Our cat's creatinine is 7.7 and rises fast. What can we do?

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tommy2015

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I didn't find something conclusive to point to but you probably do need to key on the urine decrease. That is meaningful particularly combined with continued not eating and would likely benefit from vet discussion at least if not exam. The main reasons urine output decreases seem to be: infection (maybe this is what you're already going through, because you mentioned one), fluid retention (as mentioned above), blockage (females can't completely block but possibly they can have some kind of obstruction issue that could cause this), or kidneys are just no longer going to function (the worst case end-stage scenario).

The first three have potential of improvement. Let's hope it's one of those, even if it means more things to do. If your vet is not receptive to more discussion of such things, you may wish to get another opinion. If you have a house call vet available in your area, this may ease the stresses of the vet visit, but it seems like she could benefit from an exam to figure out what is the latest complication. I don't know if a house call vet can do an x-ray, though, which would be needed for some of those diagnoses. Just be aware, though, that one possibility is you've done all you could and this is it. Hang in there.
Thank you for sharing Amber's story. It is lucky for both Amber and you to be together for 17 years. We wish Dusty could give us more time.

Agree with you that the urine decrease is most urgent. Will discuss with vet on Monday and keep you all updated.
 
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puck

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@tommy2015   Dusty sounds dehydrated. Many renal failure kitties need a boost with hospitalization periodically, to diurese their kidneys and bladder, improve production, blood pressure, perfusion, and GI elasticity and emptying. Intravenous fluids rather than subcutaneous fluids may be just the ticket to turn her around, while maintaining Cerenia (drug name maropitant) once daily, famotidine injectable once to twice daily, oral omeprazole daily if ulceration is already present, and additional supportive care.

Sucralfate is often started prophylactically by your vet and human vets, prior to seeing vomiting, knowing esophageal reflux and inflammation are so common; and once present, they're a booger to heal and the appetite usually is diminished or nonexistant for many days in an affected cat.

Sucralfate, brand Carafate, is indeed Rx only. The suspension is great, as you don't need to split the large 1g or 500mg tabs down to size, then dissolve in warm water, to a slurry, and administer directly by mouth via syringe.

Is she on pain management, specifically buprenorphine syringes to administer every 6 to 8 hours? Analgesia is very important during renal disease progression.

Let me know what else you observe, if she shows any interest at all towards food, but once close enough to lick or bite into, she turns away, drools, buries it, or combination therein.  If she does have hypertension, hyperthyroidism, or other disease/disorder related to renal failure, effectively treating any of these can lead to happier, less overworked kidneys. Ensure her blood pressure is checked with a Doppler reader, his heart listened to by multiple vets in the practice to verify grade of murmur or arrhythmia, etc, and get them to treat any underlying heart disease.

Acupuncture is very beneficial for pain, circulation (blood through vessels and kidneys), heart health, respiration, and metabolism.

Was an abdominal and thoracic ultrasound or Xray every performed to estimate size of remaining kidneys, look for any masses or metastases, check bladder and urethra, etc?

Good Luck, as you provide her with palliative care and TLC!
 

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I just lost 2 kitties to renal failure and it was awful. I treated both of them for about a year. My younger 8 year old Battle Cat had a Creat of 13.8 that only came down to 12 after 4 days of hospitalization. He was acting ok even with the high numbers but one day I noticed a little bit of drooling and I opened his mouth and it was covered in ulcers which explained why he acted like he wanted to eat but didn't. That was the point I decided to let him go because I knew he was in pain and there really was nothing else short of a transplant that could help him. My heart goes out to you, it's very stressful taking care of a CKD cat. Also if she has a stubborn infection it might be a good idea to hospitalize her for iv antibiotics and fluids.
 
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tommy2015

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Thank you all for the suggestions. We took Dusty to vet Monday afternoon. Attached please find the result. Her cre increased from 5 to 6.

The doctor believed her urine decrease and poor appetite are due to infection.  The antibiotics was changed to Convenia, one shot for two weeks. And we were referred to a specialist to treat her anemia. The teeth and mouth were also checked. No problem found.

The doctor did not keep Dusty in the vet for IV, because she thought more fluids may make anemia worse. 

A problem is Dusty is very stressful and resistant in the vet (I believe this is one of the major reasons why the vet always tends not to have her hospitalized). So they failed to obtain her urine sample to get the culture of the infection. We also tried at home but were not successful. Any suggestions or tricks are appreciated.

