Could it be Hyperthyroidism but Free T4 and Total T4 normal? I'm so distraught

I posted a week ago about my cat Fuzzy. I feel so helpless and frustrated.

To recap:

-she's at least 15 yrs old (strictly indoors)
-Jun 3 had bloodwork done....Creat 227 (range: 71-203), BUN 14.5 (range: 5-12), Potassium low @ 3.5 (range: 3.9-5.3).....everything else good (I have a copy of results so can verify that). At my request, free T4 and Total T4 done (to check for HyperT) and both normal, at the low end of the range, in fact. Urinalysis; all normal except small protein and pH of 5.0. I'd taken her in for bloodwork as I noticed her drinking water more, occasionally vomiting clear liquid, felt a bit thinner. Started her on Potassium Gluconate. Vet said she had Stage 2 kidney disease. Said her heart had a 'galloping' rhythm which nobody had ever said before.
-appetite not so great since starting Pot.Gluc, but it can be upsetting to stomach so I attributed it to that.
-last Friday took her for Potass. recheck; up to 3.8. Had blood pressure done; through the roof, around 220-230/145-150...heart rate about 185-200. Stupid Vet didn't call me back that day to talk about starting her on meds for high bp so took her to Emerg Vet that night......that vet agreed about galloping heart.....agreed her BP was high previously that day (I took readings with me)....but stupidly said I could wait until the next day to have my own Vet start something. Had BP done there, by Doppler; systolic average of 180. That Vet suggested cardiac ultrasound and figured her issues were her heart and that her kidneys were really no big deal.
-next day (Last Saturday) see own Vet.....he claims he can't hear galloping rhythm but maybe a bit of a whoosh (usually means valve issues). He started her on Benazepril 2.5mg once a day (started in that evening). Agreed about cardiac ultrasound. I'd read that Benazepril can cause high potassium levels so asked him what we should do about the twice daily Pot. Gluconate I was giving her; he'd apparently never heard about the risk of elevated potassium on Benazepril (obviously not very informed; every reputable article online about this med warns of this)....I think to pacify me though, he told me to just STOP the potassium. That made me uneasy to just stop it totally.....it had help raise it from 3.5 to 3.8 (still low but better) in 2 weeks...now we stop it and what if the Benazepril doesn't cause it to elevate and it stays low or gets lower? That's been on my mind a lot. Low potassium isn't good for the heart.
-I'd started her on 1/4 tab of Pepcid AC a 2 weeks ago because of the occasional throwing up clear liquid and sometimes very gurgly tummy (acid). She continues on this.
-her appetite isn't great. I have to open several cans of canned food twice a day and coax her to eat them. I've somewhat attributed that to the Benazepril which can cause lack of appetite and nausea...........but what can I do? She has to have it. I try to supplement at times with Nutri-Cal supplement....and treats, even.

We have an appt for cardiac ultrasound this Wednesday.

My own Vet stupidly told me that she didn't need to have her BP rechecked after starting the Benzepril for "one month"....I told him I didn't feel comfy waiting that long (geezus, her BP was so high the machine almost didn't go much higher) and that i'd get it rechecked in 2 weeks. He gave in but said not sooner than that because it takes time for the Benaz. to really take effect.......BUT that if it wasn't working we could add some Amlodipine (what, and he originallly wanted me to wait a whole month?)

2 days ago I saw her eat in the morning without me prompting her and I was so thrilled ......but that was an isolated incident.

I think the drinking that she does is not because of her kidneys, I think it's nausea.........because when she comes down to the kitchen at meal time, that's when she goes for the water bowl......I'll stick the canned food under her....and she'll walk away and go to the bowl again. Sometimes a couple of times.

I don't see her going to the litterbox very much (meaning, peeing excessively as you often see with cats who have CRF)....so I don't think she's drinking all that much.....I think it's just nausea (cats will drink water when nauseated I've read).

Tonight I got to thinking............weight loss (lost 2 lbs over past 2 yrs, she's 9 lbs now).....high blood pressure.....elevated heart rate.....galloping heart rate.......nausea......impacted kidneys.......poor appetite.........she's a longhair cat and her fur on top is all nice but her underside looks so ratty (it's always been so downy and soft and perfect, now it looks scruffy, even when I brush it).............It makes me wonder if she's not Hyperthyroid, despite the Free T4 and Total T4 being normal !!!

