One year old in acute renal failure

In a grotesquely ironic twist, my little girl, Rory, who everyone believed was mildly anemic due to FeLV, turns out to be actually be FeLV negative.  Ordinarily it would be a cause for celebration, but it was discovered a couple of days ago that her anemia is the result of acute renal failure, most likely due to a congenital condition.  She's abnormally small, 5 lbs. at her heaviest with a tiny kittenish body, so it's not unsurprising that something has gone wrong.

She's doing remarkably well at the moment, so well, in fact, that her vet and I have decided to take a conservative approach to treatment despite her stage 4 condition.  She has a decent appetite, almost normal at times, she's alert and playful, only displaying signs of discomfort periodically.  We've started her on sub-q fluids, Pepcid, and she'll be starting Azodyl, Epakitin and Astro's CRF oil (high potency fish oil + ubiquinol) very soon.  The vet gave us an appetite stimulant/anti-nausea drug to use if needed. The prognosis is, of course, not good.  She doesn't do well with hospitals, vets, etc., so there's also the question of whether or not aggressive treatment and hospitalization is warranted if it's going cause undue stress and only prolong her life by a meager few months.  The vet's philosophy is Quality Over Quantity, and I'm in agreement.  

I thought I knew what was happening, the direction treatment was headed in, and everything I thought I knew turned out to be flat-out wrong.  We were supposed to be treating felv-related anemia, and then trying an experimental anti-viral, and there was hope.  And now all I can do is make her comfortable and wait for the inevitable.  It isn't fair.  It just isn't fair.

So here's where we're at: 

BUN: 146

Creatinine: 9.6

Albumin: 4.6

Phosphorus: 11.4

Calcium: 11.7

Really, really awful numbers.  The vet was amazed that she's doing as well as she is.  I have copies of her blood work in case she goes into crisis mode....but my question is this: What good would hospitalization do, really?  Is it going to give her a new lease on life, or prolong the inevitable by days or weeks?  I honestly don't know what to do if she crashes because I don't want to put her through an ordeal that's ultimately going to provide temporary relief.  If she'll end up right back at that point again before long, I can't justify putting her through it all.  I just can't.  I don't want her to suffer, more than anything I don't want her to suffer.

Any advice?  My heart is just breaking in two over this. 

Ask the attending vet what his/her opinion is and use that information to make your decision. A good vet will give you an objective response with alternatives.

MDaisy said:

 
Ask the attending vet what his/her opinion is and use that information to make your decision. A good vet will give you an objective response with alternatives.

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The thing is, if she crashes she would have to go to the emergency hospital for treatment.  We wouldn't be seeing our vet and they would automatically treat her aggressively and try to stabilize her condition.  Do I want to put her through that, is my question, if her prognosis is poor regardless of how well the ER docs can handle a crisis.  

Instinctively, I want to try to save her, and I'm afraid I'm going to do whatever possible in that scenario to help her, completely overlooking the fact that she can't go on indefinitely with kidneys that were never going to function normally.  There's no such thing as dialysis for cats, or kidney transplants.  Unless someone can offer some long-term hope here, I just don't know what to do.

I'm no expert on ER vets as our nearest ER vet is about 100 miles away and we've only used an ER vet once. When I did take our cat to the ER vet, the ER vet did go through the options which were few. He also said there was little hope of my cat surviving and the best option would be to euthanize our cat. That's exactly what we did.

Cats suffering from kidney disease rarely have emergency events, but it can happen. I can speak from personal experience as my old brown tabby Andy did suffer from kidney disease (and almost died from a urinary tract blockage which was a medical emergency) and during that event our vet went through the options for treatment.

Good vets will walk you through the various treatments available and help you decide what's best and that includes euthanasia.

the3rdname said:

 
Any advice?  My heart is just breaking in two over this. 