Now she still walks to her bowl and litter box, and then walk back. Is that a sign that she still wants to eat?  Sometimes there is smell in her mouth. The doctor said that's due to toxins accumulated in her body. Anything we can do for that?

Dusty did ultra-sonic last July to diagnose her IBD. She's been on anti-hypertension meds and Vitamin B complex for months. Now pepcid and anti-nausea meds, as well as antibiotics added. In the past few days we had to do syringe feeding.

Can we wait for a few days before taking her to the anemia specialist?  This evening, back from the vet, she tried to hide herself from us in the closet, which was unusual in the past. The little kitten might be too scared by the vet trip and blood work. Wish to give her a few days to recover. Or is it possible that we go there with the results but without the cat?

 

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Just a quick hit right now on trouble getting a urine sample because I have a suggestion.  Here's something that worked very easily for me, and Amber pretty much didn't even realize anything was different:  http://www.kit4cat.com/  The kit is a hydrophobic sand which means the urine won't absorb into it.  It even comes with a little tube to collect the sample.  Drawbacks are that the amount of sand is very small, won't even come close to filling a litter box.  My big thing was that I needed to raise up the level of the litter box contents because if only this little bit of sand is in there it would have been hard for her to get into the box.  So, if I remember right I wrapped some towels in a large plastic trash bag.  Or maybe it was just putting her litter inside a large trash bag.  Could also be thick ziploc freezer bags or something.  I don't know.  I seem to remember it being clear though as to extend the illusion that oh this is just a little bit of weird sand in your otherwise normal litter box.  (Who knows if her vision was good enough to care at that point.)  Then I spread the sand over top although in her large box it really wasn't that much sand!  I was worried she would tear the plastic but it didn't seem to be a problem.  I easily collected more than enough urine to test.

My vet didn't know about this particular product and I gave them the package afterwards so they could learn about it.  Many years before I had used those plastic pellets and had a not so great experience.  Apparently some vets do carry the Kit 4 Cat but I just ordered it on Amazon.
 

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While at the Vet did you discuss NOT giving the Pepcid since it didn't seem to be doing any good AND because it can cause anemia in humans?  Did you discuss giving a different appetite enhancer?  Did you discuss all the things Puck mentioned?  What were the responses?   Did you discuss the sucralfate slurry? 

Iwould give the anemia specialist a call and see if you can simply bring in Dusty's records and discuss what's going on WITHOUT Dusty, since she's so stressed out right now.  It's definitely worth a shot.  All they can tell you is "no, we need to see her as well".   But I would call right away. 

So, are you still to give her sub-q/s or not?  Is she dehydrated?  Is she still hiding from you?  Boy old girl
  I think the issue with the anemia and sub-qs is to not give too much at any one time, but think daily is still good.  What are your instructions now? 

As to collecting a urine, the above sounds like a good idea.  If you don't want to go that route, we simply took a clean litter box, no litter at all, and locked our Sven in a room by himself (no other cats), and he was so fastidius that when he needed to go, he went into the box even though it didn't have any litter.  Then I was able to get a sample and run it down to the Vet.  The key is to make sure the litter box is  CLEAN.  That meant emptying it and washing it with a little bleach and water and letting it dry in the sun before I set it in there for him. 

So, all in all, how many meds is Dusty on per day.  I guess i didn't realize just how many health issues she had
  Are you giving all separate pills, or what.  She must be a very good patient.  You know you can buy empty gel caps and combine meds into one capsule (if they can be given at the same time) and do only one pill, don't you? 

I would say if she is still walking to her bowl then yes, she is still wanting to eat, but something is stopping her.  Did you read that webpage that I posted above in my post #32?  Did any of those things in there about loss of appetite seem to apply?  Did you discuss those with the Vet?  I guess the only thing we can rule OUT is dental problems
.  Is that why she changed her antibiotic, in case it was making her sick?  It might BE the amemia that's doing it.  Here's a link on Anemia and the kidney cat:  http://www.felinecrf.org/anaemia.htm
 

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Nothing really specific to add for suggestions I don't think at this juncture, just been wondering how Dusty has been doing last few days.  Take care.
 
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tommy2015

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Nothing really specific to add for suggestions I don't think at this juncture, just been wondering how Dusty has been doing last few days.  Take care.
Thank you all for the caring posts. Had thought to wait for more information to answer your questions. Since  @2bcat is asking, here are some updates:

1) Dusty still doesn't eat, and not urinate as much as before. She increasingly urinated on the carpet. And she still walks to  her bowl, licking lips, then walks away.