Has anyone ever had a cat who had classic symptoms of HyperT but bloodwork normal? Not just free T4 (because that one is not really accurate at all in older cats)..but the Total T4 too?

I've read it can happen.........and there's another test they can do, a T3 Suppression test. Not sure if anyone around here does that or knows how.

I don't know if I should be pursuing that test to be done.............first, before spending $700 that I don't really have on Wednesday, to do the cardiac ultrasound. I need to spend my money wisely......meaning, maybe I should be spending it on further testing for HyperT......or a scan of her thyroid?

I feel so hopeless and helpless.

I've signed up at one of the Yahoo HyperT Groups but am impatiently waiting for approval.

Thoughts?

Thanks.

I don't have any advice about this disease, but I wanted to send you and Fuzzy many, many vibes until someone comes along that can help...

It could be.

My RB kitty Chynna was demonstrating hyperthyroidism long before it showed up in the test results. And she had all of the symptoms that you describe: drinking water more, occasionally vomiting clear liquid, weight loss, poor coat, high blood pressure, rapid heart rate.

She was ultimately diagnosed with hypertension (given amlodipine), renal insufficiency and later renal failure, and hyperthyroidism.

Did they do a TSH?

...It makes me wonder if she's not Hyperthyroid, despite the Free T4 and Total T4 being normal !!!....Has anyone ever had a cat who had classic symptoms of HyperT but bloodwork normal? Not just free T4 (because that one is not really accurate at all in older cats)..but the Total T4 too?

I've read it can happen.........and there's another test they can do, a T3 Suppression test. Not sure if anyone around here does that or knows how...I don't know if I should be pursuing that test to be done

Click to expand...

There's a very reputable website for Feline CRF (which I suspect you've come across at some point) that has an excellent section on CRF "related" conditions. One of those conditions is Hyperthryoidism, and in that section there is good coverage of this exact point: " the normal ranges do not apply to older cats" and speaks to the need for the T-3 test as well (seemingly it's a common part of Hyper-T diagnosis). Here's the "Diagnosis" section http://www.felinecrf.org/related_dis...perT_diagnosis

The entire "Related Diseases" area is here http://www.felinecrf.org/related_diseases.htm (corrected 6/26/2011*)
I can only say what I would do - which would be to pursue clarification the thryoid function first (I have to tell you that my gut feeling says this is the underlying problem). Hyper-T often masks more serious kidney issues, so I would also be prepared to hook up with one of the CRF Yahoo groups too.

It is essential to treat hyperT because hyperT is a strain on the cat's body, particularly the heart. However, you do need to proceed cautiously. If a cat has both CRF and hyperT, the hyperT can actually mask the effects of CRF; but once the hyperT is treated the CRF can then appear to worsen. http://www.felinecrf.org/related_dis...erT_treatments

Click to expand...

There's lots about dealing with her stomach acid here http://www.felinecrf.org/stomach_acid.htm#treatments Having that under control can make a huge difference from what I've seen.

Hopeless and helpless...I've had a little one with a different condition...I well remember. I only wish I knew about the support groups back then.

Thinking of you

Could it be hyperthyroidism?

Maybe, maybe not. But even if it is, please be extremely careful if you go ahead with testing and decide to try medication because, for some cats (like one of mine), trying to treat an elevated thyroid value (even if it's only very slightly elevated) can have a devastating effect on the kidneys. I'm including some potentially life-saving information for you.

From
www.vetinfo4cats.com/cthyroidtreat.html

under

Continue with Tapazole or not

Many cats tolerate methimazole long term with no problems and it works well to control the hyperthyroidism in these cats, as well. About 20% of cats can not tolerate methimazole for one reason or another. Most of these cats have gastrointestinal problems such as vomiting, due to the medication. A few cats will develop more serious signs, including damage to the kidneys or anemia induced by the methimazole. Usually, stopping the medication will allow recovery from these problems, as long as they are caught early. Due to this, we recommend drawing blood after one week of therapy and again after a month, to rule out these problems.
As long as none of these side effects occur in a patient, methimazole seems to be tolerated long term pretty well.