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I believe that most kidney treatments can be done at home, exactly what you're doing, and so long as sufficient sub q fluids, anti nausea meds etc are keeping her comfortable (eating, not lethargic) then you keep doing that as long as you can and when that doesn't work anymore its probably time to say good bye.  Hospitalization to get her over an acute crisis certainly, but for long term maintenance care, home treatment is the wqay to go.

A very knowledge vet contributed to this subject in depth with a number of threads here http://www.thecatsite.com/f/5825/kidney-issues-in-cats-with-dr-kris

MDaisy said:

 
I'm no expert on ER vets as our nearest ER vet is about 100 miles away and we've only used an ER vet once. When I did take our cat to the ER vet, the ER vet did go through the options which were few. He also said there was little hope of my cat surviving and the best option would be to euthanize our cat. That's exactly what we did.

Cats suffering from kidney disease rarely have emergency events, but it can happen. I can speak from personal experience as my old brown tabby Andy did suffer from kidney disease (and almost died from a urinary tract blockage which was a medical emergency) and during that event our vet went through the options for treatment.

Good vets will walk you through the various treatments available and help you decide what's best and that includes euthanasia.

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It sounds like the ER vet you used is set up a little differently.  The emergency (and specialty) hospital nearest to me is run like a human hospital ER.  If you walk in with an animal in crisis, they immediately take the animal from you and rush them back to the ER department where they get to work on stabilizing the patient.  The fur parents then sit in the waiting room for eons, and eventually a vet either comes out to discuss testing and treatment options or, in dire cases, you're led to an office area where you consult privately with the vet.  

That's a lot of chaos, poking, prodding, etc. just to get to the discussion of options bit.  That's not the sort of environment or experience I would choose for a cat's last day on earth.  Which is why I think if we went to the ER, it would be with the intention of trying to save her.  If I didn't think it was an ordeal she needed to be put through, if I wanted her to have a tranquil and pleasant ferry ride to the rainbow bridge, I'd take her somewhere else or opt for in-home euthanasia.  I'd hate to have to make that decision at the ER, if you see what I mean.  And I'm trying to think through a migraine, so I'm sure this is muddled and confusing.  Bleah.

StephenQ said:

 

the3rdname said:

 
Any advice?  My heart is just breaking in two over this. 

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I believe that most kidney treatments can be done at home, exactly what you're doing, and so long as sufficient sub q fluids, anti nausea meds etc are keeping her comfortable (eating, not lethargic) then you keep doing that as long as you can and when that doesn't work anymore its probably time to say good bye.  Hospitalization to get her over an acute crisis certainly, but for long term maintenance care, home treatment is the wqay to go.

A very knowledge vet contributed to this subject in depth with a number of threads here http://www.thecatsite.com/f/5825/kidney-issues-in-cats-with-dr-kris

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She's getting sub-q at the vet's for the time being because it took three of us (!!!) to accomplish this task.  Two people to hold her still (a little 4.7 lb. kitty, if you can imagine) and one to do the fluids.  The two of us, one of the techs and I, had a terrible time keeping her stationary.  She went ape poo when the needle was inserted.  There's no way I could do it at home right now; I can only hope she starts to relax as it becomes more routine.

I appreciate the very helpful advice.  Cut-and-dry, easy to understand, guidelines.  The conversations with Dr. Kris were helpful, too.  

I think maybe I'm being overly pessimistic at the moment...I'm just mentally depleted from dealing with all these health problems.  Two short months ago Rumi was near death and hospitalized, is now doing better but every day is a giant question mark, which is the best you can expect with FeLV.  Now Rory's kidneys are shutting down.  It's all just too, too, too much.  I can't catch a break.  

So we'll keep on with the sub-q, meds and supplements.  The vet says she's seen and dealt with similar cases of acute renal failure (as a congential illness in young animals) and the prognosis is a few months of quality life at most, with a sharp decline in the end.  She also said most animals are off food and extremely lethargic with Rory's numbers, so maybe the little girl is a fighter.  She thinks I should pursue more aggressive treatment with a specialist if Rory responds really well to the sub-q.  I guess we'll just have to wait and see what happens.

the3rdname said:

  I guess we'll just have to wait and see what happens.