2) Last Monday the vet gave her a shot of   Convenia, a new antibiotic.  On Wednesday she did eat some, and everything looked better. But since the next day she's stopped eating again.

3) We took her to a specialist on anemia this Saturday. Now she's on the first course of treatment. Will see how it goes.

4) The specialist found Dusty may have a heart problem, which may conflict with the kidney treatment. He will send us detailed results next week.  Dusty does not like SQ, but we didn't find she has any discomfort with the fluids. Hopefully her heart disease, if any, is not too serious to do SQ. 

5) Both the specialist and the vet agree not to give her Sucralfate. We don't know the exact reason.

6) The specialist suggested increase Pepcid to twice a day. He didn't think this med would lead to more serious anemia.  And he also suggested using appetite stimulant, although we pointed out it didn't work.

Dusty has become less active. Most time she stays in bed. The good part is she is still very sweet, and plays with us. 
 

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You'd really benefit from an internal medicinist, aka internist, board certified in specialty care.  We are accustomed to dealing with fractious, less-then-best disposition patients, as they are stressed, fearful, as well as painful and we don't expect them to enjoy our poking and prodding ;] 

I have 3 wombats myself, that become some of the "worst patients" as I call them, as you can't convince them you are only trying to help them by drawing their blood or urine, by positioning them for Xrays or Ultrasound with the radiologist. They. Don't. Believe. Me.  And I'm their mom, wielder of all things tasty, soothing, calming, massaging, and playful. Strangers definitely aren't gonna convince a sick, injured, or traumatized cat they are anything but aliens trying to take over their bodies.

Aluminum hydroxide is a better phosphorus binder than those containing calcium, as they can too easily overdo calcium, leading to a progression of renal disease. Separate fiber binders to limit protein, such as the psyllium husk (Metamucil) I already mentioned, are better probiotics than the Epakitin. The chitin fiber in Epakitin is a great idea, but as it's also laced with phosphorus-binders high in calcium, we don't use this with cats. If they could combine chitin with the AlHO powder/gel, then we'd be onto a good combo product. Virbac, Zoetis, get on that!  Customizing her "kidney supplement kit" rather than using a pre-packaged, veterinary specific product is best, so you can control the amount of AlHO, psyllium husk prebiotic (just fancy word for fiber, prebiotic, jeesh!), and potassium.

AlHO gel is best administerd to kitties directly, by oral syringe, as it doesn't taste good, even the flavored varieties, and you don't want them going off their food the few times they will eat. Best to give it after she's eaten, so medicating time isn't associated with food time, but she still gets it in time to bind the dietary phosphorus. I mix each dose with fish oil (Welactin) in the syringe, making it a little more palatable.  If her appetite ever normalizes, then you may be able to just mix small amount at a time into her regular diet, or convince her to eat Rx diets low in phos so you don't need the AlHO.

Elevated phosphorus and creatinine are the 2 primary indicators of progressing renal disease. Often, phosphorus binders use while feeding regular diet, or feeding primarily low-phosphorus diet, such as Dave's Pet Food Low Phos (he made a cat and dog line years ago, great stuff!) or Rx kidney diets, will back that elevated phosphorus in the blood down.

Creatinine will go down again sometimes, if we get the phosphorus lower again, get them eating consistently, and keep them hydrated. Regardless of her grade of heart disease, she will need diuresis, or she'll be dehydrated, electrolyte-imbalanced, and very painful as a result. Her Potassium (K) is borderline low, so starting Tumil-K powder or tablet is needed now, or the Renal K gel, which needs to be given in a high volume 3mL, to be effective, not ideal for a cat on many other meds with a low appetite.  If Dusty eats primarily Rx Kidney diets, these are already higher in potassium, compensating for the body's use of more electrolytes. Cardiac diets and Renal diets are very similar, as the disease processes can affect each other. Both patient protocols are low sodium, low phosphorus, higher potassium.  The Rx diets such as Hill's g/d and k/d, as well as Royal Canin Renal diets, already match these criteria. And High Value dietary protein sources, so less volume of protein is needed to support the muscles/tissue of the declining system, be it cardiac, or kidney/liver of waste removal system.

Next, if she does have pylonephritis, a kidney infection, or a bacterial cystitis, bladder infection, she needs antibiotics that can reach that potential infection, located deeply in the body, down the urethra. Blood moves through the kidneys for filtration. Any antibiotic absorbed into the bloodstream will be exposed in the kidneys. Subcutaneous antibiotic, as well as oral antibiotic, are taken into the blood across vasculature that surrounds the dermis tissue and intestinal tissue respectively.

