Behavior of very old cat with kidney failure has changed...is it "time"?

The above photo is of Smokie, the cat I've had since the age of 3 months, and would turn 21 years old in May.  (She is 17 or 18 in the photo.)

She has suffered from advanced kidney failure for 3+ years; we've addressed it by giving her plenty of water, low-protein canned food, prescription kidney dry food, onion-free and sodium-free chicken stock, and 100 mL daily of IV fluids.  Unfortunately, she's been at her minimum possible weight (5 1/4 pounds) for a few months and won't eat very much.  At her last checkup (in December), she was well past the "red line" for kidney function I remember she had a score of 60 where anything past 25 or 30 was abnormal - but there's nothing more, short of a transplant, we can do for her.  She has also noticeably weakened: she "misses" when trying to jump on the couch about half the time, and on slick floors her rear legs bow outward.  Despite all of this, she has no other health problems - she still has good vision and hearing, steady heartbeat, etc.

I could have lived with all of this indefinitely, because until very recently, she still seemed pretty happy - she would come climb on my lap and "snuggle", purr when I pet her, look forward to me coming home from work, etc.  She was also decently mobile in my apartment, and showed healthy protests whenever I gave her her IV fluids.  At her December checkup, the vet described her as "spunky".  But in the past month or so she's REALLY slowed down...she often spends all her time sleeping or lying awake on a rug in the kitchen, and only gets up every once in a while to eat a couple bites or use the litter box.  She is starting to have trouble breathing - due to the IV fluids - and it's more difficult, though still possible, to get her to purr.  She rarely protests (audibly or with paws) during the IV injection, though she does still try to get away.  And she's also started "licking" where the fluid accumulates under her skin, like it's hurting her.  And yet, she doesn't yelp when she moves around - she has no arthritis - and only rarely when I pick her up; she also hasn't taken the "nose to the floor" position I was warned about.  And she still enjoys some things--I got her to take interest in a piece of string briefly tonight, and she got excited when I got a can of food out for her.

I'm providing all of this description, because I'm trying to figure out whether she's just slowing down due to the kidney disease - which is to be expected - or whether she's actually hurting.  I don't mind this change in behavior so long as it's not due to pain.  I know I'll have to put her to sleep soon, if nature doesn't take its course...I'm just not sure if it's that time yet.  Any thoughts are appreciated.

Oh boy.  I'm so sorry.  This is the most difficult time of a pet owner's life, trying to make that 'call'.  

Perhaps something in this article can help you make the decision:  http://www.thecatsite.com/a/when-is-it-time-making-the-difficult-decision

Perhaps your kitty will help you know--I often say that when my beautiful kitty was failing from kidney disease that I wasn't ready for her to go but she was ready to go.  She stopped eating and--well, I just knew she was telling me it was time.  

Thanks for the link!  It gave me some good advice and helped me realize it's not quite time yet.  As if to reinforce that, she crawled up on me earlier tonight, nuzzled me a bit, started purring, and promptly fell asleep. 

Aww.  Sweet kitty.  I'm glad the link helped--there are some wonderful resources on this site.     

Please keep us posted on how she--and you--are doing.  

She's showing the natural signs and symptoms of advanced age. As long as she is still eating a little bit and shows the signs of SOME interest in every day living I would try to let her live out her life at home with the people she loves. It's not uncommon for a human's liver or kidneys to fail at the end of life, and I'm sure it's common with animals too. Since you are her caregiver and the most loved in her life, I have faith in your ability to determine whether she is suffering or not to the point of being unbearable. The most any of us can pray for is to die at home in our sleep, and I pray this will happen with Smokie too, when she is ready. My heart cries for you, but no matter what, remember we are here to give what comfort we can during this time. Please give her a kiss for me, love her as much as you can, and I'll pray for both of you. Bless you for loving her so much.

Hi, I'm sorry you are having to go through this.  We also have a kidney cat that also has bladder cancer.  We've been on "quality of life" watch for over a year.  It's tough for everyone. 

