answers you've had to go through - I'm guessing it's soooo frustrating!

Warmly,

Julie O'

Not sure if this would help convince your vet.

http://www.felinecrf.org/diagnosis.htm#low_potassium

Low Potassium Levels (Hypokalaemia)

The increase in urination and vomiting caused by CRF may lead to low levels of potassium, which can have various effects, such as back leg weakness or constipation (see Index of Symptoms and Treatments). Low levels of potassium are known as hypokalaemia.

Potassium levels may appear to be normal when in fact there is a deficiency. This is because, although potassium is used in the body's cells, the regulatory mechanism of the body is actually set to maintain a certain level of potassium in the blood, not the cells. Thus, when potassium levels drop, as they tend to do in CRF, the cat's body will try to maintain levels of potassium in the blood by taking potassium from the cells. This means that at the intra-cellular level where the potassium is really needed, potassium levels are too low, even though the blood levels of potassium may appear to be normal. One study, Feline renal failure: questions, answers, questions (1992) Lulich JP, Osborne CA, Oâ€[emoji]8482[/emoji]Brien TD and Polzin DJ Compendium on Continuing Education for the Practising Veterinarian 14 pp127-153) estimated that approximately 30% of CRF cats have low potassium levels.

In addition, if a cat has metabolic acidosis, the potassium level may appear normal or high in blood tests, but may subsequently fall after the metabolic acidosis is treated. It is very important to treat both conditions because, according to Dr David Polzin, "potassium depletion and metabolic acidosis may promote potentially fatal reductions in plasma taurine concentrations in cats."

Because of this, and since there is no way of measuring levels of potassium in the cells, many vets supplement potassium in CRF cats when it falls below the middle of normal, usually about 4.4 mmol/L/l (US: 4.4 mg/dl). The reason for this is that if it is impossible to raise the levels in the blood to the middle of normal, it must be because the cells are depleted to such an extent that they cannot release any more potassium into the blood. Therefore, if your cat's bloodtests show a low-normal level of potassium, it is worth discussing the use of a supplement with your vet. Ways to increase potassium levels can be found in Treatments.

Cats with diabetes may also have low potassium levels. Very occasionally, low potassium levels may be caused by a condition known as hyperaldosteronism, but this is very rare in cats. If hyperaldosteronism is present, the cat will often also have high sodium levels, and will frequently develop hypertension. Less common feline endocrinopathies (2004) is a presentation by BR Jones to the World Small Animal Association World Congress 2004. Scroll to the last section for information on hyperaldosteronism.

Do not supplement potassium without your vet's knowledge and approval, because not all CRF cats have low potassium levels, and giving potassium to a cat who does not need it can be very dangerous.

Penn State University College of Medicine has some information on low potassium levels in humans.

My goodness! Color me stoopid! I thought you were talking about Hypercalcemia, not Hypokalaemia.

But the Hypercalcemic information still stands; upping the Potassium levels when they are within normal limits could lead to hypercalcemia.

Okay, color me in error for misreading the word.

Warmly,

Julie O'

Thanks so much for taking the time to work through this all with me, and give me your feedback and thoughts. Much appreciated!

I really never believed it could be ringworm and both Vets didn't think so, either. It was initially 'crusty' only because she'd licked the original spot repeatedly (while I was gone all day at work, not knowing anything about it) and it broke down the skin a bit and it was a clear serous fluid that had dried on the area. Her skin has never been crusty since. I'd asked Vet if it could be caused by a fungal infection and he told me it was no possible because the skin to the areas was so healthy. I did not, however, in 2 of the areas where the fur is growing back, the skin beneath seems to be a little more darkly pigmented...or maybe it's just fur?

The fur to all areas is growing back very nicely, much moreso since stopping the sleeper. If it had been ringworm, believe me, myself and the other 4 cats would have it too.

Included is a pic I took of one area last week. Also I think it would be getting worse and it's getting so much better....now you have to really "look" in her fur for the thinned out areas.

I live in Calgary, AB, Canada. I only WISH I could try out the clinic you suggest in warm, sunny California!!! :-)

PS - of course I had to include a pic of her in her favorite sleeper. She looked so cute/sweet/girlie wearing them......particularly a pink one she wore. LOL.

Ah! You're right, doesn't look like ringworm at all! (Ringworm actually is a fungal infection).

It's so clear, and the digging went deep it seems.

I DO love her jammers; green, my favorite color! :-D :-D :-D

AHA! Look what I found in Calgary AB Canada:

http://www.carecentre.ca/website/Des...ex=0&tabid=195

It's a Surgical/Medical specialty group just like the VMSG here in Ventura! So you have a little snow to walk through - you could always come to sunny California and check out the VMSG!

But the place above looks just about like the one I go to for specialty care and final answers - the first time!

I'm honestly out of ideas without finding my Merck Veterinary Manual which is still packed in a box in my little storage here (has EVERYthing and how to treat). Since I sold my (sniff) beloved bookshelves when I was super poor, and for dirt cheap (they were high quality from when I made a lot more money), I have no place to put my beloved books. Waaaaaaaaaaaaaaaaaaaaa (or, as they cry in Portugese: Buaaaaaaaaaaaaaaaaaaaaaaaaaaaaa!)

It might be an option, expensive as these places are, to get a true and final answer instead of having to go back and forth to vets for more tests and re-tests - they can do everything at the one place and come back with the diagnosis(es) the same day (the same as emergency vets) instead of having to wait a day, etc.

I sure hope this gets figured out soon for you and your cat's sake . . .

I wish, wish, wish I could be of more help.