Note, however, that Convenia, a cephalosporin, belongs to a class of antibiotics utilized for superficial infections, such as dermatitis, bite wound, abscess, not a urinary tract infection. So then exposing her to the side effects of a long-acting subcutaneous medication, without the benefits, while she is immunocompromised and sub-par health, is not a good medical call.

As difficult as adding another oral med is to her regime, the orbifloxacin (Orbax) or even Clavamox, would be a better choice, while waiting to get to that internist, so they can perform a cystocentesis and analyze her urine for white blood cells and bacteria. The high WBC, neuts, and monocytes could be due to a systemic infection, and have nothing to do with her urine. Either way, Convenia will only treat a superficial infection, so ask that no more of these injections be given. Once a urine culture is done, it may reveal the bacteria is sensitive to a cephalosporin, very unusual, but not unheard of. Typically, penicillins (i.e. clavamox) and fluoroquinolones (Orbax or Zeniquin) are best for feline UTIs, or stubborn oral/dermal infections.

If she's too inappetant for oral abx, ask your vet to administer a subcutaneous injection of ampicillin or unasyn twice a day for 2 days. In extreme cases with a sick fractious cat stressed in hospital, we'd send home the first 3 or 4 doses, after demonstrating to an owner how to give an injection under the skin. It's easier than a bolus of fluids under the skin at least! The injectable antibiotics must be refrigerated, so they are sent home on ice for transport. Often, just getting them into the first 2 days will enable the cat to feel well enough to start eating, then their antibiotic can be given by mouth or mixed into canned food. Orbax and Clavamox come in suspensions that can be easily dosed and mixed into canned food. Orbax doesn't even need refrigeration either! We appreciate that when needing to hide it, as Clavamox is kept cold, and cats find it in food easier than Orbax.

I never heard a response from you about her current hypertension control, if her current dose of "amlodipine?" or "benazapril/enalapril" effective, as she could be uncontrolled again what with renal and heart disease.  Also, is Dusty on Cerenia (maropitant)?  Oncologists and internists swear by it daily, for the rest of a cat's life, to hlep with nausea, vomiting, and visceral abdominal pain in cancer and kidney cats.  Is she on pain management, as renal disease, dehydration, and any GI/stomach/esophageal emptying is very painful?  Those buprenorphine pre-loaded syringes are worth their weight in gold for a kidney cat. Given at least every 8 hours, just after the first day, owners will often see their baby finally eat and drink, enough to potty #1 AND #2 in the box by day 3 on pain meds!

Dusty is very fortunate to have devoted advocates for her health, as you strive to give her the best life possible near her denouemont, so to speak. Please, if you ever have any concerns, feel free to privately message me Tommy2015, and I'll get a notice in my email, so I can respond. I do not come on TCS daily, due to my own work and personal schedule. Feel free to message, especially when you're trying to take full advantage of having a specialist in front of you, so you can ask certain questions, get answers, comb through what they're telling you, and customize a plan for Dusty. 

If she has esophageal or stomach or peptic ulceration she will not want to eat; ulceration is common in kidney cats. Treating these ulcers is primary to getting her appetite back. Very few things will do this as effectively as sucralfate, other than IV pantoprazole, and longterm omeprazole, which takes a while to be effective. Ulcers are common in kidney cats, as they eat less, and churn more bile acid/stomach acid on an empty stomach. Heart disease is very common in kidney cats, as kidney disease is very common in heart cats; poor circulation can lead to renal cell death; poor waste removal or cleaning of the blood by the kidneys can lead to cardiac insufficiency. And hyperthyroidism often links them all together, as poor metabolism leads to imbalance of hormones and electrolytes throughout the body. Even if euthroid, kidney and heart disease is a common factor.  Hypertension needs to be closely monitored, as renal disease alone can lead to high blood pressure, just as heart disease alone can. With both, her risk for hypertension is higher, and high blood pressure just feeds back to the disease process, making both kidney and heart disease worse. Treating the blood pressure can often help control the renal disease.
 
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lcat4

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I worked my way through Puck's recommendations, wanted to express my best wishes, and share the treatment given to our cat.  He lost his battle last October, CRF, Hyper-T, and bladder cancer, but he gave a great fight.  