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Ok keep us updated !

StephenQ said:

 

the3rdname said:

  I guess we'll just have to wait and see what happens.

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Ok keep us updated !

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Will do.  If I'd posed it as a "What would you do if this was your cat and she crashed" question, would you try to save her, or would you opt to give her peace?  

My cat is older and has chronic renal failure, but the treatment is basically the same as what you've listed for your cat.

I have actually brought my cat through two "crashes" by myself, giving extra fluids, helping her eat and use the litterbox (she was very weak and wobbly). She's still here and doing pretty well, eating on her own and acting normal for an elderly cat.

If you can manage to give the sub-q fluids at home, and possibly assist feed if she needs it, you might be able to get her through a crisis at home if it happens. I went through the same thing at first, I was sure I wouldn't even be able to give her fluids, she fought the vet tech so much, but now it's easy. It just takes practice (and the cat is much calmer at home with me than at the vet).

My current kidney cat is 15 1/2 years old, and I would NOT put her through emergency procedures, but I would let her go in peace.      But there is certainly a difference between an elderly cat and a baby! 

Anyway, back to the topic at hand.  You mentioned they don't do kidney transplants on cats.  Well, guess what?  They DO!  They aren't cheap, and not all cats are candidates, but that is an option.  I found this article by the University of Georgia that speaks to it:  http://vet.uga.edu/hospital/services/surgery_sa/renal_transplants/

Also, even though my hubby is a retired nurse, and we used to give sub-q fluids to our LAST kidney cats, he simply cannot give them to our current one .  This cat is his soul mate and he is so afraid of hurting her (I keep telling him he's not hurting her, he's helping her!) , that we actually have a Vet Tech come over to our house to give her her fluids.  I just called around to all the Vets in our area and asked if any of the techs wanted to earn some extra money by doing it, and found a couple.  Then we negotiated a price and Voila!  What's great is that this one lives about 1/4 mile from us, so if we happen to have any issues, she can come over and help.   If you could find someone like that, perhaps they could help teach you in your home and eventually you could take over.  One thing is, you all were probably extremely nervous, which Rory could sense, and that's one reason why it didn't go very well

So...as well as giving those supplements, what are you doing about food?  I see you'll be using a phosphorus binder (epakatin), so I'm guessing you'll be adding that to her regular food?  Does she eat kibble or canned?  If kibble, you might think about feeding her canned, simply because the more liquid you can get into her, the better!  However, you don't want to have her lose any weight, so if she balks at it, don't push her.

Also, I gather she DOES have anemia too?  Yes, it does go along with kidney disease.  Has your Vet discussed adding Vitamin B to the regimen?  Certainly ESA's are an option too, depending on her PCV, which you didn't provide.  And,yes, I would think a "regular" Vet would know about these things.  Doesn't he treat anemia be itself?  I don't really know what kind of specialist you would need to see to get an ESA.  Perhaps a new Vet IS in order, because you definitely need someone who can treat all issues together.

Here is another website that is a MUST HAVE for anyone with a kidney cat.  I refer to this often.  It is chock full of information.  I happen to have to "open" to the anemia page, but look all around:  http://www.felinecrf.org/anaemia.htm

momto3cats said:

 
My cat is older and has chronic renal failure, but the treatment is basically the same as what you've listed for your cat.

I have actually brought my cat through two "crashes" by myself, giving extra fluids, helping her eat and use the litterbox (she was very weak and wobbly). She's still here and doing pretty well, eating on her own and acting normal for an elderly cat.

If you can manage to give the sub-q fluids at home, and possibly assist feed if she needs it, you might be able to get her through a crisis at home if it happens. I went through the same thing at first, I was sure I wouldn't even be able to give her fluids, she fought the vet tech so much, but now it's easy. It just takes practice (and the cat is much calmer at home with me than at the vet).