I won't comment on when it's time, and I hope I'm not stepping out of turn, but did want to suggest you consider a diet addition for your cat.  Obviously you are making every effort to get food in your little girl, but with all the kidney prescription food she is eating, or not eating, I wonder if she is truly getting enough protein to sustain?  Cats, especially older cats, require high protein to not have muscle wasting.    The purpose of the prescription kidney diet is to reduce the phosphorus in the food, which is so hard for kidneys to process.  This is accomplished by reducing the meat protein and increasing the carbohydrate in the food.  Unfortunately, this protein percentage falls below a cat's basic nutrient requirements. 

Here are a couple links from a vet endocrinologist that discuss diet.   Dr. Peterson's specialty is hyperthyroidism, but these articles discuss protein needs of an elderly cat and he also has an article for the kidney cat. This is probably overkill, but I found this information invaluable. 

http://endocrinevet.blogspot.com/2011/11/optimal-protein-requirements-for-older.html    http://endocrinevet.blogspot.com/2011/09/best-diet-to-feed-hyperthyroid-cats.html     http://endocrinevet.blogspot.no/sea...0-05:00&max-results=20&start=14&by-date=false     http://www.animalendocrine.com/wp-c...-Hyperthyroidism-Concurrent-Renal-Disease.pdf

When my Clark's kidney numbers took a turn for the worse three months ago, I spent a lot of time discussing diet with his vet internist.  Clark can't eat the prescription kidney food because of the carbs included in the food (counter intuitive to cystitis and cancer).  He's been eating a home made diet for over a year now, very high in protein.  The vet suggested I modify it a bit, adding more fat (skin) to the meat to lower the overall protein, and thus lower the phosphorus a bit more.  His food now is probably closer to 60% protein, had been closer to 80%.  The kidney diet, I think, is closer to 30%.  She said the only food study out there for the kidney cat relates to the prescription food, and it does support a longer life if there is renal failure.  But she also said that she has not seen a cat with the health issues that my cat has, that looks as good as him.  In spite of everything, there has been no muscle wasting and his coat is beautiful. 

Clearly you need to discuss this with your vet, but my suggestion is to add a little real meat protein to your cat's diet.  Maybe add some cooked chicken thigh to his prescription food?  You can't feed only chicken meat to a cat; it's not a complete diet and would be very dangerous for the cat in the long term.  The unofficial rule of thumb is that you can add up to 15% of un-balanced meat to the cat's diet without too much concern, the thought being that the other food provides sufficient other nutrients to have an overall complete diet.  Maybe try it for a little while, see if she'll eat it, and see if she perks up a bit and gains a little muscle back.  You could look for a canned cat food that has a higher meat protein but still low in phosphorus that can be served in addition to the kidney food.  Or look in the Raw and Cooked Food section for ways to balance plain meat. 

Another option, that mrsgreenjeens is following, is adding slightly cooked egg whites to her kidney cat's canned food.  She uses pasteurized egg whites, slightly cooks them because of the avidin in the egg white, and then blenderizes it into the canned food.  Egg whites are almost all protein, but have very little phosphorus.  You shouldn't have to worry about balancing the egg white.  My cat avoids egg whites at every turn, and since he gets enough protein, I've stopped trying to give it to him.  But that would be a great way to up the protein in your cat's diet without affecting the overall phosphorus very much. 

We can only do what we can for the cat, to give them the best circumstances.  How fortunate that you've had 20+ years with your cat.  I know diet suggestions weren't what you were seeking when starting this thread, but maybe it will help.  Best wishes for you and your little girl!

I knew it was time by the look in her eyes. I firmly believe cats understand what we say to them, so through my tears, I asked her if she wanted to keep fighting or if she was ready to stop. Something in her eyes was very different that day. I could tell she'd had enough and any other treatments would have been selfish on my part. She was only 10 years old and had been battling CRF for just 4 months.

People always talk about how hard it is to make that decision, but in my personal experience, the decision was easy. Following through, now that was the most heartbreaking thing I've ever done. But I've always felt peace in knowing I did all I could for her and made the best choices for her, even when it wasn't best for myself.