We were under care of an internist, specialty of radiology/endocrine systems.  When my cat had an acute spike in his kidney values, she put him on antibiotic Marbofloxacin (which Puck mentions above), 1/2 tablet (12.5mg) daily, then recheck.  If values improved, he was to be on it for 6 weeks.  We actually continued for two weeks, because he seemed to feel better, but his values did not change (at least from the antibiotic).  My cat was also not eating well, and although not vomiting, she put him on Cerenia.  She didn't know if this would improve his eating, but as Puck mentioned, she thought it might help with inflammation and pain.  And he regularly was given Budesonide, .3mg/ml.    He was of course also given Methimazole for the thyroid and daily sub-q.  Originally sub-q was 100ml every other day, but that shifted to <50 ml daily as he became frail.  

As to food, we certainly went through periods of syringe feeding, when he stopped eating on his own.  I mixed Hills A/D with reconstituted KMR, sometimes adding in baby food, sometimes slippery elm.  I found that the syringe did in fact help him through a couple humps.  After one week of syringing, when my spirits were low, I decided to offer him Radcat (a commercial raw).  That cat proceeded to eat that food, 10+ ounces a day, for two weeks.  Then, of course, he wouldn't touch it again.  But it gave him new life for awhile!  

One thing I realized as he wasn't eating (going to the bowl and walking away) was he was a bit constipated.  Even though he was having movements, they were not very big.  Now he wasn't eating much, so it didn't really cause a concern to me initially, but he was straining.  I started giving him Miralax (mixed with Hills A/D and syringed).  Sorry for the graphics here, but that cat pooped a 9 inch log.  It had to have hurt coming out.  But he ate much better after that.  I continued with the Miralax.

Because of the bladder cancer, my cat had a history of peeing small amounts about a 100 times a day.  Very hard to quantify volume.  He was incontinent at the end, and to be honest I don't know if it was from the kidneys or the cancer.  It didn't matter.  We lined our bed with plastic sheets, placed plastic sheets and bath towels under his favorite spot, put a litter box in the family room so he wouldn't have to walk so far, and replaced the area rug after he was gone.  

All through the process we evaluated his quality of life.  In the end, what was the deciding factor, was he developed an ulcer under his tongue - a common side effect from kidney failure.  He had stopped eating on his own two days before and could not tolerate the syringe.  

I tell you all this not to just share my story, although remembering is always good for me, but that the many steps along the way can extend happy times with your cat.  
 

mrsgreenjeens

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I will add about the constipation part.  My Callie hasn't eaten well (again
) for the past few days, and then last night she passed a rather large stool.  I also had no idea she was backed up as she has been passing smaller stools along the way.  I DO give her Miralax every day, but the problem is, if she doesn't finish her food that has the Miralax in it, then I never know if she got a full dosage or not
.

Additionally, even if Dusty has heart issues, she can still get daily sub-q's, they just may need to be of a lesser amount so as not to stress her heart. 

Did you get a DIFFERENT appetite stimulant for her?  It's like beating a dead horse to keep giving her one that doesn't work, IMHO. 

Gosh, I'd be really curious as to WHY neither Vet wants to put her on the Sucralfate slurry.   What are they giving her for the Anemia?  Hopefully whatever it is will help with her appetite if she starts feeling better with the treatment


With our old guy
Sven
, toward the end he kept missing the litter box, so we we using a lot of plastic too.  Poor guy, he tried his best, but he would get his front legs in the box, then squat and pee, completely missing the box 
.    When I think back on it now, I should have tried getting him a very low sided box, and maybe that would have helped.  Plus I probably should have moved the box closer to his bed, but live and learn.  If Callie starts having these issues, I can try them for her.  
 
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tommy2015

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Thank you all for suggestions. In the past few days Dusty has improved slightly. She ate a very small amount, and drank and urinated more than last week. This may be a result of the treatment of anemia started last Saturday, as well as increased dose of pepcid. She will get the second shot on anemia tomorrow. Will see how it goes.

We bought her Rad Cat and she did eat a few bites everyday. Thank @LCat4  for the recommendation.

Looks she does not have the problem of constipation (we wished she had, might make problem easier). She did poop regularly every other day.

Her heart problem (Gallop arrhythmia) is not so serious that we could not give her SQ. The anemia specialist suggested doing SQ in a slow pace.

To answer @ puck's questions, I list all the medications Dusty is taking at this stage.

Darbepoetin 25mcg/ml vial
Epakitin, 
amlodipine 0.3125mg SID, 
maropitant 4mg SID, 
famotidine 2.5mg SID,
orbax 9mg SID (replaced by Convenia last week), 
calcitriol (stopped by the anemia speciliast from this week), 
prednisolone
subcutaneous fluids

Tomorrow (Saturday) we will send Dusty to our family vet for the second shot of Darbepoeth. Will discuss with the vet some of the points suggested by the posts here. Will keep all of you updated.
 