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Sorry for the delayed response    It's reassuring to know others are following the same treatment regimen.  And we're now doing sub-q at home!    Running back and forth to the vet's was getting to be too much of a trial for everyone, so I decided, what the hey, let's give it a shot.  The process gets quicker and easier every time, and Rory is starting to realize that the more tolerant she is, the faster it's over.  She almost fell asleep last time 

mrsgreenjeens said:

 
My current kidney cat is 15 1/2 years old, and I would NOT put her through emergency procedures, but I would let her go in peace.      But there is certainly a difference between an elderly cat and a baby! 

Anyway, back to the topic at hand.  You mentioned they don't do kidney transplants on cats.  Well, guess what?  They DO!  They aren't cheap, and not all cats are candidates, but that is an option.  I found this article by the University of Georgia that speaks to it:  http://vet.uga.edu/hospital/services/surgery_sa/renal_transplants/

Also, even though my hubby is a retired nurse, and we used to give sub-q fluids to our LAST kidney cats, he simply cannot give them to our current one

.  This cat is his soul mate and he is so afraid of hurting her (I keep telling him he's not hurting her, he's helping her!) , that we actually have a Vet Tech come over to our house to give her her fluids.  I just called around to all the Vets in our area and asked if any of the techs wanted to earn some extra money by doing it, and found a couple.  Then we negotiated a price and Voila!  What's great is that this one lives about 1/4 mile from us, so if we happen to have any issues, she can come over and help.   If you could find someone like that, perhaps they could help teach you in your home and eventually you could take over.  One thing is, you all were probably extremely nervous, which Rory could sense, and that's one reason why it didn't go very well

So...as well as giving those supplements, what are you doing about food?  I see you'll be using a phosphorus binder (epakatin), so I'm guessing you'll be adding that to her regular food?  Does she eat kibble or canned?  If kibble, you might think about feeding her canned, simply because the more liquid you can get into her, the better!  However, you don't want to have her lose any weight, so if she balks at it, don't push her.

Also, I gather she DOES have anemia too?  Yes, it does go along with kidney disease.  Has your Vet discussed adding Vitamin B to the regimen?  Certainly ESA's are an option too, depending on her PCV, which you didn't provide.  And,yes, I would think a "regular" Vet would know about these things.  Doesn't he treat anemia be itself?  I don't really know what kind of specialist you would need to see to get an ESA.  Perhaps a new Vet IS in order, because you definitely need someone who can treat all issues together.

Here is another website that is a MUST HAVE for anyone with a kidney cat.  I refer to this often.  It is chock full of information.  I happen to have to "open" to the anemia page, but look all around:  http://www.felinecrf.org/anaemia.htm

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Food is high quality protein, low carb, minimal ingredients, and mostly wet.  I do put a little dry out for them at various times (Orijen), but Rory is my wet food lover.  She'll always choose wet over dry- thank goodness!  The phosphorus binder is given twice a day, morning and evening (those are the instructions it came with), so she gets it in a small meal of baby food.  

She is anemic, but the vet is hoping the sub-q treatments will effect an improvement in her overall condition.  So far her color isn't improving, but I don't know if it simply hasn't been long enough or if sub-q alone isn't enough.  Her HCT was 22%, so not low enough to qualify for an ESA just yet, but close.  As disappointed as I am with our vet's lack of knowledge in certain areas (ESAs), she is the first vet that was willing to put in real time and effort researching Rumi's condition (FeLV) and is helping me enroll him in a preclinical trial.  It's extraordinarily difficult to find well-informed vets in this area and the best you can hope for is someone who is willing to listen, learn, and work with you as an ally.  

I have a feeling we'll end up seeing a specialist, which is a prospect the vet has been pushing from the beginning. More $$$ and distance to travel, which I'd hope to avoid, but I feel like Rory's condition is more complex than we realize.  I want everything to be simple and straightforward, but darnit, life is just not that accomodating 

Thanks for the link!  The more info, the better.  