Click to expand...

From
http://www.vetinfo4cats.com/ceffect.html

Under

Methimazole -( Tapazole Rx) side effects –

The side effects of methimazole (Tapazole Rx) are reported to be the same whether it is used transdermally, or orally, according to Dr. Alice Wolf, writing on the Veterinary Information Network. That is the only reference I can find. It does seem to make sense that GI signs might be less when it is administered in this manner, though.

The primary problems with methimazole are gastrointestinal irritation, liver disease and anemia due to adverse effects on the bone marrow. Of these effects the bone marrow suppression is the most severe when it occurs. Kidney disease is not a direct effect of methimazole but successful treatment of hyperthyroidism will sometimes cause problems in a cat that has pre-existing kidney failure. The kidneys try to induce high blood pressure to keep up blood flow when they are damaged. Hyperthyroidism aids this process and seems to actually mask kidney disease in some cats. When these cats are successfully treated for their hyperthyroidism there is a drop in blood pressure. In a few cats with kidney failure this will be enough of a problem to cause a sudden worsening of the kidney failure they already had. It is important to monitor for this effect whenever treatment for hyperthyroidism is undertaken, regardless of the treatment method (methimazole, surgery, radioactive iodine therapy).

Click to expand...

Originally Posted by Violet

Could it be hyperthyroidism?

Maybe, maybe not. But even if it is, please be extremely careful if you go ahead with testing and decide to try medication because, for some cats (like one of mine), trying to treat an elevated thyroid value (even if it's only very slightly elevated) can have a devastating effect on the kidneys....

Click to expand...

Violet, well said, indeed. It's all about gently "nudging" thryoid activity back into a balance. From cases I've observed, many Vets start the therapy with a too high dosage of the med (usually methimazole), often leading to the crisis of a massive "crash". The CRF site I referenced speaks to this here

For cats with pre-existing CRF, an even lower starting dose is suggested in How to treat a cat with hyperthyroidism and concurrent renal insufficiency (2010) Daminet S Presentation to the 35th World Small Animal Veterinary Association World Congress, which states "methimazole or carbimazole are used (orally or transdermal), at a low starting dose (i.e., 1.25 mg orally once a day). This allows assessing the impact of anti-thyroid therapy on renal function. These patients should be monitored every 2 weeks. Dosage adjustments should be made prudently". http://www.felinecrf.org/related_dis...imazole_dosing

Click to expand...

Here's the complete section of that study's report

Pre-Existing Azotemia in a Newly Diagnosed Hyperthyroid Cat

First, in such a case, the diagnosis of hyperthyroidism can be somewhat complicated by a decline in thyroid hormones (euthyroid sickness) within the reference range. Second, given the further decline in GFR to be expected after resolution of the hyperthyroid state, it is important to start an azotemic hyperthyroid cat with a reversible anti-thyroid therapy (trial therapy). Methimazole or carbimazole are used (orally or transdermal), at a low starting dose (i.e., 1.25 mg orally once a day). This allows assessing the impact of anti-thyroid therapy on renal function. These patients should be monitored every 2 weeks. Dosage adjustments should be made prudently. The presence of overt signs of thyrotoxicosis (heart murmur, emaciation, proteinuria) underlines the importance of treating the hyperthyroidism. Management of CKD (CRF) is also warranted. http://www.vin.com/proceedings/Proce...6121&O=Generic (emphases are mine)

Click to expand...

A very delicate balancing act indeed...but, if there's to be any hope, action is required.

Thank you, thank you everyone!

I'm now accepted on the HyperT Group. I signed up on the Feline CRF Group last week and posted there but didn't get much response.

I am pretty much convinced it's HyperT, that's what my gut says. I am thoroughly disgusted that my Vet wouldn't be the one to KNOW that T4 levels in older cats aren't accurate when ruling out HyperT. I could seriously write a novel on my experiences over the past 20 years with respect to Vets who dropped the ball and weren't aggressive enough in thoroughly investigating things. I have surely spent thousands of dollars above what I should have, getting second opinions as a result. It seems an owner these days has to constantly do their own homework and then hope to God you can find a Vet who will be open to pursuing things.