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tommy2015

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Dusty has been in continuous improvement. Now she eats around as half as she used to do. The amount of urine and drink roughly returned to normal. One problem is that her nose is often dry. Anyone has idea of what it may indicate?

Last Saturday she got the second shot of anti-anemia. Blood work showed her anemia was improved and she has no hyperthyroidism.

Per @puck's suggestions, we raised concern about Convenia, The vet agreed to stop it, but didn't resume Orbax. Will discuss this again in next visit.

We added Tumil-K powder into Dusty's SQ fluids, as her Potassium (K) is borderline low. This also thanks for @puck's suggestion.

As for other suggestions about pain management, Sucralfate, and slippery elm, the vet did not support.

Thank you all for the caring posts. Without such information we would not be able to talk with the vet in so many details and improve our kitty's life.  
 

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Thank you all for suggestions. In the past few days Dusty has improved slightly. She ate a very small amount, and drank and urinated more than last week. This may be a result of the treatment of anemia started last Saturday, as well as increased dose of pepcid. She will get the second shot on anemia tomorrow. Will see how it goes.

We bought her Rad Cat and she did eat a few bites everyday. Thank @LCat4  for the recommendation.

Looks she does not have the problem of constipation (we wished she had, might make problem easier). She did poop regularly every other day.

Her heart problem (Gallop arrhythmia) is not so serious that we could not give her SQ. The anemia specialist suggested doing SQ in a slow pace.

To answer @ puck's questions, I list all the medications Dusty is taking at this stage.

Darbepoetin 25mcg/ml vial
Epakitin, 
amlodipine 0.3125mg SID, 
maropitant 4mg SID, 
famotidine 2.5mg SID,
orbax 9mg SID (replaced by Convenia last week), 
calcitriol (stopped by the anemia speciliast from this week), 
prednisolone
subcutaneous fluids

Tomorrow (Saturday) we will send Dusty to our family vet for the second shot of Darbepoeth. Will discuss with the vet some of the points suggested by the posts here. Will keep all of you updated.
Hey Tommy,  I responded privately to your message. The maropitant is the Cerenia, bully for the belly ;]  Her stomach/nausea and abdominal pain threshold thank you daily.

Epakitin is a calcium based binder of phosphorus; effective until we determine the blood calcium is climbing, a common occurence in chronic renal insufficiency kitties. High calcium toasts the kidneys, so we monitor this monthly if we are giving calcium to them; with Dusty on Epakitin AND calcitriol previously, she was at higher risk to develop high calcium. A renal cat often already has higher blood calcium as they don't absorb it from the blood as efficiently when their kidneys are malfunctioning. High blood calcium can be very detrimental, depending on how high and how chronically they experience this elevation. Calcium controls muscle movement/activation; muscles suffer if they don't have the cellular calcium needed... if it's high in the blood, the body  a.) isn't absorbing it from the blood well  b.) isn't eliminating the excess/waste in the urine. Great that she is off calcitriol now.

Is the "anemia specialist" her veterinary board-certified internal medicinist? These guys really know their stuff; some are more pragmatic and practical, not demanding diagnostics every day or week as we just start treatment, giving treatment time to be effective. Glad the "specialist" whoever they may be had the foresight to stop the calcitriol. A lot of vets jump to calcitriol and it isn't great for kidney cats as they often already have high normal or elevated blood calcium.

I've never added Tumil-K to sterile subcutaneous fluid... This is what injectable sterile Potassium chloride is used for... add it to fluids, then administer intravenously or subcutaneously. How do they know if the Tumil-K powder is distributing and constituting with the fluids (with are Lactated Ringer's or 0.9% Sodium Chloride fluids usually), and how do they know the Tumil-K is not contaminating the fluids, as Tumil-K powder is stored in a big, open, bacteria laden bottle, not in individual small doses to add to fluids? Perhaps they "dumbed it down" calling the Potassium Chloride (KCl) Tumil-K, rather than tell you they injected sterile KCl into the bag to administer to Dusty at home subcutaneously. Run this by your vet, ensuring Dusty is getting KCl additive subcutaneous fluids, not Tumil-K additive. I'm assuming your rDVM did this, as an internist never would call KCl Tumil-K, and would never add Tumil-K to sterile fluids to administer under the skin or in a vein...