Unfortunately, I don't have anything to add except good luck to you and Rory! I hope everything turns out well. He certainly sounds like a fighter and, although he'll never have a normal life, he can have a happy one with you.

As for when to euthanize, I expect you'll have some warning signs before he flat-out crashes. For instance, he'll hide, refuse to be petted, stop eating or using the litter box, etc. There are numerous tell-tale signs. Just be on the lookout for changes in mood/behavior. As soon as you see Rory going downhill, get him to the vet.

Keep us posted on Rory's progress. Good luck to you both!

Best regards.

PHarber-Murphy said:

 
Unfortunately, I don't have anything to add except good luck to you and Rory! I hope everything turns out well. He certainly sounds like a fighter and, although he'll never have a normal life, he can have a happy one with you.

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She is a fighter all right....she resists taking medicine and supplements like a real champ    On a serious note, she has got youth and a spunky attitude going for her, so those are definite pluses.  I know the sub-q is going to be a weekly routine for the rest of her life, but I'm hopeful she'll become even more cooperative with time.  I look forward to a day when I can administer the sub-q without help.  There's a harness thingy you can use to keep the needle from being dislodged, allowing them unrestricted movement while receiving their treatment. The only hitch is getting the needle into the cat.  Well, and getting the harness on the cat.  Tackle those issues and it would be a cinch.

I never in a million years thought I'd be dreaming of a day when my cat let me truss her up and stick a needle into her back (!)  

Quick question for anyone to field: If Pepcid gives Rory side-effects- and it's impossible to know exactly what's going on, but I'm guessing nausea and/or headaches; I only know she's miserable after taking it- would Zantac be any different?  Or maybe there's a different class of medication that works similarly?  

Absolutely I would get her off the Pepcid and get her on the Zantac!  Number One reason is that Pepcid has been known to cause anemia in humans   There is no evidence of this in cats that I can find, but still.  Since Rory already has anemia and is showing ill effects on Pepcid, I would change.  Here is the section of the go to website that discusses it:  http://www.felinecrf.org/nausea_vomiting_stomach_acid.htm#famotidine

mrsgreenjeens said:

 
Absolutely I would get her off the Pepcid and get her on the Zantac!  Number One reason is that Pepcid has been known to cause anemia in humans

  There is no evidence of this in cats that I can find, but still.  Since Rory already has anemia and is showing ill effects on Pepcid, I would change.  Here is the section of the go to website that discusses it:  http://www.felinecrf.org/nausea_vomiting_stomach_acid.htm#famotidine

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Oh my god!  It seems to me that if there's the slightest possibility Pepcid could cause health problems in cats, it shouldn't be prescribed.  Especially to a cat that's already anemic!  We'll be looking into Zantac pronto!!

the3rdname said:

 
Oh my god!  It seems to me that if there's the slightest possibility Pepcid could cause health problems in cats, it shouldn't be prescribed.  Especially to a cat that's already anemic!  We'll be looking into Zantac pronto!!

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No need to panic, Pepcid is well tolerated by many cats. Mine was on it for 5 years

StephenQ said:

 
No need to panic, Pepcid is well tolerated by many cats. Mine was on it for 5 years

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Yes, as I said, there is no evidence that it causes anemia in cats, however, since she isn't tolerating it well, and there ARE other options, I'd definitely go for them instead if I were you.  I also had a cat on Pepcid A/C (and the prescription Famotadine) and he tolerated it well.  And now that I know it can be given via injections, we're going to give it a try with Callie, since she's impossible to pill.  BUT, she's not anemic.   

mrsgreenjeens said:

 
Yes, as I said, there is no evidence that it causes anemia in cats, however, since she isn't tolerating it well, and there ARE other options, I'd definitely go for them instead if I were you.  I also had a cat on Pepcid A/C (and the prescription Famotadine) and he tolerated it well.  And now that I know it can be given via injections, we're going to give it a try with Callie, since she's impossible to pill.  BUT, she's not anemic.   

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yes injectable Famotadine is a good way to go when indicated