I've been reading for hours now about HyperT diagnosis in cats......and I've learned so much...........that even a Free T4 is fairly useless in confirming HyperT; that a 'negative' can be a false negative...and that T3 Suppression testing is paramount.

Violet - I do know that if it turns out to be HyperT that treating that can have a negative impact on the kidneys......because in treating it, you thereby reduce the bloodflow to the kidneys....but I've read that a proper balancing act is necessary..........and the key is, for a cat w/ kidney issues, as White Shadow points out, is to start with a very low dose. Seems a lot of Vets are ignorant in this regard and will treat every cat the same, often starting with the 'usual' dose of 5mg a day.............often with disasterous results (according to the posts I'm reading on the HyperT group).

I managed to change my appointment with the Vet Specialist (she was my old Vet for many years until she went to work at the Specialist Clinic) to tomorrow. She's an expert here in feline HyperT and the only Vet in Southern AB who does Radioactive treatments for HyperT cats. she's an internal medicine doc. I loved her immensely when she was my regular Vet years ago, the sharpest cookie ever and she worked closely with me.....so I thank GOD that I get to see her tomorrow. There is nobody I trust more than her. Back when I had my first CRF cat, she was my vet at the time.....and I remember back then we were concerned my cat then might be HyperT.....and I remember her talking about how treatment of it could negatively impact kidneys so it was a balancing act. I think the goal, as White Shadow explains, if Fuzzy is HyperT - is just as she put it....to give things a 'nudge' with respect to the HyperT but not so much so that it kills the kidneys.

I don't see it as a case of having to make a choice between treating one or the other; I think that if you're careful and conservative, you can try to help both; the kidneys (CRF) and the HyperT. Let's face it, untreated HyperT will eventually do in the kidneys, the heart, cause retinal detachment, heart failure, etc. So you can't just ignore it because you don't want to worsen the kidneys; I think that if you don't treat the HyperT conservatively, keeping the CRF in mind, you will really wear out the tired kidneys in the end....and the heart.

I will reschedule the Cardiac U/S for next week..........instead of cancelling it totally.......to give us enough time for the additional thyroid testing to be done and results reviewed; and if for some reason they come back confirming no HyperT, then we'll proceed with U/S...........but I'm not wanting to spend $700 on the U/S for nothing, so to speak (if the issues are underlying HyperT).

I feel so much better at this point. I thank God that I was able to reschedule appt from Jul 5 to tomorrow. I have been racking my brain and so stressed for the past week about all of this.............feeeling that my hands are tied and I'm just at the mercy of sitting around and doing nothing......worrying about whether the Benazepril has helped with her BP.....worrying about how low her Potassium is going now that the supplementation was stopped.......as a human nurse, I can't imagine having a patient with a BP of 230/150 and starting them on a med and not rechecking their BP for 2 weeks (or "one month" as my Vet originally advised). that is just ludicrous to me. I also know how low potassium can impact the heart.

I wish I'd thought of the HyperT thing sooner...........

If it turns out that she does have this, I will sure as hell not be returning to my current Vet and I will tell him what I think of him for not doing his dang job.

Will keep you all posted.

Kind regards,
Lisa

My cat Sneakers has very similar issues, she has had high blood pressure for a while and was losing weight. My vet suspected hyperthyroid as well but when the bloodwork results showed extremely high kidney values and normal thyroid numbers. So we have started treating her kidney issues. I asked about whether there could still be a thyroid issue and my vet said even if there were, the treatments would not be recommended because she is probably pretty far along with kidney failure.
Sneakers is on amlodipine and benazepril but her potassium is normal. With the possible issues with the benazepril I'd ask the vet about whether amlodipine might be better for your cat.
The nausea, poor appetite and poor coat are all symptoms that can be seen in CRF and high blood pressure is also fairly common with CRF so it may be that this is the cause of most of the symptoms? Is she on any medications or fluids for her kidneys?

My piper was just diagnosed with being in the GREY area abt being hyper thyroid so I am still awaiting more results. Anyway just a suggestion in regard to food. Try meat baby food all of mine love and will eat this even if they won't touch anything else