If the famotidine seems ineffective the next week as she finally has an appetite (YaY!), monitoring closely for nausea or any bilious vomit produced when going long in between meals, discuss ranitidine (Zantac) with your vets. One of them may be familiar with the feline patient sometimes not responding as well to famotidine clinically, as we see them respond to ranitidine.

Glad she's on blood pressure medication. As long as they check her blood pressure once to twice a month, while she is in her calmest state, so not when they are drawing her blood or restraining her, but rather have her in your lap or near you while placing the cuff and measuring, they can ensure she's on enough amlodipine. Some cats need 0.625mg once to twice daily as their hypertension worsens. Some need less as their renal disease is more controlled, and goes from acute to chronic. As the tablets are so small and unreliably fractured/split into 1/4's or 1/8's to be able to effectively dose a cat, this, as many of her medications, can be compounded into 0.3125 or 0.625 treat, tablet, capsule, or concentrated flavored suspension so she only needs 0.1mL of a 6.25mg/mL suspension, for example.

The Epogen, or epoetin, rather darbopoetin, brand Aranesp @ your rDVM, is helpful when their packed cell volume is low enough to warrant it. We balance the side effects and possible benefit against the eventual ability of injected erythropoetin to limit the body's production of red blood cells over time, but sometimes we don't see this "reaction" for many months, so the benefit is worth it. The key is not giving any epoetin/darbopoetin when it is not yet warranted. Anemia must consistently be low enough, severe enough, to try encouraging erythropoetin generation; after B complex and iron supplementation has failed to help generate red blood cells. If Dusty had sat at 15% PCV/HCT despite iron/B vitamin supplementation for 2 weeks, we'd start Epogen. Or Aranesp, alternatively, if we could get it... difficult to get Aranesp as there is less demand and production of it worldwide. Aranesp is better for cats, and less likely to induce a reaction in her blood, so many points, many kudos, to Dusty's team of DVMs for choosing it!

We inject weekly, separate from the subcutaneous fluid therapy session that particular day, and monitor PCV weekly, with a very small blood volume, checked in house, to verify the red blood cells are responding to the artificial erythropoetin. They could check PCV weekly until she's at 20%, for ex, then go to every 2 weeks, then monthly as she sits above 20%. We don't expect them to ever get back to 30% or higher, as that would be a healthy, non-kidney cat's PCV/HCT. The weeks she's not getting her blood drawn, she could have her blood pressure checked, her hydration checked (skin tent/mucous membrane tackiness), and weight checks. This way, blood pressure visits are separate from blood draw visits, so she is less stressed when we are getting her numbers and verifying her hypertension is controlled.

NOTE, the body needs additional iron and B vitamins to make hemoglobin, the big component of red blood cells. Anemic patients don't have enough iron and B vitamins dietarily, due to poor appetite. She needs supplementation while on darbopoeitin. Hopefully, they already started this, so she can make red blood cells. Typically, they're on it before the darbopoetin, as we try supplements without erythropoetin injections first, to see if the body just didn't have enough dietary iron/B vitamins to make RBC's.

Iron Dextran is injectable, given once daily, if you can't get oral Pet Tinic in her; throwing everything down her throat just isn't possible with all the meds kidney cats tend to be on. Also, B complex is in Pet Tinic, but B Complex Injectable can be added to subcutaneous fluids as long as the bag is kept covered to protect the vitamins from light, or add to each dose of subcutaneous fluids you draw into a syringe. Review supplementing her with your vet, as they'd need to order you a bottle of Iron Dextran and a bottle of B Complex to have at home, after reviewing how to use it, dose, storage, aseptic needle use, etc.

Team Dusty sounds like it is really pulling her through this slump! Way to go Tommy! My own kidney dog had a slump like this, as did 2 coworkers' cat/dog, and we get them through it, now 3 years later for Charles Xavier (my deceased Veteran dad's, now my, 16 year old grumpy old man cocker) and 2-4 yrs later for the cohorts' babies, these geriatrics are comfy and controlled!! First comes to mind, My old 22 year old DSH patient Spencer (CRF/hyperthyroid/HCM) the last 6 years, and 10 yo Great Dane patient Jujube (blood/lymphatic cancer) the last 3 years, just needed to be supported through their intermittent slumps and they go so strongly!