Thanks all.  Your advice and thoughts are greatly appreciated.

Boy, I don't know what to think.  Smokie still gets excited whenever I get canned food or her favorite (non-onion) chicken stock out to drink, and enjoys belly rubs, petting, sleeping on my lap, etc. as much as always.  And she also seems to be in little pain - she sounds a bit asthmatic due to the 200% doses of IV fluids we're giving her, but she has no arthritis, limping, etc. and makes no painful noises.  Yet her behavior's becoming increasingly bizarre.  In the past 2 weeks, she's found a series of rather strange hiding/sleeping places.  Whereas she slept next to or under my bed for years, she's now alternating between a couple of rugs in the kitchen (near her food bowl and litter box), a hiding spot under the bed, a narrow gap between the water heater and the wall (in the same room as the litter box), and IN her litter box.

Should I be worried about this additional change in behavior?  I know that cats will seek out hiding spots when they're hurting, but her curling up and falling asleep in her (fortunately clean) litter box today is a new one for me.  Maybe she just knows she has to go to the bathroom a lot and wants to stay near it?

It's hard to say--my Skittles used to always sleep in bed with me for many, many years.  Towards the end, she didn't any more.  She'd find a corner to curl up in.  I really worried at first but that went on for months.  She just changed her sleeping pattern at the end.  

But I don't know about sleeping IN the litter box, that seems odd.  Maybe another member has some experience or ideas about that.

Hi, I joined here because I was browsing the site and felt I had to respond to this thread. You have described symptoms you feel are related to the SQ fluids you are giving. Cats with this degree of renal failure can be prone to congestive heart failure. Given the symptoms you have described I would recommend a discussion with the vet regarding congestive heart failure. A chest x-ray will show if she has fluid in her chest cavity. At the least I would recommend looking at how much fluids you are giving and think about cutting back. Remember, the purpose of the fluids is to keep her hydrated, and it sounds like she may very well be overhydrated. I lost a cat to kidney disease and towards the end she had a lot of trouble managing the fluids and I had to cut way back, just 50 mls a day.

My heart goes out to you. I, too , had a cat called Smokie. We got her from our vet and she was already an adult. No one knew exactly how old she was but I had her for more than 20 years.

She was naturally a small cat. Towards the end of her time she was very weak and wobbly. She fell off of the bed one night and landed hanging over a trash can. When I took her to the vet he found nothing broken but he did warn me that her time was short.

A few days later I found her in a pool of urine on the bed. I knew she would not do that on purpose.

I had the same problem as most of us do when our beloved pets begin to decline. I didn't want to end her life prematurely but I also didn't want her to be miserable at the end. I prayed about it and talked to friends and family. It is true, it seems, that you just know when it is time to say goodbye.

I discovered that even though it is a hard decision to make it is one that is made from love.

I loved her to the last and love her still.

The sub q fluids should not make a change in her breathing.  I would have her checked out.  Some cats will hide when they are in pain, are your sure she has not arthritis?  I noticed very subtle changes in my cat DeeJay's demeanor and walk, she doesn't really limp but she does have arthritis. 

Several years ago, I lost my 18 year old kitty, Fancy, to kidney failure.  We caught this pretty early  and was on special food to keep her numbers down for about five years.    The last  3 years she was on the IV fluids  ....we went from fluids twice a week, to daily ...she slowed down a lot, but really was doing well until the IV fluids stopped being effective.  She just slept most of the time, although she ate ok, not great.   

If I remember correctly, I gave her cooked white meat shredded chicken, meat baby food and the tasty canned grocery store cat food, per our vet...anything she would eat that was ok for her, because it was about getting her to eat whatever she would get down...she would no longer eat the heatlhy prescription diets, wholistic, etc.  

She slowed down more and more...until he explained that the toxins were getting to her brain despite our best efforts....I consulted with him almost weekly and finally, the last 7-10 days she was not moving around, refused to eat, and instead of rallying back, she was getting worse despite our best efforts. we had to take her in the final time. 

