Sub Q: CKD cat with cardiac issues

Hi hi, wondering if anyone has had experience with subcutaneous fluids for an older CKD cat with cardiac issues. Mao got I-131 treatment for hyperthyroidism in July 2014 at 14 years of age, and it has been downhill ever since. She was diagnosed with stage 2 CKD in August 2014 and commenced sub Q fluids (75mL of lactated ringers  every other day) in November 2015 when her creatinine levels went from 2.5 to 5.5 in 3 months (unfortunately not a lab error). After 3 months of sub Qs, canned k/d food, azodyl and a host of other supplements, her creatinine level is now 3.5.

In 2014, we were considering surgical work to remove a growth and took her to a cardiologist to assess the appropriateness of anesthesia. Turns out the darling has 3rd degree atrioventricular block and bradycardia (heart rate has increased and is typically normal level). She also has a very mild murmur (Grade I/VI sternal systolic murmur).

I'm not sure what part of the kidney protocol has helped Mao. She eats like a champ as usual and is much less bony now vs in November 2015 even though her weight has held steady at 10.5lb. I suspect the sub Qs have been helpful but I know they are tough on the heart. Has anyone had a CKD cat with cardiac issues? What is your cat's protocol and what has been your cat's experience?

Thanks.

I'm sorry no one has answered your question, yet.   I've never been in your situation so don't know the answer but am hoping maybe someone else will come along who does.   What does your vet say about using sub-q fluids ? Did (s)he suggest cutting down?  I know this is like walking a tight rope.  Fingers crossed that Mao continues to do well.  

We are reading your message but so far, nobody seems to have any experience with this particular combination.  Just checking in so you know you are not being ignored!

I'm reading your post now, will post my reply in a moment. Lucky didn't have confirmed cardiac issues, but we believe (based on his reaction to some things) that he likely had a mild form of heart disease.

I'm not surprised your cat had kidney issues come up after the i131. Treating hyper-t can un-mask any kidney disease that may be there. That happened with Sara.

Anyway, can you split up the fluids even further? Are you still giving 75 every other day? Perhaps you can give 40 every day instead, as that would stress the heart less. That is generally what is suggested when a cat has both heart disease and kidney disease - smaller doses of subqs at more frequent intervals. Is it always absorbing before you give the subqs again?

Subqs are very... I don't know the word for it, but I keep thinking "versatile". You really need to administer them based on how your cat reacts to them. Obviously talk with your vet about it but I know my vet is of the opinion that I'm the one that sees my cat every day, so I know how they are reacting to things better than he does.

With Lucky, he was on super-high subq doses - 200ml per day. He could handle it two days in a row, but by the third day he'd get very lethargic. He also had a heart murmur and the vet decided it was better to lower the amount given per day. He unfortunately died not too long after that (he had acute on chronic renal failure).

I'm really glad to hear he is eating well though and doing well otherwise!

I would clear this with your vet to be sure and keep your kitty safe.   The information I have is that you do not want to give a cat with known cardiac issues subQ fluids, unless your vet okays it. http://www.felinecrf.org/subcutaneous_fluids.htm

From Tanya's Comprehensive Guide:

When NOT to Give Subcutaneous Fluids                                                                      Back to Page Index

Fluids are not always acceptable treatment, and should only ever be administered with veterinary approval. Subcutaneous fluids should NOT be administered to your cat if any of the following criteria apply:

1. 
   Your cat is so severely dehydrated that your vet considers intravenous fluid therapy (IV) more appropriate. In certain circumstances IV is the only correct treatment, because sub-Qs are not well absorbed in a severely dehydrated cat.
2. 
   If your cat has high bloodwork levels (creatinine over 7), s/he might benefit more from IV fluids initially, with sub-Qs provided once s/he returns home as needed.
3. 
   Your cat has a heart condition. Fluid therapy may still be possible but your vet must decide if it is appropriate for your cat, and determine the amounts and frequencies to be administered.
4. 
   Your vet has refused to agree to the procedure on other medical grounds.
5. 
   fluids from the previous session have not yet been absorbed.
6. 
   your cat is over-hydrated. This may be obvious, or your cat may feel "squishy", the way water in a plastic bag feels  - squishiness sometimes happens if a little air gets in with the fluids, and is not normally a problem, but if it happens consistently, your cat may need less fluid. Other symptoms of overhydration may include sudden weight gain, coughing and nasal discharge. See Symptoms for more information. Overhydration may be associated with a heart condition, but contrary to what some vets claim it can still happen in a cat with a perfectly normal heart. It is a good idea to weigh your cat regularly, to check for sudden or continous weight gain which may give early warning of a problem; or
7. 
   Processing the extra fluids in itself places an additional workload on the kidneys which can make the CKD progress faster; plus it can flush out certain nutrients, and giving fluids when they are not needed may increase blood pressure; so it is best not to begin fluids until the advantages are likely to outweigh the disadvantages. Dr Katherine James of the Veterinary Information Network believes that most CKD cats will benefit from subcutaneous therapy once creatinine levels are consistently over 300 -350 (US: 3.5-4). If your vet thinks your cat's CKD is less advanced than this, then it is probably safer to hold off on sub-Qs for the moment;
8. 
   My vet agreed to us doing fluids in part because she felt Thomas would not find them too distressing. You and your vet do need to take your cat's personality into account in deciding whether to go this route; but do not necessarily assume your cat cannot cope, many cats who ordinarily hate medication of any kind tolerate sub-Qs because they make them feel so much better. I would suggest trying them for a few weeks at least.  
9. 
   Many cats appear happier (more active and alert, with a better appetite) after sub-Qs. However, some may become lethargic for an hour or so afterwards. This is probably nothing to worry about, but if it happens frequently it may be that your cat is not processing the fluid very well, so I would ask your vet to check your cat for possible heart problems or fluid retention.

Definitely, always check with the vet. I'm assuming the 75ml every other day was under vet supervision. But, typically, if fluids are given in the presence of a cardiac condition, they are smaller doses at more frequent intervals.

Thanks so much for everyone's thoughts. Yes, 75mL every other day was the primary care vet's protocol based on the fact Mao has a heart condition. The vet recommended I take Mao to a cardiologist to make sure. Mao went to the cardiologist this week where she got a physical exam, a full review of her medical records and an echocardiogram (I still cannot believe all the technology available to our furry friends!). Thankfully, her heart condition has not worsened. The cardiologist said that once hyperthyroidism is under control, the heart often strengthens although it won't get back to its pre-hyperthyroid state. Based on the echocardiogram, her physical presentation and improving kidney profile since receiving fluids, I can and should give priority to her kidneys. She has been cleared for sub Q therapy.

Even after scouring the warnings about sub Q fluids, I still was unable to identify HOW and WHY sub Qs tax the heart. The cardiologist explained it to me thus: pumping the excess fluids creates more work for the heart (I assume this is why hyperthryoidism is hard on their little hearts - the extra blood flow that helps their kidneys is a big strain on their hearts). While sub Qs do create an additional burden on the heart, they are absorbed slowly. As such, they are not as taxing as, say, an IV would be. Congestive heart failure is the cardiac concern; when the heart can't pump the fluids fast enough, they back up into the lungs (which is why vets ask if your cat is coughing, wheezing or sneezing). For 3rd degree A/V block, we are to monitor Mao for lethargy, loss of appetite, diarrhea and vomiting. The cardiologist mentioned that these are also symptoms of end stage kidney failure so it can be difficult to identify the cause. He said that most cats with 3rd degree A/V block keep chugging along; hopefully Mao is one of them! 

Hope this is helpful to anyone else with a cat with kidney and heart issues. The cardiology appointment was expensive but it provided tremendous peace of mind about what ailment to give priority to. Furthermore, the cardiologist gave guidance on recommended upper limits of sub Q therapy should her kidneys need more help. Now I'm waiting to hear from the primary care vet to see whether to alter the sub Q protocol given.

missko said:

Hope this is helpful to anyone else with a cat with kidney and heart issues. The cardiology appointment was expensive but it provided tremendous peace of mind about what ailment to give priority to. Furthermore, the cardiologist gave guidance on recommended upper limits of sub Q therapy should her kidneys need more help. Now I'm waiting to hear from the primary care vet to see whether to alter the sub Q protocol given.

Click to expand...

I love your whole post but especially this part. Peace of mind is absolutely priceless. I'm so glad to hear your vet (including the cardiologist) cleared her for subqs! And yes, there is the worry about heart failure when it comes to subqs. When the time comes that Sara needs them, I'll have to keep a close eye on her. She has a heart murmur and also severe hyper-t that is under control with methimazole (her T4 was 21 when it was caught), but of course there is the chance she had some damage.