There is light at the end of the "struggle tunnel," we just can't "talk them through it" and rally them emotionally like we can human patients. If we could "talk" them into eating the way human nurses do, so many meds could be avoided! Same for my vet oncology patients. Oh, some of those RNs don't know how much I wish my patients could talk, and yet, RNs have human patients that make me grateful mine don't, at the same time ;] I've ran into some rough riders when in ER/ICU at human hospitals myself. Sometimes a mute doctor would come in handy too, just write down the orders or place 'em in the computer, and I'll carry them out, thank you very much, without the hullabaloo, patient badgering, client guilt-tripping judging, nurse-whippin, just get outta my ICU, know-it-all omniscient omnipotent perfect doctor
 
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tommy2015

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We are heartbroken today...

Dusty started Darbopoetin 25mcg/1ml shot two weeks ago for her anemia. The 25mcg was supposed to be given in 10 times, once a week. An anemia specialist, who prescribed this med, did the first shot on May 16. All the following shots are supposed to be done by our family vet. She did so last Saturday and was about to do the third shot today, then we realized there is a HUGE disaster: she had injected all the rest of the 25mcg into Dusty last Saturday, and the bottle is empty now.

The problem is on the label, which says “Give 25 mcg under skin once weekly unless otherwise directed” (Please see the attached). Then the vet gave whatever in the bottle to Dusty in one injection.

The family vet called the specialist. Now both of them don’t know how to handle the situation. To make it more heart-broken, today’s blood work shows Dusty’s CRE 8.1 and BUN 104, increasing rapidly from CRE 6.0 BUN 72 on May 11 (Please see the attached).

In the past two weeks Dusty did show signs of improvement. She has better appetite, drinking and urinating more. But she has become significantly less active, sleep more than ever.

Any suggestions are highly appreciated. Is this rapid increase in CRE related to the overdose? Is there anyway to antidote Darbopoetin? Can we take any legal action for this perhaps fatal harm to our poor kitten? 


 

stephenq

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We are heartbroken today...

Dusty started Darbopoetin 25mcg/1ml shot two weeks ago for her anemia. The 25mcg was supposed to be given in 10 times, once a week. An anemia specialist, who prescribed this med, did the first shot on May 16. All the following shots are supposed to be done by our family vet. She did so last Saturday and was about to do the third shot today, then we realized there is a HUGE disaster: she had injected all the rest of the 25mcg into Dusty last Saturday, and the bottle is empty now.

The problem is on the label, which says “Give 25 mcg under skin once weekly unless otherwise directed” (Please see the attached). Then the vet gave whatever in the bottle to Dusty in one injection.

The family vet called the specialist. Now both of them don’t know how to handle the situation. To make it more heart-broken, today’s blood work shows Dusty’s CRE 8.1 and BUN 104, increasing rapidly from CRE 6.0 BUN 72 on May 11 (Please see the attached).

In the past two weeks Dusty did show signs of improvement. She has better appetite, drinking and urinating more. But she has become significantly less active, sleep more than ever.

Any suggestions are highly appreciated. Is this rapid increase in CRE related to the overdose? Is there anyway to antidote Darbopoetin? Can we take any legal action for this perhaps fatal harm to our poor kitten? 
The ASPCA's poison control hotline handles (all the time) vet prescribed drug overdoses and can even call your vet to discuss it.  The one time $65 fee (as many calls as needed for this case all come under the one fee including calls to your vet) can be reduced to $18 if your cat is microchipped and registered with HomeAgain.  If your cat is chipped but not registered you can register at home again website (http://public.homeagain.com/)

The ASPCA hotline is (888) 426-4435 and the website is https://www.aspca.org/pet-care/animal-poison-control
 

mrsgreenjeens

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I would definitely have the two Vet's cal that hot line and try to figure out what to do, although since the overdose happened a week ago, not sure anything can fix that at this point.

I DID read that currently UC Davis doses 6.25 mcg every week, so perhaps getting all 25 mcg at once isn't a death sentence
.  Here's where I read that:  http://www.felinecrf.org/esas.htm#aranesp_usage_guidelines  Maybe your Vets could contact someone there at UC Davis? 

I honestly don't know how this could affect her Creatinine or BUN, but I guess anything is possible


I am SO sorry this has happened
.   Dusty is still acting like she feels ok though...just tired?  My kidney cat spends most of her time sleeping too.  She comes out to eat and get a few pets, then back to bed. 
 
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tommy2015

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Dusty stopped eating today, and slept more. Looks the overdose began to take effects now. I guess the next week will be critical. Pray for her...
 

mrsgreenjeens

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Dusty stopped eating today, and slept more. Looks the overdose began to take effects now. I guess the next week will be critical. Pray for her...
I see you've gotten what appears to be some very knowledgeable advise on your other thread concerning this overdose.  Has your Vet implemented any of those things yet? 
 
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