If your kitty is still showing interest in things, walks around the house and is still eating, paying attention to you and your vet feels she has quality of life, I would wait.  Its important to keep the vet in this process all along the way.  

I don't pretend to know how they are feeling during all this, but with mine, her decline was in stages over a long period of time.  When she lost interest in me, eating, etc. and seemed to almost have dementia, it was time. 

This is a good point...my Fancy had arthritis, too during that last few years.  

Wow! 21 years old. You've truly been blessed to have her so long. It makes it even harder. I'm so sorry that you're having to go through this. I'm taking my cat to the vet tomorrow. He will be fifteen in April. He's just skin and bones. He eats two or three bites of kibble and then he's done. I'm hoping it's not his kidneys. I'm hoping you'll be able to tell if she's in pain. It's going to be rough when the time comes. You've done everything to help her and I'm sure she loves and appreciates you. Sending good vibes and prayers for you and your baby.

I was reading in the behavior forum last night about cats who lay in their litterboxes-the (unanimous?) opinion was they do it when they're stressed and want to be where they can smell themselves...so I would echo the advice about a chest xray asap

Thank you, everyone, for your comments and suggestions.  Sadly, Smokie passed away a little over an hour ago; happily, she did so peacefully, with me petting her and while lying on her favorite blanket, and she was happy and alert until 12 hours or so before the end.

After all of this, she ended up making the decision for me, like many of you said she might.  She made it clear when it was time.  In one day she went from wandering around the apartment, taking turns between eating, visiting the litter box and napping, to where she could barely stand up.  I knew something might be wrong when I couldn't interest her in her favorite cat treats or canned food; I knew something was REALLY wrong when, while scratching her nose, I accidentally touched her eye and she didn't even flinch.

I had been prepared, though - just last week I took her in to the vet, and they couldn't even measure her kidney values because they were so high.  A diluted sample had BUN at 113 (normal is 16-36) and creatinine at 5.8 (normal is 0.8-2.4).

Interestingly, unlike most cats, she also made it clear that she didn't want to be alone when the time came.  At least, I'd like to think so.  Until an hour or so before the end, any time I would get up to go do something, she would seem to rouse what little energy she had left to let out a raspy "meow", as if to tell me I shouldn't go.  Then when I'd get back, she'd calm down a little.  She did seek out a hiding place a couple of times, but I put her on my lap (on top of her favorite blanket) and she seemed to like it.  I stayed up most of the night with her, petting her, talking to her, and trying to coax her to sleep, hoping that nature would take its course and it would be peaceful...but after 5 hours, when she was clearly in distress (cold to the touch, trouble breathing, no movement of any kind, slow heartbeat), I was afraid I was letting her suffer unnecessarily.

I'm not sure whether it was the right decision to take her in and euthanize versus letting her pass away in the home she's lived in most of her life...or maybe I should have taken her in quicker, as soon as she and I both knew it was time.  I also wonder if there's anything more I could have done to make her comfortable.  I'm just glad she's at peace now, and without getting into religion here, I hope I'll get to see her again some day.

I'm so, so sorry about Smokie.  You did it all just right--you got to spend some sweet time together and then you made the hard, and right, decision to help her at the end.  She was with you when she passed, that's what's important.  

This is a wonderful post by one of the members here--it's brought many of us comfort:  http://www.thecatsite.com/t/237066/when-the-moment-comes

My deepest condolences and my thoughts are with you.

I'm so very sorry about the passing of your loved one, but so happy you were with her to give comfort and love. It's natural to second guess yourself on the should haves, would haves, but she died with you by her side, with the one she loved the most in the world, and THAT is what counts. It hurts so bad when they leave us because we loved them so much. The hole she left will heal in time, she will forever be there in your heart, a love like that is never ending. She is free of pain now, safe and warm at the Rainbow Bridge. Take care of yourself, I'll keep you both in my prayers. RIP beautiful Smokie!